Oral Maxillo-facial Surgical

2. Dr / Hamed Gad

3. Dental Implant
I. Definition
II. Indications
III. Materials used for dental implant.
IV. Types of dental implant
V. Osseointegration
VI. Surgical procedures

4.  Dental implant is an artificial
mtallic or non metallic fixture
which is placed surgically into the
jaw bone to substitute for a missing
tooth or teeth .
DENTAL IMPLANT

5. Dental implants

6. History of Dental Implants
In 1952, Professor 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, to form a permanent biological adhesion. He
named this phenomenon "osseointegration".
After years of careful research and study, dental implants
placed into the jawbone to support replacement teeth
were refined with high success rates.

7. Indications of dental implant
1. Patients who do not accept removable prosthesis
2. Where complete denture has deleterious effect on tissues
3. High gag reflex
4. Long edentulous span
5. Unfavorable number and location of abutments
6. When it offers to solve psychological problems associated
with edentulism
7. esthetics

8. Types of dental implant
1. Sub-periosteal implant
2. Transosseous
(transmadibular)implant
3. Endosteal or Endosseous implant

9. 1- Sub-periosteal
implant
2- Trans-mandibular Implants

10. these implants is the most
popular implants in the
world today.
3- Endosteal or Endosseous implant

11. Clinical implant
components of
endosseous implant

12. Implant( fixture)

14. Cover Screw

15. Abutment

16. Clinical implant components
Abutment

17. Impression Coping

18. Clinical implant components
Implant Analog

20. Retaining screw

22. (Patients selection)
1. Medical history.
2. Psychological status.
3. Dental history.
4. Study cast
5. Clinical and radiographic examination
6. Decision making and surgical phases

23. I. Medical History
Diseases that complicate or contraindicate
of implant selection:
1. Bleeding disorders
2. local or systemic bone diseases
3. Maxillofacial radiotherapy
4. Uncontrolled diabetes
5. Epilepsy
6. Hormonal dysfunctions
7. tobacco and alcohol

24. Pt selection
Psychological Status.
The dentist assesses the patient's
attitude, ability to cooperate during
complex procedures, and overall
viewpoint on dental treatment.

25. Pt selection
III. Dental History
It is also vital to evaluate the patient’s
chief complaint, or pt demand.
For example, the treatment plan
recommended to the patient desiring a more
secure lower denture will be quite different from
the one proposed to the patient seeking a fixed
and rigid appliance.

26. Evaluation of Implant Site
 Clinical examination.
 Visual inspection and Palpation

27.  Pathologic conditions in the
jaws
 Status of remaining teeth
 Quality of the bone (bone
density)
 Quantity of the bone height and
diameter of implant
 Vital structure and anatomical
27

28. Pt selection
Diagnostic imaging for dental implants
1. Intraoral (Periapical, Occlusal)
2. Extra-oral (Panoramic radiograph)
3. CT scan
4. Cone beam CT (CBCT scan)
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29.  PERIAPICAL RADIOGRAPH

30. Diagnostic imaging for dental implants
PANORAMIC IMAGING
30

31. 31
Cross sectional slices revealing the
height and B/L dimension of alveolar
ridge

33. STUDY CAST

34. Osseo-integration
Osseointegration refers to the
structural, and functional union between
functional implants and healthy bone
without soft, noncalcified connective
tissue intervening

35. Factors affecting osseointegration
1. Implants selection
2.Patients factors
3.Operators roles

36. Factors affecting osseointegration
1. Implant biocompatibility
2. Implant design
3. Implant surface treatment
4. Bone quality and quantity
5. Surgical technique
6. Loading condition
7. Soft tissue-to-implant interface

37. 1. Implant biocompatibility
1. Pure titanium
2. Titanium alloy
3. Calcium phosphate ceramic
material

38. 2. Implant form
 threaded,
 non-threaded

39. 3- Implant surface treatment
a. Titanium plasma—Sprayed
coating
b. Sand blasting—Surface etching
c. Laser induced surface roughening
d. Hydroxyapatite coating

40. Consequently Increased surface
area :
1. Implant number
2. Implant size
3. Implant body design
4. Implant surface treatment

41. 4- Bone Quality
 Quality I (D1)
Was composed of homogenous
compact bone.

42. 4- Bone Quality
 Quality II (D2)
Had a thick layer of
cortical bone surrounding
dense trabecular bone,
usually found in the
posterior lower jaw.

43. 4- Bone Quality
Quality III (D3)
Had a thin layer of
cortical bone surrounding
dense trabecular bone

44. 4- Bone Quality
Quality IV (D4)
Had a very thin layer of
cortical bone surrounding a core of
low-density trabecular bone

45.  4- Bone quantity
 Implants placed in the posterior mandible are
usually shorter, do not engage cortical bone
inferiorly, and must support increased
biomechanical occlusal force once loaded.
 As a result, slightly increased time for
integration may be beneficial.
 Additionally, if short implants (8 to 10 mm) are
used, it is advisable to "overengineer" and to
place more implants than usual to withstand the
occlusal load.

