Dental Implants / dental implants courses

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Good Morning
www.indiandentalacademy.com

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Classification, Type of Fixtures
Sterilization and Passivation
INDIAN DENTAL ACADEMY
Leader in continuing dental education

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Contents
 Introduction
 Definition
 Rationale for Dental Implant Design
 Classification
 Type of Fixtures (Implant body)
 Commonly used Endosseous Implant System
 Sterilization and Passivation

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Introduction
 Over the past 20 years, Dental Implants have
undergone remarkable changes. Many
clinicians designed implants to fit certain
needs and properties. Some of those
designs had only a short application period,
whereas others survived to this very day.
Dental implants vary in several aspects,
such as shape, place of anchorage (within
the bone or on top of the bone),
composition, coatings, etc.

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Classification:
Implants are classified into three basic
categories :
Endosseous Implants (in bone)
Subperiosteal Implants (through bone)
Transosseous Implants (on bone)

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Endosseous Implants :
are implants that are surgically inserted into the
jawbone.
 They are further classified into :
 Ramus form
 Pin Form
• Disk Form
 Plateform Concept
 Cylindrical Or Root form Concept

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Ramus Concept
 The ramus blade originated in late 1960s .
 It is now made of grade 2 CP titanium and used
as posterior support for a mandibular fixed
partial denture when insufficient height and width
exit in body of the mandible.
 The implant remain unloaded until proper
osseous healing occurs.

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Pin Concept
 This concept originated with J. Scialom in 1950s
and was popularized by Michelle.
 This implant was originally made of tantulum, but
now titanium alloy is used in.

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Disk Concept
 This implant originated with Dr. G. Scorteci of
France in 1970s.
 The unique two stage design resembles an 18th
century candle stick , and uses a facial or
buccal placement with special osteotomes.

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Plateform Concept
 This implant also originated with Dr Harold and
Ruberts in late ’60s.
 Many design variations exit, and commercial sources
stock one and two stage protected healing types
whether single tooth, single or double headed,
maxillary or mandibular versions.

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Cylindrical or Root Form Concept
 The concept has evolved over centuries with
earlier crude forms.
 These implants come in a variety of shapes,
sizes, and materials and are being offered by
many different companies worldwide
 Cylindrical Root Form depend on a coating to
provide microscopic retention and/or bonding to
bone and are usually pushed or tapped into bone
site.

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Implant body / fixture :
 referred as surgically
placed part which goes
either into or set on the
top of the jaw bone.

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Parts of Fixtures
 Components of the
Implant Body may be
separated into
 A crest module
 A body
 An apex region

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A SCIENTIFIC RATIONALE FOR ROOT FORM
DENTAL IMPLANT DESIGN
 Dental implants function to transfer load to
surrounding biologic tissues. Thus the primary
functional design objective is to manage
(dissipate and distribute) biomechanical load to
optimize the implant supported prosthesis
function.
 Biomechanical load management is dependent
on two factors:
 the character of the applied force and
 the functional surface area over which the
load is dissipated.www.indiandentalacademy.com

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CHARACTER OF FORCES APPLIED TO
DENTAL IMPLANTS
 Stress and strain have been shown to be important
parameters for crestal bone maintenance and implant
survival. These factors may be measured and
compared for different implant body designs.
 Forces applied to dental implants may be characterized
in terms of five distinct, although related, factors :
magnitude, duration, type, direction, and
magnification. Each factor must be carefully
considered, with appropriate weight, in the critical
analysis of implant design.

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1. Force Magnitude
 Physiologic Constraints On Implant Design.
 Normal physiology imposes constraints on the
magnitude of forces that must be withstood by
engineering designs in the oral environment.
 The magnitude of bite force varies as a function of
anatomic region and state of the dentition.
 Following sustained periods of edentulism, the bone
foundation often becomes less dense. Its ultimate
strength is highly dependent on its density.

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 As such, less dense bone may no longer be
able to support normal physiologic bite forces
on implants.
 So careful treatment planning, including
appropriate implant design selection, is
imperative to lower the magnitude of loads
imposed on the vulnerable implant-to-bone
interface.

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2. Force Duration
 Physiologic Constraints on Design
 The duration of bite forces on the dentition has a
wide range. Under ideal conditions, the teeth come
together during swallowing and eating for only brief
contacts. The total time of those brief episodes is
less than 30 minutes per day. Patients who exhibit
bruxism, clenching, or other parafunctional habits,
however, may have their teeth in contact several
hours each day.

