OVERVIEW OF DENTAL

IMPLANTOLOGY


Dr. Deborah M. Ajayi
Consultant Restorative Dentistry,
University college Hospital,
Ibadan.
EDENTULOUS SPACES
INTRODUCTION.
Implantology is the science of implanting
foreign (alloplastic) materials to replace
endogenous (lost) organ functions with the
objective of tissue-friendly setting
(biointegration).

A Dental Implant is a device inserted into or on
the jaw bone to anchor an artificial tooth or
denture (prosthesis).

A root analog.

HISTORICAL BACKGROUND
Mayan civilization first used the earliest known endosseous
implant over 1400 years ago.
In 1931, Archaeologists from Honduras confirmed it.
In 1950, Researchers at Cambridge University implanted a
chamber of titanium in rabbits ear.
In 1952, Swedish Orthopaedic Surgeon I-P Branemark
implanted titanium rabbit femur.
In 1952, Dr. Leonard Linkow at the New York University
College of Dentistry placed his first dental implant.
In 1965, Branemark placed his 1
st
titanium dental implant.
1960s Sub-periosteal implants introduced.
1970s Blade implants was in vogue.


TYPES OF IMPLANT
1. Mucosal Insert

2. Endodontic Implant (Stabilizer)

3. Transosseous implant

4. Sub-periosteal implant

5. Endosteal or Endosseous implant


MUCOSAL INSERT

ENDODONTIC IMPLANT (STABILIZER)
Endodontic implants are
similar to prosthodontic
implants in many
respects.

However, they serve
another purposethe
stabilization and
preservation of
remaining natural teeth,
not the replacement of
lost teeth.

TRANSOSTEAL IMPLANTS
Placed through the
mandible (only)
Attachments reside
above ridge
Rarely used

SUBPERIOSTEAL IMPLANT
rests on alveolar ridge,
no bone invasion

Less invasive,

less stable

Supports denture

ENDOSSEOUS
3 types; plate/blade form,
ramus frame and the root
form-(Most common)
Placed in the bone
Single tooth or multiple
teeth replacement
Screwed or non screwed
Cylindrical or tapered
Surface treatment
Grit blasting, plasma
sprayed etc

ENDOSSEUS IMPLANT SYSTEMS
BRANEMARKS OSSEOINTEGRATION.
Prof Branemark
Root form implants
Improved the
designs &
techniques
Reports of success
rates from over 15
years experience.
Improved
understanding

OSSEOINTEGRATION
A direct structural and functional connection between ordered
living bone and the surface of a treated implant, which is visible
under the light-optical microscope. (Branemark 1952)

A time-dependant healing process where by clinically
asymptomatic rigid fixation of alloplastic materials is achieved,
and maintained, in bone during functional loading. (Zarb &
Albrektson,1991)


Relies on an understanding of
Tissue healing and repair
Tissue remodelling
Effects of force in all vectors
Immune response to the insertion of foreign bodies.
FACTORS AFFECTING OSSEOINTEGRATION
1. Implant biocompatibility
2. Implant design
3. Implant surface
4. Implant bed
5. Surgical technique
6. Loading condition
OUTCOME OF OSSEOINTEGRATION

Similar soft tissue relationship to natural
dentition(sulcular epithelium)
Hemidesmosome like structures connect
epithelium to titanium surface
Circumferential and perpendicular connective
tissue
No connective tissue insertion
No intervening sharpey fiber attachment
BONE-IMPLANT INTERFACE
Osteoblast is in close proximity to interface
Separated from implant by thin amorphous
proteoglycan layer
Oxide layer continues to grow- mineral ion
interaction
Increase in trabecular pattern
Bone deposition and remodeling in response
to stress.
IMPLANT MATERIAL.
Usually a metal or alloy which must be biocompatible,
strong and lightweight.
Most commonly used
Commercially pure titanium (CP titanium)
Lightweight, Biocompatible,Corrosion resistant,
Strong and low priced
Titanium-aluminum-vanadium alloy (Ti-6Al-4V)-
stronger and used with smaller diameter implants
Zirconium
Hydroxyapatite (HA), one type of calcium
phosphate ceramic material

ADVANTAGES OF DENTAL IMPLANT DISADVANTAGES OF DENTAL IMPLANT.
No preparation of adjacent
teeth.
Bone stabilization and
maintenance
Retrievability
Improvement of function
Psychological improvement
May be fixed or removable.
High level of predictability.
It can last for a life time.

