DENTAL IMPLANTOLOGY

Introduction Dr. Thair Abdul Lateef

Generally the term implantation applies to the transplantation of non-viable tissue,

it is the use of inert foreign body implants (alloplasts) in human body tissues.
The term transplant is usually preserved for a true transplantation of living tissue
(soft tissue, cartilage and bone). Implantation can benefit patients psychologically
and in terms of masticatory efficiency.
A dental implant is "a non-viable device of biocompatible material(s) placed within
or against the mandibular or maxillary bone to provide additional or enhanced
support for a prosthesis or tooth".
Implants are subjected to the same problems, except for caries, as the natural
dentition. Therefore, the same care that must be given to the oral cavity prior to any
rehabilitative procedure must be given prior to implantation.
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Bone remodeling
Modeling is the appropriate term to characterize changes in bone morphology occur
during growth (turnover & replacement). Ridge resorption and atrophy are
misnomer because resorption is a part of normal turnover process occurring in all
bones, whereas atrophy implies a passive process.
Remodeling of bone involves 3 steps:
 Activation: begins as a result of specific local (i.e. stress) and systemic (i.e.
hormonal) stimuli.
 Resorption: occur in all four of skeletal envelopes (periosteum, haversian, cortical-
endosteal, trabecular). It is mediated strictly by osteoclasts which is the only cell in
the body capable of resorbing bone. Often resorption occur parallel to the stress
placed upon bone. Resorption also occurs in the absence of stress, but it does so in a
less organized manner. Once resorption phase is complete, there is usually a delay
period of 12-14 days after which formation begins.
 Formation: osteoblasts begin to lay down organic matrix, after 14 days osteoid
begins mineralization. The site at which resorption ceases and formation begins is

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 termed as cement line. The time involved is about 3 months in compact bone and 2
months in trabecular bone (trabecular bone turnover is of higher rate).
The progression of healing after a tooth extraction goes through certain resorptive
stages of:
1. Fibrin clot organization (first 4 weeks)
2. Immature (woven) bone formation (4–8 weeks)
3. Mature (lamellar) bone development (8–12 weeks)
4. Bone stabilization stage (12–16 weeks or about 4 months)
Post-extraction bone resorption is always three-dimensional, with the greatest loss
of bone in the bucco-palatal or horizontal direction (the width) and occurring mainly
on the buccal side of the alveolar ridge. Schropp et al reported that two thirds of the
horizontal bone loss occurs within 3 months and one-third takes place within the
remaining 9 months of the first year post-extraction. A mean reduction of the width
of the ridge has been reported to be 5-7 mm within a 6-month period or 50% during
the 12 months following tooth extraction. The loss of bone height is smaller,
reported to be about 1 mm within the first 6 months post-extraction.
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Factors Influencing Edentulous Bone Loss
A. Metabolic factors: metabolic bone disease is any process that influences the normal
modeling of bone. Osteopenia is a clinical term for any loss in bone density. The
common metabolic bone diseases are:
1.Osteoporosis → characterized by a reduction in the mass of bone per unit volume
resulting in mechanical failure and pain, the ratio of mineral to organic matrix is
usually normal. Clinical signs and symptoms of advanced osteoporosis include pain
in the spine, loss of height and/or thoracic kyphosis due to vertebral compression
and fractures due to secondary trauma, in most cases serum and urine biochemical
examinations are normal. Osteoporosis seen in senile osteoporosis, postmenopausal
osteoporosis, hyperparathyroidism and Cushing syndrome.
2.Osteomalacia → is any disease in which excess osteoid is not mineralized and impaired
bone healing is present. Osteomalacia seen in vitamin D deficiency, malnutrition,
renal osteodystrophy, secondary hyperparathyroidism and drug therapy (chronic
corticosteroid therapy, chronic heparin therapy, anticonvulsant therapy, alcohol).

B. Anatomic factors:
1.Facial morphology → peoples with long faces (dolichocephalic) have more voluminous
anterior alveolar ridge than those with short faces (brachycephalic). Brachycephalic
faces (low mandibular plane angle and gonial angle) are capable of higher biting

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 forces in both anterior and posterior regions, there is a direct correlation between
short facial heights and edentulous bone loss.
2.Trauma and alveolectomy technique → maximum conservation of bone should be
practiced during extraction and management of the trauma patients.

