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Dental implant

A dental implant (also known as an endosseous im- 15 year lifespans for the prosthetic teeth.[4]
plant or xture) is a surgical component that interfaces
with the bone of the jaw or skull to support a dental
prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor. The basis 1 Medical uses
for modern dental implants is a biologic process called
osseointegration where materials, such as titanium, form Common uses of dental implants
an intimate bond to bone. The implant xture is rst
placed, so that it is likely to osseointegrate, then a dental
prosthetic is added. A variable amount of healing time
is required for osseointegration before either the dental
prosthetic (a tooth, bridge or denture) is attached to the
implant or an abutment is placed which will hold a dental
Individual teeth were replaced with implants where it is
prosthetic.
dicult to distinguish the real teeth from the prosthetic
Success or failure of implants depends on the health of the teeth.
person receiving it, drugs which impact the chances of osseointegration and the health of the tissues in the mouth.
The amount of stress that will be put on the implant and
xture during normal function is also evaluated. Planning the position and number of implants is key to the
long-term health of the prosthetic since biomechanical
forces created during chewing can be signicant. The position of implants is determined by the position and angle Movement in a lower denture can be decreased by
of adjacent teeth, lab simulations or by using computed implants with ball and socket retention.
tomography with CAD/CAM simulations and surgical
guides called stents. The prerequisites to long-term success of osseointegrated dental implants are healthy bone
and gingiva. Since both can atrophy after tooth extraction
pre-prosthetic procedures, such as sinus lifts or gingival
grafts, are sometimes required to recreate ideal bone and
gingiva.
The nal prosthetic can be either xed, where a person
cannot remove the denture or teeth from their mouth or
removable, where they can remove the prosthetic. In
each case an abutment is attached to the implant xture.
Where the prosthetic is xed, the crown, bridge or denture is xed to the abutment with either lag screws or
dental cement. Where the prosthetic is removable, a corresponding adapter is placed in the prosthetic so that the
two pieces can be secured together.

A bridge of teeth can be supported by two or more


implants.

The primary use of dental implants are to support


dental prosthetics. Modern dental implants make use of
osseointegration, the biologic process where bone fuses
tightly to the surface of specic materials such as titanium and some ceramics. The integration of implant
The risks and complications related to implant therapy and bone can support physical loads for decades without
[5](pp103107)
are divided into those that occur during surgery (such failure.
as excessive bleeding or nerve injury), those that occur For individual tooth replacement, an implant abutment
in the rst six months (such as infection and failure to is rst secured to the implant with an abutment screw.
osseointegrate) and those that occur long-term (such as A crown (the dental prosthesis) is then connected to the
peri-implantitis and mechanical failures). In the presence abutment with dental cement, a small screw, or fused with
of healthy tissues, a well integrated implant with appro- the abutment as one piece during fabrication.[6](pp211232)
priate biomechanical loads can have long term success Dental implants, in the same way, can also be used to rerates of 93 to 98 percent for the xture[1][2][3] and 10 to tain a multiple tooth dental prosthesis either in the form
1

of a xed bridge or removable dentures.


An implant supported bridge (or xed denture) is a group
of teeth secured to dental implants so the prosthetic cannot be removed by the user. Bridges typically connect to
more than one implant and may also connect to teeth as
anchor points. Typically the number of teeth will outnumber the anchor points with the teeth that are directly
over the implants referred to as abutments and those between abutments referred to as pontics. Implant supported bridges attach to implant abutments in the same
way as a single tooth implant replacement. A xed bridge
may replace as few as two teeth (also known as a xed partial denture) and may extend to replace an entire arch of
teeth (also known as a xed full denture). In both cases,
the prosthesis is said to be xed because it cannot be removed by the denture wearer.[6]

TECHNIQUE

2.1 Planning
Techniques used to plan implants

To help the surgeon position the implants a guide is made


(usually out of acrylic) to show the desired position and
angulation of the implants.

A removable implant supported denture (also an implant


supported overdenture[7](p31) ) is a type of dental prosthesis which is not permanently xed in place. The dental
prosthesis can be disconnected from the implant abutments with nger pressure by the wearer. To enable this,
the abutment is shaped as a small connector (a button, Sometimes the nal position and restoration of the teeth
ball, bar or magnet) which can be connected to analogous will be simulated on plaster models to help determine
adapters in the underside of the dental prosthesis. Facial the number and position of implants needed.
prosthetics, used to correct facial deformities (e.g. from
cancer treatment or injuries) can utilise connections to
implants placed in the facial bones.[8] Depending on the
situation the implant may be used to retain either a xed
or removable prosthetic that replaces part of the face.[9]
In orthodontics, small diameter dental implants, referred
to as Temporary Anchorage Devices (or TADs) can assist tooth movement by creating anchor points from which
forces can be generated.[10] For teeth to move, a force
must be applied to them in the direction of the desired
movement. The force stimulates cells in the periodontal
ligament to cause bone remodeling, removing bone in the
direction of travel of the tooth and adding it to the space
created. In order to generate a force on a tooth, an anchor
point (something that will not move) is needed. Since
implants do not have a periodontal ligament, and bone
remodelling will not be stimulated when tension is applied, they are ideal anchor points in orthodontics. Typically, implants designed for orthodontic movement are
small and do not fully osseointegrate, allowing easy removal following treatment.[11]

Technique

CT scans can be loaded to CAD/CAM software to create


a simulation of the desired treatment. Virtual implants
are then placed and a stent created on a 3D printer from
the data.

2.2 General considerations


Planning for dental implants focuses on the general health
condition of the patient, the local health condition of the
mucous membranes and the jaws and the shape, size, and
position of the bones of the jaws, adjacent and opposing teeth. There are few health conditions that absolutely
preclude placing implants although there are certain conditions that can increase the risk of failure. Those with
poor oral hygiene, heavy smokers and diabetics are all
at greater risk for a variant of gum disease that aects
implants called peri-implantitis, increasing the chance of
long-term failures. Long-term steroid use, osteoporosis
and other diseases that aect the bones can increase the
risk of early failure of implants.[6](p199)

2.5

2.3

Main surgical procedures

Bisphosphonate drugs

3
stent) prior to surgery which guides optimal positioning of
the implant. Increasingly, dentists opt to get a CT scan of
the jaws and any existing dentures, then plan the surgery
on CAD/CAM software. The stent can then be made
using stereolithography following computerized planning
of a case from the CT scan. The use of CT scanning in
complex cases also helps the surgeon identify and avoid
vital structures such as the inferior alveolar nerve and the
sinus.[17][18](p1199)

The use of bone building drugs, like bisphosphonates and


anti-RANKL drugs require special consideration with
implants, because they have been associated with a disorder called Bisphosphonate-associated osteonecrosis of
the jaw (BRONJ). The drugs change bone turnover,
which is thought to put people at risk for death of bone
when having minor oral surgery. At routine doses (for
example, those used to treat routine osteoporosis) the effects of the drugs linger for months or years but the risk
appears to be very low. Because of this duality, uncer- 2.5 Main surgical procedures
tainty exists in the dental community about how to best
manage the risk of BRONJ when placing implants. A
Basic implant surgical procedure
2009 position paper by the American Association of Oral
and Maxillofacial Surgeons, discussed that the risk of
BRONJ from low dose oral therapy (or slow release injectable) as between 0.01 and 0.06 percent for any procedure done on the jaws (implant, extraction, etc.). The
risk is higher with intravenous therapy, procedures on
the lower jaw, people with other medical issues, those
on steroids, those on more potent bisphosphonates and An area with a single missing tooth
people who have taken the drug for more than three
years. The position paper recommends against placing
implants in people who are taking high dose or high frequency intravenous therapy for cancer care. Otherwise,
implants can generally be placed[12] and the use of bisphosphonates does not appear to have an impact on implant survival.[13]
An incision is made across the gingiva, and the ap of
tissue is reected to show the bone of the jaw.

