complete advances in surgical aspects of dental implants

1. By Dr Pulak Mishra
Final year PG

2.  MEDICAL USES
 HISTORY
 TECHNIQUE
 PLANNING
 GENERAL CONSIDERATIONS
 BIOPHOSPHONATE DRUGS
 MAIN SURGICAL PROCEDURES
 ADDITIONAL SURGICAL PROCEDURES
1. HARD TISSUE MANAGEMENT
2. SOFT TISSUE MANAGEMENT
 CONCLUSION
 REFERENCES

3.  A dental implant (also known as an endosseous implant or fixture) 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 for modern dental implants is a biologic process
called osseointegration where materials, such as titanium, form an
intimate bond to bone. The implant fixture is first 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 prosthetic.

4.  The risks and complications related to implant therapy are divided into
those that occur during surgery (such as excessive bleeding or nerve
injury), those that occur in the first six months (such as infection and
failure to osseointegrate) and those that occur long-term (such as peri
implantitis and mechanical failures).
 In the presence of healthy tissues, a well integrated implant with
appropriate biomechanical loads can have 5-year plus survival rates from
93 to 98 percent. and 10 to 15 year lifespans for the prosthetic teeth.

5. Implants have evolved into three basic types:
1. Root form implants; the most common type of implant indicated for all
uses.
2. Zygoma implant; 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.
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.

6. 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.

7.  Sometimes the final position and restoration of the teeth will be simulated
on plaster models to help determine the number and position of implants
needed.

8.  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.

10. FIRST STAGE SURGERY
 Fixture installation is done in the first stage surgery. The operator must
have a thorough knowledge of fixture installation procedures and detailed
knowledge of instrumentation use during this first surgery.
The first stage surgery consists of five events, listed as follows
1. Surgical incision of gingiva and mucoperiosteal flap reflection
2. Drilling and countersinking procedures
3. Tapping procedure
4. Fixture installation and cover screw placement.
5. Soft tissue re-adaptation and suture procedures.

11. An area with a single missing tooth
An incision is made across the gingiva, and the flap of tissue is
reflected to show the bone of the jaw.
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 fixture is turned into the osteotomy. Ideally, it is
completely covered by bone and has no movement within the
bone.
A healing abutment is attached to the implant fixture, and the flap
of gingiva is sutured around the healing abutment.

12.  The incision line is marked on the crestal ridge
between the canine regions. The surgical incision is
made with a no. 15 blade and cut through mucosal
tissue along the same line.
 Blade is angled towards the basal body of the
mandible.
 When the muscle fibers have been dissected in the
direction of the crestal ridge, the periosteum can be cut.
 The periosteum is cut carefully 5.0 mm below the
crestal ridge between the canine regions but not near
the mental foramina.

13.  Use of any of the drilling instruments
requires copious saline irrigation. Two
methods for irrigation include use of sterile
syringes or use of irrigation equipment
provided for the System
 During drilling, the bur is moved in an up-
and-down motion into the prepared site to
help remove residual bone and maintain
adequate cooling as deep into the site as
possible.

14. Use of 2.0 mm Twist Drill
 The 2.0 mm diameter twist drill is used to
enlarge the fixture site.
 Initially fixture site is prepared closest to the
midline. The direction can be checked with the
surgical splint for labiolingual orientation, but
the mesiodistal orientation should be
perpendicular to the alveolar crest.
 After the twist drill has been used, a direction
indicator into the prepared site is inserted.
 Next, the most distal site on the left with the
2.0 mm diameter twist drill is prepared.

15. Use of pilot drill
 After placement of all direction indicators into prepared
sites, use the pilot drill to enlarge the site from 2.0 mm to
3.0 mm diameter.
 After pilot drilling is finished, the fixture site is
enlarged with a 3.0 mm diameter twist drill. This
procedure is important for preparing the fixture site to
the proper depth.
 If the quality of cortical bone is hard and dense, drilling
can generate heat with detrimental side effects.
 If the quality is low with low density, the length may be
increased to engage cortical bone.
 After using 3.0 mm twist drill in the first site. The
direction indicator is inserted into the prepared site.

16. Use of Countersink
 After all fixture sites have been enlarged with
either the 3.0 or 3.15 mm twist drills, the
countersink procedure is done to all fixture
sites to achieve a fixture and cover screw
height level with the alveolar bone.
 If a short 7.0 mm fixture is to be used, the
short countersink should be used for this
procedure.
 After completion of drilling with the high
speed motor, each fixture site should be
checked with the depth gauge to establish final
fixture length.

17. Tapping procedures
 Tapping is the procedure of creating threads into the
fixture site and requires careful technique and profuse
irrigation. These procedures are completed using the
low speed handpiece to avoid heat generation in
bone.
 Attach the screw tap to the hand-piece connector.
Begin tapping the fixture sites from the distal most
left site and check using the direction indicators for
parallelism.
 Do not apply pressure while the threading procedure
is being done and continue profuse irrigation.
 After tapping procedure is completed on one fixture
site, fixture installation should follow immediately.

18. Fixture Installation
 The fixture is in a titanium cylinder case, then removed with
titanium forceps and placed into the titanium organizer.
 Next, attach a fixture mount to the fixture using the open-ended
wrench and long screwdriver.
 The fixture is initally installed without irrigation until the
horizontal hole of the fixture has threaded into the site and is not
visible. In this manner, saline is prevented from being pressed
into the narrow space adjacent to the fixture.
 At the time of the second surgery, mobility is a reliable test for
osseointegration.

19.  Position the explorer near probable fixture sites and insert
through the tissues. Change the explorer position slightly
to make contact with the cover screw through attached
gingiva.
 A surgical incision is made approximately five millimeters
in length to locate the center of the cover screw. A
periosteal elevator is used to reflect the flap and expose all
cover screws.
 When a cover screw is located, the punch blade needle is
inserted into the cover screw center hole, pushed apically,
and rotated to cut tissues circumferentially.

20. Removal of the cover screw
 When the cover screw is exposed, use either a short or long screw driver to
unscrew the cover screw.
 After removing the cover screw, use the punch blade to cut and remove
excess periosteum.
 All excess soft or hard tissue should be removed prior to seating the
abutment, otherwise the connection between the fixture and abutment will
be incorrect.

21. Abutment connection
 Use the depth gauge to measure the depth of tissue between the fixture
head and gingival margin. Abutment lengths are available in various
lengths, 3.0, 4.0, 5.5, 7.0, 8.5, and 10.0 mm.
 In the maxilla, the abutment selected should be at the same height or one
millimeter higher than the gingival margin. This is important for esthetic
and functional speech purposes.
 In the mandible, the abutment selected should be one to two millimeters
higher than the gingival margin.

22.  The gingival height changes may require changing the abutment lengths
prior to prosthetic treatment.
 After connecting the abutment to the fixture, the percussion sound is
checked for clarity. When the sound is clear, direct bone anchorage is
present. When the sound has a dull quality, this may be indicative of soft
tissue interposed between the abutment and fixture.
 When direct bone anchorage is questionable, design of the prosthesis
should be conservative.

