2. CONTENTS
Introduction
Classification of Bone density
Osseointergration
General principles of implant therapy
The Implant Kit
Surgical Procedures
Healing after Implant placement
Implant Surgical Guides
Complications of Implant procedure
Conclusion
3. INTRODUCTION
The goal of modern dentistry is to restore the patient tooth to normal contour,
function, comfort, aesthetics, speech and health by removing caries from a tooth or
replacing several teeth
An implant is an alloplastic material surgically inserted into a residual bony ridge,
primarily as a prosthodontic foundation
The surgical procedures for the placement of dental implants currently used are
based on the original work of Professor Per-Ingvar Branemark and colleagues in
Sweden in the 1960s and 1970s
4. BONECLASSIFICATIONRELATED TO
IMPLANT DENTISTRY
Linkow (1970)
Class I Ideal bone type consist of evenly spaced
trabeculae with small cancellated spaces
Class II This type of bone has slightly larger
cancellated spaces with less uniformity of the
osseous pattern
Class III Large marrow-filled spaces exist between
bone trabeculae
5. Lekholm and Zarb (1985)
Quality 1 Homogenous compact bone
Quality 2 Thick layer of compact bone surrounding a
core of dense trabecular bone
Quality 3 Thin layer of cortical bone surrounding
dense trabecular bone of favourable
strength
Quality 4 Thin layer of cortical bone surrounding a
core of low density trabecular bone
6. Misch (1988)
Bone
Density
Description Anatomical location
D1 Dense cortical Anterior mandible
D2 Porous cortical and coarse
trabecular
Anterior mandible
Posterior mandible
Anterior maxilla
D3 Porous cortical (thin) and fine
trabecular
Anterior maxilla
Posterior maxilla
Posterior mandible
D4 Fine trabecular Posterior maxilla
7. OSSEOINTEGRATION
The apparent direct attachment or connection of osseous tissue to an inert
alloplastic material without intervening connective tissue
(Glossary of Periodontal Terms 2001)
Contact established without interposition of nonbone tissue between normal
remodeled bone and an implant entailing a sustained transfer and distribution of
load from the implant to and within the bone tissue
(American Academy of Implant Dentistry 1986)
An intimate bone-to-implant apposition that offers sufficient strength to cope with
the load transfer
(Branemark 1950)
8. Branemark (1960s) conducted an experimental study where he placed titanium
implants on the legs of rabbits and found that it could not be removed after the
healing period
Studies were performed on the healing and anchorage stability of titanium implants
of various sizes and designs. They found that a shell of compact cortical bone was
formed around the implant without any apparent soft tissue intervention following
an adequate immobilized healing period
(Jayesh RS, Dhinakarsamy V. Osseointegration. J Pharm Bioall Sci 2015;7:S226-9)
10. BasicPrinciples of Implant Therapy to Achieve Osseointegration
1. Implants must be sterile and made of a biocompatible material
2. Implant site preparation should be performed under sterile
conditions
3. Implant site preparation should be completed with an atraumatic
surgical technique that avoids overheating of the bone during
preparation of the recipient site
4. Implants should be placed with good initial stability
5. Implants should be allowed to heal without loading or
micromovement for 2 to 4 months (mandible) and 4 to 6 months
(maxilla)
12. DRILLS
The kit contains 5 universal
drills of diameters
• D2.0mm
• D3.3mm
• D3.8mm
• D4.5mm
• D5.7mm
All drills are internally coded
with easily identifiable depth
markings
Drills – Depth Markings
The depth markings on each
drill correspond to the
various lengths of implants
available
• L8mm
• L9.5mm
• L11m
• L13mm
• L15mm
Depth Gauge
Designed to fit
the 2mm pilot
hole as well as
the 3.3mm
osteotomy sites.
The markings on
the gauge
correspond to
the lengths of
the Implants
13. Drill extender
Can be used in
situations where
implants are being
placed in spaces where
extra length of the
instruments are
required
The torque ratchet
Can be used for surgery
and prosthetics with
indicated torque values
ranging from 0-70 Ncm.