2.4

Biomechanical considerations

The long-term success of implants is determined, in part,


by the forces they have to support. As implants have no
periodontal ligament, there is no sensation of pressure
when biting so the forces created are higher. To oset this, the location of implants must distribute forces
evenly across the prosthetics they support.[14](pp1539)
Concentrated forces can result in fracture of the bridgework, implant components, or loss of bone adjacent the
implant.[15] The ultimate location of implants is based
on both biologic (bone type, vital structures, health) and
mechanical factors. Implants placed in thicker, stronger
bone like that found in the front part of the bottom jaw
have lower failure rates than implants placed in lower density bone, such as the back part of the upper jaw. People
who grind their teeth also increase the force on implants
and increase the likelihood of failures.[6](p201208)

Once the bone is exposed, a series of drills create and


gradually enlarge a site (called an osteotomy) for the
implant to be placed.

The implant xture is turned into the osteotomy. Ideally,


it is completely covered by bone and has no movement
The design of implants, has to account for a lifetime within the bone.
of real-world use in a persons mouth. Regulators and
the dental implant industry have created a series of tests
to determine the long-term mechanical reliability of implants in a persons mouth where the implant is struck
repeatedly with increasing forces (similar in magnitude
to biting) until it fails.[16]
When a more exacting plan is needed beyond clinical A healing abutment is attached to the implant xture, and
judgment, the dentist will make an acrylic guide (called a the ap of gingiva is sutured around the healing abutment.

TECHNIQUE

3. Late implantation (three months or more after tooth


extraction).
2.5.1

Placing the implant

There are also various options for when to attach teeth to


[21]
Most implant systems have ve basic steps for placement dental implants, classied into:
of each implant:[6](pp214221)
1. Immediate loading procedure.
1. Soft tissue reection: An incision is made over the
2. Early loading (one week to twelve weeks).
crest of bone, splitting the thicker attached gingiva
roughly in half so that the nal implant will have a
3. Delayed loading (over three months)
thick band of tissue around it. The edges of tissue,
each referred to as a ap are pushed back to expose
the bone. Flapless surgery is an alternate technique, 2.5.3 Healing time
where a small punch of tissue (the diameter of the
implant) is removed for implant placement rather For an implant to become permanently stable, the
than raising aps.
body must grow bone to the surface of the implant
2. Drilling at high speed: After reecting the soft tis- (osseointegration). Based on this biologic process, it was
sue, and using a surgical guide or stent as neces- thought that loading an implant during the osseointegrasary, pilot holes are placed with precision drills at tion period would result in movement that would prevent
highly regulated speed to prevent burning or pres- osseointegration, and thus increase implant failure rates.
As a result, three to six months of integrating time (desure necrosis of the bone.
pending on various factors) was allowed before placing
3. Drilling at low speed: The pilot hole is expanded by the teeth on implants (restoring them).[6]
using progressively wider drills (typically between However, later research suggests that the initial stability
three and seven successive drilling steps, depend- of the implant in bone is a more important determinant of
ing on implant width and length). Care is taken success of implant integration, rather than a certain penot to damage the osteoblast or bone cells by over- riod of healing time. As a result, the time allowed to heal
heating. A cooling saline or water spray keeps the is typically based on the density of bone the implant is
temperature low.
placed in and the number of implants splinted together,
4. Placement of the implant: The implant screw is
placed and can be self-tapping,[18](pp100102) otherwise the prepared site is tapped with an implant
analog. It is then screwed into place with a torque
controlled wrench[19] at a precise torque so as not
to overload the surrounding bone (overloaded bone
can die, a condition called osteonecrosis, which may
lead to failure of the implant to fully integrate or
bond with the jawbone).

rather than a uniform amount of time. When implants


can withstand high torque (35 Ncm) and are splinted to
other implants, there are no meaningful dierences in
long-term implant survival or bone loss between implants
loaded immediately, at three months, or at six months.[21]
The corollary is that single implants, even in solid bone,
require a period of no-load to minimize the risk of initial
failure.[22]

5. Tissue adaptation: The gingiva is adapted around


the entire implant to provide a thick band of healthy
tissue around the healing abutment. In contrast, an
implant can be buried, where the top of the implant is sealed with a cover screw and the tissue is
closed to completely cover it. A second procedure
would then be required to uncover the implant at a
later date.

2.5.4 One-stage, two-stage surgery

2.5.2

Timing of implants after extraction of teeth

After an implant is placed, the internal components are


covered with either a healing abutment, or a cover screw.
A healing abutment passes through the mucosa, and the
surrounding mucosa is adapted around it. A cover screw
is ush with the surface of the dental implant, and is designed to be completely covered by mucosa. After an
integration period, a second surgery is required to reect
the mucosa and place a healing abutment.[23](pp1901)

In the early stages of implant development (19701990),


There are dierent approaches to placement dental im- implant systems used a two-stage approach, believing that
it improved the odds of initial implant survival. Subseplants after tooth extraction.[20] The approaches are:
quent research suggests that no dierence in implant survival existed between one-stage and two-stage surgeries,
1. Immediate post-extraction implant placement.
and the choice of whether or not to bury the implant in
2. Delayed immediate post-extraction implant place- the rst stage of surgery became a concern of soft tissue
ment (two weeks to three months after extraction). (gingiva) management[24]

2.6

Additional surgical procedures

When tissue is decient or mutilated by the loss of teeth,


implants are placed and allowed to osseointegrate, then
the gingiva is surgically moved around the healing abutments. The down-side of a two-stage technique is the
need for additional surgery and compromise of circulation to the tissue due to repeated surgeries.[25](pp912) The
choice of one or two-stages, now centers around how best
to reconstruct the soft tissues around lost teeth.

2.5.5

height of bone.
For an implant to osseointegrate, it needs to be surrounded by a healthy quantity of bone. In order for it
to survive long-term, it needs to have a thick healthy soft
tissue (gingiva) envelope around it. It is common for either the bone or soft tissue to be so decient that the surgeon needs to reconstruct it either before or during implant placement.[18](p1084)

Immediate placement

An increasingly common strategy to preserve bone and


reduce treatment times includes the placement of a dental implant into a recent extraction site. On the one
hand, it shortens treatment time and can improve esthetics because the soft tissue envelope is preserved. On the
other hand, implants may have a slightly higher rate of
initial failure. Conclusions on this topic are dicult to
draw, however, because few studies have compared immediate and delayed implants in a scientically rigorous
manner.[20]

2.6

Additional surgical procedures

Hard tissue reconstruction

2.6.1 Hard tissue (bone) reconstruction


Main articles: Sinus lift and Bone grafting
Bone grafting is necessary when there is a lack of bone.
While there are always new implant types, such as short
implants, and techniques to allow compromise, a general
treatment goal is to have a minimum of 10 mm in bone
height, and 6 mm in width. Alternatively, bone defects
are graded from A to D (A=10+ mm of bone, B=79
mm, C=46 mm and D=03 mm) where an implants
likelihood of osseointegrating is related to the grade of
bone.[26](p250)
To achieve an adequate width and height of bone, various
bone grafting techniques have been developed. The most
frequently used is called guided bone graft augmentation
where a defect is lled with either natural (harvested or
autograft) bone or allograft (donor bone or synthetic bone
substitute), covered with a semi-permeable membrane
and allowed to heal. During the healing phase, natural
bone replaces the graft forming a new bony base for the
implant.[23]:223

If bone width is inadequate it can be regrown using either Three common procedures are:[26](p236)
articial or cadevaric bone pieces to act as a scaold for
natural bone to grow around.
1. The sinus lift
2. Lateral alveolar augmentation (increase in the width
of a site)
3. Vertical alveolar augmentation (increase in the
height of a site)
When a greater amount of bone is needed, it can be taken
Other, more invasive procedures, also exist for larger
from another site (commonly the back of the bottom
bone defects including mobilization of the inferior alvejaw) and transplanted to the implant site.
olar nerve to allow placement of a xture, onlay bone
grafting using the iliac crest or another large source of
bone and microvascular bone graft where the blood supply to the bone is transplanted with the source bone and
reconnected to the local blood supply.[14](pp56) The nal
decision about which bone grafting technique that is best
is based on an assessment of the degree of vertical and
The maxillary sinus can limit the amount of bone height horizontal bone loss that exists, each of which is classiin the back of the upper jaw. With a sinus lift, bone ed into mild (23 mm loss), moderate (46 mm loss) or
can be grafted under the sinus membrane increasing the severe (greater than 6 mm loss).[27](p17)

6
2.6.2

3
Soft tissue (gingiva) reconstruction

RECOVERY

3 Recovery

Main articles: Gingival graft and Subepithelial connective tissue graft


Soft tissue reconstruction

When mucosa is missing, a free gingival graft of soft


tissue can be transplanted to the area.

