introduction to dental implants

INTRODUCTION,INTRODUCTION,
DIAGNOSIS ANDDIAGNOSIS AND
TREATMENT PLANNING INTREATMENT PLANNING IN
DENTAL IMPLANTSDENTAL IMPLANTS
GUIDED BY
DR PRASHANTH SHETTY
DR NISHANT RAJWADHA
PRESENTED BY
DR PRANAV VERMA
(PG STUDENT FINAL YR)

CONTENTS
INTRODUCTION
•DEFINITIONS
•HISTORY AND EVOLUTION OF IMPLANTS CAN BE STUDIED AS
-The ancient era
- The Medieval period
- The foundational period
- The Premodern era
- The dawn of the modern era
- Contemporary oral implantology
•INDICATIONS,ADVANTAGES AND DISADVANTAGES OF IMPLANTS
•CLASSIFICATION OF IMPLANTS
•PARTS OF IMPLANT
•MECHANISM OF INTEGRATION OF IMPLANTS
•TYPES OF IMPLANT SUPERSTRUCTURES

DIAGNOSIS AND TREATMENT PLANNING
IN IMPLANTS
• PATIENT SCREENING & MEDICAL EVALUATION
• GENERAL EXAMINATION
EXTRA ORAL EXAMINATION
INTRA ORAL EXAMINATION
• CLASSIFICATION OF ARCHES
• BONE EVALUATION
• EVALUATION OF NATURAL TEETH ADJACANT TO IMPLANTS
• ESTHETIC RISK FACTORS
• DIAGNOSTIC IMAGING
• DIAGNOSTIC CASTS
• VARIOUS TREATMENT OPTIONS
• CONCLUSION

The social recognition of implants in dentistry has shown a dramatic increase in recent years and
in Japan the term “implant” has come to represent dental implant. However, the definition of a
dental implant: “artificial material that is inserted into the jawbone or the periosteum by an
invasive method, and one that can be used as a substitute for teeth”, is vague, and has not been
strictly defined. An appropriate name for a dental implant that would be most suited to current
practice would be the term, “artificial root”.
The term “implant” itself remains ambiguous. According to the “Glossary of Oral and
Maxillofacial Implants”, which was compiled by W. R. Laney who served for a long time as the
Editor in Chief of the International Journal of Oral and Maxillofacial Implants (JOMI), an implant
is defined as “an artificial material or tissue that shows biocompatibility upon its surgical
implantation”. This is inclusive of implants that are removed afterwards for diagnostic or
experimental purposes.
This definition has been authorized by four academic groups: the Academy of Osseointegration,
the American Academy of Periodontology, the American College of Prosthodontists, and the
European Association for Osseointegration. The use of this definition, however, would indicate
that dental implants include composite resins and crowns, and cover allografts in the
terminology.

• Def of Implant (GPT 8 )
• Any object or material such as an alloplastic substance or other
tissue, which is partially or completely inserted or grafted into
the body for therapeutic, diagnostic, prosthetic or experimental
purposes.
• Def of Implantology
• Term historically conceived as the study or science of planning
and restoring dental implants.

• Def of Dental Implant
• A prosthetic device made of alloplastic material implanted into
the oral tissues beneath the mucosal or/ & periosteal layer &/or
within the bone to provide retention & support for a fixed or
removable dental prosthesis ;a substance that is placed into or /
& upon the jaw bone to support a fixed or removable dental
prosthesis.
• Def. Of Osseointegration
• The apparent direct attachment or connection of osseous
tissue to an inert, alloplastic material without intervening
connective tissue.

A BRIEF HISTORICAL PERSPECTIVE ON DENTAL IMPLANTS, THEIR SURFACE COATINGS AND TREATMENTS.
CELESTE M. ABRAHAM* THE OPEN DENTISTRY JOURNAL, 2014, 8, (SUPPL 1-M2) 50-55
• ANCIENT ERA - 1000 A.D

• History of dentistry….3000 B.C .
• HISTORY TRACED IN MIDDLE EAST
• In 1862 Gaillardot discovered a prosthodontic appliance near the ancient
city of Sidon. Appliance was dating 400 B.C period .
• Carved ivory tooth replacing the two missing incisors.

