Dental Implants surgical considerations / implant dentistry course/ implant dentistry course

INDIAN DENTAL ACADEMY
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The Mayan civilisation  earliest
known examples of endosseous
implants dating back to 600 AD.
This mandible had 3 tooth-shaped pieces of shell placed into the
sockets of three missing lower incisors. Compact bone formation
around two of the implants was noted.

 It was 1350 years later that professor Per-Ingvar Branemark
discovered the phenomenon of “Osseointegration”.
 In 1965 he placed the first titanium dental implant into a
human volunteer, a Swede named Gosta Larsson.

SURGICAL ANATOMY

1. Optimally plan and place dental implants.
2. Locate and determine the distance to vital anatomic structures
3. Measure alveolar bone width and visualize bone contours
4. Determine if a bone graft or sinus lift is needed
5. Select the most suitable implant size and type
6. Optimize the implant location and angulation
7. Increased case acceptance
8. Reduced surgery time
9. Build patient confidence

Maxilla

Nasopalatine foramen & canal
 incisive foramen
Incisive canals/foramina of Stenson
4.6mm wide
~7.4mm from labial surface (unresorbed ridge
Large canal – relocation(Artzi et al)
enucleation (Rosenquist & Nystrom)
Angulation of implant

Infra-orbital foramen
 ~ 5mm below infra – orbital ridge
 Care taken in case of severely resorbed ridges
during flap elevation
Infra-orbital Artery
 Anastomose with PSA within buccal plate of bone
 Lateral window preperation – hemorrhage
 Apply pressure
 CT scan- create lateral window inferior to it.
 Use of piezosurgery

Greater Palatine Artery
 Foramen – opp 3rd molar
 Foramen – mid sagittal plane = 16mm
 Greater palatine artery – 12.7to14.7mm from gingival
margin
 Incision – 2mm from the artery
 Low vault – 7mm
 Avg vault – 12mm
 High vault – 17mm

Maxillary sinus
 Antrum of Highmore
 Typical dimensions  ht(36-45mm),width(25-
35mm), length (38-45mm)
Osteum to antral floor  28.5mm. Hence, graft not to
be filled beyond 15mm during sinus lift
Septa – Underwood’s cleft. Get larger towards the
medial. Hence membr elevation shoud proceed lateral
to medial
Schneiderian’s membr – 0.3-0.8mm thick. If thicker
get ENT consultation prior to implant placement

Mandible

Arteria submentalis/ Vena facialis
 Bleeding
 Swelling
 At times may be life-threatening

 Careful palpation  a concavity below the mylohyoid
ridge, as will tomographic views of this region.
 Implants placed in the posterior mandible are at risk of
entering this region, which is highly vascularized, with
resultant risks of haemorrhage.
Mylohyoid ridge

Mandibular Foramen
 Location – varies based on race and ethnicity
 2.5%-23.5% block injections given at the occlusal level 
ineffective
 Inject 6-10mm above the occlusal plane
 Needle length  short (21mm)
 Patient symptomatic even after symptoms of good block
 infiltrate lingual aspect of molar teeth (C2, C3)

Inferior Alveolar Canal
 It houses the inferior alveolar nerve, artery, vein
and lymphatics.
 Canal  ~ 3.4mm wide, Nerve  ~ 2.2mm thick
 The nerve (IAN) mainly contains sensory fibers.

 Osteotomy over mandibular nerve  cortical bone
followed by cancellous bone
 IAC  surrounded by cortical bone
 However tactile feedback cannot be relied upon
No substitutes for radiometrics, safety devices

 The variations in the course of IAC are frequent.
(Nortje´ et al.1977; Berberi et al. 1994; Anil et al. 2003)
 Liu et al (2009)
OPG classification of the course of the nerve
Linear Spoon shaped Elliptic arc Turning curve

TYPE 1
(Linear)
Smallest curvature
TYPE 4
(Turning Curve)
Largest variation
TYPE 3
(Elliptic Arc)
Most common
(48.5%)
TYPE 2
(Spoon shaped)
Largest curvature
Highest bone height
Most secure
Relatively secure
Greater risk Greater risk

The distance from the superior border of IAC to the alveolar crest (U5,U6,U7,U8)
The distance from inferior border of IAC to the inferior border of mandible (D5,D6,D7,D8)