When the metal of an implant becomes visible a con- The steps taken to secure dental crowns on the implant xture
nective tissue graft can be used to improve the mucosal including placement of the abutment and crown
height.
The prosthetic phase begins once the implant is well inThe gingiva surrounding a tooth has a 23 mm band of tegrated (or has a reasonable assurance that it will intebright pink, very strong attached mucosa, then a darker, grate) and an abutment is in place to bring it through the
larger area of unattached mucosa that folds into the mucosa. Even in the event of early loading (less than 3
cheeks. When replacing a tooth with an implant, a band months), many practitioners will place temporary teeth
of strong, attached gingiva is needed to keep the implant until osseointegration is conrmed. The prosthetic phase
healthy in the long-term. This is especially important of restoring an implant requires an equal amount of techwith implants because the blood supply is more precar- nical expertise as the surgical because of the biomechanious in the gingiva surrounding an implant, and is theo- ical considerations, especially when multiple teeth are to
retically more susceptible to injury because of a longer at- be restored. The dentist will work to restore the vertical
tachment to the implant than on a tooth (a longer biologic dimension of occlusion, the esthetics of the smile, and
the structural integrity of the teeth to evenly distribute
width).[28](pp629633)
the forces of the implants.[6](pp241251)
When an adequate band of attached tissue is absent, it
can be recreated with a soft tissue graft. There are four Prosthetic procedures for single teeth, bridges and
xed dentures
methods that can be used to transplant soft tissue. A roll
of tissue adjacent to an implant (referred to as a palatal An abutment is selected depending on the application.
roll) can be moved towards the lip (buccal), gingiva from In many single crown and xed partial denture scenarios
the palate can be transplanted, deeper connective tissue (bridgework), custom abutments are used. An impression
from the palate can be tranplanted or, when a larger piece of the top of the implant is made with the adjacent teeth
of tissue is needed, a nger of tissue based on a blood and gingiva. A dental lab then simultaneously fabricates
vessel in the palate (called a vascularized interpositional an abutment and crown. The abutment is seated on the
periosteal-connective tissue (VIP-CT) ap) can be repo- implant, a screw passes through the abutment to secure it
sitioned to the area.[25](pp113188)
to an internal thread on the implant (lag-screw). There are
Additionally, for an implant to look esthetic, a band of variations on this, such as when the abutment and implant
full, plump gingiva is needed to ll in the space on ei- body are one piece or when a stock (prefabricated) abutther side of implant. The most common soft tissue com- ment is used. Custom abutments can be made by hand,
or zirplication is called a black-triangle, where the papilla (the as a cast metal piece or custom milled from metal
[18](p1233)
conia,
all
of
which
have
similar
success
rates.
small triangular piece of tissue between two teeth) shrinks
back and leaves a triangular void between the implant and
the adjacent teeth. Dentists can only expect 24 mm of
papilla height over the underlying bone. A black triangle
can be expected if the distance between where the teeth
touch and bone is any greater.[18](pp8184)

The platform between the implant and the abutment can


be at (buttress) or conical t. In conical t abutments,
the collar of the abutment sits inside the implant which
allows a stronger junction between implant and abutment
and a better seal against bacteria into the implant body.

3.2

Maintenance

To improve the gingival seal around the abutment collar,


a narrowed collar on the abutment is used, referred to as
platform switching. The combination of conical ts and
platform switching gives marginally better long term periodontal conditions compared to at-top abutments.[29]
Regardless of the abutment material or technique, an impression of the abutment is then taken and a crown secured to the abutment with dental cement. Another variation on abutment/crown model is when the crown and
abutment are one piece and the lag-screw traverses both
to secure the one-piece structure to the internal thread
on the implant. There does not appear to be any benet, in terms of success, for cement versus screw-retained
prosthetics, although the latter is believed to be easier to
maintain (and change when the prosthetic fractures) and
the former oers high esthetic performance.[18](p1233)

3.1

7
Alternatively, stock abutments are used to retain dentures
using a male-adapter attached to the implant and a female
adapter in the denture. Two common types of adapters
are the ball-and-socket style retainer and the button-style
adapter. These types of stock abutments allow movement
of the denture, but enough retention to improve the quality of life for denture wearers, compared to conventional
dentures.[31] Regardless of the type of adapter, the female
portion of the adapter that is housed in the denture will
require periodic replacement, however the number and
adapter type does not seem to impact patient satisfaction
with the prosthetic for various removable alternatives.[32]

3.2 Maintenance
After placement, implants need to be cleaned (similar

Prosthetic procedures for removable to natural teeth) with a Teon instrument to remove any
dentures
plaque. Because of the more precarious blood supply to

the gingiva, care should be taken with dental oss. Implants will lose bone at a rate similar to natural teeth in
the mouth (e.g. if someone suers from periodontal disease, an implant can be aected by a similar disorder)
but will otherwise last. The porcelain on crowns should
be expected to discolour, fracture or require repair approximately every ten years, although there is signicant
variation in the service life of dental crowns based on the
A cast bar of metal is secured to the implants. The com- position in the mouth, the forces being applied from opplete denture then attaches to the bar with semiprecision posing teeth and the restoration material. Where implants
are used to retain a complete denture, depending on the
attachments allowing no movement of the denture.
type of attachment, connections need to be changed or
refreshed every one to two years.[14](p76) A powered irrigator may also be useful for cleaning around implants.[33]
Overdentures

Ball and socket type attachments can be placed on


implants and dentures to prevent most movement.

4 Risks and complications

When a removable denture is worn, retainers to hold the


denture in place can be either custom made or o-theshelf (stock) abutments. When custom retainers are
used, four or more implant xtures are placed and an impression of the implants is taken and a dental lab creates a custom metal bar with attachments to hold the
denture in place. Signicant retention can be created
with multiple attachments and the use of semi-precision
attachments (such as a small diameter pin that pushes
through the denture and into the bar) which allows for
little or no movement in the denture, but it remains
removable.[7](pp3334) However, the same four implants
angled in such a way to distribute occlusal forces may be
able to safely hold a xed denture in place with comparable costs and number of procedures giving the denture
wearer a xed solution.[30]

4.1 During surgery


Placement of dental implants is a surgical procedure and
carries the normal risks of surgery including infection, excessive bleeding and necrosis of the ap of tissue around
the implant. Nearby anatomic structures, such as the
inferior alveolar nerve, the maxillary sinus and blood vessels, can also be injured when the osteotomy is created or
the implant placed.[34] Even when the lining of the maxillary sinus is perforated by an implant, long term sinusitis
is rare.[35] An inability to place the implant in bone to
provide stability of the implant (referred to as primary
stability of the implant) increases the risk of failure to
osseointegration.[14](p68)
Implant complications

Bone loss (peri-implantitis) on implants over 7 years in a


heavy smoker

4 RISKS AND COMPLICATIONS

Dental cement under the gingiva causes peri-implantitis


and implant failure.