46.  4- Bone quantity
the quality of the bone in the
maxilla, particularly the posterior
maxilla, is poorer than mandibular
bone.
which affect treatment planning
because increased time must be
allowed for integration of implants.

47. 5- Surgical technique
a) Prevent Heat generation
b) Precisely implant site preparation
c) post insertion care

48.  5- Surgical technique
 Heat generation
 If the temperature rises, alkaline phosphatase within
the bone is denatured, which prevents alkaline
calcium synthesis.
 Temperatures at 47° -56° C, lead to irreversible bone
damage occurs.

49. 5. Surgical technique
Heat generation
So careful cooling while surgical drilling is performed at low
rotatory rates
 Use of sharp drills
 Use of graded series of drills
 High torque (35-55N)

50. 5- Surgical technique
Heat generation
 Copious irrigation by either internal or external
methods to keeps mean maximum temperature
not exceed 47°C.

51. Surgical technique
B-Precisely implant site preparation
4
Use of sharp drills
Use of graded series of drills
High-torque drills are
essential to precise a
traumatic bed preparation

52. C- post insertion care
 Once the implant is placed, a healing cover is inserted
and the mucosa is sutured over the implant.
 In some cases the implant is not covered and a short
healing screw protrudes through the gingival.
 In all cases the implant is protected from occlusal
forces.

53. C- post insertion care

54. C- post insertion care

55. C- post insertion care

56. 6. Loading condition
1. Immediate loading:
(placed within 48 hours postsurgery)
3-Delayed loading:
implant remain functionless for 3-6 months

57. 7- Soft Tissue-to-Implant Interface
 The successful dental implant should have an
unbroken, perimucosal seal between the soft
tissue and the implant abutment surface.
 To maintain the integrity of this seal, the patient
must maintain a high level of oral hygiene
specific to dental implants.

58. Timing of implantation
Treatment options
• immediate - place implant at time of tooth
extraction
• delayed - 9-10 months or longer
 immediate will not allow bone resorption, but
delayed allows bone fill for stabilization

59. Immediate placement in extraction
socket
implant placement at the time of extraction
will require the following:
• No purulent drainage or exudate from the
site
• Excellent gingival tissue quality without
excessive granulation tissue
• Lack of periapical, uncontrolled
radiolucency
• Adequate bone levels circumferentially
without the need for additional soft or
hard tissue grafting

60. Implants placed in fresh extraction sockets must have 4 mm of precise fit
along apical aspect of implant. They should be countersunk 2 mm, and
gap between sides of extraction socket and implant should be less than
1 mm. If gap is greater than 1 mm, grafting with demineralized allogeneic
bone should be considered.

61. Surgical procedure
 The placement of osseointegrated
implants includes two stages:
 Stage one surgery
 Stage two surgery

62. Basic Treatment Order
1. Examination—clinical and radiographic/medical history/pathological test, etc.
2. . Fabrication of provisional or transitional restorations
3. . Fabrication of surgical guide or stent
4. . Surgical placement of implants
5. . Allow adequate time for osseointegration
6. . Prosthodontics phase
7. . Maintenance phase
Decision regarding the treatment order may vary, based on the degree
of difficulty. But, for cases involving a traditional plan, the following may
be used.

63. Stage one
surgery

64. Surgical micromotor appropriate for placement
of implants

65. Set of instruments for placement of osseointegrated implants

66. Anesthesia
 Local Infiltrations
 Nerve blocks
 Conscious sedation

67. Flap design
1-Envolped flap using crestal incision
2- triangular or pyramidal flap
3- Punch flapless technique

68. Clinical features after punching the soft tissue at the
proposed implant sites with a 3-mm soft tissue
punch.

69. 1-Envolped flap using crestal incision

70. Reflection of flap and exposure of bone where implants are to
be placed.

71. Implant Recipient Site Preparation
- Guiding drill
the round guide bur first used to flatting
the bone at the implant site with speed,
approximately 2000 rpm
Constant irrigation of saline solution, while
the bur must move in an up-down
direction

72. Guide drill preparation at cortical bone using
round bur.

73. Preparation of initial recipient site with a 2-mm-
diameter bur and placement of paralleling pin.

74. The entire length of the recipient sites
is widened with serial diameter of
drills according to the diameter of
the selected implant and the
quality of the bone.

75. a Completion of reparation of recipient site

76. Installation of implant by way of screwing into prepared
recipient site at bone.

77. Universal ratchet or torque wrench
10-45 N

78. Continuation of insertion manually with cylinder wrench, until
implant reaches deepest part of recipient site.

79. Hex driver/hex tool/screw driver

80. Placement of cover screw over implant, to preventing
intervention or proliferation of mucosal tissues inside implant.

81. Operation site after repositioning and suturing
of flap.

83. Implant Placement
After the desired depth and diameter of the
recipient site is accomplished, the implant is
placed using implant carrier .
Avoid implants touching with instruments made of
a dissimilar metal or by contact with cloth, soft
tissue, or even surgical gloves that may affect the
degree of osseointegration.

84. Implant Placement
In this step, the implant is adapted to the
receiver of the implant mount, which has
been placed in the low-speed contra-angle
handpiece and is transferred to the
implant recipient site. The implant is
screwed into the bone without pressure.

