Comparision of tooth and implant/ cosmetic dentistry training

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 STRUCTURE OF PERIODONTALSTRUCTURE OF PERIODONTAL
LIGAMENTLIGAMENT
 STRUCTURE OF PERI-IMPLANT TISSUESSTRUCTURE OF PERI-IMPLANT TISSUES
 CLINICAL PARAMETERS COMPARINGCLINICAL PARAMETERS COMPARING
TEETH AND IMPLANTTEETH AND IMPLANT
 BIOMECHANICAL DIFFERENCEBIOMECHANICAL DIFFERENCE
BETWEEN TEETH AND IMPLANTBETWEEN TEETH AND IMPLANT
 CONCLUSIONCONCLUSION
 BIBLIOGRAPHYBIBLIOGRAPHY

INTRODUCTIONINTRODUCTION
 The primary function of a dental implant is toThe primary function of a dental implant is to
act as an abutment for a prosthetic device,act as an abutment for a prosthetic device,
similar to a natural tooth root and crown. Thesimilar to a natural tooth root and crown. The
restoring dentist designs and fabricates arestoring dentist designs and fabricates a
prosthesis similar to one supported by a toothprosthesis similar to one supported by a tooth
and as such also evaluates and treat the dentaland as such also evaluates and treat the dental
implant similarly to a natural tooth. Yetimplant similarly to a natural tooth. Yet
fundamental differences in the support systemfundamental differences in the support system
have to be recognized.have to be recognized.

PERIODONTAL LIGAMENTPERIODONTAL LIGAMENT
 Synthetic cellsSynthetic cells
 Resorptive cellsResorptive cells
 Epithelial cellsEpithelial cells
 Extracellular matrixExtracellular matrix
- fibers- fibers
- ground substances- ground substances
 Other structuresOther structures
 Functions.Functions.

PERI-IMPLANT TISSUESPERI-IMPLANT TISSUES
 3 mm tissue3 mm tissue
 2 layers - epithelial2 layers - epithelial
- connectiveconnective
 Few epithelial layerFew epithelial layer
 lacks keratinizationlacks keratinization
 Increased susceptible.Increased susceptible.
 Sole vascular supply –Sole vascular supply –
alveolar supraperiosteal.alveolar supraperiosteal.
 Connective tissue rich inConnective tissue rich in
collagencollagen
 Acellular and avascular.Acellular and avascular.

CLINICAL PARAMETERSCLINICAL PARAMETERS
 LongevityLongevity
 PainPain
 Mobility Vs rigid fixationMobility Vs rigid fixation
 PercussionPercussion
 Crestal bone lossCrestal bone loss
 Radiographic evaluationRadiographic evaluation
 Keratinized tissueKeratinized tissue
 Probing depthsProbing depths
 Bleeding indexBleeding index
 Peri-implant diseasePeri-implant disease

LONGEVITYLONGEVITY
 Criteria for implant success;[Albrektsson]Criteria for implant success;[Albrektsson]
1.1. An individual unattached implant isAn individual unattached implant is
immobile when tested clinically.immobile when tested clinically.
2.2. The radiograph does not demonstrate anyThe radiograph does not demonstrate any
evidence of periimplant radiolucency.evidence of periimplant radiolucency.
3.3. Vertical bone loss is less than 0.2mmVertical bone loss is less than 0.2mm
annually after the first year of service of theannually after the first year of service of the
implant.implant.

4.4. Individual implant performance isIndividual implant performance is
characterized by an absence of persistent orcharacterized by an absence of persistent or
irreversible signs and symptoms such asirreversible signs and symptoms such as
pain, infections, neuropathies, paresthesia, orpain, infections, neuropathies, paresthesia, or
violation of the mandibular canal.violation of the mandibular canal.
5.5. Success rate is a minimum of 85% for 5Success rate is a minimum of 85% for 5
years and 80% for 10 years.years and 80% for 10 years.

PAINPAIN
 Subjective findings of pain, tenderness andSubjective findings of pain, tenderness and
sensitivity are commonly seen in natural tooth.sensitivity are commonly seen in natural tooth.
A natural tooth often becomes hyperemic andA natural tooth often becomes hyperemic and
cold temperature sensitive as the first indicatorcold temperature sensitive as the first indicator
of the problem. Tooth becomes sensitive toof the problem. Tooth becomes sensitive to
heat and painful to percussion, indicatingheat and painful to percussion, indicating
pulpitis.pulpitis.