4.2 First six months


4.2.1 primary implant stability
Primary implant stability refers to the stability of a dental
implant immediately after implantation. Its value is deRecession of the gingiva leads to exposure of the metal rived from a mechanical engraving of the titanium screw
abutment under a dental crown.
implant in the patients bone tissue. High initial stabilization may be an indication for immediate loading with
prosthetic reconstruction.
The value of primary implant stabilization decreases
gradually with reconstruction of bone tissue around the
implant in the rst weeks after surgery, ceding to secBlack triangles caused by bone loss between implants ondary stability. Its character is quite dierent from the
and natural teeth
initial stabilization, because it results from the ongoing
process of osseointegration. When the healing process is
complete, the initial mechanical stability is fully replaced
by biological stability. The most dangerous moment for
implantation success is the moment of the lowest initial
stabilization, pending sucient bone reconstruction supporting long-term maintenance of the implant. Usually
this occurs during the 34 weeks after implantation. If
primary stability was not high enough following implantation, the implants mobility is high and can cause failure.
Fracture of an implant and abutment screw is a catastrophic failure and the xture cannot be salvaged.
4.2.2 Immediate post-operative risks
1. Infection (pre-op antibiotics reduce the risk of implant failure by 33 percent but have no impact on the
risk of infection)[36]
2. Excessive bleeding[14](p68)
Fracture of an abutment (all-zirconia) requires replacement of the abutment and crown.

3. Flap breakdown (less-than 5 percent)[14](p68)


4.2.3 Failure to integrate

An implant is tested between 8 and 24 weeks to determine if it is integrated. There is signicant variation in
the criteria used to determine implant success, the most
commonly cited criteria at the implant level are the abFracture of abutment screws (arrow) in 3 implants sence of pain, mobility, infection, gingival bleeding, rarequired removal of the remainder of the screw and diographic lucency or peri-implant bone loss greater than
replacement.
1.5 mm.[37]
Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the

4.3

Long term

patients oral hygiene, but the most important factor is


primary implant stability.[38] While there is signicant
variation in the rate that implants fail to integrate (due
to individual risk factors), the approximate values are 1
to 6 percent[14](p68)[21]

in cement-retained crowns compared to screw-retained


crowns overall.[40] In compound implants (two stage implants), between the actual implant and the superstructure (abutment) are gaps and cavities into which germs
can penetrate from the oral cavity. Later these germs will
Integration failure is rare in most cases, particularly if a return into the adjacent tissue and can cause periimplanthese implant interior spaces should
dentists or oral surgeons instructions are followed closely titis. As prophylaxis
[41]
be
sealed.
by the patient. Immediate loading implants may have a
higher rate of failure, potentially due to being loaded im- Criteria for the success of the implant supported dental
mediately after trauma or extraction, but the dierence prosthetic varies from study to study, but can be broadly
with proper care and maintenance is well within statistical classied into failures due to the implant, soft tissues or
variance for this type of procedure. More often, osseoin- prosthetic components or a lack of satisfaction on the
tegration failure occurs when a patient is either too un- part of the patient. The most commonly cited criteria
healthy to receive the implant or engages in behavior that for success are function of at least ve years in the abcontraindicates proper dental hygiene including smoking sence of pain, mobility, radiographic lucency and perior drug use.
implant bone loss of greater than 1.5 mm on the implant,
the lack of suppuration or bleeding in the soft tissues and
occurrence of technical complications/prosthetic mainte4.3 Long term
nance, adequate function, and esthetics in the prosthetic.
In addition, the patient should ideally be free of pain,
The long-term complications that result from restoring paraesthesia, able to chew and taste and be pleased with
teeth with implants relate, directly, to the risk factors of the esthetics.[37]
the patient and the technology. There are the risks associated with esthetics including a high smile line, poor The rates of complications vary by implant use and prosgingival quality and missing papillae, diculty in match- thetic type and are listed below:
ing the form of natural teeth that may have unequal points
of contact or uncommon shapes, bone that is missing, at- 4.3.1 Single crown implants (5-year)
rophied or otherwise shaped in an unsuitable manner, unrealistic expectations of the patient or poor oral hygiene.
1. Implant survival: 96.8 percent[42]
The risks can be related to biomechanical factors, where
2. Crown fracture: a) metal-ceramic: 95.4 percent, allthe geometry of the implants does not support the teeth
ceramic; 95.4 percent (cumulative rate of ceramic or
in the same way the natural teeth did such as when there
veneer fracture: 4.5 percent)[42]
are cantilevered extensions, fewer implants than roots or
teeth that are longer than the implants that support them
3. Peri-implantitis: 9.7 percent[42]
(a poor crown-to-root ratio). Similarly, grinding of the
teeth, lack of bone or low diameter implants increase the
4. Implant fracture: 0.14 percent[42]
biomechanical risk. Finally there are technological risks,
where the implants themselves can fail due to fracture
5. Screw or abutment loosening: 12.7 percent[42]
or a loss of retention to the teeth they are intended to
6. Abutment screw fracture: 0.35 percent[42]
support.[39](pp2751)
From these theoretical risks, derive the real world complications. Long-term failures are due to either loss of bone 4.3.2 Fixed complete dentures
around the tooth and/or gingiva due to peri-implantitis or
1. Progressive vertical bone loss but still in function
a mechanical failure of the implant. Because there is no
(Peri-implantitis): 8.5 percent[3]
dental enamel on an implant, it does not fail due to cavities
like natural teeth. While large-scale, long-term studies
2. Failure after the rst year 5 percent at ve years, 7
are scarce, several systematic reviews estimate the longpercent at ten years [3]
term (ve to ten years) survival of dental implants at 93
98 percent depending on their clinical use.[1][2][3] During
3. Incidence of veneer fracture at:
initial development of implant retained teeth, all crowns
5-year:
13.5[3] to 30.6
were attached to the teeth with screws, but more recent
[4]
percent,
advancements have allowed placement of crowns on the
10-year: 51.9 percent (32.3 to
abutments with dental cement (akin to placing a crown
75.5 percent with a condence
on a tooth). This has created the potential for cement,
interval at 95 percent)[4]
that escapes from under the crown during cementation
15-year: 66.6 percent (44.3 to
to get caught in the gingiva and create a peri-implantitis
86.4 percent with a condence
(see picture below). While the complication can occur,
interval at 95 percent)[4]
there does not appear to be any additional peri-implantitis

10

HISTORY

4. 10-year incidence of framework fracture: 6 percent


(2.6 to 9.3 percent with a condence interval at 95
percent)[4]
5. 10-year incidence of esthetic deciency: 6.1 percent
(2.4 to 9.7 percent with a condence interval at 95
percent)[4]
6. prosthetic screw loosening: 5 percent over ve
years[3] to 15 percent over ten years[4]
The most common complication being fracture or wear of
the tooth structure, especially beyond ten years[3][4] with
xed dental prostheses made of metal-ceramic having signicantly higher ten-year survival compared those made
of gold-acrylic.[3]
4.3.3

While studying bone cells in a rabbit tibia using a titanium chamber, Branemark was unable to remove it from bone. His realization that bone would adhere to titanium led to the concept of
osseointegration and the development of modern dental implants.
The original x-ray lm of the chamber embedded in the rabbit
tibia is shown (made available by Branemark).