Mental Foramen and Nerve
3 nerve branches

 Location  differs in horizontal and vertical plane
 Whites – b/w apices of pre molars
 Chinese – next to 2nd pre molar
 Atypically – near canine or 1st molar
1st premolar 2nd premolar
Apical to apex 38.6% 24.5%
At apex 15.4% 13.9%
Coronal to apex 46.0% 61.6%

Anterior loop – IAN courses inferiorly and anteriorly and
then loops back to emerge from the foramen.
No Loop
Loop present
Loop
Foramen

 Loop dimensions – on radiographs (0-7.5mm), on cadaver
specimens (0-1mm), on panoramic radiographs (0.5-3.0mm)
 When there is concern , the nerve should be exposed to identify
its position
 Chosen implant length  a safety margin of 2mm
 Incase of an anterior implant longer than the safety distance –
6mm anterior to foramen

Mandibular Incisive Canal
 “True” incisive canal
 Reaches midline – only 18%
 Terminates apical to lateral or central incisor
 Width ~1.8mm
 OPG – 15%, CT – 93%
 Only large sized canals may pose a problem

Lingual Foramen & Lateral Canals
 Lingual foramen – an artery
 Risk of haemorrhage in case of a large canal >
1mm
Submental & Sublingual Arteries
 Dia ~2mm
 Close to lingual plate
 Submental or sublingual hematoma  swelling  airway
obstruction

Lingual & Mylohyoid Nerve
 Lingual nerve – 3mm apical to the crest & 2mm from the
lingual cortical plate in the flap
 Avoid lingual vertical incisions
 Vertical incision distal to 2nd molar – buccal aspect
 Mylohyoid nerve – may contribute to incomplete anesthesia
in mandibular teeth
 Long Buccal Nerve – Turner’s variation

MENTALIS
Witch’s chin – entire resection of the muscle
Incase of sharp vestibular desection – special suturing
MYLOHYOID MUSCLE
An important landmark seperating sublingual &
submental spaces
GENIOHYOID &
GENIOGLOSSUS
Inserted at genial tubercle
Complete retraction  tongue falls back  airway obstruction
DEPRESSOR ANGULI
ORIS &LABII INFERIORIS
Need reflection to expose mental foramen
BUCCINATOR
ORBICULARIS ORIS
May need to be incised for coronal repositioning of flap
MASSETER
Released during harvesting of graft from ramus

Zone of Safety
 An area within the bone that can safely
support implants without fear of
impingement on the mandibular
neurovascular bundle.
 Given by MISCH(1980)
 Determined on OPG or clinically
during surgery.

Nerve Relocation
Buccal repositioning of the inferior alveolar canal :
Removal of buccal cortical plate
Inferior alveolar nerve is relocated from the canal
Implant placement
The nerve is brought back into roughly the same position
Bone plate can be repositioned.
In case of doubt the bone plate should not be repositioned
to avoid any compression of the nerve

History & Examination
 Medical Questionnaire…
 Physical Examination…
 Laboratory Evaluation
- Complete blood cell count
- Bleeding Disorder tests
 3 basic categories of information :
- Past Medical History
- Social & Family History
- Review of patient’s Systemic Health

 History of drug allergy…….. LA, Antibiotics etc.
 Use of any particular drug… ( Aspirin )
 Vital signs ( BP, Respiratory Rate, Pulse,
Temperature)
 Complete Blood Cell count :
- RBCs, WBCs, Leukocyte differential count,
Hb% & Platelet count.

DIAGNOSTIC METHODS

1. Consider the position of the ridge crest
2. Conceptualise the height, width and length of the proposed
operative sites.
3. Determine the amount of well-keratinized masticatory
mucosa.
4. Level of lip line, anu muscle attachments
5. Condition of remaining teeth and adjacent soft tissues
Visual Examination

Manual Palpation
Boley’s gauge

'Ridge mapping/Bone sounding’
Anesthetise the area
Sharpened probe  soft tissue thickness
Sterelised Boley’s guage  bone width
Done repeatedly from superior to inferior and medial to distal
at 5mm intervals
A topographic map of soft and hard tissue dimensions

 Study Casts :
Diagnostic cast
Second (surgical )cast for surgical planning
Mounted using semi adjustable articulator
<7mm in posterior region and <8 to 10mm in anterior
region space, between potential implant site and opposing
occlusal surface…. Additional space needs to be created.