C. Mechanical factors:
1.Disuse atrophy plays a role in the low-turnover type of remodeling.
2.Excessive loading may contribute to high-turnover type of remodeling. In bone loss
secondary to the influence of dentures, the denture-bearing area of the maxilla is
1.8 times than that of the mandible. Therefore, compression (in pound/inch2) are
greater on the mandible resulting in increased bone loss which is 4 times that of the
maxilla, in this situation edentulous bone loss can be reduced through decreasing
occlusal contact area and balancing the occlusion during occlusal arrangement of
dentures.
3.Parafunctional activity (clenching & bruxism) → contact during mastication occupies less
than 15 minutes/day, whereas the teeth may be forcibly held together several
hours/day in these activities, however the effects are not clearly understood.
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Classification
Babbush 1985 classified implants according to the site into 4 types:
1. Mucosal Inserts:
Was introduced to the dental profession in 1943 by Dahl. It has been discarded due
to complicated and prolonged insertion technique and stormy post-operative
periods. The mucosal inserts are composed of 2 parts the retentive base, which is
placed into a prepared site in the prosthesis, and the vertical component (buttons),
which enters the soft tissue receptor site in the oral mucosa. They were indicated in
cases of severe atrophy of the alveolar ridge in maxilla that not permit the use of
endosseous implant due to the presence of anatomical limitations which are the
maxillary sinus and the nasal cavity. The use of mucosal inserts in complete
mandibular dentures is not tenable because of thin friable non-retentive nature of
the tissues. These appliances are designed to be inserted into surgically prepared
sites in the mucoperiosteum. Preparation of oral mucosa done by bur and the
receptor site should be narrower and deeper than the inserts. The denture should
not be removed for longer than 8-12 hours at any time after insertion otherwise the
receptor sites will begin to close, and the patient will have to be retreated.

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2. Subperiosteal Implant:
Was firstly introduced and performed in 1949. The design consist of 2 parts
substructure which is a metallic framework that rests on bone under the periosteum,
and superstructure which are abutment posts connected to the framework and
penetrate the mucoperiosteum protruding in the oral cavity. The maxillary implant
not done routinely. Transplantation of mucosal grafts (palatal patch grafts) or even
split-thickness skin grafts may be required to enhance the soft tissue cuff-post
interface.
3. Transmandibular Staple Bone Implant: was developed by small in 1975, it is placed
into the anterior portion of the edentulous mandible. The purpose of this implant is
to act as a stabilizer and fastener for mandibular full denture. It is mainly indicated
for edentulous mandible with minimal alveolar ridge height of 8-9 mm, and to
rehabilitate various types of mandibular deformities. The staple plate is inserted by
drilling through the mandible using a specific set of instruments. The staple is
composed of an inferior horizontal plate which acts as a base for the 3-5 vertically
attached 9 mm retentive pins, and 2 completely threaded transosseous vertical
components that penetrate the alveolar crest and mucoperiosteal tissue in the
canine region. Each implant is equipped with 4 fasteners and 2 locknuts. The basic
procedure has been done under GA through extra-oral approach or a modified intra-
oral approach
4. Endosseous Implants:
History  in 1950s and 1960s Linkow developed the blade implants, the mandibular
staple implant developed by Small 1966. In 1951 Branemark began research leading
to the development of an endosseous implant system that popularized the concept
of osseointegration ( 15 years study work until the placement of the 1st dental
implant in a human being ). It was until 1982 that Branemark encouraged the world
to exposed to osseointegration, by the conference arranged by Zarb in Toronto that
May. The successful treatment of edentulous and partially edentulous patients with
osseointegrated implant has revolutionized dentistry. Babbush 1985 described 3
main types of endosseous implants:
1. Blade-vent implants: firstly introduced by Linkow 1967.
2. Hollow-basket implant system (C.E, H, K or F)
3. Screws and other implant systems: such as TPS-Screw (Titanium plasma-sprayed
screw system). Vitreous Carbon Implant, Tubingen Aluminum Ceramic, TPC Implant

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(Tetracalcium Phosphate), IMZ Implant Branemark Osseointegrated Titanium Implant
etc…..