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3. Force Type
 Three types of forces may be imposed on
dental implants within the oral environment:
compression, tension, and shear. Bone is
strongest when loaded in compression, 30%
weaker when subjected to tensile forces, and
65% weaker when loaded in shear .
 Endosteal rootform implants load the bone
toimplant interface in pure shear (e.g., a
smooth sided cylinder) unless surface
features are incorporated in the design to
transform the shear loads to more resistant
force types.

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 Influence on Implant Body Design
 A smooth cylinder implant body results
in essentially a shear type of force at the
implanttobone interface. Thus this
body geometry must use a microscopic
retention System by coating the implant
with titanium or hydroxyapatite.
 Threaded implants have the ability to
transform
type of force imposed at the bone interface
through careful control of thread geometry.
Thread shape is particularly important inwww.indiandentalacademy.com

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Thread shapes in dental implant designs includes :
 square
 V-shape
 buttress

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 Under axial loads, to a dental implant, a V -thread face
(typical of Paragon,3i and Nobel Biocare) is
comparable to the buttress thread (typical of Steri-
Oss) when the face angle is similar and has
approximately a 10 times greater shear component of
force than a square or power thread (typical of
BioHorizons).

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4. Force Direction
 The anatomy of the mandible and maxilla places
significant constraints on the ability to surgically
place root form implants suitable for loading along
their long axis. Resorptive patterns following
prolonged edentulism exacerbates the normally
occurring angulation challenges .
 Bone is strongest when loaded in its long axis in
both compression or tensile forces. A 30-degree
offset load reduces the compressive strength of
bone by 11%, and reduces the tensile strength by
25%.

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Influence on Implant Body Design
 As the angle of load increases, the stresses around
the implant increase, particularly in the vulnerable
crestal bone region. As a result, virtually all
implants are designed for placement perpendicular
to the occlusal plane. This place-ment allows a
more axial load to the implant body and reduces
the amount of crestal stress. Additionally, axial
alignment places less stress on the abutment
components and decreases the risk of short- and
long-term fracture.

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The face angle of the thread or plateau can change the
direction of load from the prosthesis to abutment
connection, to a different force direction at the bone.
 As a result, the axial load on the
implant platform may be a
compressive load, but the 30-
degree angle of the V -shape
thread can reduce the amount of
load the bone interface is able to
resist.
 The power thread design can
take the axial load of the
prosthesis to abutment
connection and transfer a more
axial load along the implant body
to compress the bone, rather
than convert it to 10 times more
shear. www.indiandentalacademy.com

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5. Force Magnification
 A surgical placement resulting in extreme
angulation of the implant and/or a patient
exhibiting parafunctional habits will likely exceed
the capability of any dental implant design to
withstand physiologic loads.
 Cantilevers and crown heights act as levers and
therefore are, force magnifiers.
 Careful treatment planning with special attention
to the use of multiple implants to increase
functional surface area is indicated when a
clinical case presents the challenge of force
magnifiers.

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Surface area
 For a given bone (and implant) volume, implant
surface area must be optimized for functional
loads.
 Thus an important distinction is made between
total surface area and functional surface
area.

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 Functional surface area is defined as the area
that actively serves to dissipate compressive
and tensile non-shear loads through the
implant-to-bone interface and provide initial
stability of the implant following surgical
placement.
 Total surface area may include a "passive"
area that does not participate in load transfer
 For example, plasma spray coatings are often reported to
provide' up to 600% more total surface a however, the amount
of area that is actually exposed to bone for compressive or
tensile loading may be less than 30% of the total surface area.

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Design Variables in Surface Area
Optimization
 Implant Macro geometry
 Smooth-sided, cylindric implants provide ease in
surgical placement however; the bone-to-implant
interface is subjected to significantly larger shear
conditions.
 In contrast, a smooth-sided, tapered implant allows
for a component of compressive load to be delivered
to the bone-to-implant interface, dependent upon the
degree of taper.

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 Implant Width
 Over the past five decades of endosteal implant
history, implants have gradually increased in
width.
 Today, dental implants generally have reflected
the scientific principle that an increase in implant
width adequately increases the area over which
occlusal forces may be dissipated. For root form
implants of circular cross-section, the load
bearing area of the abutment platform increases
as a function of the radius squared.
 A 4-mm root form implant has 33% greater
surface area than a 3-mm root form implant.

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Thread Geometry
 Functional surface area per unit length of
the implant may be modified by varying
three thread geometry parameters:
 Thread pitch,
 Thread shape
 Thread depth.