The indicated torque
value for tightening of
all abutment screws is
30 Ncm
Abutment remover
Offers an elegant
solution to retrieving the
abutments by simply
screwing the remover
into the implant –
abutment assembly. The
abutment gets easily
vertically displaced and
can be removed
14. Screw Driver and Torque Driver
For secure fastening of screws, a hand
screw driver as well as a torque driver is
used
The hand screw driver also fits the torque
ratchet and the torque driver can be used
in the handpiece
15. • Torque: Upto 80 Ncm
• Speed control: Between 200 ~ 40,000
min-1
CONTROL
BOX
FOOT
PEDAL
HANDPIECE IMPLANT
MOTOR
Physiodispenser
17. Two-Stagesurgery
The first-stageends by suturing the soft tissues together over the implant
cover screw so that it remains submerged and isolated from the oral cavity
In the two-stage surgery, to of the implant is
completely submerged under gingiva
18. In areas with dense cortical bone (mandible) and good initial implant support, the
implants are left to heal undisturbed for a period of 2 to 4 months
In areas of loose trabecular bone (maxilla), grafted sites, and sites with lesser
implant stability, implants may be allowed to heal for periods of 4 to 6 months or
more
The width of the bone is often reduced after initial socket healing, therefore if
required bone grafting procedures should be preformed before implant insertion
In more experienced situation the implant maybe inserted at the same appointment
19. C, Minimal flap reflection is used to expose the alveolar bone. D Buccal flap is partially
dissected at the apical portion to provide a flap extension. This is a critical step to ensure
a tension-free closure of the flap after implant placement
A. Partial edentulous ridge. B, Mesial sulcular and distal vertical incisions are
connected by a crestal incision.
20. Suturing completed. Interrupted and
horizontal mattress sutures are used to
ensure tension-free, tight closure of the
flaps
Use of the guide pins ensures parallelism
of the implant placement
After placement of two implants, the
cover screws are placed. The cover screws
should be placed at the level of the ridge
to minimize the chance of exposure
21. For a knife-edge alveolar process with sufficient alveolar bone height and sufficient
distance from vital structures, a large round bur is used to recontour or flatten the bone
to provide a wider, level surface for the implant site preparation
If the vertical height of the alveolar bone is limited (e.g., <10 mm), the knife-edge
alveolar bone height should be preserved
A narrow, sharp ridge can be surgically reduced/contoured
to provide a reasonably flat bed for the implant
22. A series of drills are used to prepare the osteotomy site precisely and incrementally
for an implant
Sequence of drills used for standard-diameter 4.0-mm implant
site osteotomy preparation: round, 2-mm twist, pilot, 3-mm
twist, and countersink.
23. Round Bur
Used to make the initial penetration into bone for the implant
site, the initial marks are checked for their appropriate buccal-
lingual and mesial-distal location, as well as the positions
relative to each other and adjacent teeth
Each marked site is then prepared to a depth of 1 to 2 mm with
a round drill, breaking through the cortical bone and creating a
starting point for the 2-mm twist drill
24. The 2-mm Twist Drill
Is used next to establish the depth and alignment of the long axis
of the implant
The twist drill is used at a speed of approximately 800 to 1500
rpm
Drills should be repeatedly pulled out of the osteotomy site while
drilling to expose them to the water coolant and to facilitate
clearing bone debris from the cutting surfaces
25. Guide pin
The relationship to neighboring vital structures can be
determined by taking a periapical radiograph with a guide
pin
2-mm twist drill is used to establish the final depth of the
osteotomy site corresponding to the length of each planned
implant.
26. When multiple implants are being placed next to one another, a guide pin should be
placed in the prepared sites to check the alignment, parallelism, and proper
prosthetic spacing throughout the preparation process
Implants should be positioned with approximately 3 mm between one another to
ensure sufficient space for interimplant bone and soft-tissue health and to facilitate
oral hygiene procedures
Therefore, the initial marks
should be separated by at least 7
mm (center to center) for 4 mm
standard-diameter implants
3mm
7mm
27. Pilot Drill
A pilot drill with a noncutting 2-mm diameter guide at the
apical end and a cutting 3-mm diameter (wider) midsection is
used to enlarge the osteotomy site at the coronal end, thus
facilitating the insertion of the subsequent drill in the
sequence
28. The 3-mm Twist Drill
The final drill in the osteotomy site preparation for a
standard-diameter (4.0 mm) implant is the 3-mm twist drill
It is the last drill used to widen the site along the entire
depth of the osteotomy from the previous diameter (2 mm)
to final diameter (3 mm)
This final drill finishes preparing the osteotomy site and
consequently is the step that dictates whether the implant
will be stable or not
29. Countersink Drill (Optional)
When it is desirable to place the cover screw at or slightly
below the crestal bone, countersink drilling is used to shape
or flare the crestal aspect of the osteotomy site allowing the
coronal flare of the implant head and cover screw to fit within
the osteotomy site
30. Implant Placement
Implants are inserted with a handpiece rotating at slow
speeds (e.g., 25 rpm) or by hand with a wrench
Insertion of the implant must follow the
same path or line as the osteotomy site
31. Postoperative Care
Antibiotics can be prescribed if the surgery is extensive, or if the patient is medically
compromised
Patients should apply cold packs over the first 24 to 48 hours
Chlorhexidine gluconate oral rinses can be prescribed to facilitate plaque control