DIAGNOSTIC IMAGING

1. Radiography :
Intraoral Periapical radiograph
 Higher resolution
 Medullary and cortical bone density
Ball Bearing Templates can be
seated intraorally prior to IOPA
radiography.(5mm dia)
rs/5 = rm/rx

Extraoral radiographs
OPG : Presents an over all view of maxilla and mandible
Unpredictable distortion of distances(≥25%)
Lateral cephalographs : Helpful for completely edentulous
patientscross-sectional morphology of residual ridges
along with angles of inclination

2. Computed Tomography : amount of bone available is
calculated to the millimeter.
3. MRI : secondary imaging technique
4. CAD-CAM stereo tactic surgical templates :
model of patient’s alveolar anatomy with osteotomy
positions and orientations.

 At the completion of the diagnostic measures,
the information available to the implantologist
will include :
alveolar ridge height, width, length, location of
the nasal floor, antrum, foramina, interocclusal
distances, periodontal status of remaining
teeth and amount of healthy gingiva.

Implant selection chart based on available bone
WIDTH RIDGE
DEPTH
LENGTH RECOMMENDED
IMPLANT TYPE
Available
bone
0-3mm 0-6mm 0-7mm Sub-periosteal
3-5mm >8mm >10mm Blade
>5mm >8mm 6-25mm Root form(1)
>10mm 16-23mm Root form (2)
24-31mm Root form (3)
>31mm Root form (1for each
additional 7mm
length)

Notes
 Narrow crestal bones can be flattened,available
depth must be re-assessed
 Distance b/w ridge crest and
1. Mandibular canal
2. Antral floor
3. Nasal floor
4. Inferior border of mandible

 Root form implants (dia-3.25 to 6.3mm) & (length-
7to20mm). 1mm of additional bone required
 Spacing b/w root form implants-equal the dia of one
implant
 Less dense bone-largest no of implants that the
available space will permit, rough coatings will
additionally help.

PHASES PROCEDURES
I INTRODUCTION Elimination of a/c conditions
Extraction of hopeless teeth
Stabilisation of occlusion
II PREPARATION Conservative periodontal therapy
Initial endodontic therapy
Pre-implant surgery
Surgical template
III SURGICAL Periodontal surgery in non-implant areas
IV SURGICAL Implant surgery
Periodontal surgery in implant areas
V HEALING Maintenance procedures
Crown preperation
VI ABUTMENT
FINALIZATION
Uncovering of implants
Use of healing caps and/or abutments
Final preperation of teeth
VII PROSTHODONTIC Impression
Placement of prostheses
Occlusal equilibration
VIII MAINTENANCE Hygiene visits and home care

Patient Consent
 Pt should be informed at the time of the initial visit about the
diagnosis, prognosis, the different possible treatments with
their expected results…
 Possible chances of
Damage to the nerve
Paresthesia
Rejection of implant
Post-op pain or swelling

Preparations for Surgery
 Armamentarium :

 The Operatory :
 electrical delivery
system
 hand pieces
 burs and drills

Sterilisation
 Universal precautions to prevent infections
includes :
protective attire and
barrier techniques
 Scrubbing of hands

•Patient should be asked to rinse his / her mouth with
0.2% Chlorhexidine mouthwash 10 min prior to the
surgery
•Para oral structures should be disinfected using
betadine prior to the surgery……

Principles of Surgery
- Incisions
- Flap design, retraction and
soft tissue management
- Bone management
- Sutures and suturing

Incisions
 Sharp scalpel – changed frequently.
 Incisions – crestal (if there is  3mm attached gingiva)
– vestibular
 If less than 3mm attached gingiva or the ridge is narrow
a more facial approach is preferred.
 May involve the sulcus of adjacent teeth.

Flap design, Retraction
 Complete flap elevation without tearing the periosteum
 Flaps with releasing incisions should have BROAD BASES
 Gingivae of neighbouring teeth avoided whenever possible.

