Shilpa Shivanand

III MDS
 INTRODUCTION
 TERMINOLOGIES
Contents
 HISTORY
 RATIONALE
 ADVANTAGES & DISADVANTAGES
 INDICATIONS & CONTRAINDICATIONS
 CLASSIFICATION
 PARTS OF DENTAL IMPLANT
 DENTAL IMPLANT DESIGN & SURFACE TOPOGRAPHY
 PROPERTIES OF DENTAL IMPLANT
Implant surface free energy
Chemical composition
Rigidity and strength
 DIAGNOSIS & TREATMENT PLANNING

Systemic examination
Dental examination
Radiographic examination
Study models
 SUCCESS CRITERIA
 LITERATURE
 CONCLUSION
 INTRODUCTION

Goal of modern dentistry  Dental implants  designed to

restore normal contour, provide a foundation for
function, comfort, esthetics, replacement of teeth that look,
speech and health of a patient. feel, and function like natural
teeth.

Partial and
removable
prosthesis may This leads to increased
not bring need and use of implant
satisfactory and implant supported
results. prosthesis.
 TERMINOLOGY
Any object or material, such as an alloplastic
substance or other tissue, which partially or
IMPLANT completely inserted or grafted into body for
therapeutic, diagnostic, prosthetic or
experimental purposes.

Can be defined as a substance that is placed into

DENTAL the jaw to support a crown or fixed or removable
IMPLANT denture.
Charles M Weiss

A prosthetic device or alloplastic material

DENTAL implanted into oral tissues beneath the mucosal
IMPLANT or periosteal tissues and/or within the bone to
provide retention and support for fixed or
removal prosthesis. Edward J Fredrickson
Different IMPLANT
commercial systems SYSTEM
which are available
for most treatment
modalities.
IMPLANT
CONFIGURATION
Various implant configuration usually
are found within each system.
An implant configuration is a
specific shape or size of implant
A wide array of configuration is
available to accommodate the
anatomic variation of available bone
commonly observed in patients for
implant treatment.
 HISTORY

 Replacing lost teeth with a bone-anchored device is not a new

concept at all.
 Archeological findings showed that the ancient Egyptian and South
American civilizations already experimented with re-implanting lost
teeth with hand-shaped ivory or wood substitutes.
 In the 18th century lost teeth
were sometimes replaced with
extracted teeth of other
human donors.
 The implantation process was
probably somewhat crude
and the success rates
extremely low due to the
strong immune reaction of
the receiving individual.
2500 BC - Ancient Egyptians -
gold ligature.

500 BC - Etruscan population -

gold bands incorporating pontics.

500 BC - Phoenician population -

gold wire.

300 AD - Phoenician population -

Carved Ivory teeth.

600 AD - Mayan population -

implantation of pieces of shell.
1911 - Greenfield –
iridoplatinum
basket soldered with 24 carat
gold.

1943 –Dahl- subperiosteal type of

implant

Late 1970s and Early 1980s -

Tatum - custom
blade implants of Titanium alloy

Early 1980s - Tatum - Titanium

root form implant
Modern Historical Developments

The first Subperiosteal Implant was placed in 1948 by Gustav Dahl

The Endosteal Blade Implant, introduced independently in 1967 by

Leonard Linkow and Ralph and Harold Roberts

After 1980s –hollow basket Core vent

implant Niznick et al
-Screw vent implant
-Screw vent implant with
Hydroxyapatite coating
- Implant with titanium plasma
spray
 The quantum leap in Oral Implantology was
achieved in 1952 in Sweden by
PER INGVAR BRANEMARK

 He founded the phenomenon of Osseointegration

 Dr. Branemark's research shifted more towards the use of

titanium appliances in human bone, including the use of titanium
screws as bone anchors for lost teeth.

 In 1982, the Toronto Conference on Osseointegration in Clinical

Dentistry laid down the first parameters on what is to be
considered successful implant treatment within the stringent
confines of the scientific community.
RATIONALE OF DENTAL IMPLANTS
 INCREASED DEMAND FOR IMPLANT-RELATED TREATMENT
RESULT FROM COMBINED EFFECT OF SEVERAL FACTORS

 Ageing population living longer

 Tooth loss related to age
 Consequences of fixed prosthesis failure
 Anatomical consequences of edentulism
 Poor performance of removable prosthesis
 Consequences of R.P.D.
 Psychological aspects of tooth loss and need and desire
of ageing population
 Predictable long term results of implant supported
prosthesis
 Advantages of implant supported restorations
 Increased public awareness
 ANATOMIC PROBLEMS AND CONSEQUENCES OF
EDENTULISM