23.  Radiographic examination is necessary to verify abutment position on the
fixture.
 If the position is not accurate, the radiograph reveals a space between the
abutment and fixture seen as a translucent area.
 When this occurs, repeat abutment connection procedures and verify with
another radiograph

24.  There are different approaches to placement dental implants after tooth
extraction.The approaches are:
1. Immediate post-extraction implant placement.
2. Delayed immediate post-extraction implant placement (two weeks to
three months after extraction).
3. Late implantation (three months or more after tooth extraction).
 There are also various options for when to attach teeth to dental
implants, classified into:
1. Immediate loading procedure.
2. Early loading (one week to twelve weeks).
3. Delayed loading (over three months)

25. One-stage, two-stage surgery
 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.
 After an integration period, a second surgery is required to reflect the
mucosa and place a healing abutment.

26.  In the early stages of implant development (1970−1990), implant systems
used a two-stage approach, believing that it improved the odds of initial
implant survival. Subsequent research suggests that no difference in
implant survival existed between one-stage and two-stage surgeries
 When tissue is deficient 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.

29.  Three common procedures are:
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)

30.  There are many well-documented approaches for
augmentation of the maxillary sinus in preparation for
implant therapy. These approaches range from very
simple to complex.

31. 1. In its simplest form, the Le Fort I osteotomy is an
aggressive and necessary for the patient with severe
maxillary atrophy.
 The accomplishment of maxillary down fracture allows
the surgeon unparalleled access to the maxilla. From this
vantage, cortico-cancellous grafting in large volumes
proceeds unimpeded.
 In addition, simultaneous maxillary advancement for the
severely deficient maxilla permits a better dental
relationship for prosthetic treatment planning. In most
circumstances, dental implants can also be placed at the
same time, with primary stability afforded by block
cortical bone grafting.

32. 2. The lateral approach, which is used far more often, is essentially a variation
of the classic Caldwell-Luc technique for access to the maxillary sinus.
 This approach permits the implant surgeon to gain access to the inferior
aspect and floor of the sinus. An incision is made at the height of the
crestal bone with releasing incisions as needed posteriorly or anteriorly to
reduce flap tension.
 An osteotomy is created in the lateral maxillary sinus wall. The lateral
maxillary wall is then either fractured medially off a superior ‘‘hinge’’ or
pushed bodily into the sinus.
 The mobilized lateral maxillary wall segment forms a ‘‘roof’’ under which
grafting can proceed along the maxillary sinus floor as necessary.
 For primary stability of the implants requires approximately 4 mm of bone
height. I

33. 3. Other approaches to the maxillary sinus can be made
through the lateral nasal wall or through the alveolus.
 The nasal approach is primarily an antrostomy, which
is an approach used by oral and maxillofacial surgeons
as well as otolaryngologists for the management of
sinus pathology.
 Augmentation of the sinus through the alveolus can be
performed through an osteotome technique whereby
progressively larger osteotomes are ‘‘tapped’’ through
the alveolus into the sinus floor, ostensibly pushing
bone superiorly and therefore creating vertical height
through the implant site.

34. (A) A typical maxillary sinus
augmentation case begins
with imaging, measurement,
and diagnosis.
(B) After incision, flap
reflection, sinus mucosa lift
and implant placement, the
augmentation material can be
packed around the implant.
(C) The flap is replaced and
incision closed.
(D) An image confirms
appropriate implant
placement and adequate sinus
augmentation.

35.  If bone width is inadequate it can be
regrown using either artificial or
cadevaric bone pieces to act as a
scaffold for natural bone to grow
around.

36.  When a greater amount of bone is
needed, it can be taken from another
site (commonly the back of the bottom
jaw) and transplanted to the implant
site.

37.  Bone grafting is necessary when there is a lack of bone.
 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=7–9 mm, C=4–6 mm and D=0–3 mm) where an implant's
likelihood of osseointegrating is related to the grade of bone.
 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 filled 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.

39.  Timing in relation to soft tissue management.
 Soft tissue management before implant placement
 Optimizing keratinized tissues
 Socket seal techniques
 Modified socket seal surgery
39
TOPICS COVERED

40.  Soft tissue management in delayed implant placement
Mucoperiosteal flap design:-
 The classic vestibular approach-
 Crestal approach:-
 Preservative interproximal papilla incision
 Modified elden-mejchar technique
 Soft tissue management in immediate implant placement:-
 Palatally rotated flap
 Buccal rotated flap
 Rehermanplasty
 Pedicle island flap
 Guided tissue regeneration
 Socket seal template technique the use of soft tissue managment
 Flapless technique for implant placement
 Mucoperiosteal flap closure in critical conditions 40

41.  Soft tissue management at the time of abutment connection:-
 Bulking keratinized or connective tissues facially.
 Scalloping the keratinized tissues
 Limiting the incision to the keratinized tissues
 Preserving intact interproximal papillae and
 Using connective tissue grafts in conjunction with second stage
surgery
 Soft tissue management postabutment connection
 Onlay grafting
 Inlay grafting
 Connective tissue pouch procedures
 Gingival recontouring techniques
 Use of provisional restorations
 Soft tissue procedures for reconstruction of the interimplant
papillae
41

42.  Osseous regenerative methods for interimplant papillae
 Noninvasive methods for papillary reconstruction
 Prosthetic solutions for papillary creation
 Other methods for papillary reconstruction
42

43.  Collar does not receive any blood supply from
a surrounding periodontal ligament or any other
vessels.
 It acquires a fibrous connective tissue band
around its collar that is more dense and
acellular.
 Very fragile nature of the oral mucosa makes its
ability to withstand excessive clinical
manipulations unpredictable, which can lead
sometimes to asymmetrical final implant
prostheses.
43

44.  Allen et al.1985 identified three categories of ridge defects in relation to the healthy
soft tissue margins:
(a) mild, a defect of less than 3 mm
(b) moderate, a defect of 3-6 mm and
(c) severe, a defect greater than 6 mm.
 Seibert and Salama ,1996 classified volumetric deformity changes of the
edentulous ridge into three general categories:
 Class I:-buccolingual loss of tissue with normal ridge height in an apicocoronal
dimension
 Class II:-apicocoronal loss of tissue with normal ridge width in a buccolingual
dimension and
 Class III:- combination of buccolingual and apicocoronal loss of tissue, resulting in
loss of normal ridge height and width.
44

45.  Soft tissue correction of a deficient edentulous ridge is best performed before
implant placement; this can help improve aesthetics, phonetics, and oral hygiene
maintenance.
 Three-month waiting period for the soft tissue to stabilize before selecting the final
abutment. (Small and Tarnow 1997)
 The majority of the recession occurred within the first three months, and 80% of all
sites exhibited recession on the buccal surface.
 It is therefore recommended to allow three months time for the tissue to stabilize
and mature before either selecting a final abutment or making a final impression in
order to avoid any unpredictable tissue behavior around the final prosthesis
45

46.  Two to four months before the first-stage implant placement
surgery takes place.
46

47. This technique provides sufficient keratinized mucosa for a soft tissue
closure procedure on top of the implant.
This new regenerated tissue subsequently minimizes surgical trauma
that occurs due to attempts to achieve primary closure in immediate
implant placement.
47

48. 48

49. 49

50.  First described by Landsberg and Bichacho 1997
 Preserves the integrity of the alveolar ridge and inhibits apical
epithelial migration into the socket.
50