Bone Management
 Maintain uninjured periosteal envelope
 Temperatures SHOULD NOT RISE BEYOND 47oC for
time as short as 30sec…therefore irrigation…

Density of Bone: Effect on Surgical Approach
Bone density classification :
D1 Mainly cortical plate compact bone
D2  Thick compact bone with a dense trabecular core
D3  Thin cortical plate with dense trabecular core
D4  Thin cortical plate with low density trabecular
core

Usually Maxilla : anterior – D3
posterior – D4
Mandible : anterior – D2
posterior – D3
D1 bone – symphysis region

Review of Literature
 Jaffin and Berman (1991) reported an overall 8.3%
surgical and initial healing loss in 444 maxillary
implants with softer bone.
 Hutton et al. (1995) identified poor bone quality and
quantity of bone as the highest risk of implant failure in
a study of 510 implants, with overall failure rate in
maxilla being 9 times greater than in mandible.

Schematic drawings showing minimum
bone volume needed for standard implants
of the Branemark System.

Schematic drawings indicating location of
minimum bone volume areas in distal
directions, and giving distances needed for
various numbers of implants.
Arrows indicate prominence and apex of
the nearest tooth.

 Many published reports ….implant surgical failure of
3.2% to 5% in mandible and failure rates in maxilla
upto 1.9% to 2%.
 Therefore consideration is given to methods to
improve surgical survival of implants.

3 factors to be considered after assessing bone quality
in order to achieve initial stability and osseointergration:
- The diameter of the implant
- The diameter of the twist drill
- The healing period

Soft bone  a narrow drill  more resistance to seating of the
implant More torque higher initial primary stability.
Moderately dense bone a slightly wider twist drillto make
seating of the implant possible without too much torque.
Dense bone  pre-tapping the bone site with a screw tap may
be necessary to eliminate the need for forceful hand-wrench
tightening.
Extended healing time  soft bone sites.

BONE DRILLING
 The internally irrigated instrumentation
requires a specific technique to prevent the
irrigation holes from becoming plugged with
bone.
 Drill in the bone for 1-2 seconds, and
then move the drill up without stopping the
handpiece motor to allow irrigation.

 Caution: The drills are approximately 1 mm longer
than the implant being placed. Allow for this additional
length when drilling near vital anatomic structures.
 Recommended drill speed is 800 rpm.
 Screwtap the bone at a maximum speed of 50 rpm.

Implant position & direction

Sutures and Suturing
 To approximate the incised tissue back together
 Complicated implant closure requires synthetic
resorbable material ..for long continous and complicated
closures
 Methods of closure : interrupted suture, continuous
suture, vertical mattress suture.
 CONTINUOUS BOX LOCK SUTURE

 Two stage – Implant heals under the soft tissue
and is , after a healing period ,accessed through
a second stage surgery.
 One stage - The implant heals without
protection of the oral mucosa and is accessible
through the mucosa during healing.
Terminologies

 Immediate implants – placement of implants into
fresh extraction sites.
 Early placement - implant placement 2-6 weeks
following tooth extraction

Two stage
One stage
Direct(flapless)
one stage surgery
Conventional or Delayed Implant Placement

Initial preparation made using a surgical guide or template
to determine the implant location
 Surgical template :
Single tooth replacement :

 Free end saddle edentulous area :
four or more teeth should be included anterior
to the edentulous area
 Completely edentulous area :

Two Stage
 Crestal incision
 Reflect the flap to directly observe the bone

 Guide drill
 Twist drill
 Pilot drill
 3mm twist drill
 Countersink

 Initial preparation :
 Round bur

 Osteotomy is prepared
2mm end
cutting starter
linderman bur
2mm pilot
drills

 Parallel indicators :

Sequential drills 2.5,3,3.2
Side cutting crestal
bone drill
Bone tap

 Threaded pre tap:
planned implant is inserted with a hand held ratchet
wrench or very low speed(5-10rpm) motor drive is used
 Threaded self tap:
firm downward pressure is exerted using a hand held
ratchet
 Non threaded press fits:
no threading required
tapped into slightly undersized osteotomies

 Pilot drill is followed by series of end cutting drills, which gradually
increase the diameter of the osteotomy
 Countersink drill is used when crest platform is at or below crest of
bone.
 Bone tap :
Used in the crestal region of the osteotomy only…
Performed at speed of less than 30rpm
 NOTE : countersinking the implant may place it below the crestal
cortical bone causing decreased stability during healing.