-Decreased width of supporting bone

-Decreased height of supporting bone
-Decrease in keratinized mucosa
-Prominent mylohyoid and internal oblique ridges
-Prominent superior genial tubercles
-Mucosal thinning with sensitivity to abrasion
-Parasthesia from dehiscent mandibular canal
-Lack of stimulation - decrease in trabeculae and
bone density in the area.
-After initial extraction of teeth, the average first year bone loss is
more than 4mm in height and 30% in crestal bone width. Although
the rate of bone loss is slower after first year,
the bone loss is continuous throughout life,
 ANATOMIC CONSEQUENCES ON SOFT TISSUE
STRUCTURE

 Effect on attached gingiva - As soon as the bone loses width and

height, the zone of attached gingiva starts decreasing.

 Either the attached tissues are completely absent or a very thin

attached tissue may lie over the advanced atrophic mandible, the
gingiva is very prone to abrasion caused by overlying prosthesis

 The size of tongue also increases to fill up the space previously

occupied by teeth. tongue becomes more active in mastication

 Unfavorable high muscle attachments and hypermobile tissue

complicate the situation.

 Conditions such as hypertension, diabetes, anemia and nutritional

disorders have a deleterious effect in elderly.

 Decreased neuromuscular control

 Aesthetic consequences

 Decreased facial height

 Loss of labiomental angle

 Deepening of vertical lines in lip and face

 Chin rotates forward and Ptosis of mentalis muscle attachment—

gives a prognathic appearance called “witch's chin"

 Decreased horizontal labial angle of lip-makes patient look unhappy

 Loss of tone in muscles of facial expression

 Thinning of vermillion border of the lips from loss of muscle tone

 Deepening of nasolabial groove

 Increase in columella-philtrum angle

 Increased length of maxillary lip, so less teeth show at rest and smiling

 Ptosis of buccinator muscle attachment—leads to jowls at side of face

 Psychological effect of tooth loss

 Dissatisfaction with appearance, low self-esteem and avoidance of

social contact
 Loss of self-confidence
 Difficulty in speech, phonation or pronunciation of specific words.
 88% claim some difficulty with speech, and 25% claim significant
problems
 A report shows that in the United States :- More than $200 million
each year spent on denture adhesive to decrease embarrassment
 approximately 80% of patients treated with implant supported
prosthesis showed that their overall psychological health improved in
comparison with their previous removable prosthesis.
 RATIONALE

Implant dentistry is a
boon for restoration of
missing teeth.

It overcomes many
What makes implant dentistry
disadvantages of
unique is the ability to achieve
other conventional
replacement of teeth
methods of
regardless of atrophy,
restoration ie.,
disease, or injury to the
removable and fixed
stomatognathic system
prosthesis.
Why are Implants preferred over Dentures and
Bridges ?

Stability

Grinding of adjacent healthy teeth

Chewing efficiency

Comfort /artificial feeling

Protection of the jawbone

Eating habits
 ADVANTAGES OF IMPLANT-
SUPPORTED PROSTHESIS
 Maintain bone height & width • Reduced size of prosthesis

 Restore and maintain occlusal • Improve stability and retention of

vertical dimension removable prosthesis

 Maintain facial esthetics • Increase survival times of

 Improve esthetics prostheses

 Improve phonetics • There is no need to alter adjacent

 Improve occlusion teeth

 Increase prosthesis success • More permanent replacement

 Improve masticatory • Improve psychological health

performance/maintain muscles of
mastication and facial expression
DISADVANTAGES OF DENTAL IMPLANTS

 Very expensive.

 Cannot be used in medically compromised patients who cannot

undergo surgery.

 Longer duration of treatment and tedious fabrication

procedures.