51. 51

52.  The soft tissue graft is prone to
thinning, necrosis, and infection,
due to the poor blood supply to
the graft.
 It generally does not come to
possess the same texture or color
as the surrounding soft tissues.
52

53.  Modified by Misch et al.
 Enhance the quantity and quality of bone and soft tissue.
 To preserve the original biological architecture of the alveolar
ridge at the place of tooth extraction.
53

54. It is preferably performed when the
socket walls are intact.
In this technique, a composite graft,
consisting of epithelial tissue,
connective tissue, periosteum,
cortical bone, and cancellous bone,
is harvested from the tuberosity
area to fill and seal the socket
54

55. 55

56. 56

57. 57

58. 58

59.  It merges and blends with the adjacent keratinized tissues
after completion of the healing process.
 The autogenous bone is found to be more predictable for bone
regenerative procedures.
59

60. Misch et al 1999 have also used platelet-derived growth
factor (PDGF) from the patient's own blood that
functions as a chemoattractant for mesenchymal cells
to enhance bone formation rate.
60

61. Nonsubmerged implant are
preferred as they do not
require a second-stage surgery
because the access to the
implant is maintained above
the soft tissue from the time of
its placement.
Buser et al 1990 stated that
osseointegration showed high
predictability in the one-stage,
nonsubmerged surgical
protocol; this referred to the
elimination of the subgingival
implant-abutment connections.
61

62.  Mucoperiosteal Flap Design:-
 The classic vestibular approach-
 First described by Branemark et al 1998
 The objective of this design is to position the incision line away from the head of the
implants.
 The design involves a horizontal incision in the vestibular mucosa parallel to the
gingival margin.
 A lingually or palatally pedicled mucoperiosteal flap is next obtained through two
vertical incisions.
 Disadvantages:-severe postoperative edema and compromised blood supply to the
site accompanied by an inflammatory reaction .
62

63. Crestal approach:-
 It is simple, does not require professional surgical experience.
 Can be easily sutured, offers faster healing, does not
compromise the blood supply to the site and
 Exhibits a mild inflammatory reaction.
63

64.  Favors aesthetics because the preservation of the papillae stabilizes the adjacent
margins of the implant-supported prosthesis, reduces postoperative soft tissue
recession, and reduces the tendency for marginal bone loss.
 lessened tendency to lacerate the interdental papillae during surgery.
 The preservative interproximal papilla flap design allows better flap adaptation upon
closure
64

65. 65

66.  Introduced by Nemkovesky et al 2000.
 Achieving primary closure on top of an immediate implant
without modifying or altering the buccal contour of
keratinized mucosa.
 A palatal pedicle flap is rotated towards the buccal mucosa to
cover the socket orifice
66

67. 67

68.  Becker and Becker 1990 developed the buccal rotated flap
technique
 The technique can achieve a complete tension-free closure
without creating any mucoginigival discrepancies.
 Becker and Becker originally recommended a split thickness
flap from the tooth adjacent to the donor tooth to cover the
exposed bone on the donor tooth itself.
68

69. 69

70. 70

71. 71

72.  Most common method among clinicians for primary soft
tissue closure in the oral cavity.
72

73. 73

74.  The flapless, immediate placement technique is utilized to maintain
the natural soft tissue contours, preserve alveolar ridge integrity, and
avoid additional soft tissue trauma by raising a mucoperiosteal flap
Preservation of the delicate vascular network adjacent to implant.
(Al-Ansari BH and Morris RR 1998)
74

75.  No absolute necessity for either
bone augmentation or primary
flap closure when placing
implants in freshly extracted
sites.
 The flapless approach is still a
blind surgical procedure
75

76.  Two basic surgical protocols are used to expose the implant
head at the second-stage surgery:-
 Reflecting a mucoperiosteal flap next to the implant to be
restored.
 Soft tissue punching technique.
76

77.  Bulking keratinized or connective tissues facially.
 Scalloping the keratinized tissues
 limiting the incision to the keratinized tissues
 preserving intact interproximal papillae and
 using connective tissue grafts in conjunction with second stage surgery.
77

78.  Develop the future
biological width & to
compensate for any
postoperative soft tissue
remodeling or gingival
recession.
78

79.  This method ensures tighter adaptation of
the soft tissue to the abutment (Herrel et
al 2001):-
 Reducing the tendency for developing a
dead space and
 Minimizing any possible soft tissue
marginal discrepancy around the
abutment.
79

80. Modified roll therapy
80

81. These techniques originally aimed
at increasing the width of
keratinized tissues, treating
mucogingival defects, and
arresting gingival recession
around natural teeth.
Onlay soft tissue grafting may be
performed prior to implant
placement or after connection of
the final abutment, to improve the
integrity of soft tissue contours,
stabilize soft tissue margins, and
treat minor deficiencies.
81

82. 82

83.  Color and texture mismatch between the graft and the surrounding tissues (tire patch
appearance)
 Difficulty of graft adaptation to the recipient site.
 Graft mobility due to hematoma formation, graft shrinkage (approximately 30%)
from its original size after healing is complete and
 Difficulty of achieving proper adherence of the graft to titanium abutments, which
has caused some clinicians to abandon this grafting procedure after the abutment
connection.
 A recent development in onlay grafting procedures is the introduction of the
acellular dermal matrix.
 Grafting with autogenous tissue or freeze-dried skin can be an accepted method for
increasing and/or restoring the width of attached gingiva.
83

84.  The technique of using inlay grafting showed success and predictability in treating
one-, two-, and three-dimensional soft tissue defects around natural teeth and dental
implants. .
 This technique is now used routinely by many clinicians to enhance soft tissue
profile with implant-supported dental restorations.
 Connective tissue grafts are applied clinically in two different forms:
(1) a graft composed solely of connective tissue or
(2) a graft composed of connective tissue that has an epithelial rim.
84

85.  The inlay grafts have an advantage over the onlay grafts because they combine the
characters of the soft tissue autograft and the pedicle flap procedure.
 This combination doubles the blood supply to the graft, thus increasing its chances
of survival
 Inlay grafts attain the same color and texture of the tissues surrounding the recipient
site after healing has occurred
85

86. 86

87.  It is used to correct confined minor ridge deficiencies, where the color and surface
characteristics of the area after grafting should not differ from the original tissue
character .
 The procedure is indicated when the alveolar defect is not large in size.
 "closed connective tissue grafting procedure" because the graft is totally embedded
under the soft tissues,
87

88. 88

89.  Gingival recontouring techniques are plastic surgical procedures used to reshape or
refine peri-implant soft tissues
 They are usually performed after the implant is restored.
 The techniques require a favorable keratinized tissue condition, in terms of quality
and quantity.
89

90.  Resurfacing by laser is widely used by plastic surgeons because:-
 it has been shown to control the depth of tissue removal better than any other
traditional method
 it allows for precise tissue trimming
 it offers a bloodless field and
 it emits less heat generation to the underlying tissues than do rotary instruments.
90

91.  Electrosurgery can be used to remove the excess bulky gingival contours or
smoothen tissue scars, as is done in laser resurfacing.
 Tissue warming due to the heat emitted from the electrodes sometimes delays
healing.
 This method should be applied with caution because there is an increased risk of
implant failure if the electrode contacts the implant surface.
91