Not to exceed 45 Ncm

 Implant is inserted at or slightly below the crest of bone
 Slow speed high torque handpiece is usually used to
thread the implant into the bone at 30 rpm or less

 Site is rinsed
 Low profile cover screw (coated with antibiotic) is then
inserted

 Tissue are then approximated over implant for
primary closure

 Healing period is about 4-6 months and longer on D4
bone and Grafted areas.
 Technique requires a second stage surgery to uncover the
implant body.

Advantages of the two stage surgery
 Observation of crestal bone before osteotomy
 Observation during osteotomy preparation
 Ability to bone graft the site at the time of implant placement
 Implant body healed at or below the crest of bone
 Bacterial infiltration are not critical during healing

 one stage surgery uses a similar incision and reflection
technique to observe crestal bone
One stage surgery

 At the conclusion of implant surgery Permucosal
healing abutment is placed into the implant .

 Implant is also placed slightly above the crest of
the bone
 Soft tissue is then sutured around the PME

Advantages one stage surgery
 Soft tissue matures while bone interface is healing
 Surgical appointment is reduced
 Higher location of implant abutment connection may
reduce some of the early crestal bone loss
 Higher profile implant body also allows the prosthetic
abutment with greater ease

 Modification of one stage surgery
 Doesn’t reflect the crestal soft tissue
Direct (flapless) one stage surgery

 Core of keratinized tissue( size of the implant
crest modules diameter) is removed over the
crestal bone

 Implant osteotomy is performed in the centre of
the core exposed bone
 Technique doesn’t require sutures
Advantages of flapless surgery
 Less soft tissue trauma coz tissue are not
reflected

Disadvantages of flapless surgery
 Inability to assess the bone volume before or
during implant osteotomy or insertion
 Only be used when the bone width is abundant
 (>6-8mm)

Factors to be considered when implant is
placed in esthetic zone

 When an implant is placed in esthetic zone
 The site must be thoroughly evaluated
 Garber has proposed a classification for such site

 Vertical and horizontal level of both soft tissue and bone
Implant placement is a straight forward
 Thin gingival biotype soft tissue
augmentation
Garber class I

 Normal vertical bone and slight horizontal bone deficiency
about 1 to 2 mm
 Expanded using serial osteotomes instead of drilling
(Summers)
 Slight expansion of bony ridge horizontally
Garber class II

 No vertical bone loss and horizontal bone loss
greater than class II
 Implant placement can be attempted
 Initial stability is achieved
 GBR is necessary
Garber class III

 No vertical bone loss but significant horizontal bone loss
 Staged approach is necessary
 Implant is placed after suitable healing period
 Block bone graft or GBR technique
Garber class IV

 Extensive apicocoronal bone loss

Garber class V
Non resorbable membrane and
delayed implant placement
Barrier membrane with an immediately
submerged implant as a space making
under the membrane
Distraction osteogenesis

Principles of Implant Body Position
Vertical position
Implant
angulation
Labiopalatal
position
Mesiodistal
position

Vertical Positioning
 Midcrestal positioning of the edentulous site
 2-3 mm below the facial CEJ of the adjacent teeth

Mesiodistal Position
 Implant should be at least 1.5-2 mm from an
adjacent tooth and 3 mm to adjacent implants.

Labiopalatal Positioning
 Should be 2mm greater than the implant diameter
 The crestal bone should be 1.5 mm on labial aspect
 0.5mm on palatal aspect .

Implant Angulation
Within the
cingulum
position of the
implant crown
Under the
incisal edge
of the final
restoration
Facial
implant body
angulation

Facial implant body angulation
 An implant is in the position of natural root of the tooth
 It places the implant too facial and angled abutment is
usually necessary.

Incisal edge of the final restoration
 Centre of the implant is located directly under the incisal
edge of the crown
 Straight abutment for cement retention emerges directly
below the incisal edge
 Decreases the crestal stresses
to the bone

Cingulum Implant body angulation
 Emerges under the cingulum of the crown
 Indicated for screw retained crown
 Facial projection of the crown ,facing away from the
implant body.
 Facial ridge lab must extend 2 to 3mm.