• HISTORY TRACED IN THE EGYPTIAN
DYNASTIES
• Evidences have shown the implantation of animal teeth
& artificial teeth carved of ivory .
• Implantation prior to mummification.

• In 1981 evidences of oldest dental implant was found in the Kalavak
Necropolis, near Izmir , Turkey.
• The discoveries were dated back to 550 B.C . A canine tooth like object made
of two piece of calcite having hardness similar to natural teeth showing wear
on the chewing surface & secured with gold wires wrapped around the neck of
adjacent teeth.

• Cranin suggested that earliest recorded dental implant specimen was
inserted during the PRE COLUMBIAN ERA.
• In 1931 Wilson Popenoe discovered a skull in the Ulua river valley of
Honduras , dating to the period 600 A.D .
• Skull had an artificial tooth replacing lower left lateral incisor, carved of a
dark stone . Radiographs showed the evidence of compact bone around the
implant.
• The Mayans practiced the implantation of alloplastic materials in living persons.

• MEDIEVAL PERIOD (1000-1799 A.D)

• Allotransplantation (18 -19 Century) mainly in England & Colonial
America.
• Albucasis de Condue ( 936- 1013 A.D) an Arab surgeon described the
transplantation procedures . He attempted to use ox bone to replace missing
teeth.

• In Japan in the 15th
& 16th
C. Wooden dowel & crown prosthesis
was designed . The pin inserted into the root canal of non vial teeth.
• This was an early ENDODONTIC IMPLANT – SUPPORTED
PROSTHESIS.

• Charles Allen in 1687 gave the first written work on dentistry.
• He described the replanting of tooth into the same patient.
• Allen emphasized on transplantation of tooth using animal
tooth.
• In European sphere transplantation became the common
practice performed by barber surgeons of the Era.
• The tooth transplant could lead to transfer of diseases .
• Implants made from ivory, shells & bone were used.

• Ambroise Pare, a French physician , a surgeon to four kings of
France.
• He replaced the missing teeth with implants made up of bone &
ivory .
• He successfully replaced missing tooth of Princess by
transplanting.

• John Hunter in 1728 – 1793 A.D
suggested the possibility of
transplanting.

• THE FOUNDATION PERIOD (1800- 1910)

• The endosseous oral implantology truly began in the 19th
Century.
• Maggilio in 1809 , a dentist at the university of Nancy , France, author of
the book called “THE ART OF THE DENTIST”. The first reference to
modern style implants.
• He has described the implant & placement.
• He made the tooth root shaped implant with 18 carat gold with three prongs
at the end to hold it in place in the bone . The implant was placed in the
freshly extracted socket site retained with the prongs. After the tissues
healed the crown was attached with the help of post placed into the hole of
root section of the implant.
• He placed the single stage gold implant.

• In mid 1800s advancement in the antiseptics & surgical
techniques , there were documentation of implanted materials.
• W. J . Younger of San Francisco introduced operations in
United States. In 1893 he wrote that his operation has
successfully entered 8th
year of life.

• In 1886 Harris treated a Chinese patient in Grass valley ,
California . He placed the tooth root shaped platinum post with
lead coating, lasted for 27 yrs Reported in Dental Cosmos in
1887.
• In 1889 Edmunds of New York reported on March 12 ,1889
to the First District dental society of that city. He implanted the
metallic capsule.

• In 1888 Berry reported about the root form implants made up
of lead.
• In 1890 , a Massachusetts minister had his lower jaw resected
& was restored with an extensive system of gold crowns
soldered & joined to hinged device attached to the remaining
dentition .
• Znamenski in 1891 reported on implantation made of
Porcelain, gutta-percha & rubber.

• Bonwill in 1895 reported on the implantation of one or two
tubes of gold or Iridium as a support for individual teeth or
crown.
• IN 1898 R. E Payne at the National Dental Association
meeting gave the first clinical demonstration by placing the
silver capsule in the extracted tooth socket.