Advantages of the screws over Subperiosteal and Staple implants:

1. Screws can be inserted under local anesthesia through a relatively small
mucoperiosteal incision.
2. Can be placed against opposing natural teeth with less risk than other implants.
3. Permits final restoration of the case immediately or after few days.
4. In case of failure the screw can be easily removed and replaced without
endangering the adjacent screws or without loss of the prosthesis.
5. Relative simplicity of the superstructure.
6. Can be used as support for Cranio-Facial prosthesis that applied in cases of
craniofacial deformities (auricle, nose, orbit, maxilla and mandible).
7. Can be applied for treatment of some orthodontic problems such as correction of
simple cross-bite.
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Parts of DI:
Fixture (DI): consist of 3 parts → crest module, body and apex
Cover screw: which is placed into the top of the implant, in first stage surgery.
Permucosal extension (healing abutment, gingival former): is the transepithelial portion
which extends above the soft tissue and results in the development of a permucosal
seal around the implant.
Abutment: is the portion of the implant that supports or retains a prosthesis or
implant superstructure.
Transfer coping: the component used to transfer the position and the design of the
implant or the abutment to the master cast for prosthesis fabrication. It is either
indirect transfer coping used in closed tray impression or direct used in open tray
impression.
Analog: used in the fabrication of the master cast to replicate the retentive portion of
the implant body or abutment (implant body analog, implant abutment analog).
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Tissue Reactions to Implants

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 1. Ankylosis → or direct apposition of bone to the implant which is accepted as
the most desirable alternative to true periodontal attachment and can provide
effective load transmission.
2. Fibrous encapsulation → fibrous capsule around implants are associated with
numerous factors including implant mobility, shape and toxicity.
3. Epithelial down growth → has been observed around both endosseous and
subperiosteal implants which cause breakdown of the bond between the
implant and the surrounding bone.
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Factors Influencing Tissue Behavior
1. Site preparation: it is important to avoid overheating when placing the implant
which may lead to osteonecrosis or delayed bone regeneration and
replacement by fibrous connective tissue.
2. Implant material: the material from which an implant is made has a profound
effect on the type of tissue which forms around it and the stability of the
implant-tissue interface.
There are 3 basic types of interaction between host and implant:
a. Bio-tolerance → where there is a mild reaction to the implant, as seen around
stainless steel.
b. Bio-inertness → where the implant is ignored, as seen around vitreous carbon.
c. Bio-activity → where the implant interacts chemically with the body in a
controlled fashion so as to become incorporated into the tissues.

3. Implant design: there is a little evidence that variations in implant surface

texture at a microscopic level influence the subsequent tissue response.
Implants with sharp corners elicit a fibrous reaction, and there is evidence that
implant shape in the cervical region can also influence pattern of bone
behavior.
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Osseointegration
According to Branemark 1982 it was defined as a "direct structural and functional
connection between living bone and a load carrying endosseous implant at the light
microscopic level".

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The term osseointegration indicates a situation in which living bone tissue is induced
to incorporate permanently a synthetic anchorage element. Reliable stability must be
achieved by incorporation of the anchorage element into normal bone tissue
providing both adequate resistance to load and load distribution resulting in bone
remodeling. An implant is said to be biomechanically osseointegrated if there no
progressive relative motion of living bone and implant under functional levels and
types of loading for the entire life of the patient. Osseointegration is not a static but a
highly dynamic condition. Even very gentle drilling, cutting and threading of bone
tissue is accompanied by some tissue injury, both thermal and mechanical.
Initial stability and successive remodeling of bone tissue depend on:
1. Gentle surgical technique
2. Controlled application of functional load
It is crucial to recognize and respect time as a critical factor in a protocol for surgical
and prosthetic procedures. The continuous remodeling of bone varies in quantity and
quality between individuals. In load-bearing reconstruction one should avoid
unnecessary risks of overloading and possible displacement of bone tissue at the
interface relative to the anchorage element during healing phase, this means that, in
the majority of situations, a two-stage procedure is recommended. In other cases of
non-load-bearing reconstruction (ear prostheses or bone conduction. hearing aids), a
modified one-stage procedure may be satisfactory. In other cases, such as when a
performed bone graft with integrated anchorage element is used, a three-stage
procedure may be necessary.

In spite of the widespread use of titanium implants, little is known about the events
taking place in the tissue at different times after insertion (hypothesis):
1. A general concept appears to be that the implant surface serves to support
osteogenic cells, thus providing favorable conditions for bone formation leading to
osseointegration.
2. Titanium oxide forming the surface of the implant has certain properties favorable
for mineralization (bind with calcium which might be beneficial for bone formation).

Types of Stability:
1. Primary stability  is largely a mechanical parameter, a function of bone
quantity & quality.
2. Secondary stability  viewed as increased stability (biological) after placement.