 The implants does not become hyperemic and is notThe implants does not become hyperemic and is not
temperature sensitive, and the early warning signstemperature sensitive, and the early warning signs
and symptoms of a problems may not be present.and symptoms of a problems may not be present.
 Pain is rarely associated with the implant afterPain is rarely associated with the implant after
primary healing.primary healing.
 Forces upto 500g are used clinically to evaluate toothForces upto 500g are used clinically to evaluate tooth
or implant pain or discomfort.or implant pain or discomfort.
 The persistent pain during percussion or function onThe persistent pain during percussion or function on
implant- removal even in the absence of mobility.implant- removal even in the absence of mobility.

 Pain in implant occurs due to ;Pain in implant occurs due to ;
1.1. Soft tissue entrapment between implant andSoft tissue entrapment between implant and
abutment- elimination of soft tissue.abutment- elimination of soft tissue.
2.2. Implant placed proximity to nerve – unthreadImplant placed proximity to nerve – unthread
the implant and reevaluate.the implant and reevaluate.
3.3. Bone stress beyond physiologic limits –Bone stress beyond physiologic limits –
address occlusion and parafunctional habits,address occlusion and parafunctional habits,
prosthesis should be modified, or additionalprosthesis should be modified, or additional
implants placed to dessipate the forces.implants placed to dessipate the forces.

MOBILITYMOBILITY
 Natural tooth, usually anteriors moves aroundNatural tooth, usually anteriors moves around
0.1mm and molars around 56 to 73microns.0.1mm and molars around 56 to 73microns.
 Implant moves less than 73 microns.Implant moves less than 73 microns.
 Mobility can be tested using two rigidMobility can be tested using two rigid
instruments apply a labiolingual force ofinstruments apply a labiolingual force of
approximately 500g.approximately 500g.

Clinical implant mobility scaleClinical implant mobility scale
Scale descriptionScale description
0 absence of clinical mobility0 absence of clinical mobility
1 Slight detectable horizontal mobility1 Slight detectable horizontal mobility
2 Moderate horizontal mobility upto2 Moderate horizontal mobility upto
0.5mm0.5mm
3 Severe horizontal movement greater3 Severe horizontal movement greater
than 0.5mmthan 0.5mm
4 Visible moderate to severe4 Visible moderate to severe
horizontal and any visible vertical movement.horizontal and any visible vertical movement.

 Natural tooth with primary occlusal trauma exhibitsNatural tooth with primary occlusal trauma exhibits
an increase in mobility and radiographic periodontalan increase in mobility and radiographic periodontal
ligament space. Once the cause of trauma isligament space. Once the cause of trauma is
eliminated, the tooth return to zero mobility and aeliminated, the tooth return to zero mobility and a
normal radiographic appearance.normal radiographic appearance.
 In implant, with 0.1mm horizontal mobility, onIn implant, with 0.1mm horizontal mobility, on
occasion may return to rigid fixation. To achieve this,occasion may return to rigid fixation. To achieve this,
implant should be completely out of occlusion forimplant should be completely out of occlusion for
several months.several months.

 Periotest – is a computed mechanical devicePeriotest – is a computed mechanical device
developed bydeveloped by SchulteSchulte that measures thethat measures the
damping effect of an object.damping effect of an object.
 The recording ranges from -8 to +50. teethThe recording ranges from -8 to +50. teeth
with zero clinical mobility have typical rangeswith zero clinical mobility have typical ranges
from +5 to +9. implant corresponds to valuesfrom +5 to +9. implant corresponds to values
ranging from -8 to +9.ranging from -8 to +9.

PERCUSSIONPERCUSSION
 It is used on teeth toIt is used on teeth to
determine which toothdetermine which tooth
is sensitive to functionis sensitive to function
or is beginning toor is beginning to
abscess.abscess.
 The ringing sound thatThe ringing sound that
occurs on percussionoccurs on percussion
corresponds to thecorresponds to the
presence of bonepresence of bone
implant interface.implant interface.

CRESTAL BONE LOSSCRESTAL BONE LOSS
 Under ideal conditions a tooth or implant should loseUnder ideal conditions a tooth or implant should lose
minimal bone.minimal bone.
 AdellAdell et al, determined that successful implants afteret al, determined that successful implants after
first year loading had an average 0.1mm bone loss forfirst year loading had an average 0.1mm bone loss for
each year.each year.
 Early loss of crestal bone beyond 1mm after prosthsisEarly loss of crestal bone beyond 1mm after prosthsis
delivery is usually a result of excessive stress at thedelivery is usually a result of excessive stress at the
crestal implant-interface.crestal implant-interface.
 the dentist should evaluate and reduce stress factorsthe dentist should evaluate and reduce stress factors
such as occlusal forces, cantilever length, andsuch as occlusal forces, cantilever length, and
especially parafunction on observation of initial boneespecially parafunction on observation of initial bone
loss.loss.