Removable dentures (overdentures)

1. Loosening of removable denture retention:


percent[43]

33

2. Dentures needing to be relined or having a retentive


clip fracture: 16 to 19 percent[43]

History

Panoramic radiograph of historic dental implants, taken 1978

of a young Mayan woman, with three missing incisors replaced by pieces of shell, shaped to resemble teeth. Bone
growth around two of the implants, and the formation of
calculus, indicates that they were functional as well as esthetic. The fragment is currently part of the Osteological
Collection of the Peabody Museum of Archaeology and
Ethnology at Harvard University.[5][44]

Greenelds basket: one of the earliest examples of a successful


endosseous implant was Greenelds 1913 implant system

There is archeological evidence that humans have attempted to replace missing teeth with root form implants
for thousands of years. Remains from ancient China (dating 4000 years ago) have carved bamboo pegs, tapped
into the bone, to replace lost teeth, and 2000-year-old
remains from ancient Egypt have similarly shaped pegs
made of precious metals. Some Egyptian mummies were
found to have transplanted human teeth, and in other instances, teeth made of ivory.[5](p26)[44][45]
Wilson Popenoe and his wife in 1931, at a site in Honduras dating back to 600 AD, found the lower mandible

The early part of the 20th century saw a number of implants made of a variety of materials. One of the earliest
successful implants was the Greeneld implant system of
1913 (also known as the Greeneld crib or basket).[46]
Greenelds implant, an iridioplatinum implant attached
to a gold crown, showed evidence of osseointegration and
lasted for a number of years.[46] The rst use of titanium as an implantable material was by Bothe, Beaton
and Davenport in 1940, who observed how close the bone
grew to titanium screws, and the diculty they had in extracting them.[47] Bothe et al. were the rst researchers
to describe what would later be called osseointegration
(a name that would be marketed later on by Per-Ingvar
Brnemark). In 1951, Gottlieb Leventhal implanted titanium rods in rabbits.[48] Leventhals positive results led
him to believe that titanium represented the ideal metal
for surgery.[48]

11
In the 1950s research was being conducted at Cambridge
University in England on blood ow in living organisms. These workers devised a method of constructing a
chamber of titanium which was then embedded into the
soft tissue of the ears of rabbits. In 1952 the Swedish
orthopaedic surgeon, Per-Ingvar Brnemark, was interested in studying bone healing and regeneration. During
his research time at Lund University he adopted the Cambridge designed rabbit ear chamber for use in the rabbit femur. Following the study, he attempted to retrieve
these expensive chambers from the rabbits and found that
he was unable to remove them. Brnemark observed that
bone had grown into such close proximity with the titanium that it eectively adhered to the metal. Brnemark
carried out further studies into this phenomenon, using
both animal and human subjects, which all conrmed
this unique property of titanium. Leonard Linkow, in the
1950s, was one of the rst to inserted titanium and other
metal implants into the bones of the jaw. Articial teeth
were then attached to these pieces of metal.[49] In 1965
Brnemark placed his rst titanium dental implant into a
human volunteer. He began working in the mouth as it
was more accessible for continued observations and there
was a high rate of missing teeth in the general population
oered more subjects for widespread study. He termed
the clinically observed adherence of bone with titanium
as osseointegration.[28](p626)
Common types of implants

A standard 13 mm root form dental implant with pen


beside it for size comparison

A zygomatic implant is longer than standard implants


and used in people without adequate bone in the maxilla.
It secures to the cheek bone.

A small diameter implant is a single piece implant (no


abutment) that requires less bone.

Ultrashort Plateau Root Form (PRF) or nned dental


implants used in regions that would otherwise require a
sinus lift or bone graft.

An orthodontic implant is placed beside teeth to act as


an anchor point to which braces can be secured.
Since then implants have evolved into three basic types:
1. Root form implants; the most common type of implant indicated for all uses. Within the root form
type of implant, there are roughly 18 variants, all
made of titanium but with dierent shapes and surface textures. There is limited evidence showing
that implants with relatively smooth surfaces are less
prone to peri-implantitis than implants with rougher
surfaces and no evidence showing that any particular type of dental implant has superior long-term
success.[50]
2. Zygomatic implants; a long implant that can anchor
to the cheek bone by passing through the maxillary
sinus to retain a complete upper denture when bone
is absent. While zygomatic implants oer a novel
approach to severe bone loss in the upper jaw, it has
not been shown to oer any advantage over bone
grafting functionally although it may oer a less invasive option, depending on the size of the reconstruction required.[51]
3. Small diameter implants are implants of low diameter with one piece construction (implant and abutment) that are sometimes used for denture retention
or orthodontic anchorage.[10]
A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface.
The majority of dental implants are made out of commercially pure titanium, which is available in four grades
depending upon the amount of carbon, nitrogen, oxygen
and iron contained.[52] Cold work hardened CP4 (maximum impurity limits of N .05 percent, C .10 percent, H
.015 percent, Fe .50 percent, and O .40 percent) is the

12

REFERENCES

most commonly used titanium for implants. Grade 5 ti- [9] Arcuri MR (Apr 1995). Titanium implants in maxillofacial reconstruction. Otolaryngol Clin North Am 28 (2):
tanium, Titanium 6AL-4V, (signifying the titanium alloy
35163. PMID 7596615.
containing 6 percent aluminium and 4 percent vanadium
alloy) is slightly harder than CP4 and used in the industry
mostly for abutment screws and abutments.[53](pp284285) [10] Chen, Y.; Kyung, H. M.; Zhao, W. T.; Yu, W. J. (2009).
Critical factors for the success of orthodontic miniMost modern dental implants also have a textured surimplants: A systematic review. American Journal of Orface (through etching, anodic oxidation or various-media
thodontics and Dentofacial Orthopedics 135 (3): 284291.
blasting) to increase the surface area and osseointegration
doi:10.1016/j.ajodo.2007.08.017. PMID 19268825.
potential of the implant.[54](p55)
If C.P. titanium or a titanium alloy has more than [11] Lee, SL (2007). Applications of orthodontic mini implants.
Hanover Park, IL: Quintessence Publishing Co, Inc. pp.
85% titanium content it will form a titanium biocom111. ISBN 9780867154658.
patable titanium oxide surface layer or veneer that encloses the other metals preventing them from contacting [12] Ruggiero, S. L.; Dodson, T. B.; Assael, L. A.; Landesberg,
the bone.[55]
R.; Marx, R. E.; Mehrotra, B. (2009). American Asso-

References

[1] Papaspyridakos, P.; Mokti, M.; Chen, C. J.; Benic, G.


I.; Gallucci, G. O.; Chronopoulos, V (Jan 2013). Implant and Prosthodontic Survival Rates with Implant Fixed
Complete Dental Prostheses in the Edentulous Mandible
after at Least 5 Years: A Systematic Review. Clinical
Implant Dentistry and Related Research 11 (5): 705717.
doi:10.1111/cid.12036. PMID 23311617.
[2] Berglundh, T.; Persson, L.; Klinge, B. (2002). A systematic review of the incidence of biological and technical
complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. Journal of clinical periodontology 29 (Suppl 3): 197212.
doi:10.1034/j.1600-051X.29.s3.12.x. PMID 12787220.
[3] Pjetursson, B. E.; Thoma, D.; Jung, R.; Zwahlen, M.;
Zembic, A. (2012). A systematic review of the survival and complication rates of implant-supported xed
dental prostheses (FDPs) after a mean observation period
of at least 5 years. Clinical Oral Implants Research 23:
2238. doi:10.1111/j.1600-0501.2012.02546.x. PMID
23062125.
[4] Bozini, T.; Petridis, H.; Gares, K.; Gares, P. (2011).
A meta-analysis of prosthodontic complication rates of
implant-supported xed dental prostheses in edentulous
patients after an observation period of at least 5 years.
The International journal of oral & maxillofacial implants
26 (2): 304318.
[5] Misch, Carl E (2007). Contemporary Implant Dentistry.
St. Louis, Missouri: Mosby Elsevier.
[6] c Branemark, Per-Ingvar; Zarb, George (1989). Tissueintegrated prostheses (in English). Berlin, German:
Quintessence Books. ISBN 0867151293.
[7] Jokstad, Asbjorn, ed. (2009). Osseointegration and Dental Implants (in English). John Wiley & Sons. ISBN
9780813804743.
[8] Sinn, D. P., Bedrossian, E., Vest, A. K.; Bedrossian;
Vest (2011). Craniofacial Implant Surgery. Oral
and Maxillofacial Surgery Clinics of North America 23
(2): 321335. doi:10.1016/j.coms.2011.01.005. PMID
21492804.