• PREMODERN ERA ( 1910-1930)

• The first two decades of 20th
C. predominated by the clinicians
namely R.E Payne& E. J .Greenfield.
• R. E .Payne presented his technique of capsule implantation at
the clinics of Third international Dental Congress, reported in
the Dental Cosmos in 1901.
• Technique- Extracting the root , enlarging the socket with
trephine, trial fitting of the capsule. He then placed grooves on
both sides of the socket & filled 2/3rds with rubber, fitted the
porcelain root into the capsule & set it with gutta-percha.
• In 1903 Sholl in Pennsylvania , implanted porcelain tooth with
corrugated porcelain root.

• In 1913 Dr. Edward J. Greenfield came up with the
surgical method to prepare osteotomy in the healed bone
using trephine.
• He fabricated the hollow cylindrical basket root of 20
gauge iridioplatinum soldered with 24 carat gold. Precursor
of hollow basket design

• GREENFIELD EMPHASIZED ON
• The importance of intimate contact between bone & implant.
Hollow implants facilitated growth of bone into implant body &
secure it.
• 3 months period of unloading.
• Implants failures because of infection.
• His techniques were similar to present concepts of osteotomy
preparation, restoring after healing time

• In 1920s Leger- Dorez developed expansible root implant, was comparable
to a concrete expansion bolt.
• Smolon described the implant as a four part device with the shaft buried in
bone with the internal threads to receive a screw , fastening the neck into
the shaft. the post for attaching the prosthesis.
• The historical basis for the internal screws provided for the retention of
prosthetic devices similar to today’s implants.
• Tomkin’s 1925 implanted porcelain teeth.
• Brill in 1936 inserted rubber pins in artificially prepared sockets.

• THE DAWN OF THE MODERN ERA 1935-1978 A.D

• The modern era of implant dentistry most definitely began in the late1930s with the work of
Venable, Strock , Dahl , Gershkoff & Goldberg.
• Venable in 1937 developed the cast Co- Chr- Mo alloy known as Vitallium.
• In 1939 Alvin & Moses Strock used the Venable screw type implant.

• Adams in 1937 developed a submergible threaded cylindrical
implant with round bottom , smooth gingival collar & healing cap.
The ball head screwed to the root was used to retain an overdenture.
• The components designed to flex vertically or laterally similar to the
IMZ intramobile element.

• In 1938 Stock placed the threaded vitallium implant into the
extraction socket, the first long term endosseous implant.
• It remained firm & asymptomatic for nearly 17 years.
• He demonstrated that the Vitallium implants were well
tolerated.

• In 1947, Formiggini developed a single
helix wire spiral implants made of stainless
steel or tantalum. Two ends of the wire were
soldered together to form a post or neck.
• Chercheve Modified by increasing the
length of the neck & double helix out of
vitallium.
• He developed the co-coordinated system of
instrumentation for implant insertion.

• Marziani’s use of porcelain &
acrylic roots to support full
dentures.
• In 1950 Lee’s Post design i.e
central narrow post with
extensions.

• In 1943 Dahl in Germany developed Intramucosal or
button implants – Mucosal inserts.

• SUBPERIOSTEAL IMPLANTS
• An implant structure that covers the almost entire crestal surface of
maxillary & mandibular RAR under the soft tissue to include the
periosteum , with the four to six posts protruding out through gingiva and
on it the complete denture will be attached.
• In 1943 Gustav Dahl placed the SP implant on maxillary RAR later on
mandibular.
• Dahl & Izikowitz described the frames placed around the teeth in partially
edentulous patients termed as SUPERPLANTS.

FABRICATION OF SUB PERIOSTEAL IMPLANT
• Goldberg & Gershkoff method
• Make an impression of the mucosa covering the RAR
• Make model & wire template made for radiography.
• Measurements of the soft tissue depth were derived from the radiography
and model was carved & casted to produce the multifenestrated Co-Chr-
Mo casting with four abutments.

• Berman introduced the Two stage surgical technique for sub periosteal implant.
• First step was a direct impression of the surgically exposed bone
• Second was implanting the subperiosteal frame generated from the stone cast.
• Kleinschmidt developed anterior single sub periosteal implant.
• Marziani reported on the fabrication of full upper & lower subperiosteal implant.

• Weinberg sectional subperiosteal
implant.
• Lew developed modified technique for
fitting upper implants by extending the
implant frame further to the periphery.