RADIOGRAPHIC EVALUATIONRADIOGRAPHIC EVALUATION
 The radiographic assessment of natural teeth assists inThe radiographic assessment of natural teeth assists in
determining the presence of decay, lesions of endodonticdetermining the presence of decay, lesions of endodontic
origin and periodontal bone loss.origin and periodontal bone loss.
 Implants do not decay and do not develop endodontic relatedImplants do not decay and do not develop endodontic related
conditions.conditions.
 Crestal bone loss around the implant can be evaluated butCrestal bone loss around the implant can be evaluated but
radiograph only illustrates clearly the mesial and distal crestalradiograph only illustrates clearly the mesial and distal crestal
levels of bone , but early bone loss often occurs on the faciallevels of bone , but early bone loss often occurs on the facial
aspect.aspect.
 An absence of radiolucency does not mean presence of bone atAn absence of radiolucency does not mean presence of bone at
the implant interface, since 40% decrease in density isthe implant interface, since 40% decrease in density is
necessary to produce a traditional radiographic difference.necessary to produce a traditional radiographic difference.

 Parallel periapical radiographs are more difficult toParallel periapical radiographs are more difficult to
obtain for implants than for tooth,obtain for implants than for tooth,
 Radiographs are taken and reviewed every 6 to 8Radiographs are taken and reviewed every 6 to 8
months until stable for two consecutive periods. Ifmonths until stable for two consecutive periods. If
bone loss greater than 2mm is observed from thebone loss greater than 2mm is observed from the
bonelevels noted from stage II uncovery to thebonelevels noted from stage II uncovery to the
prosthesis delivery, parafunction on the transitionalprosthesis delivery, parafunction on the transitional
prosthesis should be suspected. Night guards andprosthesis should be suspected. Night guards and
stress reduction on the affected implants arestress reduction on the affected implants are
indicated.indicated.

KERATINIZED TISSUE CONCERNSKERATINIZED TISSUE CONCERNS
 Minimum of 2mm keratinized tissue and 1mmMinimum of 2mm keratinized tissue and 1mm
attached gingiva.attached gingiva.
 Least amount of keratinized tissue is in I PMLeast amount of keratinized tissue is in I PM
 If other periodontal index are normal,If other periodontal index are normal,
keratinized gingiva plays minimal rolekeratinized gingiva plays minimal role
 Its not mandatory but benefit if present.Its not mandatory but benefit if present.

PROBING DEPTHSPROBING DEPTHS
 The correct pressureThe correct pressure
recommended for probing is 20recommended for probing is 20
g,g,
 Sulcus depths greater than 5 toSulcus depths greater than 5 to
6 mm have a greater incidence6 mm have a greater incidence
of anaerobic bacteriaof anaerobic bacteria
 the probing depth next to athe probing depth next to a
healthy implant is typicallyhealthy implant is typically
greater than that of a healthygreater than that of a healthy
natural toothnatural tooth
 material from which the probematerial from which the probe
should be fabricatedshould be fabricated

BLEEDING INDEXBLEEDING INDEX
 Gingival bleeding when probing correlatesGingival bleeding when probing correlates
with Inflammation and the plaque Indexwith Inflammation and the plaque Index
 inflammation is typically less around implantsinflammation is typically less around implants
than around teeththan around teeth
 Loe and Silness gingival indexLoe and Silness gingival index

PERI-IMPLANT DISEASEPERI-IMPLANT DISEASE
 Initial pellicle composition is similarInitial pellicle composition is similar
 They contain gram +ve bacilli and cocci.They contain gram +ve bacilli and cocci.
 Supra gingival calculus is seen in implant butSupra gingival calculus is seen in implant but
not subgingival .not subgingival .
 Calulus around the implant is less tenaciousCalulus around the implant is less tenacious
 Gingivitis is a bacteria-induced inflammationGingivitis is a bacteria-induced inflammation
involving the region of the marginal gingivainvolving the region of the marginal gingiva
above the crest of bone and is similar in bothabove the crest of bone and is similar in both
teeth and implant- peri mucositis.teeth and implant- peri mucositis.

 The bacteria in gingivitis around a tooth may affectThe bacteria in gingivitis around a tooth may affect
the epithelial attachment but without loss ofthe epithelial attachment but without loss of
connective tissue attachment. Because the connectiveconnective tissue attachment. Because the connective
tissue attachment of a tooth extends an average oftissue attachment of a tooth extends an average of
1.07 mm above the crestal bone, at least 1 mm of1.07 mm above the crestal bone, at least 1 mm of
protective barrier above the bone is left.protective barrier above the bone is left.
 In contrast, no connective tissue attachment zoneIn contrast, no connective tissue attachment zone
exists around an implant because no connective fibersexists around an implant because no connective fibers
extend into the implant. Hence no connective tissueextend into the implant. Hence no connective tissue
barrier exists to protect the crestal bone around anbarrier exists to protect the crestal bone around an
implant.implant.