ciation of Oral and Maxillofacial Surgeons Position Paper


on Bisphosphonate-Related Osteonecrosis of the Jaws
2009 Update. J Oral and Maxillofac Surg 67 (5): 212.
doi:10.1016/j.joms.2009.01.009. PMID 19371809.
[13] Kumar, M. N.; Honne, T. (2012). Survival of dental implants in bisphosphonate users versus non-users: A systematic review. The European journal of prosthodontics and restorative dentistry 20 (4): 159162. PMID
23495556.
[14] Branemark, Per-Ingvar Worthington, Philip, ed (1992).
Advanced osseointegration surgery: applications in the
maxillofacial region (in english). Carol Stream, Illinois:
Quintessence Books. ISBN 0867152427.
[15] Pallaci, Patrick (1995). Optimal implant positioning and
soft tissue management for the Branemark system (in english). Germany: Quintessence Books. pp. 2133. ISBN
0867153083.
[16] Guidance for Industry and FDA Sta - Class II Special
Controls Guidance Document: Root-form Endosseous
Dental Implants and Endosseous Dental Abutments.
FDA. 2004-05-12. Retrieved 2013-11-11.
[17] Spector, L (2008). Computer-Aided Dental Implant
Planning. Dental Clinics of N Amer 52 (4): 761775.
doi:10.1016/j.cden.2008.05.004. PMID 18805228.
[18] Lindhe, Jan; Lang, Niklaus P; Karring, Thorkild, eds.
(2008). Clinical Periodontology and Implant Dentistry 5th
edition (in English). Oxford, UK: Blackwell Munksgaard.
ISBN 9781405160995.
[19] McCracken, Michael S.; Mitchell, Lillian; Hegde,
Rashmi; Mavalli, Mahendra D. (2010). Variability of
Mechanical Torque-Limiting Devices in Clinical Service
at a US Dental School. Journal of Prosthodontics 19 (1):
2024. doi:10.1111/j.1532-849X.2009.00524.x. ISSN
1059-941X. PMID 19765196.
[20] Esposito, M.; Grusovin, M. G.; Polyzos, I. P.; Felice,
P.; Worthington, H. V. (2010). Timing of implant
placement after tooth extraction: Immediate, immediatedelayed or delayed implants? A Cochrane systematic review (PDF). European journal of oral implantology 3 (3):
189205. PMID 20847990.

13

[21] Esposito, M.; Grusovin, M. G.; Maghaireh, H.; Worthington, H. V. (2013). Interventions for replacing missing
teeth: Dierent times for loading dental implants. The
Cochrane database of systematic reviews 3 (CD003878):
doi:10.1002/14651858.CD003878.pub5.
CD003878.
PMID 23543525.
[22] Atieh, M. A.; Atieh, A. H.; Payne, A. G.; Duncan, W. J.
(2009). Immediate loading with single implant crowns:
A systematic review and meta-analysis. The International
journal of prosthodontics 22 (4): 378387.
[23] Peterson, LJ. Miloro, M (2004). Petersons Principles
of Oral and Maxillofacial Surgery, 2nd Edition. PMPHUSA.
[24] Esposito, M.; Grusovin, M. G.; Chew, Y. S.; Coulthard,
P.; Worthington, H. V. (2009). One-stage versus twostage implant placement. A Cochrane systematic review
of randomised controlled clinical trials. European journal of oral implantology 2 (2): 9199.
[25] Sclar, Anthony (2003). Soft tissue and esthetic considerations in implant dentistry (in english). Carol Stream, IL:
Quintessence Books. ISBN 0867153547.
[26] Buser, Daniel; Schenk, Robert K (1994). Guided bone
regeneration in implant dentistry (in english). Hong Kong:
Quintessence Books. ISBN 0867152494.
[27] Laskin, Daniel (2007). Decision making in oral and maxillofacial surgery. Chicago, IL: Quintessence Pub. Co.
ISBN 9780867154634.
[28] Newman, Michael; Takei, Henry; Klokkevold, Perry,
eds. (2012). Carranzas Clinical Periodontology (in English). St. Louis, Missouri: Elsevier Saunders. ISBN
9781437704167.
[29] Atieh, M. A.; Ibrahim, H. M.; Atieh, A. H. (2010).
Platform Switching for Marginal Bone Preservation
Around Dental Implants: A Systematic Review and MetaAnalysis. Journal of Periodontology 81 (10): 135066.
doi:10.1902/jop.2010.100232. PMID 20575657.
[30] Patzelt, S. B. M.; Bahat, O.; Reynolds, M. A.; Strub, J.
R. (2013). The All-on-Four Treatment Concept: A Systematic Review. Clinical Implant Dentistry and Related
Research 16: 836855. doi:10.1111/cid.12068. PMID
23560986.
[31] Assuno, W. G. A.; Baro, V. A. R.; Delben, J. A.;
Gomes, . A.; Tabata, L. F. (2009). A comparison of patient satisfaction between treatment with conventional complete dentures and overdentures in the elderly: A literature review. Gerodontology 27 (2): 154
162. doi:10.1111/j.1741-2358.2009.00299.x. PMID
19467020.
[32] Lee, J. Y.; Kim, H. Y.; Shin, S. W.; Bryant, S.
Number of implants for mandibular
R. (2012).
implant overdentures: A systematic review.
The
Journal of Advanced Prosthodontics 4 (4): 2049.
doi:10.4047/jap.2012.4.4.204. PMC 3517958. PMID
23236572.
[33] Susan Wingrove. Focus on implant home care Before,
during, and after restoration. RDH MAGAZINE 33 (9).

[34] Greenstein G, Cavallaro J, Romanos G, Tarnow D. (Aug


2008). Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry: a review.. J Periodontol 79 (8): 131729.
doi:10.1902/jop.2008.070067.
[35] Ferguson, M (May 23, 2014). Rhinosinusitis in oral
medicine and dentistry.. Australian dental journal 59 (3):
28995. doi:10.1111/adj.12193. PMID 24861778.
[36] Esposito, M.; Grusovin, M. G.; Talati, M.; Coulthard,
P.; Oliver, R.; Worthington, H. V. (2008). Interventions for replacing missing teeth: antibiotics at
dental implant placement to prevent complications..
Cochrane Database of Systematic Reviews 3 (CD004152):
doi:10.1002/14651858.CD004152.pub2.
CD004152.
PMID 18646101.
[37] Papaspyridakos, P.; Chen, C. - J.; Singh, M.; Weber, H. - P.; Gallucci, G. O. (2011).
Success Criteria in Implant Dentistry: A Systematic Review. Journal of Dental Research 91 (3): 242248.
doi:10.1177/0022034511431252. PMID 22157097.
[38] Javed, F.; Romanos, G. E. (2010). The role of primary stability for successful immediate loading of dental
implants. A literature review. Journal of Dentistry 38
(8): 612620. doi:10.1016/j.jdent.2010.05.013. PMID
20546821.
[39] Renouard, Frank (1999). Risk Factors in Implant Dentistry: Simplied Clinical Analysis for Predictable Treatment. Paris, France: Quintessence International. ISBN
0867153555.
[40] De Brando, M. L.; Vettore, M. V.; Vidigal Jnior,
G. M. (2013). Peri-implant bone loss in cement- and
screw-retained prostheses: Systematic review and metaanalysis. Journal of Clinical Periodontology 40 (3): 287
295. doi:10.1111/jcpe.12041. PMID 23297703.
[41] Fritzemeier, C. U., W. Schmdderich: Periimplantitisprophylaxe durch Versiegelung der Implantatinnenrume, Implantologie 2007;15(1):71-80
[42] Jung, R. E.; Pjetursson, B. E.; Glauser, R.; Zembic,
A.; Zwahlen, M.; Lang, N. P. (2008). A systematic review of the 5-year survival and complication rates
of implant-supported single crowns. Clinical Oral Implants Research 19 (2): 119130. doi:10.1111/j.16000501.2007.01453.x. PMID 18067597.
[43] Goodacre, C. J.; Bernal, G.; Rungcharassaeng, K.; Kan, J.
Y. K. (2003). Clinical complications with implants and
implant prostheses. The Journal of Prosthetic Dentistry
90 (2): 121132. doi:10.1016/S0022-3913(03)00212-9.
PMID 12886205.
[44] Balaji, S. M. (2007). Textbook of Oral and Maxillofacial
Surgery. New Delhi: Elsevier India. pp. 301302. ISBN
9788131203002.
[45] Anusavice, Kenneth J. (2003). Phillips Science of Dental
Materials. St. Louis, Missouri: Saunders Elsevier. p. 6.
ISBN 978-0-7020-2903-5.
[46] Greeneld, E.J. (1913). Implantation of articial crown
and bridge abutments. Dental Cosmos 55: 364369.