Immediate Implants
Indication
Retained deciduous teeth
Vertically and
horizontally fractured
teeth
Tooth loss due to caries,
endodontic failure
Poor esthetics

Risk factor
for
immediate
implant
If overt infection
Poor bone
quality and
quantity
Presence of high
masticatory
Parafunctional
habit

Certain Clinical Requirement for Immediate
Implants
Absence of active
infection
Preservation of labial plate
Use of appropriate
implant design
Good mechanical
anchorage
Proper implant
position

Protocols
for implant
placement
in
extraction
socket
Type
I
Type
IV
Type
III
Type
II

 Implant placement immediately following tooth extraction
Part of same surgical procedure
Advantages
 Reduced no of surgery
 Reduced overall treatment time
 Optimal availability of existing bone
Type 1

Disadvantages
 Site morphology
 Thin tissue biotype
 Lack of keratinized mucosa
 Technique sensitivity

 Complete soft tissue coverage of the sockets (typically 4-
8 weeks)
Advantages
 Increased soft tissue area and volume
 Resolution of local pathology
Type 2
Disadvantages
 Varying amount of resorption
 Increased treatment time
 Adjunctive surgical procedure

 Substantial clinical or radiographic bone fill of the
socket.(typically 12 – 16 weeks)
 Advantages
• Bone fill facilitates implant placement
• Mature soft tissue facilitates flap management
 Disadvantages
• Same as type 2
Type 3

 Healed site ( typically >16 weeks )
 Advantages
 Healed ridges
 Matured soft tissue
 Facilitates flap management
Type 4

Histology and clinical trials
 Most reports on immediate implants placement describe
small peri-implant osseous defects resulting in a gap.
 Horizontal defect dimension or jumping distance
(DCNA 2006 50 )

 These small defects heal with bone fill
 Defect less than 2mm in width , no augmentation or
membrane is required
 Dehiscence or fenestration defects required bone grafting
and barrier membrane
(DCNA 2006 50 )

Guideline for extraction when planning
for immediate implant placement
Preoperative evaluation
Antibiotic therapy initiation
Preservation of bony receptor site
Procedural delays
Avoidance of excessive pressure

Osteotomy preparation
Improvements of placement
 bone graft
Soft tissues closure
Successful osseointegration

 Thoroughly evaluated
 Acute situation may not allow for preliminary evaluation
 Any sign of potential acute infection
 Antibiotic therapy should be initiated before surgery
Preoperative evaluation
Antibiotic therapy initiation

 Use periotome for removal of teeth in atraumatic manner
Preservation of bony receptor site

 If any purulent is discovered after removing the tooth
 placement of the implant should be delayed
 Affected area should be irrigated and closed .
 Tissue is then allowed to heal for several weeks until soft
tissue closure is complete .
Procedural delays

 Socket consists of thin, dense layer of cortical bone.
 During socket preparation care must be taken not to
create any force or pressure
Avoidance of excessive pressure

 In maxilla palatal wall is thicker than the buccal wall
 denser palatal bone will cause the drill to forced to the
labial
 Bone resorption ,leading to failure

 The best position of implant is under incisal edge
 This doesn’t coincide with root apex position
Osteotomy preparation

 Once correct position is confirmed
 Standard drilling procedures are performed
2mm twist drills prepare the osteotomy to the opposing
landmark side cutting drills

The osteotomy is kept in an angulation aligned with the
incisal edge of the adjacent teeth

 incremental drills prepare to the final length and diameter

 Bone tap is used to its final depth
 Implant is threaded into position using
slow speed, high torque handpiece.

 Bone cell will damaged if temp is raised in the bone to 47
degree for more than 1 mins.
 Careful cooling with copious sterile saline
 Use of sharp drills
 Control of the cutting speed

 Implant should be seated two third in the host bone.
 The apex should be 1mm or 2mm longer than tooth being
replaced
 Implant diameter at the cervical area should be wide as
possible to prevent soft tissue ingrowths.
 Totally immobilized .
Improvements of placement

 The gap between the osseous walls of the socket and the
implant fixtures is filled with the bone grafting materials

 Complete soft tissue closure on top of implants might
present for the overall success of dental implants therapy
(Lekholm et al. 1993)
 Protect bone grafting materials from the oral environment
 Prevent the migration of epithelial tissue along the socket
wall
Soft tissues closure

 Successful osseointegration can be increased
by a stress free nonfunctional healing period

Improved
preservation of
the soft tissue
Bone
architecture
Bone
augmentation
and soft tissue
grafts may be
avoided
Reduced
surgical
sessions
Reduced cost
Advantages

Better esthetic
Simplification of prosthetic
design
Improvement in patient
psychological