 Requires a lot of patient co-operation because of repeated recall

visits for after care is essential
 INDICATIONS

 Severe morphologic compromise of denture supporting areas that

significantly undermine denture retention.
 Poor oral muscular coordination.
 Para functional habits leading to recurrent soreness and instability of
prosthesis.
 Unrealistic prosthodontic expectations
 Active or hyperactive gag reflexes elicited by removable prosthesis.
 Psychological inability to wear a removable prosthesis, even if adequate
denture retention and stability is present.
 Unfavorable number and location of potential abutments in a residual
dentition.
 Single tooth loss to avoid involving neighboring tooth as abutments.
 Esthetic zone
 preserve interdental diastemas
 ABSOLUTE RELATIVE
CONTRAINDICATIONS CONTRAINDICATIONS

1. Recent myocardial infarction • Systemic hematological

2. Valvular prosthesis disorders
3. Severe renal disease • Irradiation of the jaw
4. Uncontrolled & treatment • Liver and kidney disorders
resistant diabetes • Osteoporosis/ low bone
5. Advanced & untreated mineral content
osteoporosis • Local pathology
6. Treatment resistant
osteomalacia
7. Uncontrolled endocrine
gland disease
8. Advanced & uncontrolled
acquired immunodeficiency
syndrome
CLASSIFICATION
Classification of implants by Charles. A. Babbush
There are five main types:
 1.ENDOSTEAL IMPLANT
 An implant which is placed into the alveolar bone and/ or
basal bone of the mandible or maxilla
 Transects only one corticle plate
 Most commonly used
Root form Ramus frame
Blade implant implant implant
Designed to mimic the Horse shoe shaped
It consists of thin
shape of the tooth stainless steel device
plates in the form of
For directional load Inserted from one
blade embedded into
distribution retromolar pad to other
the bone
 2. SUBPERIOSTEAL IMPLANT
 Placed directly beneath the periosteum overlying the
bony cortex
 Do not penetrate into the jawbone.
 Consists of non-Osseo integrated framework that
rests on the surface of the jaw or beneath the
mucoperiosteum.
 Can be bilateral or unilateral
 3. TRANSOSTEAL IMPLANT
 Other names- staple bone implant
Mandibular staple implant
Transmandibular implant
 Combines the subperiosteal and endosteal components
 Penetrates both cortical plates
 very similar to a nut and bolt arrangement
 Used in mandibles only
 penetrate the entire jaw to emerge opposite the entry site, usually at
the bottom of the chin.
 4. INTRAMUCOSAL IMPLANTS

 Inserted into oral mucosa

 Mucosa is used as attachment site for metal inserts

•Described by
BRANEMARK
•Direct contact between bone
& surface of loaded implant
•Bio active materials that
stimulate formation of bone
are used
•Described by Dr CHARLES
WIESS
•Complete encapsulation of
implant with soft tissue
•Soft tissue interface could
resemble highly vascular
periodontal fibers of natural
dentition
Cylindrical dental implants
• In the form of cylinder
• Depends on coating or surface conditioning to provide microscopic
retension & bonding to bone
• pushed or tapped into prepared bone site
• Straight, tapered or conical

Threaded dental implants

• The surface is threaded, to increase surface area of implant
• This results in distribution of forces over greater peri-implant bone
volume

Perforated dental implants

• are made of inert micro porous membrane material (mixture of
cellulose acetate) in intimate contact with & supported by layer of
perforated metallic sheet material (pure titanium)
Plateau dental implant
• Plateau shaped implant with sloping shoulder

Solid dental implant

• They are of circular cross section without vent or hollow in the body

Vented dental implant

• It is hydroxyapetite coated cylinder with patented vertical groove
connecting to apical vents designed to facilitate seating and allow
bone in growth to prevent rotation

Hollow dental implant

Hollow design in apical portion
Systematically arranged perforations along sides of implant
Increased anchoring surface
Smooth surface implant
• Has very smooth surface
• Surface is smoothened to prevent microbial plaque
retention

Machined surface implant

• Surface of implant is machined for better anchorage
of implant to bone

Textured surface implant

• Have increased rough surface area to which bone
can bond

Coated surface implant

• Implant is covered with porous coating such as
titanium & hydroxyapatite
Metallic implants
• Most popular metal in use today is titanium
• Other metals used- stainless steel, cobalt chromium molybdenum
alloy & vitallium

ceramic/ ceramic coated implants

• Ceramic used to coat metallic implants to produce bio active surface
• Can be either plasma sprayed or coated
• Non reactive ceramic materials are also present

Polymeric implants
• Made of polymethylmethacrylate & polytetrafluoroethylene
• Used only as adjuncts stress distributers along with implant
rather than implants by themselves

Carbon implants
• Made of carbon with stainless steel
• Modulus of elasticity equivalent to bone & dentine
• Brittleness leads to fracture
• Depending on the materials used:
Metallic implants
[titanium, titanium alloy, cobalt chromium molybdenum alloy]