Adequate pain medication should be prescribed
Patients should be instructed to maintain a relatively soft diet after surgery
Patients should also refrain from tobacco and alcohol use after surgery
32. The second-stage (exposure) surgery
1. Simple circular punch incision:
In areas with sufficient zones of keratinized tissue, the
gingiva covering the head of the implant can be exposed
with a circular or punch incision
2. Partial thickness repositioned flap
33. Clinical view of second-stage implant surgery in a case with adequate keratinized tissue.
A, Simple circular or a punch incision is used to expose implant when sufficient
keratinized tissue is present around the implant(s). B, Implant exposed. C, Healing
abutment attached. D, Final restoration in placed.
Simple circular punch incision
34. Advantage
Less trauma to the soft tissue as its not reflected
Disadvantage
Inability to assess the bone volume before or during the surgery
Difficult to see the markings on the drills as soft tissue covers the crest of the ridge
Can be use only when the bone has abundant thickness
35. Partial thickness repositioned flap
Two endosseous implants were placed 4 months
previously and are ready to be exposed.
Note the narrow band of keratinized tissue
Two vertical incisions are connected by crestal incision. If
facial keratinized tissue is insufficient, it is necessary to
locate the crestal incision more lingually so that there is
at least 2 to 3 mm of keratinized band
Buccal partial-thickness flap is sutured to the periosteum
apical to the emerging implants
36. Gingival tissue coronal to the cover
screws is excised using the gingivectomy
technique
Cover screws are removed, and
heads of the implants are cleared
37. Healing at 2 to 3 weeks after second-
stage surgery
Four months after the final restoration.
Note the healthy band of keratinized
attached gingiva around the implants
Abutments are placed, visual inspection
ensures intimate contact between the
abutments and the implants
38. Advantages
1. Direct observation of crestal bone volume before ostectomy and during
ostectomy procedure
2. Ability to place bone graft material at the time of implant placement
3. Reduces the risk of early loading during initial bone healing
4. Bacterial infiltration are not critical factors during initial healing
5. Ability to deliver a provisional appliance in the esthetic zone
39. ONESTAGEsurgery
In the one-stage implant surgical approach, a second implant exposure surgery is not
needed because the implant is exposed from the time of implant placement.
The implants are left unloaded and undisturbed for a period similar to that for implants
placed in the two-stage approach.
In the one-stage surgical approach, the implant or the healing abutment protrudes
approximately 2 to 3 mm from the bone crest, and the flaps are adapted around the
implant/abutment.
40. A, Crestal incision made along the crest of
the ridge, bisecting the existing zone of
keratinized mucosa.
B, Full-thickness flap is raised buccally and
lingually to the level of the mucogingival
junction. A narrow, sharp ridge can be
surgically reduced or contoured to provide
a reasonably flat bed for the implant
C, Implant is placed in the prepared
osteotomy site.
D, Tissues are adapted around the neck
of the implant to achieve flap closure
with the implant protruding through the
soft tissues.
41. Advantage
A second-stage exposure surgery is not necessary
The soft tissue matures while the bone interface is healing
The abutment to implant connection may be placed above the crest of bone which
may reduce early crestal bone loss
The higher profile implant body also allow the operator to attach the prosthetic
abutment with greater ease and tactile ability
42. Esposito et al., 2009 conducted a review study (n=239) with a
minimum follow up of 6 months after loading, to evaluate if a one-stage
implant placement procedure is as effective as a two-stage procedure
They found no statistically significant differences for prosthesis and
implant failures between the two procedures
They concluded that one-stage approach might be preferable in
partially edentulous patients
Two-stage submerged approach could be indicated when an implant
has not obtained an optimal primary stability and when grafts are
indicated
(One-stage versus two-stage implant placement. A Cochrane systematic review of randomised controlled clinical trials, European
Journal of Oral Implantology . 2009, Vol. 2 Issue 2, p91-99. 9p, Esposito et al.,)
43. HEALING AFTER IMPLANT
PLACEMENT
The osseointegration process observed after implant insertion can be compared to
bone fracture healing.
Initially, blood is present between the fixture and bone, then blood clot forms.
Extracellular matrix proteins, such as osteocalcin modulate apatite crystal growth
and growth factors such as platelet derived growth factor (PDGF) and transforming
growth factor beta (TGF- b) are activated which helps in the proliferation of
osteoblast
44. • Woven bone is quickly formed in the gap
between the implant and the bone, it grows fast
up to 100 μm per day in all directions.