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 Thread Pitch is defined as the distance
measured parallel with its axis between
adjacent thread forms
 Or the number of threads per unit length in the
same axial plane and on the same side of the
axis

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The thread shape is another very important characteristic of
overall thread geometry. As described previously, thread
shapes in dental implant designs include:
 Square
 provides an optimized surface
area for intrusive, compressive
load transmission
 V-shape
 the V -thread design is called
"fixture" and is primarily used
for fixturing metal parts
together-not load transfer.
 Buttress
 is optimized for pullout loadswww.indiandentalacademy.com

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Differences in shear loading on the standard
V-thread and the square thread
 V-thread has 10 times
greater shear loads on
bone compared with a
square thread
 The reduction in shear
loading at the thread-to-
bone interface provides for
more compressive load
transfer, which is
particularly important in
compromised D3 and D4
bone. www.indiandentalacademy.com

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 The thread depth refers to the distance between the
major and minor diameter of the thread.
 Conventional implants
provide a uniform thread
depth throughout the
length of the implant.
 This unconventional design
feature results in dramatic
increases in functional
surface area at the crest
of the bone, where the
stresses are highest.

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 As the length of an implant increases, so does
the overall total surface area. As a result, a
common idea has been to place an implant as
long as possible preferably, into the opposing
cortical plate.
 Attempting to engage the opposing cortical plate
and preparing a longer osteotomy may result in
overheating the bone.
 Longer implants have been suggested to provide
greater stability under lateral loading conditions.
Implant Length

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 Studies have shown that the highest stresses
were observed in the crestal bone regions,
regardless of the implant length.
 This biomechanical analysis supports the
opinion- that longer implants are not necessarily
better.
 Instead, there is a minimum implant length for
each bone density, depending on the width and
design.
 The softer the bone, the greater the length
suggested.

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Crest Module Considerations
 The crest module of an implant body is the
transosteal region from the implant body and
characterized as a region of highly
concentrated mechanical stress.
 Instead, it is a transition zone to the load-
bearing structure of the implant body
 In. fact, bone loss has been observed so often,
many implant crest modules are designed to
reduce plaque accumulation once bone loss
has occurred

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 A smooth, parallel-sided crest
module will result in shear
stresses in this region, making
maintenance of bone very
difficult.
 An angled crest module of
more than 20 degrees, with a
surface texture that increases
bone contact, will impose a
slight beneficial compressive
component to the contiguous
bone and decrease the risk of
bone loss.

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Apical Design Considerations
 Most root form implants are circular in cross-
section. This permits a round drill to prepare
a round hole, precisely fitting the implant
body.
 Round cross-sections, however, don’t resist
torsional/shear forces when abutment
screws are tightened or when free-standing,
single tooth implant receive a rotational
(torsional) force.www.indiandentalacademy.com

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 As a result, an anti-rotational
feature is incorporated, usually
in the apical region of the
implant body, with a hole or
vent being the most common
design.
 The apical hole region may also
increase the surface area
available to transmit
compressive loads on the bone.

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Surface Coatings
Titanium Plasma Spray
Hydroxyapatite Coatings
 The clinical advantages of TPS or HA coatings may
be summarized as the following:
 Increased surface area ( can be up to 600%)
 Increased roughness for initial stability
 Stronger bone-to-implant interface
 Additional advantages of HA over TPS include the
following:
 Faster healing bone interface
 Increased gap healing between bone and HA
 Stronger interface than TPS
 Less corrosion of metal

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Disadvantages of coatings include
1. Flaking, cracking, or scaling upon insertion
2. Increased plaque retention when above bone
3. Increased bacteria and nidus for infection
4. Complication of treatment of failing implants
5. Increased cost

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 The present designs fall into four
morphological categories:
 Screw or Threaded
 Bullet or Conical
 Basket or Vented
 Fin or Plateau
 Others are:
 Titanium plasma sprayed screw implant
system
 Cylindrical Hydroxyapatite coated implant
 Grooved Hydroxyapatite coated cylinder
 Vitreous carbon implantswww.indiandentalacademy.com

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Root form Implants contd…
Screw root forms are threaded into bone
site and have macroscopic retentive
elements for initial bone fixation.
 Three basic screw thread geometries exist:
 V- Thread
 Buttress thread
 Power thread design

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Screw type of implants have been used for
more than two decades.
Earlier placement technique resulted in
traumatic site preparation of bone and
immediate or early loading of the implant
that interfered with bone healing.
Branemark showed 2 keys to predictable
screw implant technique and success: avoid
traumatizing and overheating the bone
during site preparation and allow adequate
time for bone healing.