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Factors Control (affecting) Osseointegration
A- Surgical: primary stability and surgical technique
B- Tissular: bone quality & quantity, healing, remodeling
C-Implantological: macrostructure (implant design and surface treatment),
microstructure and dimensions
D- Occlusal ̸ Mechanical: forces (loading) & prosthetic design

Measurement of OI :
1. Tensional test (lateral load)
2. Push-out/Pull-out test (only for non-threaded cylinder DI)
3. Percussion test (subjective)
4. Insertion torque
5. Removal torque (reverse)
6. Thread cutting force
7. Periotest (1986)
8. Resonance Frequency Analysis 1998 (Osstell ISQ) → (produce alternating sine waves
in a specific frequency range by uniform amplitude. Resonance frequency between
3.5 KHz and 8.5 KHz formed from magnetic field is converted into ISQ values)
9. Radiographic evaluation (difficult to perceive changes in bone structure &
morphology of bone-implant interface unless over 30% bone loss occur)
10. Histology & Histomorphometry (non-clinical studies & experiments)

Surface Characteristics of Titanium Implants:

For most metal surfaces (except those of the noble metals) exposed to air or other
oxidizing media, this results in the formation of a thin surface oxide (10 nm in
thickness).
The composition of surface oxide is in most cases Titanium oxide. The surface of
Titanium implants prior to implantation consist of a thin surface oxide which is
covered by a hydrocarbon-dominated contamination layer.

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 Roughness at implant surface can be modified by
1. Sandblasting  the surface is bombarded by fast hard particles in order to
remove gross surface defects and contamination.
2. Plasma spraying  in which the surface is coated by spraying molten drops of
metal onto the surface at a high velocity.
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Clinical and Radiological Assessment for Dental Implants

 CLINICAL:
A. History
1. Patient’s complaints and expectations:
a. Elicit the patient chief complaints
b. Major concerns
c. Treatment requests
2. Medical:
a. The general health status
b. Contraindications : Absolute V/S Relative
 Implants are not recommended for elderly infirm persons
 Drug or alcohol dependence, uncontrolled depression and those with some
psychiatric disorders
 Heart failure, uncontrolled diabetes and blood dyscrasias,
immunocompromised
 Heavy smokers , irradiation of the face and jaws, osteoporosis in the oral
region, parafunctional habits
 Unfinished cranial growth and teeth eruption
3. Dental History:
a. Cause of teeth loss
b. Compliance
4. Social History

B. Examination:
1. Extraoral
a. Facial proportions
b. Mouth opening
c. Jaw relationship

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 d. Morphology and function of the lips
e. Facial muscles hypertrophy
2. Intraoral
a. Oral hygiene assessment
b. Condition of the remaining dentition
c. Palpation of the alveolar ridge at the prospective implant sites:
Ridge defect class (horizontal as vestibular concavity, vertical, combined), bony
profile of the ridge, gingival profile
d. Space analysis of edentulous areas:
 Height, Width, and Length (Inter-coronal distance) → Osteometer (bone
caliper), alveolar ridge mapping
 Inter-arch distance (Rule of 6)
 Thickness of the soft tissue

 RADIOLOGICAL:
Radiographic Presurgical Assessment of Endosseous Implants; the specific imaging
objectives for implant surgery are:
1. Jaw Size (height & width) the horizontal and vertical dimensions of the alveolar
and basal bone are important for treatment planning and implant retention. The
larger and denser alveolar ridge the better the long-term success for implant
integration. It is ideal to have at least 1 mm of bone on all sides of the implant and
therefore the cross-sectional dimension of the alveolar ridge should be at least 6
mm. Implants that have bicortical anchorage are more successful than those that are
suspended in trabecular bone. Therefore, determination of the implant length is
necessary to allow for engagement of the terminal end in cortical bone.
2. Orientation of the Vertical Long Axis of the Jaw  The axis orientation can be
determined only with cross-sectional imaging techniques.
3. Jaw Boundaries  the buccal and lingual walls of the maxilla and mandible are not
always parallel, the canine fosse on the buccal surface of the anterior maxilla and the
submandibular fossa on the lingual surface of the mandible arc common normal
anatomic depressions.
4. Internal Anatomy  to reveal the location of neurovascular structures, cortices,
sinuses, nasal fossae and nasopalatine duct.