14

7 SOURCES

[47] Bothe, R.T.; Beaton, K.E.; Davenport, H.A. (1940). Reaction of bone to multiple metallic implants. Surg Gynecol Obstet 71: 598602.
[48] Leventhal, Gottlieb S. (1951). Titanium, a metal for
surgery. J Bone Joint Surg Am 33A (2): 473474.
[49] Fraunhofer, J.A. von (2013). Dental materials at a glance
(Second edition. ed.). John Wiley & Sons. p. 115. ISBN
9781118646649.
[50] Esposito, M.; Murray-Curtis, L.; Grusovin, M. G.;
Coulthard, P.; Worthington, H. V. (2007).
Interventions for replacing missing teeth:
dierent
types of dental implants.
Cochrane Database of
Systematic Reviews 4 (CD003815):
CD003815.
doi:10.1002/14651858.CD003815.pub3.
PMID
17943800.
[51] Esposito, M.; Worthington, H. V. (2013). Interventions for replacing missing teeth: dental implants in zygomatic bone for the rehabilitation of the severely decient
edentulous maxilla. Cochrane Database of Systematic
Reviews 9 (Cochrane Database of Systematic Reviews):
CD004151.
doi:10.1002/14651858.CD004151.pub3.
PMID 24009079.
[52] Arturo N. Natali (ed.) (2003). Dental Biomechanics.
Taylor & Francis, London / New York, 273 pp., ISBN
978-0-415-30666-9, pp. 69-87.
[53] Ferracane, Jack L. (2001). Materials in Dentistry: Principles and Applications (in English). Lippincott Williams &
Wilkins. ISBN 9780781727334.
[54] Reza, M (2007).
Nanomaterials and Nanosystems
for Biomedical Applications [Mozafari] (in English).
SpringerLink: Springer e-Books. ISBN 9781402062896.
[55] Guo, Cecilia Yan; Matinlinna, Jukka Pekka; Tang,
Alexander Tin Hong (2012).
Eects of Surface
Charges on Dental Implants: Past, Present, and Future. International Journal of Biomaterials 2012: 15.
doi:10.1155/2012/381535. ISSN 1687-8787.

Sources
c Branemark, Per-Ingvar; Zarb, George (1989).
Tissue-integrated prostheses (in English). Berlin,
German: Quintessence Books. ISBN 0867151293.
Branemark, Per-Ingvar Worthington, Philip, ed
(1992). Advanced osseointegration surgery: applications in the maxillofacial region (in english).
Carol Stream, Illinois: Quintessence Books. ISBN
0867152427.
Laskin, Daniel (2007). Decision making in oral and
maxillofacial surgery. Chicago, IL: Quintessence
Pub. Co. ISBN 9780867154634.
Lee, SL (2007). Applications of orthodontic mini
implants. Hanover Park, IL: Quintessence Publishing Co, Inc. pp. 111. ISBN 9780867154658.

Sclar, Anthony (2003). Soft tissue and esthetic


considerations in implant dentistry (in english).
Carol Stream, IL: Quintessence Books. ISBN
0867153547.
Buser, Daniel; Schenk, Robert K (1994). Guided
bone regeneration in implant dentistry (in english). Hong Kong: Quintessence Books. ISBN
0867152494.
Pallaci, Patrick (1995). Optimal implant positioning and soft tissue management for the Branemark
system (in english). Germany: Quintessence Books.
ISBN 0867153083.
Renouard, Frank (1999). Risk Factors in Implant Dentistry: Simplied Clinical Analysis for Predictable Treatment. Paris, France: Quintessence International. ISBN 0867153555.
Lindhe, Jan; Lang, Niklaus P; Karring, Thorkild,
eds. (2008). Clinical Periodontology and Implant
Dentistry 5th edition (in English). Oxford, UK:
Blackwell Munksgaard. ISBN 9781405160995.
Newman, Michael; Takei, Henry; Klokkevold,
Perry, eds. (2012). Carranzas Clinical Periodontology (in English). St. Louis, Missouri: Elsevier
Saunders. ISBN 9781437704167.

15

Text and image sources, contributors, and licenses

8.1

Text

Dental implant Source: https://en.wikipedia.org/wiki/Dental_implant?oldid=689017896 Contributors: Edward, Ronz, Netsnipe, Janko,


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Acroterion, Magioladitis, Bongwarrior, Diabetic monkey, JamesBWatson, Nyttend, Allstarecho, Mike Payne, Frotz, Bbowenjr, Yobol,
Poeloq, Nono64, Randyallain, Schjoy, Public Menace, Johnbod, AntiSpamBot, RenniePet, DMCer, Bonadea, Dentalvisit, TheNewPhobia,
Davecrosby uk, Funandtrvl, VolkovBot, Drellis, Dbjdmd, Yavor3423, TXiKiBoT, Alesnormales, Mselimy, Nos1nos2, Osseointegration,
Epgui, Drksvant, Doc James, Simbamford, Lrattner, Lativusgroupltd, VantheVandal, SieBot, Teresaduncan, Srobert, Flyer22 Reborn,
05, Fbotero, Srobert1944, Jwri7474, Stfg, Maxgmoses, Joedoedoe, Murry1, The sunder king, ClueBot, The Thing That Should
Not Be, Mweiner13, JOSEPOLIVA, Wutsje, Osseo, Niceguyedc, Ottawahitech, MartinSchweppe, P. S. Burton, Newagedental, Whoosis,
Getje1, Quarkfactor, Dramrzahran, Swervin15, Tnxman307, Ivan2.5, Mwinther, Thingg, Tn2si58c, Sucofocus, Bridies, Gnowor, Little Mountain 5, SilvonenBot, Thebestofall007, Addbot, Pyfan, Richard707, Mvasquez19, Jmagno, MrOllie, Debresser, Cgreen2, Lightbot, Luckas-bot, Yobot, Tohd8BohaithuGh1, Oral BioTech, Sgtangie95, AnomieBOT, Logicwhatelse, RobertGougalo, SearchEnginuity,
Jim1138, Bluerasberry, Materialscientist, Citation bot, LilHelpa, Luckyboy1965, Shivvy01, Xqbot, Jordiferrer, Transity, Jusufac, Millahnna, Adam1870, Markp1968, Tuvalisa22, Mandeepshukla, GrouchoBot, Abigor, 33rogers, MohsenUK, Smanoj24u, Implant Seminars,
Ian Furst, Deardoctormagazine, Webknight74, Clarekatz, Citation bot 1, Jellyjoke, Xavier Canals-Riera, Dr.josep.oliva, RobertSeviour,
Lightlowemon, Mercy11, No One of Consequence, Icdentist, Brooksby1, Yoshimacntosh, Djmdmd, Jlaurenson, DentalSchoolProfessor, EmausBot, John of Reading, Dolescum, T3dkjn89q00vl02Cxp1kqs3x7, NoisyJinx, Tariqbashirawan, K6ka, Drharpaz, Lucas Thoms,
Jwozni2, Haquedmd, Wikfr, SporkBot, Wayne Slam, Clifonte, Innovguide, Dental Implants, Drgulizio, Dds7777, Gerlachrm, Sessen,
Dave ashworth, Oraldr, ClueBot NG, Cyberservice, Tortora32310, Workreviews, Jjwozni2, Ashumann, Xenophonix, DentalSchoolProf,
Helpful Pixie Bot, Charlesdent, Eric Hahn, BG19bot, Mohamed CJ, AAEWeb, Fromthehill, Dailey78, MrBill3, Talvieno, Onedentalclinic,
Nimrodrai, BattyBot, Souljahdgw, Tvkyadav, ChrisGualtieri, Contident, Neerajpuri, Mogism, Eurodude99, Drharenpandya, Janine Rice,
Bea0118, Scipio235, Lornd Gergely, Marcela louis, Manuhemant, Megan90029, Lettwentyve, Faizan, Linguakappa, Gresta, Shsalmanshahid, Cho Stephen, DRWIKIFORMAL, LT910001, Comrade pem, Manul, JEMZ1995, Lizia7, Garmaa, Austin5string, Fractallyte,
Monkbot, Filedelinkerbot, Zadehdentistrydds, SilviuPopovici, FixtTeeth, Daniel Teigman, Blogsiva, Marshall4572, Zypcu, JonnyDepth,
Implant24, Friham, Sergio Traversa, Nishime~enwiki, Jlayerbear, Getreal1234, JakeFristoe, Charsa, KasparBot, Adert, Vector4 intl, Bnawnaw, Dain488 and Anonymous: 373