• Linkow developed Sub periosteal implant consisting of three
islands

• CT scan imaging technique used to obtain three dimensional replica
of the mandible & CAD-CAM models used for fabricating the
frame work.
• Long term success only 50 to 60%.

ONE STAGE ENDOSTEAL PINS, SCREWS, & CYLINDERS
• The early 1960s marked the beginning of an active developmental
era in implant design.
• Scialom developed a tantalum tripodal pin .
• Three intersecting pins were joined by acrylic to support the
crown. Difficulty in maintaining the trifurcation limited the
comfortable survival.

• In 1960 Onlay developed Virilium
posts placed into endodonticaly treated
teeth extending beyond the apex.

SCREW TYPE IMPLANT
• Tramonte introduced a stress resistant drive screw implant.
• Meglan & Lehman reported on the expandable implants.
• Lew introduced a self tapping Vitallium screw implant with conventional threads & square
post.
• Muratori & Pasquallini introduced hollow cores along with the screw threads.
• The majority of these screw shaped implants were one piece & were not submerged , did not
osseointegrate .It was emphasized that the fibrous peri implant membrane with its shock
absorbing feature preferred than bone fusing to implant.

• In 1963 Dr. Linkow , American Dentist
developed first screw type of implant –
Vent Plant.
• This was the first self tapping , self
threading implant . It had an open cage
like design that went into bone first , with
a few threads on solid body at the top. He
used Vitallium first latter on titanium.

BLADE IMPLANTS
• Linkow blade implants invented in 1967.
• Long thin blade that will be surgically inserted into the groove in the bone .
• Abutment projecting out from the blade to this crown or attachment for denture
can be placed.
• It required the shared support of natural teeth also.
• Restored within month so became most widely used in united states.
• Linkow modified the design configuration for broad applicability in maxilla &
mandible, narrow ridges.

• In 1970 Roberts & Roberts developed Ramus blade
implants .
• It was to be positioned by anchoring distally between
the cortical plates in the ramus of the mandible

• RAMUS FRAME IMPLANT developed Roberts & Roberts in 1970 .
• The endosseous implant received stabilization from its anchorage in ramus
area bilaterally & in the symphyseal region.

TRANSOSTEAL IMPLANTS
• In 1975 Small introduced the transosteal mandibullar staple & bone plate, a
reconstructive device placed through a submental incision & attached to the mandible
with multiple fixation & two transosteal screws to support a full arch prosthesis.
• He presented 16 yrs evaluation,
• Cranin developed single transosteal implant.

• In 1970 Kawahara was developing a ceramic implant in Japan .
• first Aluminium oxide implant placed.
• In 1970 Grenoble placed Vitreous Carbon implant .

• CONTEMPORARY ORAL IMPLANTOLOGY
1978 to present

• In 1978 conference held at Harward , co- sponsored by NIH.
• This was the milestone for further research.

• In 1976 Dr. Andre Schroeder in Switzerland reported the bone growth into
titanium plasma sprayed hollow endosseous implants.
• At the same time , Prof. Willischulte in Germany reported the success with
immediate placement of Vitreous Carbon implant after dental extraction &
invented Frialit-2 implant.

• In 1978, Dr. P. Brånemark presented a two-stage threaded titanium
root-form implant; he developed and tested a system using pure
titanium screws which he termed fixtures.
• These were first placed in his patients in 1965 and were the first to be well-
documented and the most well maintained dental implants thus far.
• In 1960 at Gothenburg…
• Branemark noticed that there was no inflammatory reaction to the
titanium.

Brånemark’s first patient
had severe deformities of the jaw and chin, congenitally
missing teeth and misaligned teeth. Four implants were inserted
into the mandible. These implants integrated within a
period of six months and remained in place for the next 40
years
He found this discovery accidentally in 1952
when he was studying blood flow in rabbit femurs by placing
titanium chambers in their bone; over time the chamber became
firmly affixed to the bone and could not be removed . The bone actually bonded to the
titanium surface. Infact if a fracture occurred, it always occurred between bone and bone,
never between the bone and the implant. He carried over this idea into the realm of dentistry.
With his implant came the concept of “osseointegration” and the confidence that dental implant
education could be introduced into dental school curricula. This term was further refined and defined
by Brånemark as “a direct structural and functional connection between ordered, living bone, and the
surface of a load carrying implant”. The original Brånemark implant was created as a cylindrical one;
later on tapered forms appeared.