Non- metallic implants

[ceramics, carbon]
• According to loading
• Immediate(<2weeks)
• Early(2weeks -2mts)
• Delayed (>3mts)
• According to method of placement
• Tapping system
• Threading system
 Based on the surface

 Machined surface
 Sand blasted
 Acid etched
 HA coating
 Plasma spray
 Bioactive surface
 Oxidized surface
 Combination of one/more
PARTS OF DENTAL IMPLANT
crown : Crown: Material Used:
replicate the original teeth to Porcelains (metal supported
provide a biting surface and or metal free) or metal
aesthetic appearance (normally gold)

Abutment
Is the part of implant, which
resembles a prepared tooth, and is
designed to be screwed into the Abutment: Materials Used:
implant body via Abutment screw Titanium.
It is the primary component, which
provides retention to the
prosthesis

Implant Body or
Implant Body or Fixture:
Fixture: the component
Materials Used: Titanium &
that is placed within the
titanium oxide
bone during first stage of
surgery.
 OTHER IMPLANT
COMPONENTS
Healing Screw
During the healing phase, this screw is normally placed in the superior surface of the body.
functions -Facilitates the suturing of soft tissue
over the edge of the implant.
Healing Caps
dome-shaped screws. Length ranges from 2-10mm.
Project through the soft tissue into the oral cavity
Function -prevent overgrowth of tissues around the implant during healing phase.

Impression posts/coping: Analogue or Implant Replica

Is a small stem that facilitates the
transfer of the intraoral location (of
the implant or the abutment) to a
similar position on the cast.
They are screwed into implant body
during impression making.
Analogues are used by laboratory technicians to
replicate implants and their position in a patient’s
mouth.
The analogue,screwed onto the impression coping, is
set into the plaster model during casting
Shilpa Shivanand
III MDS
 INTRODUCTION
 TERMINOLOGIES
Contents
 HISTORY
 RATIONALE
 ADVANTAGES & DISADVANTAGES
 INDICATIONS & CONTRAINDICATIONS
 CLASSIFICATION
 PARTS OF DENTAL IMPLANT
 DENTAL IMPLANT DESIGN & SURFACE TOPOGRAPHY
 PROPERTIES OF DENTAL IMPLANT
Implant surface free energy
Chemical composition
Rigidity and strength
 DIAGNOSIS & TREATMENT PLANNING

Systemic examination
Dental examination
Radiographic examination
Study models
 SUCCESS CRITERIA
 LITERATURE
 CONCLUSION
IMPLANT SURFACE TOPOGRAPHY
 Roughness parameters
 0.04 –0.4 m - smooth
 0.5 – 1.0 m – minimally rough
 1.0 –2.0 m – moderately rough
 2.0 m – rough

 Wennerberg (1996) – Moderately rough implants developed the best

bone fixation.

In vivo studies
 Smooth surface < 0.2 m will – dislodged fibrin clot- no bone cell
adhesion  clinical failure.
 Moderately rough surface- more bone in contact with implant 
better osseointegration.
METHODS TO ALTER THE SURFACE TEXTURE

ADDITIVE SURFACE TREATMENT

• Titanium plasma spraying and HA coating

ABRASIVE SURFACE TREATMENT

• Grit blasting
• Acid etching
• Grit blasting with acid etching

MODIFIED SURFACE TREATMENT

• Oxidized surface treatment

• Laser treatment
• Ion implantation
 ADDITIVE SURFACE TREATMENT

the first rough titanium surface

introduced by this procedure
Coated with titanium powder
particles in the form of titanium
hydride
Titanium plasma sprayed coating (TPS)

ADVANTAGES of TPS & HA COATING

Steinemann(1988) Tetsch(1991)- Titanium Plasma Sprayed coating
provide 6-10 times increase surface area.
HA coating can lower the corrosion rate of the same substrate
alloys.
HA coatings has been credited with enabling to obtain improved
bone to implant attachment compared with machined surface.
 ADDITIVE SURFACE TREATMENT

CERAMIC AND CERAMIC COATED IMPLANTS

 Ceramic materials are used to coat metallic implants to produce an ionic

ceramic surface, which is thermodynamically stable and hydrophilic,
thereby producing a high strength attachment to bone and surrounding
tissues.

These ceramic can either be plasma sprayed or coated on to the metal

implant to produce bio-active surface.
Aluminum oxide (Al2O3) is used as the gold
standard for ceramic implants because of
its inertness with no evidence of ion release
THE TÜBINGEN IMPLANT OF ALUMINUM OXIDE HAS
SPECIFIC MICRO-IRREGULARITIES ON THE SURFACE,
CLAIMED TO ALLOW BONE INGROWTH.
or immune reaction in vivo.