8.2

Images

File:Alloplastic_particulate_graft.jpg Source: https://upload.wikimedia.org/wikipedia/commons/9/94/Alloplastic_particulate_graft.


jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Autogenous_block_graft.jpg Source: https://upload.wikimedia.org/wikipedia/commons/2/29/Autogenous_block_graft.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Dental Specialty Group
File:Basicimplant_implantplacement.jpg
Source:
https://upload.wikimedia.org/wikipedia/commons/c/cd/Basicimplant_
implantplacement.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Basicimplant_preop_ridge.jpg Source: https://upload.wikimedia.org/wikipedia/commons/2/2c/Basicimplant_preop_ridge.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Basicimplant_ridge.jpg Source: https://upload.wikimedia.org/wikipedia/commons/c/ce/Basicimplant_ridge.jpg License: CC BYSA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Basicimplant_slowspeed.jpg Source: https://upload.wikimedia.org/wikipedia/commons/6/68/Basicimplant_slowspeed.jpg License:
CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Basicimplant_slowspeed2.jpg Source: https://upload.wikimedia.org/wikipedia/commons/9/9a/Basicimplant_slowspeed2.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Black_triangles_large.jpg Source: https://upload.wikimedia.org/wikipedia/commons/a/ac/Black_triangles_large.jpg License: CC
BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Branemark{}s_initial_radiograph.jpg Source: https://upload.wikimedia.org/wikipedia/commons/4/47/Branemark%27s_initial_
radiograph.jpg License: CC BY-SA 3.0 Contributors: Transferred from en.wikipedia to Commons. Original artist: Per-Ingvar Brnemark
File:CT_CADCAM_IMPLANTPLACEMENT.gif Source: https://upload.wikimedia.org/wikipedia/commons/a/ab/CT_CADCAM_
IMPLANTPLACEMENT.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Commons-logo.svg Source: https://upload.wikimedia.org/wikipedia/en/4/4a/Commons-logo.svg License: ? Contributors: ? Original
artist: ?
File:Connective_tissue_graft_to_implant.gif Source:
https://upload.wikimedia.org/wikipedia/commons/2/21/Connective_tissue_
graft_to_implant.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Dental-implant.gif Source: https://upload.wikimedia.org/wikipedia/commons/f/f3/Dental-implant.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]

16

8 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

File:Dental_setup_for_implants.jpg Source: https://upload.wikimedia.org/wikipedia/commons/2/2f/Dental_setup_for_implants.jpg


License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Dentalimplantstent.jpg Source: https://upload.wikimedia.org/wikipedia/commons/2/2f/Dentalimplantstent.jpg License: CC BYSA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Folder_Hexagonal_Icon.svg Source: https://upload.wikimedia.org/wikipedia/en/4/48/Folder_Hexagonal_Icon.svg License: Cc-bysa-3.0 Contributors: ? Original artist: ?
File:Fractured_abutment.gif Source: https://upload.wikimedia.org/wikipedia/commons/f/fa/Fractured_abutment.gif License: CC BYSA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Fractured_abutment_screws_3_implants.jpg Source:
https://upload.wikimedia.org/wikipedia/commons/3/31/Fractured_
abutment_screws_3_implants.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Fractured_implant.jpg Source: https://upload.wikimedia.org/wikipedia/commons/0/0e/Fractured_implant.jpg License: CC BYSA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Freegingivalgraft_socketpreservation.gif Source:
https://upload.wikimedia.org/wikipedia/commons/0/04/Freegingivalgraft_
socketpreservation.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Gingival_recession_on_an_implant.jpg Source: https://upload.wikimedia.org/wikipedia/commons/5/55/Gingival_recession_on_
an_implant.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Greenfield_implant.jpg Source: https://upload.wikimedia.org/wikipedia/commons/f/f9/Greenfield_implant.jpg License: Public
domain Contributors: Implantation of articial crown and bridge abutments Original artist: E.J. Greeneld
File:Implant-overdenture-4-implants-mandible.gif
Source:
https://upload.wikimedia.org/wikipedia/commons/4/4e/
Implant-overdenture-4-implants-mandible.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental
Specialty Group[1]
File:Implant_orthodontic_anchor_model.jpg Source: https://upload.wikimedia.org/wikipedia/commons/0/09/Implant_orthodontic_
anchor_model.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Implant_overdenture_model.jpg Source: https://upload.wikimedia.org/wikipedia/commons/2/24/Implant_overdenture_model.
jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Implant_overdenture_semipercision_bar.jpg
Source:
https://upload.wikimedia.org/wikipedia/commons/6/69/Implant_
overdenture_semipercision_bar.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty
Group;[1]
File:Implant_retained_bridge_model.jpg Source: https://upload.wikimedia.org/wikipedia/commons/5/55/Implant_retained_bridge_
model.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Mini_Dental_Implant_3M.jpg Source: https://upload.wikimedia.org/wikipedia/commons/e/e7/Mini_Dental_Implant_3M.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Roderick Dailey
File:Panoramic_radiograph_of_historic_dental_implants.jpg Source:
https://upload.wikimedia.org/wikipedia/commons/b/b3/
Panoramic_radiograph_of_historic_dental_implants.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Dentistxxx
File:Periimplantitis_due_to_dental_cement.gif Source: https://upload.wikimedia.org/wikipedia/commons/b/b0/Periimplantitis_due_
to_dental_cement.gif License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Periimplantitis_progression_over_5_years_in_heavy_smoker.gif Source: https://upload.wikimedia.org/wikipedia/commons/c/
c0/Periimplantitis_progression_over_5_years_in_heavy_smoker.gif License: CC BY-SA 3.0 Contributors: Own work Original artist:
Coronation Dental Specialty Group[1]
File:Portal-puzzle.svg Source: https://upload.wikimedia.org/wikipedia/en/f/fd/Portal-puzzle.svg License: Public domain Contributors: ?
Original artist: ?
File:Relative_size_of_implant.jpg Source: https://upload.wikimedia.org/wikipedia/commons/5/5b/Relative_size_of_implant.jpg License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
File:Sinus_lift.gif Source: https://upload.wikimedia.org/wikipedia/commons/a/a7/Sinus_lift.gif License: CC BY-SA 3.0 Contributors:
Own work Original artist: Coronation Dental Specialty Group
File:Three_Bicon_plateau_root_form_(finned)_implants.tif Source: https://upload.wikimedia.org/wikipedia/commons/5/55/Three_
Bicon_plateau_root_form_%28finned%29_implants.tif License: CC BY 4.0 Contributors: Own work Original artist: Jlayerbear
File:WhichTeethAreImplants.gif Source: https://upload.wikimedia.org/wikipedia/commons/7/79/WhichTeethAreImplants.gif License:
CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group
File:Wikibooks-logo.svg Source: https://upload.wikimedia.org/wikipedia/commons/f/fa/Wikibooks-logo.svg License: CC BY-SA 3.0
Contributors: Own work Original artist: User:Bastique, User:Ramac et al.
File:Zygomatic-implant.gif Source: https://upload.wikimedia.org/wikipedia/commons/1/1e/Zygomatic-implant.gif License: CC BY-SA
3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]

8.3

Content license

Creative Commons Attribution-Share Alike 3.0