92.  Minor plastic surgical procedures known as gingivoplasty can be used to treat
undesirable aesthetic gingival contours, provided a sufficient amount of keratinized
tissue is present.
 It is usually limited to patients with the thick flat tissue biotype
 It is used when final maturation of the soft tissue around the implant-supported
restoration has occurred.
 The procedure entails removal of the excessive facial gingival tissues using either a
sharp scalpel or a high-speed diamond bur.
92

93. Implant-supported provisional restoration is
considered an important tool for reshaping and
profiling the periimplant soft tissues without
performing any surgical intervention after the
second-stage surgery is completed and soft tissue
is healed.
It is considered the most important factor
responsible for a natural appearance of implant-
supported restorations.
stimulates periimplant tissues to attain the same
configuration and dimensions as missing original
natural soft tissue contours.
93

94. The presence of the interproximal
papillae around implant supported
restorations allows symmetrical soft
tissue margins and a state of
harmony between natural and
dental implant components.
The slightest change in the level of
the interproximal papillae around
dental implants due to pathologic
reasons or poor soft tissue handling
during implant treatment can lead to
major aesthetic and phonetic
complications.
94

95.  Interimplant papillae have a connective tissue fiber orientation,they have a high percentage of
collagen fibers with fewer fibroblasts, and attain a less adequate blood supply because of the
absence of the periodontal ligament.
 This makes the interimplant papillae more like scar tissue, which may complicate any
attempts for surgical repair or reconstruction.
 When the interimplant papilla is missing or does not totally fill the embrasure space, the
condition looks like and is called a black triangle.
95

96.  Nordland et al. have classified the clinical condition of the interdental papillae
according to their marginal level.
96

97.  Tarnow et al. developed a useful classification for clinically
identifying the predictability of the presence of interdental
papillae:-
97
•They concluded that when the
measurement from the contact point of
the natural tooth to the crest of the bone
was 5 mm or less, the papilla was present
almost 100% of the time
•when the distance was 6 mm, the papilla
was present 56% of the time
•when the distance was 7 mm or more,
the papilla was present in only 27% of
the time or less

98.  Salama et al. proposed another interesting classification that
furnished a prognostic classification system for the peri-
implant papillae.
98

99.  class I-A cases:- no need to increase the alveolar ridge
contour in vertical or horizontal dimensions.
 Class II-B:-- A proper soft tissue augmentation technique
can be of utmost importance in class II-B cases
 Abutment installation has been performed using the tissue-
punch technique
 Surgical technique to restore a papilla-like tissue between
implants
99

100.  Class III-C
 Bone grafting aims at restoring adequate support for the
implant and soft tissue.
 The subsequent clinical situation should approach class II-
B and then class I-A after performing soft tissue
augmentation.
 Class IV-D
 vertical dimension of the future implant site has been
markedly altered.
 Bone resorption and soft tissue collapse require major
surgical reconstruction prior to implant placement 100

101.  Bone grafting
 Orthodontic eruption of the ridge
 Segmental osteotomy.
 Distraction osteogenesis.
101

102. Soft Tissue Procedures for Reconstruction of the
Interimplant Papillae
10
2

103.  Beagle's technique entails a palatal pedicle flap that is
folded and tied on itself on the facial side in order to
increase the height of the interimplant papilla.
 This method did not attain a high success rate because of
the compromised blood supply of the smallsized pedicle
10
3

104.  Alternatively, Han and Takei described a technique that makes
use of a pedicle graft with a semilunar incision and total
coronal displacement of the gingival unit.
10
4

105.  Azzi et al. employed a connective tissue graft to be placed on
the defective area then tucked under buccal and palatal flaps,
thus providing the graft with an adequate blood supply .
10
5

106.  The interimplant papilla regenerative template is
a carrier fabricated from pure titanium.
 It acts as a housing that supports the bone-
grafting material on the alveolar ridge, and it is
placed between two implants to regenerate an
osseous foundation for the interimplant papilla.
 The template is to be placed at the time of
implant insertion, therefore eliminating the need
for any additional surgical procedure.
 Other advantages of the template are that it
carries and protects the bone graft material and
also separates the bone-grafting mix from the
undesired fibroblast and epithelial cells, which
favors graft predictability.
10
6

107.  The use of the template requires a space of not less than 3 mm between two adjacent
implants.
 After the implants are inserted, the interimplant bone is decorticated, to provide
sufficient blood supply to the graft.
 use of 100% autogenous chips can provide a more predictable clinical outcome.
 The template is then placed on the ridge with its two perforated ends facing the
alveolar ridge.
 Two GBR fixation pins are fitted into the perforated ends of the template to
stabilize the template and secure it in place.
 Soft tissue closure can be performed
10
7

108.  used to improve aesthetic and phonetic
problems associated with losing
interimplant papillae.
 Papillary illusions are yet another
method used to modify the final
prosthesis :-
 By moving the contact area in an apical
direction.
 Thus making the gingival embrasures
smaller in size and giving the impression
that the interimplant papilla fills most of
the gingival embrasure space.
10
8

109.  Jemt observed that the peri-implant papillae can regenerate without any clinical manipulation
of the soft tissue to some extent one to three years after completing the implant therapy.
 He reasoned that plaque accumulation in the proximal areas causes gingival inflammation
and hyperplasia, which sequentially leads to overgrowth of the papilla to fill the
interproximal space.
 Scaling and root planing also may induce proliferation of the gingival tissues .
 This can lead to regeneration of the interdental papilla after nine months time.
 Creeping of the interdental papilla around the root surface is not clinically predictable in
many clinical conditions.
10
9

110.  Soft tissue ballooning concept has been investigated as a technique for developing a
subgingival tissue space that can be filled later with any commercially available silicon
material or bone cement.
 Also, titanium papilla inserts were inserted subgingivally to regain the shape of the
interimplant papilla.
 Unfortunately, the delicate nature of the oral mucosa did not allow any success for these
trials.
 The current thought is to use mini osteodistraction devices to increase bone height in the
future interimplant papilla areas, or to distract all of the bone segment that will receive the
implants to a higher level than the CEJ of the adjacent teeth.
 This method is still under investigation because the construction of mini osteodistractors will
be expensive and the treatment time will be doubled, which is considered a handicapping
factor
11
0

112.  Advanced diagnostic methods
 Advances in implant materials.
 Advanced surgical techniques.
 Changing concepts in implant dentistry.
 Conclusion.

