Advanced course

2. Dr. Amal Fathy Kaddah
Professor of Prosthodontic,
Faculty of Oral & Dental Medicine,
Cairo University

3. When You Do
Your Best
God Does The Rest

4.  Definition
 Historical Development Of Implant Biomaterial
 Indication
 Components of a Typical Implant Restoration
 Classification Of Dental Implants
 Osseointegration.
 Healing Of Endosseous Implants (Wound
Response)
 Dental Implants Materials and Composition
 Occlusion In Implantology
Outline

5. WHAT IS A DENTAL IMPLANT?
 Is an artificial titanium fixture (similar to those
used in orthopedics) which is placed surgically
into the jaw bone to substitute for a missing
tooth and its root(s).
Dental implant

6. History of Dental Implants
1. Ancient implant materials:
During the ancient Egyptians era, and in
South America in the 18th century
wood, carved stone and animal teeth.
2. Metallic implants:
Gold, platinum, Lead coated platinum, Silver,
Vitallium, Stainless steel and Recently
titanium.

7. History of Dental Implants
In 1952, Professor Per-Ingvar Branemark,
a Swedish surgeon, while conducting research
into the healing patterns of bone tissue,
accidentally discovered that when pure
titanium comes into direct contact with the
living bone tissue, the two literally grow
together to form a permanent biological
adhesion. He named this phenomenon
“ Osseointegration"

8. Indications
 Severe bone loss that significantly
endanger denture retention.
 Poor oral muscular coordination.
 Low tolerance of mucosal tissues.
 Para-functional habits leading to
recurrent soreness and denture
instability.

9.  Unrealistic prosthodontic expectation.
 Active or hyper-active gag reflex
precipitated by removable denture.
 Psychological inability to wear denture,
even with adequate one.
 Massive bone and tissue loss following
surgical removal of tumors.
Indications

10. What is a dental implant?
 It is made by titanium and
shaped like a screw.
 Placed in the jaw bone it
serves as a secure root for
the new tooth.
 Restorations such as crowns,
bridges or dentures can be
attached.
Fixture
Abutment
Crown

11. Implant fixture
Abutment
Retaining screw
Abutment screw
Components of an
implant restoration
Composite resin
- Screw retained implant
restorations consist of three
components.
(a) implant fixture
(b) abutment
(c) restoration
Gutta percha
The abutment screw secures the abutment to the fixture
- the prosthetic retention screw secures the prosthesis to the
abutment

12. Abutment
Abutment screw
Abutment
(Screw retained restoration
- Can be either parallel (standard)
or conical (estheticone) in shape.
- Are secured with an abutment
screw that is tightened to 20
ncm.
Abutment
(Cemented restoration)
- Cera One abutment
- secured with a square head screw tightened to
32 Ncm.
(green)
(red)

13. Retaining
screw
Prosthetic retaining
screw
- Can have a slot or hex head
- Access is usually covered
by a combination of gutta
percha and composite.
- Used to retain the prosthesis to the
abutment.
- Tightened to 10 ncm.

14. Hand Screw Drivers
Prosthetic retention slot screw
driver
Prosthetic retention hex screw
driver
Hex Abutment driver
Standard and conical
(estheticone)
Square abutment driver
Cera One or square abutment
screws

15. Slot Screw Driver
- Used to remove or replace slotted
prosthetic retention screws.
- Tighten to 10 Ncm

16. Hex Screw Driver
- Used to remove or replace hex
prosthetic retention screws.
- Tighten to 10 Ncm.

17. Abutment Screw Driver
- Used to remove or replace abutment screws
for standard or conical (estheticone / mirus
cone) abutments.
- Tighten to 20 Ncm.

18. Square Screw Driver
- Used to remove or replace Cera One
abutment screw.
- Tighten to 32 Ncm

19. What is a dental implant?
 The implant (fixture): it is the actual part that is
inserted into the bone.
 The abutment: it is the core area which is
connected to the implant where the prosthetic
part is attached to it.
 The prosthesis: it is either single crown, fixed
partial denture, over denture or any type of
restoration connected to the implant and the
abutment.