85. Implant Placement
Afterwards, a cylinder wrench is used to screw
the implant manually as far as the deepest
part of the recipient site. The implant mount
is removed either by hand using a
screwdriver, or mechanically with a
screwdriver attached to the lowspeed contra-
angle handpiece.

86. Cover screw placed
In the final step, a cover screw is placed,
screwed over implant, thus preventing
intervention or proliferation of the mucosal
tissues inside the implant. Final tightening
must be done by hand, being careful that it is
not so tight that removal is rendered difficult
in the second stage of surgery.

87. Wound closure
the wound is closed. A tension-free closure is
important to prevent wound dehiscence.
Horizontal mattress closure with
monofilament suture will produce a
watertight closure.

88. Post operative care
A radiograph should be taken postoperatively to evaluate the
position of the implant in relation to adjacent structures
-antibiotics
-analgesics for management of postoperative pain.
-Regular oral hygiene
- The sutures are removed 7 days after the operation.

89. Periapical radiograph taken
immediately

90. Delayed postoperative care
The patient is evaluated on a weekly basis
until soft tissue wound healing is complete
(approximately 2 to 3 weeks). If the patient
wears a denture over the area of implant
placement, the denture can be relined with
a soft liner after 1 week and may be worn.

92. Stage 2 surgery

93. second stage of the surgical
procedure
Uncovering
The length of time necessary to achieve integration
varies from site to site and may require modification
based on the particular situation. Successful loading
with shorter integration times has been reported
when various protocols are follow.

95. the second phase of the surgical
procedure
Abutment Connection.
After the first-stage surgical procedure, the second phase of the surgical
procedure follows, which involves the exposure of the implants and
the placement of abutments on the implants. After administration of
local anesthesia, the position of the implants is identified with
palpation and the cover screw is localized using an explorer.
Exposure is achieved with a continuous incision on the alveolar
mucosa, corresponding to the pre-calculated positions of the implants.

96. Flap design:
1. Cristal incision,
2. Tissue punch,
3. Apically repositioned flap

97. Flap design

98. Flap design

99. Flap design

100. Identification of position and exposure of implants. Incision along
length of alveolar crest, respective to precalculated positions of
implants.

101. Removal of soft tissue over cover screw with tissue punch

102. Removal of osseous overgrowth over cover screw with
cover-screw mill. b, c Removal of cover screw manually with
screwdriver

103. Healing cap

104.  A radiograph to ascertain the precise connection between
the abutments and implants is only necessary for external
implant abutment connections (Branemarktype).
 Then 15–20 days after placement of the abutments, the
patient is ready to begin the procedure for a fixed or mobile
prosthetic restoration .
 A bar may be fabricated joined to the implants with screws,
and an over denture may be adapted to the bar with the aid
of clips.

105. Implants joined by over-denture bar over which
prosthetic restoration is to be placed

106. Complications
The main complications that may arise during placement
of the implants as well as postoperatively are:
􀁏 Damage to adjacent anatomic structures, in the case of
perforation of the maxillary sinus, nasal cavity, and
mandibular canal by the implant

107. Complications
􀁏 Failure of osseointegration, which may be due to
premature loading of implants during the
healing period, to bone damage because of the
surgical procedure, to improper design of the
prosthetic restoration or ill-fitting prosthetic
work, and to poor judgment of the quality of
bone at the implant recipient site

108. Complications
􀁏 Gingivitis, gingival hyperplasia, or the
appearance of a fistula
􀁏 Exposure of implant threads
􀁏 Fracture of implant, which usually involves
the abutment screw or the implant itself

109. Criteria for successful implants
 • Implant clinically immobile
 • No radiographic evidence of any peri-implant
radiolucency
 • Vertical bone loss of <0.2 mm after the first year of
function
 • Absence of any symptoms, such as pain, infection,
numbness, or maxillary sinus or nasal symptoms
 • Success rate of 85% after 5 years and 80% after 10 years

110. ADVANTAGES Of DENTAL IMPLANTS
1. Aids in bone maintenance—prevents the
progress of residual ridge resorption.
2. Restoration and maintenance of occlusal
vertical dimension.
3. Maintenance of facial esthetics (muscle tone)
Implants also provide a natural emergence
profile.
4. Improved phonetics
5. Improved occlusion
6. Improved occlusal awareness
7. Improved masticatory performance,
maintenance of masticatory muscles and
muscles of facial expression
8. Reduced size of prosthesis
(elimination of palate or flanges)
9. Provision for fixed or removable
prosthesis
10. Improved stability and retention
of fixed prosthesis implants provide
stable retention due to
osseointegration
11. Eliminates need to alter adjacent
teeth
12. More permanent replacement
13. Improved psychological health
14. Improved comfort level.

111. Basic principles of implant surgery
1. Implants must be sterile and made of a biocompatible material (e.g.,
titanium).
2. Implant site preparation should be performed under sterile conditions.
3. Implant site preparation should be completed with an atraumatic
surgical technique that avoids overheating of the bone during
preparation of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without micro-movement
111

113. Dr,salah hegazy
THAN
K YOU Thank You!