• He started thinking about the potential of titanium to
act as an anchorage point, so the spur for the next
experiment whether titanium can be used as a bridge
in bone healing application.
• Concept of Osseo integration developed
• The first clinical trail was done in 1965.
• In 1971 surgical equipments.
• In May 1982 Dr. George Zarb organized the Toronto
conference on osseointegration. Branemark presented
Two stage threaded root form implant along with the
15 yrs research work & clinical trail.

BRANEMARK SYSTEM COMPONENTS
• FIXTURE –
• pure titanium with machined
threads .
• The top of the fixture has hexagonal
design & threads ..
• The apical portion tapered with four
vertical notches.
• COVER SCREW- seals the coronal
potion of fixture during the interim
period.

• ABUTMENT- -made of titanium in a cylinder shape. the apical portion has hexagonal shape to
fit the coronal portion of fixture.

• ABUTMENT SCREW – insert through the abutment
& threads into the fixture to connect the two
components .
• GOLD CYLINDER- made of lAu , Pl, Pd. It is
machined to fit the coronal portion of the abutment. It
becomes integral part of final prosthesis.
• GOLD SCREW –inserted through the gold cylinder
& threads into the abutment screw to connect the gold
cylinder & abutment.

IMZ IMPLANT SYSTEM
• Kirsch developed the IMZ implant system in 1974.
Since 1978 in clinical use.
• Intramobile cylinder endosseous two stage
osseointegrated implant.
• The polyoxymethylene & polyacetal used as IME.
• Available in 3.5 to 4mm diameter and 8,10,13,15mm
length.
• Surface coating may be titanium plasma spray or
plasma sprayed HA coated surface.

IMZ IMPLANT SYSTEM
• Kirsch developed the IMZ implant system in 1974. Since 1978
in clinical use.
• Intramobile cylinder endosseous two stage osseointegrated
implant.
• The polyoxymethylene & polyacetal used as IME.
• Available in 3.5 to 4mm diameter and 8,10,13,15mm length.
• Surface coating may be titanium plasma spray or plasma
sprayed HA coated surface.

LEDERMAN SCREW IMPLANT
• In 1977 Dr. Philippe Lederman in collaboration with strauman
co. developed the Titanium plasma spraed screw type implant.
• In 1989 Lederman developed the New Ledreman screw
implant Surface roughened by sand blasting & acid etching.

ITI BONE FIT IMPLANT SYSTEM
• Developed by ‘International Team for Implantology’.
• Three different types
• Single stage & two stage.
• Transgingivally placed in healing phase so second surgical
procedure for uncovering the implant is avoided.

THE HAND-TITANIUM IMPLANT
SYSTEM
• Clinical use since 1985 at Switzerland & now in use world
wide ( Lederman 1986).
• A conical, step- screw, pure Ti implant with self thread.
• Length- 10 to 20mm.
• Diameter – 3.5 to 7mm.

• In early 1980s Tantum introduced Omni R implant -
A Ti root form implant with horizontal fins.
• Omni S implant – for placing into bone grafted
maxillary sinus.

• In 1983 EL Blasty & Kamel introduced the new endosseous implant material
i.e Poly acrylic acid reinforced with ceramic alumina particles 0.3 microns.
• The hydrophilic matrix swells in contact with aqueous solution.
• The gradual pressure on the surrounding bone stimulates osseous activity.
• Implanted in canine, premolar sites with promising results.

MINI DENTAL IMPLANT
• In 1985 Victor Sendax developed MDI.
• Ultra – small diameter 1.8 mm, biocompatible Ti alloy implant
screws.
• Bulard added single one piece `O- ball’ design .

CORE VENT
• Developed by Dr. Gerald Niznick in 1986.
• Hollow basket design made of Ti alloy.
• Different fixture designs Screw –Vent, Micro-Vent, Bio –Vent.