20. Dental implant can be classified into two
groups:
CLASSIFICATION OF DENTAL
IMPLANTS
1.Tooth implants which include transplantation,
reimplantation and endodontic endosseous
implants.
2.Non tooth implants which include subperiosteal,
transosteal and endosteal balde and root- form
implants.

21. 1.Classification of implants according
to position:
1. Endodontic stabilizer
2. Mucosal inserts
3. Subperioteal implant
4. Endosteal implants (transosseous)
CLASSIFICATION OF DENTAL
IMPLANTS

22. I-Endodontic stabilizer
It is a Smooth or threaded
metallic pin implant that
extends through the root canal
into the periapical bone to
stabilize the mobile tooth.

23.  Classification of implants according
to position:
1. Endodontic stabilizer
2. Mucosal inserts
3. Subperioteal implant
4. Transmandibular dental implants
5. Endosteal implants
CLASSIFICATION OF DENTAL IMPLANTS

24. Stainless steel inserts attached to the tissue
surface of a removable prosthesis that
mechanically engage undercuts in surgically
prepared mucosal sites.
II-Mucosal inserts
(Mucoperiosteal - implant interface)
1

25.  Classification of implants according
to position:
1. Endodontic stabilizer
2. Mucosal inserts
3. Subperioteal implant
4. Transmandibular dental implants
5. Endosteal implants
CLASSIFICATION OF DENTAL IMPLANTS

26. • Its framework is made of cobalt chromium
molybdenum based alloy resting on the alveolar
bone beneath the periosteum, with abutment posts
and intraoral bars to attach a prosthesis
III- Subperiosteal implants

27. Indication
 When there is not enough bone
in which to place an endosteal
implant.
 Severely atrophied mandible.
Construction
The shape of bone for frame construction is obtained
through:
Direct bone impression (2 surgical exposures)
CAD-CAM generated model (only one surgical exposure)

28. Upper framework
III- Subperiosteal implants
A three- dimensional replica of the mandible can be
developed from computerized tomography (CT) images.
Lower framework

29.  Classification of implants according to
position:
1. Endodontic stabilizer
2. Mucosal inserts
3. Subperioteal implant
4. Transmandibular dental implants
5. Endosteal implants (Endosseous)
CLASSIFICATION OF DENTAL IMPLANTS

30. IV-Transmandibular dental implants
“staple boneplates”
Transossous
dental implant
Transosteal threaded posts
which penetrate the full
thickness of the mandible and
pass into the oral cavity in the
parasymphysial area The staple
bone plate is used to rehabilitate
the atrophic edentulous
mandible
.

31.  A plate that fits against
the lower border of the
mandible at the
symphysis
Transosseous
dental
implant
and which has
posts rising
from it

32. - The implant is placed into
the alveolar bone.
Composed of
1. Anchorage component
(body) and
2.Retentive component
(abutment).
V- Endosteal (Endosseous) implants

33. V- Endosteal (Endosseous)
implants
1- Root form endosteal implants.
a- Cylinders endosteal implant.
b- Screws or spiral post
implant.
2- Blade form endosteal implant.

34.  Blade form (plate form): wedge shaped or
rectangular in cross section and are generally
2.5 mm wide, 8 to 15 mm deep and 15 to 30 mm
long.
 Root forms can be designed as cylinders or
screws or fluted or combination. They are 3 to 6
mm in diameter and 8 to 20 mm long root form
also could be internal connection or external
endosteal implants
Designs:

35. Root forms also categorized as
 One-stage implant be placed in the bone and to
immediately project through mucosa into the oral cavity
(and to place the cover screw or healing collar).
 The two stage implant requires two surgical procedures.
First it is placed in bone to the level of the cortical plate
and the oral mucosa is sutured over it. Then left for a
prescribed healing period (usually 3 month in the mand.
and 6 to 9 months in the max.) depending on the quality
of bone. In a 2nd surgery the mucosa is reflected from the
superior surface of imp. and healing collar is placed and
project into the oral cavity is fastened to the implant.
Designs:

36. Transosseous
dental
implant
Sub-
periosteal
implant
Endosteal
implants

37. a- Cylinders (Tubes ) which may be either tapered or
baskets (hollowed with fenestrations)
b- Screws or spiral post implant which may be either
solid or hollowed.
V- Endosseous implants
Root form implants:

38.  In 1973 Flander a new design of endosseous implants
to decrease the high rate of failure of the old screw
implants.
 The endosteal implant shaped in the approximate
shape of the tooth root.
 It may be used for fixed, removable or fixed detachable
prosthesis.
 It requires more than 10 mm vertical bone height, more
than 6mm buccolingual thickness, and more then 8mm
mesiodistal width to avoid undesirable complications.
Root form implants:

39. First Implant Design by Branemark
All the implant designs are obtained by the
modification of existing designs.
John Brunski

40. Comparison
of
Implant
Systems
Astra Tech.
ITI
Bicon

41. different implant designs
different implant-
abutment interfaces

43. V- Endosteal (Endosseous)
implants
1- Root form endosteal implants.
a- Cylinders endosteal implant.
b- Screws or spiral post implant.
c- Blade form endosteal implant.

44.  It is a wedge shaped implant composed of head,
neck and body with vents which develops fibro
osseous integration with bone.

45. dimensions do not permit the use of root
form implants. The blade implant was
restorable within a month of placement
by the superstructure
The blade implant is a mean
of utilizing the narrow and/
or shallow areas of
remaining alveolar bone
where

46. Ramus frame implant was designed to be placed in
the ramus of the mandible. to solve the problem that
existed in knife edge ridges

47. Osseointegration
 A direct structural and functional
connection between ordered living
bone and the surface of a load
carrying implant.
 This type of connection is considered
the most desirable one by many
authors.

48. Osseo-integrated. Non osseo-integrated.

49. CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO THE MATERIAL INTO:
 Ceramics.
 Polymers, or
 Carbons which decreases the induced
stresses in bone, but of lower strength
quality.
a- Non metallic implants
b- Metallic implants, high strength metals. It is
one of the most suitable types.

50. a- Pure titanium: the titanium oxide surface was
responsible for the formation of the direct
bone- implant interface.
b- Titanium alloy: the titanium alloys exist in three
forms: alpha, beta and alpha beta phases and they
all originate when pure titanium is heated and
mixed with aluminium and vanadium.
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO THEIR MATERIAL:

51.  Made from Ti-Alloy. Outer layer is titanium
oxide. Which may be pure titanium surface
or with other option such as TPS titanium
plasma-sprayed surface, tit. coated with
HA or porous ceramic substitute or (tri ca
ph)
 GRIT Blasted or acid etched to roughen
the surface and increase the area for bone
contact.
Material:

52. a- Sand blasted surface.
b- Titanium Plasma Sprayed surface (TPS),
It has satisfactory results regarding the
osseointegration and the clinical prognosis.
c- Titanium oxide surface: coating the implants
to make the inert metal a bioactive one.
d- Hydroxyapetite coating
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO SURFACE CHARACTERISTICS:

53. a- Press fit technique, Unthreaded implants, the implant
site is drilled slightly smaller than the actual implant
size, where the implant is pressed into the recipient site
with slight friction.
b- Self tapping technique, Threaded implants, the threads
are used to tap its site during insertion.
c- Pre-tapping technique, in case of very dense bone, the
implant sites are better to be previously tapped using
the bone tap instrument before insertion of the threaded
implant
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO THE INSERTION TECHNIQUE:

54. a- Single stage design (none submerged – transgingival):
the body of the implant is inserted into the bone with its
abutment portion penetrating through the
mucoperiosteum during the healing period.
b- Two stage design: the implant body is completely
embedded in bone for complete osseointegration. Then
exposed and the healing abutment is placed for soft
tissue healing before the impression is made for
prosthesis fabrication
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO SURGICAL STAGES:

55. CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO SURGICAL STAGES:
a- Biointegration: a non mineralized zone, a
pseudo-periodontium.
b- Ligamental integration: soft tissue layer
surrounding the implant.
c- Fibrointegration.
d- Osseointegration.