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5. Soft-tissue Morphology  it is important to determine the thickness of the soft
tissues overlying the alveolar ridge for accurate determination of the location and
alignment of the prosthetic element that attached to the implant.
6. Three-dimensional Spatial Localization  2 planes perpendicular to each other
(longitudinal and cross-sectional images), this allow localization of relevant anatomic
structures.
7. Pathology Detection  any disease process or abnormal condition may diminish
the probability of successful implant placement and retention (root tips,
inflammatory processes, cysts and tumors).
8. Bone Quality  the amount of mineralized bone / unit area at implant site affect
the success of implant integration (I-e: maxillary tuberosity is a poor implant site
because of the paucity of trabeculated bone).

Imaging Modalities
A. Conventional Imaging:
1. Panoramic Projections  provide information about the vertical height of the
mandible and location of the mental foramina. It may give improper size if the target
anatomy misaligned toward the film the image is reduced in size, and conversely
magnified if it is misaligned farther away from the film. There may also vertical and
horizontal distortion. All panoramic beam angles are approximately at 8 degrees,
which gives the image inherent magnification (20 -30%). Effective dose 10-14 µ SV.
2. Cephalometric Projections  lateral cephalometry provide information about the
cross-sectional dimensions of the mandible. The main disadvantage is the significant
superimposition.
3. Periapical projections produce excellent anatomic detail and information related
to bone quality, but it 1) does not provide information about cross-sectional
anatomy of the jaws, 2) nor does it demonstrate all regions of the law, 3) relatively
high radiation dose per image.
4. Occlusal projections the same to periapical but demonstrates larger areas. This
image can evaluate 1) curve of the jaws 2) bone quality 3) largest buccolingual
dimensions of the mandible.
5. Tomographic projections  it is an imaging technique that provides an image of a
tissue plane or layer. The main disadvantage due to this single image plane is blurred
image.

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B. Digital Imaging:
I. Computed Tomography CT  produce image with contrast sensitivity much greater
than that of images produced by conventional methods, the images are superior
because there is no superimposition. The main disadvantage is the high radiation
dose and cost.
2. Cone Beam Computed Tomography CBCT → less dose than CT.
CT or CBCT give 3-dimensional images, and applied when cross-sectional images
required.
3. Intraoral Detectors  allow direct digital capture and display of intraoral images on
a video monitor, once the images have been captured they can be enhanced,
archived, retrieved, transmitted and printed. It may be very useful to the
surgeon as an operative imaging tool during the surgical placement of implants.

Post-implant Imaging Objectives:

1. Implant Placement  location is considered ideal when the implant located within
the boundaries of the jaws and is terminated in thick cortical bone.
2. Integration of the implant.
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Bone Density (bone volume, bone quantity)
There are various conditions of residual ridge depending on history and duration of
edentulism. A tooth loss due to advanced periodontal disease lead to rapid
resorption to the apex 13-15 mm, while a tooth loss due to apical ostietis or trauma
may preserve the alveolar process for longer period of time. In infraforaminal region
there is a visible angle between the axial inclination of the teeth/alveolar process and
the basal bone, this angle must be taken into account in order to prevent perforation
of the lingual cortical bone and possible trauma to lingual artery. A ridge width of at
least 6 mm is necessary for placing implant of a 3.5 mm diameter.
Bone density varies substantially from one anatomic region to another, the failure
rate of implantation is greater for regions with very low density which result in 
low primary stability, or regions with very high density  risk of overheating during
drilling. A good evaluation of bone density allows the surgeon to do the following:
1. Select the proper implant diameter.
2. Decide about the optimal drilling sequence, in soft bone  use of final drill of half
depth only with minimal use of countersink and use of smaller drill diameter than
standard, while in hard (dense) bone  use of oversized drill diameters.

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3. Determine the length of healing period.
4. Evaluate occlusal loading capacity of different implants.