Zirconia (ZrO2) has also

demonstrated a high degree of
inertness.
 ABRASIVE SURFACE TREATMENT
 BLASTING
 Blasting with particles of various diameters is one of the frequently
used method of surface alteration.
 In this approach, the implant surface is bombarded with particles
of aluminum oxide (Al2O3) or titanium oxide (TiO2), and by abrasion,
a rough surface is produced with irregular pits and depressions.
Roughness depends on particle
size, time of blasting, pressure, and
distance from the source of particles
SAND BLASTED IMPLANT
to the implant surface.
Blasting a smooth Ti surface
with Al2 O3 particles of 25 µm, 75 µm,
or 250 µm produces surfaces with
roughness values of 1.16 to 1.20, 1.43,
and 1.94 to 2.20, respectively.
 SAND BLASTING & ACID
ETCHING

The objective
Sand blasting – surface
roughness
Acid etching – cleaning

Wennerberg et al 1996 - superior bone fixation and bone adaptation

Lima YG et al (2000), Orsini Z et al (2000).

Acid etching with NaOH, Aq. Nitric acid, hydrofluoric acid – better
cell attachment.
Acid etching with 1% HF and 30% NO3 after sand blasting - increase
in osseointegration by removal of aluminium particles (cleaning).
POROUS SURFACE

•Porous sintered surfaces are produced when spherical powders of metallic or

ceramic material becomes a coherent mass with the metallic core of the
implant body.
• Lack of sharp edges is what distinguishes these from rough surfaces.
•Porous surfaces are characterized by pore size, pore shape, pore volume, and
pore depth, which are affected by the size of spherical particles and the
temperature and pressure conditions of the sintering chamber.

surface of a porous titanium fibroblasts cultured for 24 hours on

alloy implant the surface of a porous titanium alloy
implant.
 POROUS SURFACE: ADVANTAGES

1. secure, 3-D interlocking interface with bone.

.
2. Predictable and minimal crestal bone remodelling
3. Greater surgical options with shorter implant lengths.
4. Shorter initial healing times
5. Porous coating implants provide the space, volume for cell
migration and attachment, thus support contact
osteogenesis.
 LASER INDUCED SURFACE ROUGHENING
Eximer laser – “Used to create roughness”
Advantage- Regularly oriented surface roughness configuration
compared to TPS coating and sandblasting

SEM x 70 SEM x 300

SEM x 300
IMPLANT SURFACE CHEMICAL COMPOSITION

 Titanium - very reactive metal that oxidizes within nanoseconds

when exposed to air.
 Passive oxide layer of the titanium -very resistant to corrosion.

 All titanium oxides have dielectric constants, which are higher

than for most other oxides - tendency to adsorb biomolecules.
RIGIDITY & STRENGTH OF ESTABLISHED BONE-TO-
IMPLANT INTERFACE

 Bone - limited elasticity,

 Elasticity modulus of 10GPa for the cortex and 1-5 GPa/m2 for
cancellous bone. Thus at the interface between implants and
bone, even when a strong apposition of lamellar bone has
occurred, differences in elasticity are present.

 Both the primary and secondary stability of an implant determine

its success and survival.
 Primary stability -achieved at surgery.
- Depends on the bone quality and available volume, the relation
between drill and implant diameter, and the implant geometry,
quantity of bone-to-implant contact area.

 Dense cortical bone -symphyseal area -guarantees a rigid primary

fixation.
- Questionable with an eggshell cortex in the maxillary
tuberosity.
 During the first weeks of one-stage implants - decreased rigidity -
Subsequently rigidity increases and continues to increases for
years.

 when a prosthesis is installed immediately (1day) or early ( in 1-2

weeks), care must be taken to control overload.

 Overload - improper superstructure designs or parafunctional

habits - cause microstrains and microfractures - bone loss at the
interface to fibrous inflammatory tissue,
 Lack of load can also be detrimental and can lead to cortical
bone resorption.

 The use of finite element analysis (FEA) do provide some

insight on stress concentrations and their relation to implant
geometry and rigidity and the prosthetic superstructures.