ENDOPORE
• A root form dental implant
developed by Doughlas et.al in
1996 made of Ti alloy & sintered
with same alloy producing porous
surface.
• Biological & clinical advantages.

STERI OSS SYSTEM
• Introduced by Denar
• Made up of 99.9% Ti, tapered apex thread design & the coronal 3rd
highly
polished surface.
• Available in 3.5 to 4mm diameter, length 12 mm,16mm,20mm,&
miniseries8mm,10mm,12mm length.

NOVUM CONCEPT
• Branemark developed the concept of providing a new set of teeth for the
mandible in a single day.
• Clinically implicated in 1996.
• Three titanium fixtures inserted , mucosa is closed & base plate is placed over
the fixtures & then the prosthesis is placed.

ZYGOMATICUS FIXTURES
• Branemark.
• The long fixture can be anchored in zygoma by approaching
through the sinus .
• Severely resorbed maxilla.

• 1984 – CT scan.
• Bone augmentation techniques.
• 1986 Tatum reported about Sinus lift / Bone graft antroplasty.
• 1988 Nerve transposition
• 1989 Pterygoid implants .
• 1991 Guided tissue regeneration using Gore-Tex or resorbable Vicryl-Mesh used
to augment narrow & shallow ridges .
• 1995 Distraction osteotomies & split ridge technique.

• The screw type implants fabricated by Hydroxy appatite based
composites by mixing HA with Al oxide coated Zr oxide powder &
compared with Cp.Ti implants.
• HA based composites showed better mechanical properties &
bioactivity.
• (Young Min Kong et.al 2002).

• Development of implants coated with Bioactive Alumina –based
composite by electrophoretic deposition method.
• Alumina is excellent biomaterial ,good biocompatibility , highly
corrosion resistance, high wear resistance & strength.
• Wollastonite has (CaO. SiO2) high apatite forming ability
deposited into the pores of foamed Alumina by Electrophoretic
deposition.

BICORTICAL SCREW IMPLANT
• Self tapping type
• Diameter 2.5, 3.5 ,4.5,5.5mm
• Length 21 -30mm
• Post extraction insertion for single tooth
replacement.

OSTEOPLATE 2000
• Atrophic RAR
• The conical plate with shoulder
width 1.3 mm & base 0.9 mm.

• Historically dental restorations supported by Osseointegrated
implants evolved as
• Fully ed. Mandibular arch -1980
• Fully ed. Maxillary arch
• Short span ed. Segment -1990
• Missing single tooth – 1990
• 1980s restorations were screw retained , 1990s cemented.

SUMMARY
• Before 1000 A.D tooth carved of stones , calcite, ivory were implanted.
• In the 1000 -1799 A.D mainly allotransplantation.
• In the 1800-1910 period beginning of root form endosseous implant of Au, Pt .
• In the 1910-1935 Greenfeild designed hollow basket implant.
• In 1935- 1978 Root form implants of the pin & screw type, Sub periosteal ,
Ramus blade, Ramus frame, Transosteal.
• In 1978 Branemark developed the Titanium implants, latter on different surface
treated Ti implants developed.

INDICATIONS AND CONTRAINDICATIONS OF
DENTAL IMPLANTS
INDICATIONS
•Single unit toothless gap with healthy adjacent teeth
When a single tooth is missing, an implant supported crown will preserve the adjacent natural
teeth by avoiding the need to prepare them. If the toothless gap is restored with a traditional
dental bridge, both adjacent teeth will have to be prepared.
This operation involves permanently removing parts of the teeth's original structure, including
portions that might still be healthy and structurally sound.

• Partial edentulism with the back (posterior) tooth missing
These conditions imply the absence of several posterior teeth (molars and/or premolars) on
one or both sides of the dental arch (Kennedy class 1 or Kennedy class 2).
In these cases, traditional dental bridges (supported by natural teeth) are difficult to design
because the back support tooth is missing. Removable partial dentures generally require the
preparation of more teeth.
Implant supported prostheses, although entailing a higher cost, are the most adequate
therapeutic solutions

• Complete edentulism
When all teeth are missing, the only traditional solution available is a full removable denture.
Implant supported prosthesis (either fixed or removable) allow to chew the food better, speak
more clearly and they have a superior stability.
• Other situations when dental implants can be indicated
 Patients who cannot tolerate a removable restoration (removable denture).
 Patients with high aesthetic and/or functional demands.