113.  Advances in diagnostic imaging
◦ Zonography
◦ Cone beam Computed tomography(CBCT)
◦ Microtomograph
◦ Multi slice helical CT
◦ Dentascan
◦ Interactive CT

114.  Advances in implant design
◦ Mini implants
◦ Transitional implants
◦ One-piece implants.
• Advances in Implant materials
-Ceramics
-Carbon and polymers
- Hyrdoxyapatite
- Bone morphogenic proteins
- Plasma spraying

115.  Advances in implant design and surface in
commerically available brands:
◦ Biohorizon
◦ Nobel biocare
◦ Astra tech
◦ Straumann

116.  Softwares simplifying treatment planning and
surgical procedures
◦ Simplant
◦ NobelGuide
◦ NobelClinician
◦ Image guided surgeries
CAD/CAM in implant dentistry.
Changing concepts in implant dentistry
-All on 4 concept
-Tooth in an hour concept
-Rescue implant concept

117. Thank you

118. 118
• Clinical periodontology by Carranza - 9th edition
• Clinical Periodontology and Implant Dentistry by Jan
Lindhe- 4th edition
• Atlas of cosmetic and reconstructive periodontal surgery
by Edward s. Cohen- 3RD edition
• Practical Periodontal Plastic Surgery by Dibart S and
Karima M- 1st edition
• Critical decisions in periodontology.Halls-4rth Edition

119.  Management of inter-dental/ inter-implant papilla.Zetu L, Wang H-L. J Clin
Periodontol 2005; 32: 831–839
 Soft tissue enhancement around dental implants. PATRICK PALACCI & HESSAM
NOWZARI. Periodontology 2000, Vol. 47, 2008, 113–132
 Free Gingival Grafting to Increase the Zone of Keratinized Tissue around Implants.(
Yadav A et al International Journal of Oral Implantology and Clinical Research,
May-August 2011;2(2):117-120
 Guided Bone Regeneration Using Injectable Vascular Endothelial Growth Factor
Delivery Gel.Darnell Kaigler et al. J Periodontol 2013;84:230-238
 Soft Tissue Biology and Management in Implant Dentistry.Yeung Stephen C H.
 Guided Bone Regeneration: biological principle and therapeutic applications.
Retzepi M, Donos. N Clin. Oral Impl. Res. 21, 2010; 567–576.
 Text book of RECONSTRUCTIVE AESTHETIC IMPLANT SURGERY. Abd El
Salam El Askary
11
9

120.  ADVANCES IN PANORAMIC IMAGING
 ZONOGRAPHY
 A modification of the panoramic x-ray machine for making
cross sectional images of the jaws.
 The tomographic layer is approximately 5mm.
 For appreciation of spatial relationship between the critical
structures and the implant site.

121.  Limitations:
 Tomographic layers relatively thick .
 Adjacent structures blurring and superimposition.
 Not useful for determining the differences in bone density or
for identifying disease at implant site.

122.  Tomography is the generic name
formed by the greek words
‘tomo’(slice) and ‘graphy’(picture).
 Enables visualization of a section of
patient’s anatomy by blurring other
regions above and below the site of
interest.
 For dental implant patients, high
quality complex motion tomography is
required.

123.  Computed tomography (CT) is a digital and mathematical
imaging technique that creates tomographic sections.
 With latest CT scanners, images with sectional thickness of
0.25 mm can be obtained .
 This can be useful for determining the implant site in terms of
bone density, and location to adjacent anatomic structures.

124.  Cone beam CT:
 It uses a cone beam and reconstructs the image in any direction
using special software.
 It gives all the information of a CT but, at 1/8th the radiation
dose and at a lower cost.

125.  Software is used to display and visualize the anatomy
in a way that is clinically meaningful.
 The manufacturers of CBCT scanners offer software that is
capable of multiplanar reformations .
 Third-party software …….
Simplant……..

126. SAGGITAL CT
AXIAL CT
CROSS SECTIONAL VIEW OF MAXILLAAND MANDIBLE

127.  Microtomograph:
 Modification of CT, it is specially useful in acquiring serial
sections of bone implant interface.
 Multi slice helical CT:
 The rapid volumetric data acquisition. The speed was further
increased by multislice CT, and offers higher accuracy of
images as compared to CT.

128.  DentaScan imaging
provides programmed
reformation, organization
and display of the
imaging study.

129.  The radiologist simply indicates the
curvature of the mandibular or
maxillary arch
 The computer is programmed to
generate referenced cross sectional
and tangential/panoramic images of
the alveolus along with 3-D images
of the arch.
 The cross sectional and panoramic
images are spaced 1mm apart and
enable accurate preprosthetic
treatment planning.

130.  1. Images may not be of true size and require compensation
for magnification.
 2. Determination of bone quality requires use of the imaging
computer or workstation.
 3. Hard copy dentascan images only include a limited range
of the diagnostic gray scale of the study.
 4. Tilt of the patients head during the examination is critical

131.  This technique enables
transfer of the imaging study
to the clinician as a computer
file….
 The clinician’s computer
becomes a diagnostic
radiologic workstation with
tools……….

132.  An important feature of ICT is
that the clinician and radiologist
can perform “electronic surgery”
(ES)……
 With an appropriately designed
diagnostic template, ES can be
performed to develop the
patient’s treatment plan
electronically in 3 dimensions.
 ES and ICT enable the
development of 3 dimensional
treatment plan…..

133.  Transfer of the plan to the patient
at the time of surgery can be
accomplished by……
 It can also be accomplished by the
production of the computer
generated, three-dimensional
stereotactic surgical templates from
the digital ICT and ES data.

134.  Refinement and exact orientation of the implant positions is
difficult and cumbersome.
 Executing the plan may be difficult for the surgical team.

135.  Mini implants/transitional implants.
 One -piece implants
 Modifications in surface topography(coatings)
 Materials used for fabrication of implants.

136.  Mini dental implants (MDIs) are
small diameter dental implants.
 Are sometimes referred to as SDIs
(small diameter implants), as well as
NDIs (narrow body implants).
 Diameter less than three millimetres
(3mm.)

137.  Diameter of 1.8mm to 2.9mm.
 Various lengths.
 Multiple tip, thread, body and head designs are available
 Thread designs vary from thin to thick and thread spacing is
also variable.
 Square, rectangular, or o-ball heads are common.

138.  Endentulous patients that have loose
lower dentures.
 Where extensive surgery required for
conventional implants is
contraindicated due to medical or
age constraints.
 Healing time is decreased.
 Lower costs

139.  Fixed crown and bridge….
 Proper case selection is critical but the
available literature has demonstrated
success that rivals standard implants.
 Transitional stabilization

140.  Available in 6 lengths: 6, 8, 10,13, 15 & 18
 Typically inserted directly through the overlying gums and
into the bone beneath
 No need to surgically cut and raise flap
 A single minimally invasive surgery is needed for insertion of
MDI implants
 Immediate loading done due to self tapping design.

141.  Each of the tiny implants is
held in finger driver that inserts
the implant and also acts as
screw driver.
 Next a winged wrench is used
to tighten the implant
 Possible to provide mini
implant treatment in single
dental office visit.

142.  Diameter ranges -1.8 to 2.8
mm
 Length -7mm to 14mm.
 Fabricated with pure titanium
in a single body with treated
surface.
 Primary function is to absorb
masticatory stress during
healing phase

143.  Provisionalisation of fully and partially edentulous jaws
 Undisturbed healing of bone grafts
 Immediate loading not possible but patient insists for fixed
transitional prosthesis
 Effective way to generate aesthetic transitional appliances
 Allows evaluation of phonetics and function.
 Cost effective.

144.  Depth of supporting bone is less than 10mm with insufficient
cortical bone to provide implant stabilization.
 Patients with excessive bruxism.
 When placement of sufficient number of transitional implants
is not possible…..
 Should be used with caution : Placed 1.5 to 2.5 mm from
definitive implants….