 Periodontitis around teeth is caused by bacteria,Periodontitis around teeth is caused by bacteria,
characterized by apical proliferation and ulceration ofcharacterized by apical proliferation and ulceration of
the junctional epithelium, progressive loss of thethe junctional epithelium, progressive loss of the
connective tissue attachment, and loss of alveolarconnective tissue attachment, and loss of alveolar
bone.bone.
 After prosthesis delivery, early crestal bone lossAfter prosthesis delivery, early crestal bone loss
around an implant usually is not caused by bacteria.around an implant usually is not caused by bacteria.
 However, bacteria on occasion may be the primaryHowever, bacteria on occasion may be the primary
factor. Anaerobic bacteria have been observedfactor. Anaerobic bacteria have been observed
especially when sulcus depths are greater than 5 mm.especially when sulcus depths are greater than 5 mm.

BIOMECHANICAL DIFFERENCESBIOMECHANICAL DIFFERENCES
TOOTHTOOTH
 Shock absorberShock absorber
 Decreased stressDecreased stress
 Mobility to occlusalMobility to occlusal
trauma, returns aftertrauma, returns after
elimination.elimination.
 MovementMovement
8-28 microns vertical8-28 microns vertical
56-108 horizontal56-108 horizontal
 Pivot movement present whichPivot movement present which
minimizes crestal bone lossminimizes crestal bone loss
IMPLANTIMPLANT
 no resilient interfaceno resilient interface
 no force dissipationno force dissipation
 irreversible bone lossirreversible bone loss
 0-5 microns, 10-50microns.0-5 microns, 10-50microns.
 No pivot movement, stressNo pivot movement, stress
concentration at bone crest.concentration at bone crest.

Biomechanical designBiomechanical design
 Greater width ofGreater width of
occlusal surface henceocclusal surface hence
lesser magnitude oflesser magnitude of
stress.stress.
 Cross section shapeCross section shape
resists bucco-lingual orresists bucco-lingual or
lateral load.lateral load.
 Similar elastic modulusSimilar elastic modulus
of tooth and implant.of tooth and implant.
 Lesser widthLesser width
 Round cross sectionRound cross section
 Difference in elasticDifference in elastic
modulusmodulus

Sensory nerve complexSensory nerve complex
 Premature contact –Premature contact –
orthodontic migration.orthodontic migration.
 Excess tongue/oralExcess tongue/oral
habits can causehabits can cause
migrationmigration
 Early detection ofEarly detection of
occlusal load. Henceocclusal load. Hence
bite force is of lessbite force is of less
magnitudemagnitude
 Increased occlusalIncreased occlusal
awareness.awareness.
 No orthodonticNo orthodontic
movementmovement
 Biting force is 4 foldsBiting force is 4 folds
greater due to lack ofgreater due to lack of
propioception.propioception.
 Decreased occlusalDecreased occlusal
awareness.awareness.

 Clinical evidence ofClinical evidence of
occlusal trauma – wearocclusal trauma – wear
facets, stress lines, linesfacets, stress lines, lines
of luder, cervicalof luder, cervical
abfraction.abfraction.
 Fatigue fracture.Fatigue fracture.

CONCLUSIONCONCLUSION
 Devan stated that preservation of that whichDevan stated that preservation of that which
remains and not the meticulous replacement ofremains and not the meticulous replacement of
what is lost. Even though the implant has gotwhat is lost. Even though the implant has got
more advantages compared to other prosthesis,more advantages compared to other prosthesis,
ultimately, it is the natural tooth whichultimately, it is the natural tooth which
remains the best.remains the best.

BIBLIOGRAPHYBIBLIOGRAPHY
 Contemporary Implant Dentistry – Carl E.MischContemporary Implant Dentistry – Carl E.Misch
 Endosseous implants for MaxillofacialEndosseous implants for Maxillofacial
reconstruction – Block and Kentreconstruction – Block and Kent
 ORBANS “Oral histology & embroyology”ORBANS “Oral histology & embroyology”
 Dental Clinic of North America.-Implantology-Dental Clinic of North America.-Implantology-
July 2006;50;3.July 2006;50;3.
 Dental implants- the art and science- CharlesDental implants- the art and science- Charles
A.Babbush.A.Babbush.
 Implants and restorative dentistry- GerardImplants and restorative dentistry- Gerard
M.Scortecci.M.Scortecci. www.indiandentalacademy.comwww.indiandentalacademy.com

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