Classification of bone density ( Lekholms & Zarb )

1. Type I  essentially cortical bone
2. Type II  dense corticocancellous bone
3. Type III  sparse corticocancellous bone
4. Type IV  thin cortical bone and very sparse medullary bone

Bone Quality (Structure)

Classification of bone quality from biological point of view (BHP bone healing
potential):
1. BHP1  bone with normal bone healing
2. BHP 2  bone with moderately reduced healing potential (as in moderate smoking
10 Cigarette / day, controlled diabetes mellitus, long-term corticosteroid treatment,
regenerated bone, long-term non-steroidal anti-inflammatory agents like
indomethacin).
3. BHP3  bone with substantially reduced healing potential (heavy smoking 20
cigarettes or more/ day, diabetes mellitus, severe anemia, Gauchers disease, severe
osteoporosis, Paget’s disease, fibrous dysplasia, hyperparathyroidism, thalassemia,
irradiated bone, rheumatoid arthritis and antimitotic drugs).
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SURGICAL TECHNIQUE:
Strict aseptic surgical technique should be followed in dental implant surgery. The
patient is draped as for other oral surgical procedures, cleaning of the perioral area
with suitable antiseptic solution to eliminate contamination during surgery, and it is
convenient to use sterile disposable suction tubing and stents. Chlorhexidine 0.12%
is used as a pre-operative mouth wash and skin preparation circum-orally.
Autoclaving of surgical instruments is essential with the use of sterilization pouch.

Approach:
 Flapped Approach
 Flapless Approach (minimally invasive approach)
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  Flapped Approach:
1. Extensive flap design (conventional three or two-sided(
2. Envelope flap
3. Conserved flap (limited flap design, papilla-saving incision(
In maxilla, an incision placed slightly palatal (palatal bias) which allows better vision,
reduce the possibility of flap trauma, and avoid incision and sutures to be directly
over fixture and hence reducing the possibility of contamination.
In posterior mandible, the incision may be placed toward buccal aspect of the ridge
to allow the flap for better retraction by a tractional suture and produce excellent
access, avoid injury to the lingual nerve and for better coverage of the fixture
postoperatively.
In edentulous mandible care taken not to injure the mental nerve with crestal
incision especially in severely resorbed alveolar ridges.

Preparation of implant site:

The implant fixtures are installed into a carefully made recipient site (osteotomy site)
in the jaw bones created by:
 Bone drilling technique
 Bone expanders and condensers (screws or osteotomes)

 Bone drilling technique:

Atraumatic preparation and removal of bone from the recipient site must be
accomplished with minimal violence. Heat production during bone preparation is a
critical factor, a maximum temperature of 47 C for 1 minute is commonly quoted as a
threshold temperature (heat with external cooling reach to 55 C° while heat during
internal cooling reach to 40 C°).
In order to avoid an irreversible bone damage that can lead to failure of
osseointergartion, use:
 A low-speed (600-1000 rpm)
 High-torque handpiece
 Intermittent drilling technique → allow the irrigant to reach the depth of the
preparation and allow the bone chips to be removed and to prevent the heat
buildup

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  Sharp drills
 Copious saline irrigation (external, internal, manual )
Unless the recipient site is quite dense, it is desirable to drill deep enough to engage
the cortex (bicortical) at the apical area of the site. This applies to the antral area,
floor of the nose and the anterior region of the mandible unless the mandible has a
dense medullary area.
Procedure: after soft tissue reflection  if available, using the surgical template
(stent) which also assist in directing the angulations of the implant. With the initial
drill (usually with a round bur) the center of the implant recipient site is marked and
the initial pilot hole is prepared and paralleling pin is placed in the initial preparation
to check the alignment and angulations. If template is not available the angulation of
the drill may be estimated from the position of the adjacent teeth or opposing teeth
and ridge, however, it is usually best to have a template as a guide  depth of the
implant site is determined by amount, density of bone and relation to the crest of
bone. One should keep in mind that the polished portion of the implant does not
integrate. Therefore, if the bone height at the implant site is minimal, it is prudent to
have little or none of the polished portion of the implant within bone. If only a small
portion of the osseointegratable portion of the implant is exposed, it may be not
necessary to cover it with bone. However, if the exposed area is large or is at the
coronal portion of the implant (dehiscence or fenestration), bone coverage is
required to enhance peri-implant strength and increase support for lateral loading by
using locally harvested bone or with the use of barrier membrane.
Adequate bone should be present between adjacent implants (about 3 mm), and
between implants and adjacent teeth (1-1.5 mm). Care should take not to damage
adjacent structures such as teeth, nerves, and nasal or sinus cavities. It is acceptable
to engage the nasal or sinus floor with a small degree of penetration (e.g. 1 to 2 mm).
An adequate safety margin of about 2 mm above the inferior dental canal is
recommended.
In maxillary posterior area  I) Bone is soft here and subject to over enlargement
during drilling process. If a loose fit is encountered, it is desirable to remove the
implant and replace it with one of larger diameter. It is appropriate not to tap on
screw shape systems.
2) In this area there is lack of dense cortices in both the occlusal surface and the floor
of antrum. To make use of little cortex available, it may be best not to countersink
the implant.