Reduced vestibular
depth
Deep or shallow
implant placement into
the socket
Increased risk of
postoperative
infections
Bone and implant
contact reduced when
facial plate resorbs
Implant angulation
problems
DISADVANTAGES

Esthetic outcome of immediate implant
 bone resorption during the first six months post
extraction esthetic defect
 IMP allows maintenance of gingival form
 facilitates peri-implant gingival tissue esthetic {
Douglass and Merin (2002)}

 Achieving esthetic success is suggested to be dependent
on ideal 3 dimensional implant position (Buser et al 2004)
 Maintenance of adequate buccal bone over the implant
surface ( Grunder et al 2005)

Implant Surgeries for Various Types of
Implants
1. Endosteal implants :
root form
blades
ramus blade and frame
transosteal
2. Sub periosteal implants
3. Intra mucosal inserts

Blade and Plate Form Implants
 Know the thickness and depth of the prospective host site
 If ridge is less than 3mm wide, flatten it …
Incision Flap retraction

osteotomy
Perforations made 2mm apart

Implant Placement

Ramus Frame and Ramus Blade
Implants
 Anterior incision and osteotomy made first
 Anterior foot of the ramus frame bent…

Anterior incision
Template bending Anterior osteotomy

Posterior osteotomy
Seating of frame Closure of site

Post operative panaromic radiograph

Ramus Blade Implants
 Distal abutment for fixed
bridge in atrophic
mandible
 Used when as little as
4mm bone present

Incision Implant in place

Transosteal Implants
 Application is in overdentures
 Suitable in mandible anterior region ; complete or partial
edentulism

Skin incision Dissection exposing inferior border
Of mandible

Osteotomy with
3/64inch diameter drill
Implant-firm frictional fit

Intraoral closure
Self tapping screw positioned

Subperiosteal Implants
 Complex impressions in several parts
 Tissue thickness measurements to be made ,to make a
casting with abutments that have accurate height
 Lab must receive good surgical centric relation records

Incision
Complete exposure of host bone

Impression made by thermolabile
EZ tray material
Elastomeric impression made

Vertical and centric relation record
Separated cast

Vitallium casting of the
lateral ramus design

radiograph of completed implant

Second stage surgery
 Not required in non submerged systems
 Submerged implants are exposed
 After 3 months of first stage surgery
 Healing abutment
 Temporary prosthesis

Post operative guidelines
ROUTINE
 Antibiotics
 Analgesics
 Edema
 Local care : saline lavage hygiene
 Diet
 Postoperative problems
SPECIAL – ANTRAL SURGERY
 Should give special instructions to patient

 Apply ice to the surgical site for the next half
an hour intermittently..
 It is convenient to avoid hot food / liquids
during the first 24 hours.
 Do not smoke.
 Pt should be informed that pain & swelling can
be seen…

Recommended Diet Following
Implant Surgery
 For first 2 days: liquid diet like soups, high protien drinks
 Day 3 and 4 : pureed diet ,any food that blanderises well
 Later : soft diet till day 14
 Day 14 : return to normal diet

Recall & Checkup
 Pt should be asked to visit after 2 days..
 Post surgical radiographs should be made to
evaluate the position of the implant..
 Wound healing should be evaluated for
uneventful healing…

Computer based treatment planning

Complications
INTRAOPERATIVE COMPLICATIONS
 Hemorrhage
 Nerve injury
 Jaw fracture
 Opening of maxillary or nasal sinus
 Consequences of improper implant placement
- osseous dehiscence
- osseous perforation
- damage to adjacent teeth
- insufficient primary stability

POST OPERATIVE COMPLICATIONS
Immediate Delayed
Hemorrhage Peri implant
pathology
Hematoma Implant fracture
Edema Chronic sinusitis
Early infection Chronic pain
Wound margin separation Secondary nerve
damage
Mucosal perforations Mucosal irritation
Implant mobility

Summary and Conclusion
 Implant surgery is highly technique sensitive and
requires adequate training and an understanding of
the restorative requirements of the proposed
treatment.
 An understanding of the basic surgical principles is
necessary to ensure successful osseointegration of
the implant in the correct location which allows good
esthetics and prognosis.

Thank you
For more details please visit

Dental Implants surgical considerations / implant dentistry course/ implant dentistry course

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