Other Indications for implant therapy:
1) Compromise of denture support area.
2) Poor oral muscular coordination
3) Low tolerance of mucosal tissue
4) Parafunctional habits
5) Unrealistic prosthodontic expectations
6) Hyperactive gag reflex
7) Psychological instability to wear removable prosthesis
8) Unfavorable number and location of potential abutment
9) To avoid involving neighboring teeth as abutment

CONTRAINDICATIONS
GENERAL CONTRAINDICATIONS
A: Absolute contraindications
•Some serious general conditions make anesthesia, surgical procedures and the overall
placement inadvisable.
•Heart diseases affecting the valves, recent infarcts, severe cardiac insufficiency, cardiomyopathy
•Active cancer, certain bone diseases (osteomalacia, Paget's disease, brittle bones syndrome,
etc.)
•Certain immunological diseases, immunosuppressant treatments, clinical AIDS, awaiting an
organ transplant
•Certain mental diseases
•Strongly irradiated jaw bones (radiotherapy treatment)
•Treatments of osteoporosis or some cancers by bisphosphonates

B) Relative contraindications
•Other situations will be evaluated on a case-by-case basis. Most often, dental implants can only
be placed (with the greatest caution) after some preliminary treatments.
•Diabetes (particularly insulin-dependent)
•Angina pectoris (angina)
•Significant consumption of tobacco
•Certain mental diseases
•Certain auto-immunes diseases
•Drug and alcohol dependency
•Pregnancy
Age
Children: not before the jaw bones have stopped growing (in general 17-18 years).
On the other, hand advanced age does not pose problems if the patient's general condition is good.

LOCAL CONTRAINDICATIONS
Some conditions or physiological changes, usually inside the mouth cavity, may
temporary prevent the placement of dental implants. Most of the times, these
conditions can be remedied before the implants are inserted in the jawbone.
•The alveolar bone where the implants would be positioned, shows chronic infections, has an
inadequate structure or an insufficient height or width. To ensure a good prognosis, a dental
implant must be surrounded by healthy bone tissue.
A dental implant must be surrounded
by healthy bone tissue (with red)

• Important anatomical structures such as the maxillary sinus, the inferior alveolar nerve
(located inside the mandible), have an abnormal position that can interfere with the dental
implants.
lowering of the maxillary sinus
Adjunctive surgical procedures have to be performed before the placement
of dental implants. These procedures aim to increase the amount of bone,
so more bone is available to support the implants.
• some local diseases of the oral mucosa or alveolar bone can temporary prevent the
placement of dental implants until the conditions are treated.
• Hypersensitivity or other allergic reactions ; rarely occurs.
• Poor oral hygiene.
• Bruxism or involuntary grinding of the teeth.

USES OF IMPLANTS
• Restore dental aesthetics
• Restore lost dental function:
- Chewing
- Speech
• Space maintenance and occlussal stability
• Orthodontic anchorage
• Convenience and comfort
• Bone preservation and prevention of disuse atrophy
after tooth loss

Advantages of dental implants (GENERAL)
•One of the biggest advantages of dental implants is that they are made to look like your natural
teeth. The crown, or artificial tooth, is sculpted so that it resembles a real tooth. It can be
difficult to tell implants from natural teeth, even up close.
•Another advantage is that they function just like real teeth. The implant’s structure acts like the
root of a natural tooth and the replacement is anchored into the jaw bone. The artificial tooth
that is placed on top of the crown, or implant, is completely functional. Implants offer the same
chewing force, unlike removable bridges or dentures. You do not have to remove dental
implants as they stay in your mouth.
•Another benefit is that dental implants are permanent. The artificial tooth may need to be
replaced every 15-20 years, but the implant itself is permanent because it is anchored to the
jawbone. This makes the price of dental implants cost-effective when compared with other
treatments such as dentures, which must be replaced every few years

Advantages of Implant supported Prostheses‐
• Bone maintenance.
• Restoration and maintenance of Occlusal vertical dimension.
• Maintenance of facial esthetics (muscle tone).
• Esthetic improvement
• Improved phonetics.
• Improved occlusion.
Single Tooth Implant: Advantages‐
• High success rates
• Decreased risk of caries of adjacent teeth.
• Decreased risk of endodontic problems on adjacent
teeth.
• Decreased cold or contact sensitivity of adjacent teeth.
• Psychological advantage.
• Decreased abutment tooth loss Increased prosthesis success.