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Mandibular Anterior Area: an anatomic problem in this area may be the slope of
lingual surface of the mandible, often in the lateral-cuspid areas, the lingual surface
of the mandible slopes anteriorly from crest to the inferior border. If angulation is
directed more vertically for a better loading axis, the drill may engage and penetrate
the lingual cortex. Penetration of the lingual cortex usually does not create a
problem, but lacerating an artery in the lingual soft tissue (sublingual A) is possible.
Remember that mental nerve usually leaves inferior alveolar nerve in a plane
anterior to mental foramen then courses posteriorly and superiorly before it exits the
mental nerve  thus the implant site in this region should be placed a few
millimeters anterior to the mental foramen.
Mandibular Posterior Area  bone above inferior alveolar nerve often insufficient
for implants of adequate length as suggested in a panoramic radiograph. There are 2
solutions for this problem: 1) Grafting, however grafting the crest of the ridge may
not be feasible, as the intermaxillary space may restrict the amount of bone to be
added. 2) Lateralizing or transposition of the IAN temporarily to allow an implant of
adequate length.
3) Short wide plat-form DI
The implant should not touch anything (other than a sterile titanium surface) before
its delivery to the prepared bone site. Contaminations by touching with dissimilar
instrument, cloth, soft tissue, and even surgical gloves, gloves powder, oil may affect
the degree of ossointegration (uncontaminated oxide layer is necessary for
osseointegration).
The insertion of the implants should be done with the same care as the preparation
of the site by maintaining the cooling irrigation and placing the implant at slow
speed.
Screw shaped implants and tapping of sites are performed at speeds of less than 20
rpm.
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.
Exposure Procedure
The procedure selected to expose the implants (after the healing period usually 3-6
months) will depend on the esthetic and functional requirement. There are 3 basic
soft tissue procedures for exposing the implant:
1. Coring out the mucosa overlying the implant.

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2. Elevation of facial flaps with some slight release of the lingual and palatal mucosa.
3. Mobilizing and moving of facial &/or lingual flaps with or without mucosal or skin
grafting

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Various treatment options devised over the years for inadequate ridge width are:
1. Increase width by osteoplasty
2. Utilize narrower diameter implants
3. Increase width by augmentation
4. Bone expansion
5. Ridge splitting
6. Horizontal distraction osteogenesis
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Treatment Protocols (Treatment Sequence)

The timing of implant placement falls into 3 categories:
A. Delayed Placement (late implant placement, traditional protocol)  in which
delay placement until an extraction site was completely filled with bone (6 month or
longer). A covered non loaded healing phase requiring a stress-free OI period of
approximately 4 months guarantees a high degree of safety if the classic surgical
protocol is followed. Edentulous patients have also been required to go out their
removable prosthesis for the 1st 2 weeks after implant placement. The 2 nd stage
involving uncovering the implants and prosthetic restoration can take at least
another 2 months or more to complete.

Healing Phase: Today 3 - 6 months non-loaded phase for dental implants is generally
accepted for safe bone apposition to implant interface. The resulting loading periods
of 3 months for the mandible and 6 months for the maxilla were based on purely
empirical data of 45-175 days trials. The regeneration process at the implant-bone
interface is a biologic process characterized by different phases  hemorrhagic
phase - cell migration & differentiation-extracellular matrix synthesis - mineralization
& bone growth.
The process is influenced by:
1. Biocompatibility of the implant material
2. Implant surface structure
3. The application of atraumatic surgical protocol
4. Prevention of micro-movement at the interface
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 Micro-movement can negatively influence the regeneration process at the implant
interface by causing fibrous repair rather than direct bone apposition. However not
every movement of an implant during healing phase necessarily lead to tissue
ingrowth, the critical value of tolerable micromovement is 50-150 µm for endosseous
implants with a biocompatible surface.
B. Immediate Placement  placing the implant at the same time as tooth
extraction. The advantage  preserve more residual alveolar bone by providing the
internal tensional load that alveolar bone requires to maintain itself this
consequently result in improved esthetic and better emergence profile, also the time
between extraction and implant placement will be significantly reduced. This
technique is most often used when multiple teeth to be extracted /or primary soft-
tissue closure can easily be achieved (usually in anterior mandible or maxilla).
Contraindications:
1. Bony or soft tissue infection
2. Inadequate bone apical to extraction site for implant stabilization
3. Inability to provide occlusion from oral contamination
4. Chronic problems such as granuloma or radicular cyst
Technique. once the tooth is removed as atraumatically as possible, intrabony soft
tissue should be carefully excavated (periodontal ligament C.T. & epithelial remnants
may interfere with integration process)  extracted tooth can be used as a template
for implant selection and preparation size, the tooth root can be a very helpful guide
to implant length by measuring root length + length of available bone apical to the
tooth socket. To fill the void between portion of the implant and the wall of alveolus,
autogenous, allogeneic or xenografting materials may be used with same success,
this may:
1. Minimize soft-tissue ingrowth
2. Improve bony apposition
3. Aid in alveolar bone preservation.
When primary closure cannot obtained a:
1. Collagen material such as collotape can be considered over the graft
2. Barrier membrane