56. a- Immediate implants, placed into a prepared
extraction socket following extraction.
b- Immediate delayed implants, placed within
6-12 weeks after the tooth loss.
c- Delayed implants, placed within 6-12
months after tooth extraction, when
complete healing and bone remodeling
occur.
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO THE TIME OF INSTALLATION:

57. a- Immediately loaded implants, an acrylic resin
prosth which is designed to be out of
occlusion, placed immediately after implant
placement, specially in anterior region for
esthetic purposes.
b- Delayed loading implant, done in maxillary
implants after 4-6 months and in mandibular
implants after 3-4 months to allow for better
Osseointegration
CLASSIFICATION OF DENTAL IMPLANTS
ACCORDING TO THE TIME OF INSTALLATION:

58. Surgical Procedure
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC RESTORATION
Success Rates
Lower jaw, front – 90 – 95%
Lower jaw, back – 85 – 90%
Upper jaw, front – 85 – 95%
Upper jaw, back – 65 – 85%

59. • Why are the screws made of titanium?
It is a metal that is well
accepted by the body and
the bone can grow very close
to titanium, “OSSEOINTEGRATION”.

60. • How safe are dental implants?
Assumptions:
 Analyses were linear, static and assumed that
materials were elastic, isotropic and
homogenous.
 100% osseointegration is assumed between bone
and implant. Bone and implant are assumed to be
perfectly bonded.
 The stresses in the bone due to the interference
fit between implant and abutment is assumed to
be relaxed after the insertion of the abutment.

61. The treatment step by step
 One - stage surgery
 Two - stage surgery
o Examination
o Implant installation
o Healing period
o Prosthetic procedure
o New teeth are put in place
o Examination
o Implant installation
o Abutment installation
o Healing period
o Prosthetic procedure
o New teeth are put in place

62.  Examination
• Your dentist examines your gum, teeth and
jaws.
• X-rays are taken to assess the amount of
bone.
• Your medical condition will be evaluated.
The treatment step by step

63. The treatment step by step
 One - stage surgery
 Two - stage surgery
o Implants and abutments are installed at the same
time and visible in the mouth directly after
surgery.
o The implants are left to “sleep” under the soft
tissue. Abutments are connected during a minor
second operation.
Implant and abutment installation

64.  Healing period
 The length of the healing period is 3–6
months or shorter in certain cases.
Depends on factors such as bone quality
and implant position.
 Missing teeth are replaced with temporary
constructions.
The treatment step by step

65.  Prosthetic procedure
The treatment step by step
Impressions are taken to fabricate
a model of your jaw.
A crown, bridge or denture is
produced which matches your
other teeth in shape and color

66.  New teeth are attached to the
implants in place
You will now have teeth that
feel and look like your own!
The treatment step by step

67. Maintenance and Recall
 Annually
 periapical radiographs should be taken to monitor the crestal bone levels. (crestal
bone can be at the level of the first thread in one year with 0.1mm continued loss
to approximately 1. 5 mm total bone loss)
 remove and reinsert screw retained implant prostheses every 2 years unless
indicated otherwise.
 Replace prosthesis with new retaining screws if removed.
 Cemented restorations are usually permanent (nonretrievable).
 Recall focus
 Occlusion - verify there are no excursive contacts. Should not hold shimstock.
Better to be out of occlusion
 Oral hygiene - same requirements as for natural teeth.
 Soft tissue health - periodontal probing for evidence of disease.
 Screw joint torque - check for loosened screws (most common problem).
 Integrity of attachments - applies to overdenture / overpartials.
 Stability of implants - must be stable (non mobile) to be successful

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