Involves elective surgery.
High operator/technique
dependent.
High initial expense.
Lengthy treatment time.
Requires some moderate
maintenance.
Depends on the availability
of adequate bone quantity
and quality.
Challenging aesthetic

N
INDICATIONS OF DENTAL IMPLANTS CONTRAINDICATIONS
Good general health
Adequate bone quality and
volume
Appropriate occlusion and
jaw relations
Inability to wear
conventional prosthesis
Unfavourable
number/location of
abutment
Single tooth loss

Unrealistic patient expectations
Alcohol/drug dependence and
smoking
Parafunctional habits
Psychological factors
Inadequate ridge/inter-arch
dimensions
Immunosuppression
Diabetes (Uncontrolled)
Coronary artery Disease
Drug therapy: e.g Anticoagulants
Osteoporosis

APPLICATIONS OF DENTAL IMPLANT
Replacement of lost tooth teeth due to :
Trauma,(Avulsed tooth, fractured tooth,etc)
Dental disease (gross caries, endodontic failures,
periodontitis etc)
or developmental abnormalities(congenitally missing tooth,).
To overcome problems of free end saddle
Anchorage for orthodontic tooth
Single tooth replacement
Fixed multiple tooth loss- Implant retained
bridge prosthesis
Completely edentulous patients implant
retained removable dentures.


INITIAL EVALUATION OF THE PATIENT

Patient Education.
Treatment options
Multidisciplinary approach.
Long-term commitment
Surgical and Restorative procedures
Maintenance and regular recall
Fee and payment policy
The inform consent.
ASSESSMENT
General Health :
History : Dental, Medical, Social and Habit
Examination ;
Laboratory investigations
Predictable risks
DENTAL EVALUATION
Teeth
Periodontium
Radiographic analysis
Surgical analysis
Aesthetic analysis
Occlusal analysis

TEETH
Number and existing condition:
Minimum 6-7mm between teeth to facilitate implant
placement
>1.5mm between implant and natural teeth
7mm from centre of implant to centre of implant for
edentulous
More than 10mm mesiodistal space- single tooth
implant not recommended
Prognosis of remaining teeth
Tooth and root angulations and proximity
Mesiodistal width of the edentulous space
PERIODONTIUM AND BONE SUPPORT
According to Lekholm and Zarb.,1985 classified bone
quality as:
Type I
Composed of homogenous compact bone, usually found in the anterior
mandible
Type II
A thick layer of cortical bone surrounding dense trabecular bone,
usually found in the posterior mandible
Quality III
A thin layer of cortical bone surrounding dense trabecular bone,
normally found in the anterior maxilla but can also be seen in the
posterior mandible and the posterior maxilla.
Quality IV
A very thin layer of cortical bone surrounding a core of low-density
trabecular bone, It is very soft bone and normally found in the posterior
maxilla. It can also be seen in the anterior maxilla.

BONE QUANTITY FOR IMPLANT.
6mm or below buccal-lingual width with
sufficient tissue volume.
8mm interradicular bone width
10mm alveolar bone above IAN canal or
below maxillary sinus
MUCOGINGIVAL EVALUATION
There is need for sufficient tissue volume to
create gingival papilla
Need some attached gingiva to maintain
peri-implant sulcus
The implant is placed 2-3mm apical to free
gingival margin of adjacent tooth/teeth.