 Assessment of implant biomechanics –by noninvasive devices

such as the Periotest and the Ostell. These tests reflect the
rigidity of the bone-to-implant interface.
 The Periotest projects a rod against the
implant or abutment using a magnetic
pulse at a certain speed. The apparatus
measures the deceleration time needed
before the rod comes to a standstill.

 This is transformed in an arbitrary unit

which reflects the rigidity of the bone-
to-implant continuum.

 Values should be below + 7, the

minimum with the most rigid being – 8.
 The resonance frequency analysis
(RFA) offers an alternative
measurement. With the Ostell device,
overall resonance frequency can be
measured at the implant surface.
 Primary stability -frequency range of
6-9 kHz- higher values in mandible.
Arbitrary values which should not
exceed 56,which indicates a level of
bone support that is consistent with
osseointegration.
•When the surface roughness is microscopic-bone
adaptation to micro topography will increase the shear
strength needed to fracture bone from the surface to a
level that is greater than a turned surface but less than that
of a plasma sprayed surface ( Klokkevold et 2001)

•Pull out tests- Screw implants- Cannot asses the biologic

adhesion force

•Pull off tests- non retentive surface is detached from the

underlying bone
 PRETREATMENT EVALUATION

 Chief complaint
 Medical history
MEDICAL HISTORY – MEDICATIONS,ALLERGIES
SOCIAL HISTORY , FAMILY HISTORY
 Dental history
A thorough clinical assessment should be undertaken for every patient
before undergoing therapy.
 Chief complaint

 Problem or concern in the patient’s own words

 Patients goal of treatment

 How realistic are the patients expectations

 History of present illness

If the patient has been referred…the extent of the desired
treatment has to be defined, referring dentist informed of the
expectations regarding the outcome.
 Medical history

 Cardiovascular system  Allergies

 Respiratory system  Bones & joints
 Central nervous system  Neoplasm
 Digestive system  Menopause
 Endocrine system  Pregnancy
 Hematopoietic system  Medications
 Genitourinary system
 Medical history

 Gender..no influence on the outcome.

 Women after menopause more prone to develop

osteoporotic conditions.

(Lekholm et al. 1994, Friberg et al. 1997, Sennerby &

Rasmusson 2001)
 Medical history

 Age..no influence.. In osseointegration..implants become

bone anchored both in young
(Thilander et al. 1994)
& elderly individuals
(Kondell et al. 1988, Jemt 1993)
 Still…elderly patients more susceptible to infections… slow
healing ..
(Sermerby & Rasmusson 2001)
 Medical history

 Growing individuals… rather react like ankylotic

teeth...infra-occlusion
(Oilman 1994)
 Not the chronological age but dental/skeletal maturation
considered in adolescents.
(Thilander et al. 1994)
 Radiographs of the hand bones..

 Psychosocial reasons …
(Koch et al. 1996)
 Medical history

 In young adults requiring tooth replacement, implant

placement should be postponed after the age of 25 due to
the prolonged changes in anterior face height & posterior
rotation of the mandible.
Jemt T 2007
 Dental history

 A history of recurrent or frequent abscesses…indicate

susceptibility to infections or diabetes.

 Presence of a number of restorations, compliance with

previous dental recommendations, the patient’s current oral
hygiene practices noted.

 The individuals past experience with surgery & prosthetics,

or any dissatisfaction with past treatment should be
discussed.
 Extra-oral parameters

1. Facial proportions
2. Facial symmetry
3. Need for lip & cheek support
4. Facial skeletal classification
5. Intermaxillary relation
6. Incisal edge position of the maxillary centrals & occlusal
plane
7. Neurologic test to serve as a baseline assessment in case of
intraoperative nerve lesions
8. TMJ movement & function
 Systemic examination

Baseline vital signs

- Blood pressure
- Pulse
- Respiration
- temperature
 INTRA ORAL EXAMINATION

 Amount of resorption of edentulous ridge

 Size & shape of edentulous ridge
 Quality of tissue
 Inter occlusal space
 Jaw relationship
 Floor of mouth
 Amount of hard tissue
 Soft tissue pathology
 Patients oral hygiene
 BONE EVALUATION

Available bone :is the amount of bone in the edentulous area

considered for implantation
it is measured in :
•width
• height
• length
• angulation
• crown : implant
Maxillary canine eminance -- greater height of alveloar bone than max ant or
post region
Mand canine & premolar reduced height than anterior  anterior loop of
mandibular canal
Available bone angulation :
Ideally it is aligned with the forces of occlusion & is parallel to the long
axis of prosthodontic restoration
angulation of force b / w the body & the abutment of an implant is
correlated with the width of the bone. wider ridge -30degree angulation.
The narrow width ridge- requires a narrower design root form implant
which cause greater crestal stress – so the acceptable angulation is 20
DIVISIONS OF AVAILABLE BONE
By Mish & Judy (1990) Resorption pattern