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 Almost all commercially available screw-type
implant systems recommend not to loading the
implant for several months to allow
osseointegration to occur.
 The only system that still recommends immediate
loading of the implants is the titanium plasma
sprayed screw system (TPS screws).
 Diferent surface finishes range from machine
tooled, sand blasted, acid etched, to
hydroxylapatite coated; an implant design can
range from self tapping to those needing threads
cut into the bone.

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Screw Root Form contd….,
 Branemark Standard Fixture
 Branemark Self tapping
Fixture
 Fixture (Impla-med)
 Self tapping fixture (Impla
med)
 Osseo-Dent (Collagen)

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 Screw Vent (Core-Vent)
 Swede Vent (Core-Vent)
 Swede Vent CST (Core-Vent)
 Swede Vent CST/HA
 Thread provides mechanical
interlock with thick labial and
lingual cortical plates.
 Apical threads engage cortical
bone on inferior border.

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 Steri OSS standard
 Steri OSS mini
 Steri OSS HA

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Screw root form contd…
 ITI solid screw (Straumann Inc )
 Osteo implant (OIC)
 Star-vent
 Star-vent TPS

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Cylindrical Bullet
IMZ (Interpore Intl.)
 IMZ-HA (Interpore Intl.)
 Integral (Calcitek)
 Steri-OSS
 Biovent(Core vent)

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Cylindrical-Bullet
 Hahn Ridgelock (Steri-OSS)
 Osseolite (Collagen)
 Anchor (Anchor)
 Osteoimplant
(HA by Impla med)

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Cylindrical Basket
 The hollow basket design provides nearly twice
the bone contact of a solid cylinder of the same
length and diameter.
 The receptor site is prepared with trephines,
producing minimal bone destruction and leaving a
vital bone core over which the implant is seated.
 Perforations in the cylinder walls enable bone
growth through the implant to increase stability
and improve load distribution.

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 Titanium or titanium alloy is used, permitting
osseointegration. The fenestrated hollow-
cylinder design minimizes stresses within the
implant on vertical loading and providing a
greater area for load transmission to the
surrounding bone.
 Two system currently incorporate the hollow-
basket concept:
 The ITI implants
 The Core-Vent implant
Cylindrical Basket contd…..

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Cylindrical Basket
 The ITI implants are made from CP
titanium, have a titanium plasma-sprayed
surface and promote increased bone
contact by increasing the surface area by
6 fold.
 Were previously provided in several
designs – designated as C,E,F,H and K.-
to fit alveolar ridges of varying ht. and
width.
 ITI hollow Cylinder
 ITI 150 offset Hollow Cylinder


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Cylindrical Basket
 Core-Vent basket design combines a
superior threaded screw section with
an inferior hollow vented basket.
 The self tapping threaded neck
provides initial stability to help prevent
micro movement during healing.
 Within the superior threaded region
there is a hexagonal-threaded
chamber that extands downward
towards the basket area but does not
communicate with it.

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Cylindrical Basket
 The Core-Vent implant is manufactured in two
diameters: 3.5 and 4.5 mm
 The threaded portion adds 0.8 to overall dimension,
creating outsides dia of 4.3 and 5.3 respectively
 Four length available are 16, 13, 10.5, and 8 mm

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Cylindrical Fin
 Finned or serrated root form implants can offer
advantages in certain clinical situations.
 These implants sometimes called plateau
implants have a series of circumferential fins
spaced along the bone interfacing portion of the
implant.
 They usually provides more functional load
bearing surface area for efficient transmittal of
occlusal loads than others implants.
 Proper socket preparation should result in light
friction fit for implant after insertion.

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Cylindrical Fin
 Omni (Omni Intl)
 Miter 2000 (Miter Inc)
 Stryker Precision
 Stryker Precision/HA
 Micro-Vent (Core-Vent)

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Titanium Plasma Sprayed Screw Implant
 It consist of fine grain titanium particles
applied to the cylinder in an argon
environment under extremely high
temp., pressure and velocity.
 It offers an increase in surface area
over the smooth surface and, thus also
more retention in the bone.
 Some research has also shown
that initial integration into the host
bone is somewhat accelerated
through that.
 Available in dia of 3.3 & 4 mm
and length of 8, 11, 13 & 15 mm.

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Titanium Screw Implant with a Hydroxylapatite
(HA) coating
 Beyond an increase in
surface area as compared
to smooth surface implants,
this surface has also shown
to have an accelerated
initial integration, which
makes it ideal for quick
initial post-surgical
stabilization in weak bone.