145.  Immediate Provisional Implant System –IPI (Nobel
Biocare)
 Modular Transitional Implant System -MTI (Dentatus)
 TRN/ TRI Implants (Hi Tec implants)

146.  Abutment and implant body in one piece and
not separate
 Material: Titanium Alloy – Ti-6Al-4V
 Diameter: 3.0mm Lengths: 12, 15 and
18mm.
 Maximum Strength - Minimum Profile.
 Minimal Surgery - Maximum Esthetics.
 Availability : Biohorizon 3.0 , Nobel direct ,
Zimmer’s one piece implant.

147.  The long-term treatment of missing
maxillary laterals and mandibular incisors.
 For treatment of spaces that cannot be
handled with larger two-piece implants….
 Also used for overdentures.

148.  Histometrically examined peri-implant soft tissue dimensions
 Conclusion: Gingival margin (GM) is located more coronally
and Biologic Width (BW) dimensions are more similar to
natural teeth around one-piece nonsubmerged implants
compared to either two-piece nonsubmerged or two-piece
submerged implants.
Clinical Oral Implants Research 2001, 12: 559–571.
Hermann J. S, Cochran D. L., Buser D., Schenk R. K. and Schoolfield J. D

149.  Increase possibility of rigid fixation
 Promote higher percentage of bone – implant contact
 Proven to increase bone bonding strength
Three general techniques used to modify surfaces:
- Add material,
- Remove material
- Change the material already present.

150.  Thick coatings - sol-gel and plasma-spraying
 Thin film coatings (sub-micron) - vapor deposition
techniques, where the coating material condenses onto a
surface from a vapor.
 The three basic vapor deposition techniques are:
i. evaporation,
ii. sputtering and
iii. chemical vapor deposition.

151.  Glow discharge treatment
 Sputter-etching.

152.  Changed without addition or removal of material by use of
laser and electron beam thermal treatments.
 Ion implantation can be used to add material to surfaces,
modify coatings, and change microstructures

153.  These treatments include passivation, anodization, ion
implantation, and texturing.

154.  Purpose: enhancing the oxide layer present and creating a
surface less likely to break down and release metallic ions in
service.
 Passivation of a surface with the action of an electric current is
known as ANODIZATION….resulting in much thicker oxide
layers…..
 IMPORTANT for highly roughened surfaces, since the
increased surface area has the potential for greater release of
metallic ions into the surrounding tissue.

155.  Surface texturing of an implant is done to increase the surface
area and provide a greater potential for interlocking with bone.
 Blasting with aluminum oxide or other ceramic particulate
materials, plasma spraying with titanium and acid etching.
 Recently, a resorbable ceramic-blasting material has been
developed…….

156.  High-strength ceramics used for
implants are very inert in the
body and exhibit minimal ion
release.
 Aluminum oxide is regarded by
many as the standard inert
material……..

157.  The ionic ceramic surface is in a high
oxidation state, thermodynamically stable
and hydrophilic
 Minimal ion release has been noted for
aluminum oxide or zirconium oxide under
normal conditions.
 Coatings may also include biologic coatings
such as proteoglycans, bone morphogenic
proteins and growth factors

158.  Zirconia (Zr02) is a ceramic material used
in implantology because:
 Biocompatibility(bio inert)
 Esthetics (because its colour is similar to the teeth), and
 Mechanical properties, which are better than alumina.
 High resistance to corrosion, flexion, and fracture
 Contact with bone and soft tissue similar to that observed in
titanium implants
 It can be used to produce a entire implant or as a coating.

159.  Carbon has been shown to exhibit an inert and biocompatible
surface when exposed to blood or tissue.
 The carbon structure used for dental implants is known as
turbostratic and is a modified graphite structure.
 Polymeric surfaces are not commonly seen for dental
implants.
 Designed to act as a shock absorber, but this polymeric
element requires periodic replacement due to wear.

160.  Bioactive surface coating
Plasma spray - titanium
- hydroxyapatite
 Sand blasted
 Acid etched

161.  Properties of HA composites is highly dependent on the
particle size and morphology of the HA filler.
 HA of sufficient fineness should be developed.
 RF induction suspension plasma spraying with a wet
suspension of HA.

162.  Modified with a thin 1 micron thickness of calcium phosphate
with HA- like chemistry for bone enhancement
Ion beam deposition

163.  Comparative study of bone response to HA-coated titanium
surface and two titanium surfaces.
 He found that bone formation and maturation clearly
occurred at a faster rate and earlier periods on HA coated
implants than on non-coated implants, they are stable both in
vivo and in vitro.
 He concluded that HA-coated dental implant results in
superior bone bonding, earlier biointegration, and better
maintenance of crestal bone than titanium surfaces.
Int J Oral Maxillofac Implants 1989,4:219-225
Block MS, Finger IM, Fontenot MG, Kent JN

164.  The influence of the micro-roughened surface, produced by
dual acid-etching (DAE) of machined commercially pure
titanium, on initial blood cell/implant interactions .
 Micro-roughened DAE implant surfaces showed, qualitative,
more platelets than machined surfaces, while the textured
glass surfaces demonstrated increased platelet aggregation.
 They believed that these early blood cell/implant interactions
may play a key role in the osteoconduction stage of peri-
implant bone healing response to micro-roughened implants.
Clini Oral Implants Res 2000,Dec 11(6);53
Park JY, Davies JE

165.  Investigated and compared the healing rates of bone around
commercially pure titanium implants and titanium implants
sputter-coated from a hydroxyapatite target.
 Histologic analysis of the bone-implant interface demonstrated
that coated implants had nearly twice the percentage of direct
bone contact compared with non coated implants.
 Accelerate the healing of bone at the implant interface.
J Prosth Dent
1992(1);93-100
David R. Cooley, Adrian F. Van Dellen DVM, John O. Burgess and A. Stewart Windele

166.  Investigated, in a mandibular dog model, bone biological
properties and the occlusal loading effects of titanium implants
provided with newly developed microplasma-sprayed CaP
coatings.
 Functional loading of MPS CaP coatings induces a favorable
bone response.
Clinical Oral Implants Res 2010
R. Junker , P. J. D. Manders , J. Wolke , Y. Borisov and J. A. Jansen

167.  Evaluated the local bone formation and osseointegration at
TPO- modified implants in type IV bone.
Result-
TPO surface possesses a considerable osteoconductive
potential promoting a high level of implant osseointegration in
type IV bone in the posterior maxilla
Clinical Oral Implant Res 2005, Vol 16 Issue 1 ;105-111
Huang YB, Xiropaidis AV, Sorensen RG, Albandar JM, Hall J, Wikesjo UM

168.  Biohorizon
 Nobel biocare
 Astra tech
 Straumann

169.  LASER- LOK TECHNOLOGY
 Unique surface characteristics
 Laser-Lok microchannels is a series of cell-sized
circumferential channels that are precisely created using laser
ablation technology.
 Extremely consistent microchannels that are optimally sized to
attach and organize both osteoblasts and fibroblasts.
 Includes a repeating nanostructure that maximizes surface
area and enables cell pseudopodia and collagen microfibrils to
interdigitate with the Laser-Lok surface.

170.  Biologic response :
 The inhibition of epithelial downgrowth and the attachment of
connective tissue (unlike Sharpey fibers).
 This physical attachment produces a biologic seal around the
implant that protects and maintains crestal bone health.
 More effective than other implant designs in reducing bone loss.