A. abundant bone

B. Adequate bone height, but reduced bone width

B-w – require bone grafting
C-w - Advanced bone width reduction
C-h - Advanced bone height loss

D - is severe atrophy
LEKHOLM & ZARB 1985

Four Mish bone densities

 Diagnostic records

• Photographs
• Study models
• Radiographs
• Diagnostic waxup
 Photographs
Intra oral & Extra oral photographs
should be taken pre-operatively,
intra-operatively &
post- operatively

Diagnostic cast
•Assist in implant site selection
&angulation requirements during
surgical phase
• surgical template
• one set – permanent record –
dentolegal cases
• used for presentations to motivate
the patient acceptance of the
proposed treatment
RADIOGRAPHIC
EXAMINATION Phase I  pre surgical
implant imaging
OBJECTIVE
• Identify disease Phase II  surgical and intra
•Determine bone operative implant imaging
quantity
• Determine bone
Phase III  post prosthetic
density implant imaging
• Identify critical
structures at the
proposed implant
regions
• Determine the
optimum position of
implant
• Placement relative
to occlusal loads
 IMAGING MODALITIES

 Periapical radiography
 Panoramic radiography
 Occlusal radiography
 Cephalometric radiography.
 Tomography
 Computed tomography
 Interactive computed tomography
 Magnetic resonance imaging
Interactive computed tomography

Interactive CT in conjunction
with a surgical guide stent, can
help guide dental implant
placement into the ideal
position with respect to function
and esthetics.
 Simplant

The Panoramic view is

similar to a normal two
dimensional panoramic
view
The axial view offers a
perspective from a
coronal/apical
direction.

There is a cross
sectional view that
allows a mesial/distal
perspective of the arch.
 Simplant 9.2 is new version of software

 Enhanced treatment plan and reduced risk of errors.

All three of these views
correlate to each other

When a marker is
moved on one view it
corresponds to the other
two views. The final
perspective is a 3
dimensional view

The 3 dimensional view allows the clinician to check for

parallelism of implants.
 Radiographic stent

 Radiographic stent - (can double as surgical stent)

 Acrylic stent with lead beads or ball -bearings (5mm)

placed in proposed fixture locations, allows more accurate

radiographic interpretation
Edentulous
jaw

Impression

RPD

Clear Acrylic
Stent
Place Metal Tubes in the Stent Make a Radiograph

Stent for surgery

 Guidelines
Inter Implant Distance:-

 Least 1mm of bone on all the 4 sides.

1mm
1mm
1mm

1mm 1.0-1.5 mm
1mm
 Implants With Natural Teeth
 0.5mm for PDL Space on either sides
 2 - 2.5mm space: soft tissue

1mm

0.5mm
1.5-2.0mm

 Edentulous space
dimensions:
7-8mm
 Inter-arch space:

 Sufficient inter-arch space is 8-10mm

necessary
 Rule:

 For fixed implant-supported

prosthesis
 7 mm - in the posterior region
7mm
 8-10 mm - in the anterior areas.

 An implant-retained removable
prosthesis requires at least 12 mm.
12 mm
Adjacent teeth:

 Rule: 7 mm

 At least 7 mm between two

adjacent teeth.

 Adjacent teeth must be

infection free:
 all restorative, periodontal,
and endodontic procedures 7 mm
should be completed prior to
implant planning.
 Esthetic evaluation:

 Smile line analysis is critical

for maxillary anterior

implants
 Use of stone cast models:

 The final step of clinical

assessment …impressions
for stone cast models

 Used during treatment

planning….surgical
position & direction
stents.
 Diagnostic casts & working models provide information
about the existing oral conditions not apparent during the
oral examination.

 Helps design optimal occlusal contact.

 Selection of the implant design

 Diagnosis & fabrication of implant positioning devices.