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Subperiosteal Implants :
Are implants, which typically lie on top of the
jawbone, but underneath your gum tissues. The
important distinction is that they usually do not
penetrate into the jawbone.

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Indications…
 Some conditions that are contraindicated for
root and blade form may be indicated such
as:
 An unusual position of mental foramen
 A dehiscence of mandibular canal
 Generally atrophic mandible
 A mutilated oral condition from extensive
surgery
 Severe gagging problems
Subperiosteal Implants :

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Maxillary HA-coated subperiosteal
implants
 Unilateral subperiosteal (Hahn) for FPD
 Complete subperiosteal (Tatum) for maxillary
plateless denture.

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CAD-CAM subperiosteal implants
 Slice/Stack concept
(Techmedica)
 Negative wax mold-
epoxy pour concept
(Cemax)

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Unilateral subperiosteal (HA coated)
 Serve as posterior abutments for FPD splinted to
canine.

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Transosseous Implants:
 Are implants, which are similar
in definition to Endosseous
implants in that they are
surgically inserted into the
jawbone.
 However, these implants
actually penetrate the entire
jaw so that they actually
emerge opposite the entry site,
usually at the bottom of the
chin. www.indiandentalacademy.com

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Transosseous Implants:
 Has been used for 22yrs to rehabilate patients with
unstable mandibular dentures.
 Adv are immediate denture placement and function
 Can perform cosmatic surgery of submental fat pad and
chin
Transmandibular
Implant

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Characteristics of six popular
cylindrical endosseous dental implant
systems
1. Branemark USA,Inc
2. Core-Vent core-Vent Corp
3. Interpore IMZ
4. Integral Clcetek Inc
5. Steri OSS Denar Corp
6. Stryker Precision Stryker inc

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Branemark USA,Inc
 Advantages
 ADA full acceptance (edentulous) and provisional
acceptance for all other uses
 Longest documented research
 Relatively simple surgery
 Excellent education availability
 Disadvantages
 Some sponsors do not allow general practitioners to
take surgery course
 Most expensive system
 Has only pure titanium implants

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Core-Vent (CORE-VENT Corp.)
 Advantages
 Extensive implant options
 Extensive Prosthodontics options
 Simple surgery
 Lower cost
 Good education
 High popularity
 Sells "Branemark" clone at lower cost
 Disadvantages
 Complexity of options (both surgical and
prosthodontic) requires good organization

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Interpore IMZ
 Advantages
ADA provisional acceptance for all uses.
Relatively simple surgery
Moderate cost
Good education
Provides simulated periodontal ligament intramobile eIement-
IMZ) if desired
Pioneer in research on hydroxylapatite coating for
faster integration
Tissue recession on HA coating leaves polished
surface
 Disadvantages
Intramobile element (IMZ) requires replacement on annual basis

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Integral Clcetek Inc
 Advantages
 ADA provisional acceptance
 Prosthodontic adaptations relatively good
 Pioneer in use of hydroxylapatite coating for faster
integration
 Simple surgery
 Good education
 Moderate cost
 Disadvantages
 Standard size and small diameter (SD) require
purchase of two separate surgical starter kits
 Has only hydroxylapatite coated implants

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Steri OSS Denar Corp
 Advantages
 Prosthodontics acceptability good
 Company will replace implants that fail
 Simple surgery
 Good education
 Moderate cost
 Disadvantages
 Suggests very low hand piece rpm (300 rpm, 70-1
reduction), can get higher rpm if desired

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Stryker PrecisionStryker Inc
 Advantages
 Moderate cost
 Relatively simple surgery
 Hand auger ostectomy is kind biologically
 Mechanical retention good
 Disadvantages
 Fair prosthodontic acceptability
 Education availability fair
 Prosthodontic esthetics can be difficult because of
some head designs
 Lacks ADA acceptance

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To Conclude
 The ultimate goal, the restoration of all lost
teeth, gingiva and bone, is rarely achievable.
The realistic goal is to restore a sufficient
quantity and quality to meet the individual
patient’s need. It is achieved when the
prosthesis is integrated into patient mouth and
patient becomes unaware of restoration. Dental
implants are successful and some brands are
well accepted and approved by major dental
organizations. Implant Prosthodontics is a
rapidly developing field.

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References:
 Ralf V McKinney Jr: Endosteal Dental Implants
 Carl E Mish: Contemporary Implant Dentistry Ed
2nd
.
 Charles English. Journal Of American Dentisty
Sept 1990;330-424.

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Thank You
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