RADIOGRAPHIC ANALYSIS
Radiographs : periapical, occlusal, panoramic
and CT scan or tomograph as indicated.
CT gives more accurate and reliable
assessment of bone
Assess
Periapical pathology
Adequate vertical bone height
Adequate space above IAN or below the maxillary
sinus
Adequate interradicular area
Bone quality and quantity
AESTHETIC ANALYSIS

Smile line
Lip shape
Existing ridge
Restored implant
should appear to
emerge from the
gingiva
Produce a natural and
desirable appearance
OCCLUSAL ANALYSIS
Assess for
parafunctional habit:
tooth lost to occlusal
trauma or
parafunctional habit is
less successful with
implant
Diagnostic cast is
produced and
mounted to determine
opposing occlusion

IMPLANT TREATMENT
Implant surgery
Single stage
Two stages
Placement of Implant
Immediate
Standard
Delayed
Implant loading
Immediate
Delayed

STEPS INVOLVED IN IMPLANT SURGERY
SURGICAL PROCEDURE

Pre-operative medication
Local Anaesthetic with or without general
sedation
Analgesics, such as ibuprofen or
paracetamol can be administered
immediately prior to surgery.
Sterile environment should be maintained
throughout the surgery.
Chlorhexidine 0.2% is used as a pre-
operative mouthwash and skin preparation.

SURGICAL PROCEDURE CONT.
A mid-crestal incision with vertical relieving
incisions (if closed to adjacent teeth including
inter-dental papilla).

A mucoperiosteal flap is raised.

The flaps should be elevated sufficiently far
apically to reveal any bone concavities,
especially at sites where perforation might
occur.

I
EDENTULOUS JAW FOR IMPLANT MARKINGS FOR INCISION

.
MID CRESTAL INCISION MUCOPERIOSTEAL FLAP
BONE PREPARATION.
It is essential not to allow the bone to be heated
above 47C during preparation of the site as this
will cause bone cell death and prevent
osseointegration.

This problem may be avoided by:
Using sharp drills

Incremental drilling procedure with increasing
diameter drills

Avoidance of excessive speed

Using copious sterile normal saline irrigation.

Preparation
commence with Initial
penetration.
Pilot drill

guide pin is placed to
check the direction
Check the final depth
with a depth gauge
IMPLANT SPACING AND ANGULATION
Check the spacing and angulation of the
implant sites carefully with direction
indicators throughout the drilling sequence

Angulations of the implants should be
consistent with the design of the restorations
IMPLANT PLACEMENT
Implant should be placed such that;
It is within bone along its entire length.
It does not damage adjacent structures such as
teeth, nerves, nasal or sinus cavities.
Multiple implants sholud be placed in fairly
parallel arrangement.

The top of implant should be placed sufficiently
under the mucosa to allow a good emergence
profile( eg 2-3mm apical to labial CEJ of adj.
Teeth)
ALLOWANCES SHOULD BE MADE BETWEEN THE IMPLANT AND
THE FOLLOWING STRUCTURES:

Buccal plate surface 0.5 mm.
Lingual plate surface 1.0mm

Maxillary sinus 1.0mm

Incisive canal avoid midline of maxilla
Nasal cavity 1.0mm

Inferior alveolar canal 2. 0 mm. From superior aspect of the
canal

Mental nerve 5. 0 mm from anterior of the bony
foramen.

Adjacent natural tooth 0.5 mm
Between 2 implants

3.0 mm

IMPLANT INSERTION
The implant is supplied
in a sterile container,
either already mounted
on a special adapter or
unmounted
necessitating the use of
an adapter from the
implant surgical kit.

In either case the
implant should not touch
anything before its
delivery to the prepared
bone site.

Cylindrical implants
are either pushed or
gently knocked into
place.

Screw shaped
implants are either self
tapped into the
prepared site or
inserted following
tapping of the bone
with a screw tap.

WOUND CLOSURE
The mucoperiosteal
flaps are carefully closed
with multiple sutures
either to bury the implant
completely or around the
neck of the implant in
non-submerged
systems.

Silk sutures are
satisfactory and others
such resorbables are
good alternatives.

POST OP RADIOGRAPH
Take Postoperative
radiographs(Periapical
s) to evaluate implant
position in relation to
adjacent structures.