 Evaluate prosthodontic criteria in the absence of the patient:

 Occlusal centric relation position, including premature

occlusal contacts
 Edentulous ridge relationships to adjacent teeth & opposing
arches.
 Position of potential natural abutments including
inclination, rotation, extrusion, spacing, parallelism, &
esthetic considerations
 Wax-up

 The diagnostic wax-up on

the working models
provides a vision of the
emergence & position of
the restoration.
 RIDGE MAPPING

 Evaluating the bucco-lingual bony contour by using a bone

probing technique & a measuring guide.
 Measurement procedure to ensure that the diameter of an
endosseous screw implant does not exceed the dimensions
of available bone.
 The Wilson Bone Caliper

 Adaptable for measuring

in both anterior &
posterior regions of the
mandible & maxilla.

 The millimeter scale can

be read from either side.
 Ridge mapping technique:

 Measurement of crestal
width.

 2 measurements taken at
each implant site: one at
the level of the ridge crest
& the other at a point
approximately 7 mm
vertically.
 Perio probe or
Mark and section Transfer the marks to the cast
an Endo file with
stopper

Trim the cast

 Assess bone density ??

 Bone density  CADIA  Kodak densitometric software

 Primary implant stability

Initial stability that is achieved at surgery

Prerequisite for implant survival

Prevents the formation of a connective tissue

layer between implant and bone, thus
ensuring bone healing

• Branemark et al. 1977; Adell et al. 1981; Albrektsson et

al. 1981; Meredith 1998; LioubavinaHack et al. 2006
 Prosthetic Options

Depending On The Treatment Options (Misch in 1989 )

 FP- 1: replaces only the crown; looks like a natural tooth.

 FP- 2: replaces the crown and a portion of the root; crown contour
appears normal in the occlusal half but is elongated or hypercontoured
in the gingival half.

 FP- 3: replaces missing crowns and gingival color and portion of the
edentulous site; prosthesis most often uses denture teeth and acrylic,
but may be made of porcelain, or metal.

 RP-4: overdenture supported completely by implant.

 RP-5: overdenture supported by both soft tissue and implant.
 Success of implants…criteria
Ideal clinical conditions for natural teeth include many factors, several of
which apply to dental implants:
 • Absence of pain is a primary implant criterion of evaluation
• Presence of pain almost always requires removal of the
PAIN implant, even in the absence of mobility

• Rigid fixation indicates an absence of clinical mobility of an

implant under 1 to 500 g vertical or horizontal forces.
MOBILITY
• Implants with less than 0.5 mm horizontal movement may
return to rigid fixation and zero mobility

• Stable rigid fixated implants have reported pocket depths of 2

to 6 mm
PROBING • Partially edentulous patients have consistently greater
DEPTH probing-depths around implants than around teeth
 • Most common sulcus bleeding gingival index used for
PAPILLA implants is the Loe and Silness gingival index
BLEEDING
INDEX

• Initial bone loss around implant during the first few years 
BONE result of excessive stress at the crestal implant-bone interface
LOSS

• Stress factors such as occlusal forces, parafunction should be

evaluated and reduced when initial bone loss is observed.
Literature…..
 Conclusion

 The increasing number of malpractice lawsuits means a thorough

evaluation of patient history and an awareness of the risk of
treatment failure and complications is required as implant
treatment outcomes are not as predictable as that of the
conventional therapies with fixed (FDP) or removable dental
prostheses (RDP), particularly in circumstances where aesthetic
considerations are the overriding concern.
 The application of a systematic patient assessment and a
straightforward diagnostic planning procedure facilitates an
optimal treatment recommendation and helps to avoid failures
and complications.
 References

 Carranza’s clinical periodontology: 10th Ed.

 Clinical periodontology and implant dentistry: Jan Lindhe-
4th Ed.
 Contemporary implant dentistry: Carl E Misch.
 Misch CE, Misch FD. Diagnostic casts, preimplant
prosthodontics, treatment prosthesis surgical templates In
Dental Implant Prosthetics. Mosby; 2005.
 Bjarni E. Pjetursson et al. Improvements in Implant
Dentistry over the Last Decade: Comparison of Survival
and Complication Rates in Older and Newer Publications.
Int J Oral Maxillofac Implants 2014;29(suppl):308–324.
 Perio 2000 vol 66;2014
 Pjetursson BE, Bragger U, Lang NP, Zwahlen M.
Comparison of survival and complication rates of tooth
supported fixed dental prostheses (FDPs) and implant
supported FDPs and single crowns (SCs).Clin. Oral Impl.
Res. 18 (Suppl. 3), 2007; 97–113.
 Ranya Faraj Elemam and Iain Pretty. Comparison of the
Success Rate of Endodontic Treatment and Implant
Treatment. ISRN Dentistry Volume 2011.