171.  Different than other surface treatments
 Virtually all dental implant surfaces on the market are grit-
blasted and/or acid-etched.
 These manufacturing methods create random surfaces that
vary from point to point on the implant……..
 The clinical advantage
 The Laser-Lok surface has been shown in several studies to
offer a clinical advantage over other implant designs to reduce
bone loss by 70% .

172.  Latest discoveries
 Laser-Lok abutments
 Create a biologic seal.

173.  NobelReplace™ Tapered Groovy implant is shaped to
resemble a tooth root.
 New and unique grooved threads implant.
 Since bone forms more rapidly in the grooves, the Groovy
implants integrate faster
 Tapered design makes surgical procedure exceptionally simple
and predictable – especially for immediate placement after
extraction.

174.  For immediate placement after extraction.
 Whenever immediate or early loading is applied.
 The Groovy implants are preferred over models without the
groove in soft bone conditions.

175.  Faster integration with grooves
 Bone formed preferentially within the grooves, compared to
other parts of the implant
 Enhanced osseoconductive properties of the grooves and a
guiding effect on bone forming cells
 Up to 30% increase in stability……
Scanning electron
microscopic
images of TiUnite®
implant with
a groovy at the thread
flank.

176.  Grooves extended to the collar of most new implants so they:
 Increase surface area
 Increase area for bone to-implant contact

177.  Features:
 Parallel walled implant
 Slightly tapered design
 TiUnite® surface provides accelerated
osseointegration over machined surface
implants .
 Narrow tip makes it perfect for flapless
surgery
 Primary stability at time of implant
placement.
 Shortening treatment time and speeding
recovery.

178.  NobelSpeedy™ implant for flapless surgery
 The innovative head design makes this implant ideal for
flapless surgery.
 Head is the same diameter as the implant body…
 Inspection of the bone margin is impossible when working
flapless……
 Preventing the use of countersinks preserves cortical bone.

179.  NobelSpeedy™ implant for Immediate Function
 The innovative implant tip is sharp so the implant works as an
osteotome…….
 This feature allows variable, and if needed, extensive under-
preparation of the site.
 The resulting higher initial stability, especially in soft bone,
supports immediate function.
 The sharp tip also secures a smooth insertion…….

180.  Since the implant cuts through any bone quality it's especially
suitable for grafted bone.
 The bone graft can be of various density levels, and the ability
to under-prepare gives the necessary flexibility when
preparing the grafted site.
 The implant will cut even in under-prepared block graft sites.

181.  NobelSpeedy™ implant -esthetics
 The parallel-walled body and innovative head of
NobelSpeedy™ secures flexibility in the final vertical position
of the implant, which is important for the emergence profile.
 It provides the possibility to increase torque and place the
implant further down without repeating the drilling procedure.
 Especially important when working with internal connection
implants where only 3 positions allow optimal esthetics.

182.  Narrow Tip ,Sharper Chamfers
 Internal Abutment Connection
 Slightly Tapered
 TiUnite® all the way up
 Extremely Short Drill Protocol
 Grooves on threads
 Increased initial stability in soft bone

183.  Same benefits as NobelSpeedy™
Replace.
In addition:
 External Abutment Connection
 Including Shorty implant
NobelSpeedy™ Shorty (7mm)

184.  NobelActive™ implants don't cut
through bone like conventional implants,
they gently press through it like a
corkscrew.
 This bone condensing capability delivers
high initial stability.
 The narrow neck is designed to preserve
marginal bone and promote long-lasting
soft tissue stability.

185.  The self-drilling ability of NobelActive™ implants allows it
to be inserted into sites prepared to a reduced depth.
 This is useful where sites are close to vital anatomical
structures: the mandibular nerve canal or the maxillary sinus,
and nose cavity.
 Operator can be confident of accurate placement while having
a minimally invasive procedure.

186.  Potentially fewer drilling protocol steps, depending on bone
density and quantity .
 Minimal osteotomy with minor trauma to bone and
surrounding tissues .
 High stability in fresh extraction sites and sites with thin sinus
floors.
 Immediate placement in the esthetic region, even when buccal
bone plate is very thin
 Excellent stabilization in wide sockets…..

187.  Excellent stabilization in soft bone…
 Adjustment to small changes for parallelism – using the self-
drilling capacity…..
 A narrow neck designed to preserve marginal bone.
 Grooves on threads and scientifically proven Tiunite™ surface

188.  Shorty implant (7mm)
 Narrow Tip
 Slightly Tapered
 Grooves on threads
 The implant for flapless surgery
 Extremely Short Drill Protocol
 Immediate Function
 Increased initial stability in soft bone
 Optimal Emergence Profile and Esthetics
 TiUnite® 'all the way up'

189.  NobelPerfect™ is a unique, anatomically designed implant for
esthetically demanding areas from premolar to premolar.
 The interproximal bone may be preserved ……………
height discrepancy between the facial and interproximal…
 The anatomic design and the unique implant surface,
TiUnite™, give esthetic support and an effective barrier
against the oral cavity.

190.  Scalloped bone apposition area follows
three-dimensional osseous contours.
 Scalloped soft tissue apposition area
allows for the development of the biologic
width around the entire neck of the
implant.
 Scalloped prosthetic table follows three-
dimensional soft tissue topography.

191.  The NobelPerfect™ One-Piece implant is
machined from a single piece of titanium…..
 The scalloped TiUnite surface contour at the
implant neck follows the same principles as for
the original NobelPerfect™.
 The One-Piece design allows placement
flexibility of the implant…
 With this design, the soft tissue is supported
entirely by the implant body, irrespective of the
shape of the osseous ridge.

192.  The NobelDirect Groovy implant features a revolutionary new
one-piece design that is
 user-friendly,
 cost-effective,
 biologically sound and
 esthetically stable.
 The implant is machined from a single piece of titanium,
incorporating both the implant body and an integral fixed
abutment.

193.  Using Brånemark System® Zygoma implants with
NobelGuide™ enables use of CT scan data as the basis for
surgical planning in a 3D computer environment.
 From computer-based planning…one or two Surgical
Templates, depending on the nature of the case….flapless
surgery.
 Immediate Function

194.  OsseoSpeed™ -chemically modified titanium surface,
 Providing unique nano scale topography,
 Stimulates early bone healing and speeds up the bone healing
process.
 The result of the micro-roughened titanium surface treated
with fluoride is increased bone formation and stronger bone-
to-implant bonding.

195.  MicroThread™
 The neck of Astra Tech implants are
designed with MicroThread that has minute
threads that offer optimal load distribution
and lower stress values.

196.  Conical Seal Design™ a strong and
stable fit
 Conical connection below the marginal bone
level transfers the load deeper down in the
bone…….
 Reduces peak stresses and thereby preserves
the marginal bone.
 Seals off the interior of the implant from
surrounding tissues, minimizing micro-
movements and micro-leakage.

197.  Simplifies maintenance and ensures reliability in all clinical
situations.
 The tight and precisely fitting implant-abutment relation......
 The abutment is self-guiding and the installation procedure is
non-traumatic, eliminating the risk of bone damage.