Also for monitoring the
ossteointegration.
POST-OPERATIVE CARE AND INSTRUCTIONS
Haemostasis
Medications
Dalacin C 300mg 12hourly for 5 days
Tab vitamin C 1g daily for 2weeks
IM Paracetamol 600mg stat
Tabs Diclofenac 50mg 12hourly for 3days
Ice packs to reduce swelling and pain
chlorhexidine 0.2% mouthwash
Avoid smoking and alcohol.


COMPLICATION OF IMPLANT SURGERY
Intra operative:
Tear of flap.
Insufficient irrigation thermal injury to bone.
Perforation of buccal or lingual cortex
Impingement on inferior dent canal/ nerve.
Impingement on adjacent tooth.
Perforation of maxillary sinus,
Lack of primary stability.
Fracture of implant.

COMPLICATION CONT.
Immediate post-op:
Pain ( rare)
Haemorrhage( also rare)
Swelling
Nerve injuries.

Delayed:
Infection
Secondary Haemorrhage.
Nerve injury.
Loosening of implant & Loss of implant

LONG TERM COMPLICATIONS

Anatomical
Neurological
Deintegration
Progressive thread exposure
Gingivitis
Hyperplastic tissue
Fractured Implant

OSSTEOINTEGRATION TIME
SECOND STAGE SURGERY AND RESTORATION
PHASE.
Exposure of implant
with minimal flap
reflection.
Removal of the cover
screw.

INSERTION OF THE IMPRESSION POST


IMPRESSION TAKING (ELASTOMER) PLACEMENT OF THE
IMPLANT ANALOG.

CAST AND GINGIVAL MASK FABRICATION
SELECTION OF ABUTMENT:
1) PREFABRICATED ABUTMENT
2) Custom
fabricated
Abutment
3) CAD/CAM fabricated
FURTHER LABORATORY WORK.

Wax up of the
superstructure
Fabricate the
framework
Venering(porcelain
baking)

FINISHING AND CEMENTATION.

The completed, metal-ceramic
superstructures
SUCCESS CRITERIA
According to Harvard success Criteria for Dental
implant, Dental implant must provide functional
service for 5 years in 75% of cases.
Criteria are both subjective and objective.
Subjective Criteria
Adequate function
Absence of discomfort
Improved aesthetics
Improved emotional and psychological wellbeing

OBJECTIVE CRITERIA
Bone loss no longer than 33% of vertical length of implant
No peri-implantitis
No associated radiographic radiolucency
Marginal bone loss 1.0-1.5mm first year; then < 0.1mm
annually thereafter
Good occlusal balance and vertical dimension
Gingival inflammation amendable to Rx
Mobility of less than 1mm in all direction
Absence of symptoms of infection
Absence of damage to surrounding structure
Healthy connective tissues

MAINTENANCE OF IMPLANT
Primary goal is to protect and maintain tissue-integration;good oral hygiene is a
key element!
Implant patients should be thoroughly instructed in maintenance therapy with the
understanding that the patient serves as co-therapist
Home-care regimen periodic recalls reinforcing regimen
strict adherence to recall schedule & verification of function, comfort, and
aesthetics.
immediate post-delivery
24 hours
one week
one month
6 months
bi-annual or annual evaluation

lifetime maintenance commitment
CONCLUSION
Dental implant is one of the defining
advances in clinical Dentistry.

Therefore every Dentist should key into the
current trend in implantology and use such to
improved the patient well being and
psychosocial life of patients.


Thank you for your attention.
REFERENCES
Stuart H. Jacobs and Brian C. OConnell Dental Implant Restoration
Principles and Procedures 2011. Quintessence publisher.
John A. Hobkirk, Roger M. Watson and Lloyd J.J Searson introducing
Dental Implant 2003. Churchhill livingstone Publisher.
Ivoclar Vivadent Competence in Implant Esthetics, Manual of Implant
Superstructures for Crown and Bridge Restorations. 2010 Pennwell
dental Group
Albrektsson el ta The longtime efficacy of current Used Dental Implant:
A review and Proposed Criteria of success. 1997
Sanjay CHAUHAN, Dental Implant Surgery, Rewari 1999
Abd El Salam El Askary Reconstructive Aesthetic Implant
Surgery. 2003 Blackwell Publisher.