• Characterized by a random orientation of its
collagen fibrils, high cellularity, and limited
degree of mineralization, the biomechanical
capacity of woven bone is poor.
• Woven bone is progressively replaced by lamellar
bone with organized, parallel layers of collagen
fibrils and dense mineralization
• Contrary to the fast-growing woven bone,
lamellar bone formation occurs at a slow pace.
• After 18 months of healing, a steady state is
reached where lamellar bone is continuously
resorbed and replaced
46. TypesofImplantSurgicalGuides
Surgical guide templates facilitate proper positioning and angulation of the
implants in the bone which can decrease clinical and laboratory complications
There are 3 design concepts which are classified based on the amount of surgical
restriction offered by the surgical guide templates
(1) Nonlimiting design
(2) Partially limiting design
(3) Completely limiting design
Types of Implant Surgical Guides in Dentistry: A Review Kathleen et al., 2012. Journal of Oral
Implantology., vol 38, issue 5.
47. Nonlimiting Design
It only provide an indication to the surgeon as to where the proposed prosthesis is in
relation to the selected implant site.
This design indicates the position of the prosthesis without any emphasis on the
angulation of the drill, thus allowing too much flexibility in the positioning of the
implant.
It has been observed that the
use of these guides may
result in unacceptable implant
angulation
48. Partially limiting design
The first drill used for the osteotomy is directed using the surgical guide, and the
remainder of the osteotomy and implant placement is then finished freehand by the
surgeon
Techniques based on this design concept involve fabrication of a radiographic
template, which is then converted into a surgical guide template following
radiographic evaluation
49. Steps in Creating a Radiographic Template
The proposed implant
locations have been
marked
The cast is
then mounted
on an
adjustable
surveyor table
Parallel holes are
drilled into the stone at
the proposed desired
angles with a 2-mm
carbide drill
50. Sections of the wooden
shaft are inserted into the
holes in the cast
Boxing wax is applied to
form the rough borders
of the stent
After application of an
appropriate separating
media, clear acrylic is
poured over the occlusal
surface
51. The entire cast is
then placed into a
pressure pot and left
to fully cure
The stent is carefully
removed from the cast,
trimmed, and polished,
Gutta-percha is warmed
and compacted into the
channels left after
removal of the wooden
shafts and the stent is
ready to deliver to the
patient
Acrylic is trimmed from
the buccal aspect of
the stent to leave
notches or indentations
at the sites of the rods.
This allows the surgeon
to place the initial drill
into the indicated
positions
52. Completely limiting design
Restricts all of the instruments used for the osteotomy in a buccolingual and
mesiodistal plane
The addition of drill stops limits the depth of the preparation
This includes 2 popular designs: cast-based guided surgical guide and computer-
assisted design and manufacturing (CAD/CAM) based surgical guide
53. Guide pins attached to the surgical guide
to verify alignment of implants
Facial portion of surgical template
removed before surgery
54. IMPLANTRELATEDCOMPLIATIONANDFAILURE
With the increasing popularity of dental implants, the presence of implant
complications has been on the rise
Generally, implant complications can be classified into four groups:
1. Surgical
2. Biological
3. Technical or Mechanical
4. Esthetic and Phonetics
55. SURGICAL COMPLICATIONS • Hemorrhage and Hematoma
• Nerosensory disturbance
- hypoesthesia
- hyperesthesia
• Damage to adjacent teeth/ Implant malposition
BIOLOGICAL
COMPLICATIONS
(40-60%)
• Dehiscence and Recession
• Periimplantitis and Bone Loss
• Implant Loss or Failure
TECHNICAL OR
MECHANICAL
COMPLICATIONS
(60-80%)
• Screw Loosening and Fracture
• Implant Fracture
• Fracture of Restorative Materials
ESTHETIC AND PHONETIC
COMPLICATIONS
56. CONCLUSION
Dental implants has become one of the most widely accepted and used treatment
modality in dentistry
It is essential to understand and follow basic guidelines to achieve osseointegration
and avoid complications
Fundamental protocols must be followed for implant placement and implant
exposure surgery.
57.
58. REFERENCES
Clinical Periodontology by Carranza 10th and 12th Edition
Contemporary Implant Dentist by Carl E Misch 3rd Edition
Periobasics: A textbook of Periodontics and Implantology by Nitin Saroch 1st Edition
Jayesh RS, Dhinakarsamy V. Osseointegration. J Pharm Bioall Sci 2015;7:S226-9