198.  Connective Contour
 The Connective Contour™ is the unique
contour that is created when you connect
the abutment to the implant.
 This contour allows for an increased
connective soft tissue contact zone both
in height and volume…
 Sealing off and protecting the marginal
bone.

199.  Chemical modification to
a sandblasted, large-grit,
acid-etched (SLA)
implant surface.
 Hyrdophilicity
 Protein adsorption

200.  Enhanced osteoblast activity
within the first weeks
 Enhanced angiogenesis and
bone healing within the first
days after contact with the
new surface.

202.  More bone apposition on
surface
 Higher implant stability .

203.  This surface reduced the average healing time from 12 weeks
(TPS surface) to only 6-8 weeks.
 Molecular optimization and the substantial reduction of the
average healing time from 6-8 weeks to 3-4 weeks,

204.  Roxolid® is a homogenous metallic alloy composed of the
elements titanium and zirconium.
 Higher tensile strength compared to pure titanium.
 Important when small diameter implants are chosen due to
their reduced size.
 Roxolid® and SLActive® combine high strength with
excellent osseointegration.
 Roxolid® implants have been used where
3.3mm titanium implants
previously were not suitable.

205.  Surgi Guides are computer-generated drilling guides that are
fabricated through the process of stereolithography.
 The SurgiGuide concept is based on the presurgical treatment
planning using SimPlant software for ideal implant
positioning.
 These successive diameter surgical osteotomy drill guides may
be either bone, teeth, or mucosa-borne.

206.  Surgi Guides have metal cylindrical
tubes that correspond to the number of
desired osteotomy preparations and
specific drill diameters.
 The diameter of the drilling tube is
usually 0.2mm larger than the
corresponding drill, thus making angle
deviation highly unlikely.

207. Step 1
The scan
 Connect to the Dental Planit button in
your SimPlant GO software to start a
case.
 A radiolucent bite index used to
stabilize jaws at the time of scanning.
 Create an open bite with no overlap in
the horizontal plane.

208. Step 1
The scan
 Digital information on the desired tooth-
setup is obtained via the wax-up created on
the plaster model.
 When your patient has been scanned, your
image conversion provider takes an optical
scan of the plaster model and wax-up
and integrates them with the scanning
images.

209.  The image conversion saves you valuable
time and ensures that the CT images are
easy to read.
 Exact tooth information – no scatter
artefacts.
 Desired tooth setup – via the plaster model
wax-up (optional).
 Soft tissue information – be able to measure
mucosa thickness.
 Indication of the alveolar nerve –result is
EASY verification.
 Exact sinus information – 3D
representations included.

210.  Step 2
 The planning in
SimPlant®
 SimPlant file.
 3D representations of patient’s
anatomy, alveolar nerve,
sinuses, plaster model and
desired tooth setup.
 Plan and communicate

211.  Step 3
 The SurgiGuide®online order
 The high resolution optical scan of the
plaster model in SimPlant is used to
design a perfectly fitting SurgiGuide.
 Specialized design team reviews and
designs a custom made SurgiGuide
which is fabricated with high precision
3D printing process.

212.  Step 4
 Surgery
 SurgiGuide is delivered
with the drilling and
installation protocol.
 Disinfect the SurgiGuide
before surgery

213.  NobelGuide is a complete
treatment concept for
 Diagnostics,
 Prosthetic-driven treatment
planning and
 Guided implant surgery – for
a single missing tooth to an
edentulous jaw.

215.  NobelClinician Software is the next generation software for
 Digital diagnostics and
 Treatment planning.
 Through various pre-defined workspaces any DICOM file can
be reviewed and analyzed.
 NobelClinician Software facilitates team collaboration and
comes with an unparalleled ease of use.

216.  NobelClinician
Software supports
the NobelGuide
concept.
 3D radiographic
data

217.  Uses
 Used in designing of prosthesis
 Used in milling /fabrication of prosthesis(framework)
 For milling of abutments.
 Advantages:
 Superior fit
 Less degree of rotational freedom so more accurate implant
abutment connection.

218. CAD/
CAM
system
Provider Implant
restoration type
Restoration
material
Procera Nobel
Biocare
Abutments
Fixed partial
denture frameworks
Milled bars
Titanium
Alumina
Zirconia
Atlantis Astra
Tech
Abutments Titanium
Titanium with gold
coating
Zirconia
Encode Biomet 3i Abutments Titanium
Titanium with gold
coating

219. CAM
StructSUR
E
Biomet 3i Milled bars Titanium
CARES Straumann Abutments Titanium
Zirconia
Etkon Straumann Frameworks
Abutments
Zirconia
Titanium
BioCad BioCad
Medical
Abutments
Milled bars
Titanium

220.  The Procera system (Nobel
Biocare) :
 Custom abutments in titanium,
alumina, and zirconia.
 A master cast is developed after
making an implant-level
impression.
 Scanned and the custom abutment is
designed by a 3d cad pro-
gram.

221.  A machined base cylinder is
screwed to the implant analog and the abutment is waxed up.
 The pattern is then removed from the master cast and scanned
by the Procera scanner.
 The design is sent to the production facility for the abutment
fabrication.
 The abutment can be further digitized, and finally a titanium or
ceramic coping is
produced using the same system.

222.  Procera implant partial
prostheses are available in
zirconia or titanium.
 CAD/CAM custom Procera
partial prostheses are screw-
retained implant-supported
restorations that can be used
with a wide range of
implant systems.

223.  The zirconia implant prosthesis is available at the implant level,
while the titanium implant prosthesis is available at the implant
and abutment levels .
 Using acrylic resin, a framework pattern is fabricated
directly on temporary implant cylinders.
 The acrylic resin framework pattern is then laser scanned, and
the framework is milled in a CNC-milling machine with 5
degrees of freedom.

224.  CAM StructSURE
precision milled bars
(Biomet 3i)
 Hader and Dolder designs for
over-denture bars and primary
bars and in fixed hybrid designs.
 Technician does not need to wax
or resin design the framework;
instead, the design is made on-
screen with a sophisticated
software program.

225.  The Etkon system can
produce frameworks up
to16 units from a variety of
materials, such as zirconia
and titanium.

226.  All on four
 Rescue implant concept
 Teeth in an hour concept

227.  The All-on-4 for edentulous jaws has
been developed to maximize the use
of available bone and to allow for
Immediate Function
 Using only four implants in
edentulous jaws…..

228.  All-on-4 using
conventional flap
procedure with
traditional planning
and a standardized
All-on-4 Guide for
predictable and
optimal positioning
of the implants.

229.  All-on-4 with NobelGuide using
flapless technique, computer-based
planning and a customized Surgical
Template to correctly drill and
position the implants.

230.  The zygomatic implant is an alternative to bone grafting in
extremely resorbed maxilla.
 With extremely resorbed maxillas, fixed prosthesis can be
provided with four zygomatic implants.
 Either a conventional two stage procedure or a one-stage
surgical procedure or flapless guided surgery with Nobelguide
and immediate function.

231.  The four zygomatic implants procedure results in
 Less morbidity,
 Shorter delays between anatomical reconstruction and
functional rehabilitation
 Provide immediate or early loading with immediate function.
 Four zygomatic implants and a fixed bridge seem to be a
valuable technique for the rehabilitation of extremely resorbed
maxillas.