C. Semi-immediate Placement  placement of implant is delayed until the mucosa

has regenerated over the socket, allowing a more predictable soft-tissue covering
over the implant site. It is indicated in situation in which closure by flap mobilization

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 cannot be done owing to lack of tissue or distortion of esthetic gingival contours.
This frequently occurs when one or two teeth are lost adjacent to natural teeth 
this require 2 months of epithelial healing and maturation. There will be some bone
resorption which make necessary to position the implant slightly more apically
(additional depth of 1-2 mm is usually adequate).
Complications of Dental Implants:
A- Intraoperative:
1. Poorly positioned Implant
2. Damage to mucosa and adjacent teeth
3. Damage to bone ( lateral perforation, alveolar bone fracture or
jaw fracture )
4. Perforation into adjacent areas ( lower border of the mandible,
nasal cavity or maxillary antrum)
5. Damage to nerves
6. Loose implant ( poor primary stability )
7. Contamination of implant and bone during surgery
8. Damage to the implant ( crossed threads or surface defect )
9. Hemorrhage during surgery ( especially in the anterior
mandible and possible airway compromise )
B- Postoperative:
1. Pain
2. Swelling
3. Reactionary or secondary hemorrhage
4. Infection of peri-implant soft tissue or bone ( peri-implant
mucositis or peri-implantitis )
5. Exposed or loose cover screw ( healing screw )
C- Late:
1. Mucosal recession
2. Bone resorption
3. Mobility
4. Implant fracture

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Criteria for Success

The term implant success may be used to describe ideal clinical conditions. It should
include a time period of at least 12 months for implant serving an implant as
prosthetic abutments. Implant success is suggested for a span of:
 1-3 years → early implant success
 3-7 years → intermediate implant success
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  More than 7 years → long-term implant success

The primary function of a DI is to act as an abutment for a prosthetic device, similar

to a natural tooth root and crown. Any success criteria, therefore, must include first
and foremost support of a functional prosthesis.
Assessment of failure according to the time when occurred:
(1) Early failures or failures during the osseointegration period (usually within the
first year after an implant insertion, during the healing period and initial loading), and
(2) Late failures or failures after the osseointegration period (usually about a year
after implant insertion, when an osseointegration process is complete and implant
function is established).

Causes of early implant failures:

1. Poor quality and quantity of bone and soft tissue
2. Patient medical condition
3. Unfavorable patient habits (bruxism, heavy long-term smoking, poor oral hygiene,
others)
4. Inadequate surgical analysis and technique
5. Inadequate prosthetic analysis and technique
6. Suboptimal implant design and surface characteristics
7. Implant position or location (functional implant zones)
8. Unknown factors

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 Health Scale for Dental Implants, Misch Criteria of Success 2008

Implant Quality Scale Group Clinical Conditions

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I. Success (optimum health) a) No pain or tenderness upon function
b) 0 mobility
c) <2 mm radiographic bone loss from
initial surgery
d) No exudates history
 
II. Satisfactory survival a) No pain on function
b) 0 mobility
c) 2–4 mm radiographic bone loss
d) No exudates history

III. Compromised survival a) May have sensitivity on function

b) No mobility
c) Radiographic bone loss > 4 mm (less
than 1/2 of implant body)
d) Probing depth > 7 mm
e) May have exudates history

a) Pain on function
IV. Failure (clinical or absolute
failure) → any of the following b) Mobility
c) Radiographic bone loss > 1/2 length of
implant
d) Uncontrolled exudate
e) No longer in mouth

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