Disadvantages of Dental Implants
•Dental implants can be costly and tend to cost more than alternative treatments. It becomes
cost effective because you don’t have to replace them as often, but the upfront cost can be
prohibitive for some.
•Dental implants require a surgical procedure, which can make it an undesirable choice for some
patients.
•The procedure itself is time-consuming, with each implant requiring, at least, two surgical
procedures. Each of these procedures is separated by three months, as healing time is needed.
•These procedures often come with side effects such as pain and swelling.

CLASSIFICATION OF IMPLANTS
1.Based on implant design
2.Based on attachment mechanism
3.Based on macroscopic body design
4.Based on the surface of the implant
5.Based on the type of the material

CLASSIFICATION BASED ON
IMPLANT DESIGN

1.ENDOSTEAL IMPLANT
• A device which is placed into the alveolar
bone and/or basal bone of the mandible or
maxilla
• Transect only one cortical plate

A) BLADE/PLATE IMPLANT
It consist of thin plates in the form of blade embedded into the bone

B) RAMUS FRAME IMPLANT
• Horse shoe shaped stainless steel device
• Inserted into the mandible from one
retromolar pad to the other
• It passes through the anterior symphysis
area

C) ROOT FORM IMPLANT
• Designed to mimic the shape of the tooth
• For directional load distribution
• Forms:
1.Cylinder
2.Screw root form
3.Combination

2. SUBPERIOSTEAL IMPLANT
Placed directly beneath the periosteum overlying the bony cortex

3. TRANSOSTEAL IMPLANT
• A dental implant that penetrates both cortical plates and passes through
the full thickness of the alveolar bone
• 2: a dental implant composed of a metal plate with retentive pins to hold it
against the inferior border of the mandible that supports transosteal pins
that penetrate through the full thickness of the mandible and pass into
the mouth in the para symphyseal region.
• also known as staple bone implant, mandibular staple implant,
transmandibular implant

4.INTRAMUCOSAL IMPLANTS
 Inserted into the oral mucosa
 Mucosa is used as attachment site for the
metal inserts

CLASSIFICATION BASED ON ATTACHMENT
MECHANISM OF THE IMPLANT

CLASSIFICATION BASED ON MACROSCOPIC
BODY DESIGN OF THE IMPLANT
• CYLINDRICAL DENTAL IMPLANTS
• THREADED DENTAL IMPLANTS
• PLATEAU- DENTAL IMPLANTS
• PERFORATED DENTAL IMPLANTS
• SOLID DENTAL IMPLANTS
• VENTED DENTAL IMPLANTS
• HOLLOW DENTAL IMPLANTS

CLASSIFICATION BASED
ON THE SURFACE OF THE
IMPLANT
• SMOOTH SURFACE IMPLANT

• MACHINED SURFACE IMPLANTS
COATED SURFACE IMPLANT

CLASSIFICATION BASED
ON THE IMPLANT
MATERIAL
Based on tissue response and systemic
toxicity effects of the implant
• Biotolerant
• Bioinert
• Bioactive

CROWN
Oxford dictionary definition:
1 The part of a tooth projecting from the gum.
2 An artificial replacement or covering for this.
Crowns are the top part of a restoration and are the part that we see in the mouth. They
replicate the original teeth to provide a biting surface and aesthetic appearance. They are
hand made by the technician.
The supporting substructure for the crown may be hand made or machined (onsite or
offsite). The completed crown is either cemented or screwed onto an abutment.
Material Used: Porcelains (metal supported or metal
free) or metal (normally gold)
Considerations: Bite, wear, material choice (due to
greater forces applied) and aesthetics.

ABUTMENT
1 The lateral supporting structure of a bridge, arch, etc.
2 The point of junction between such a support and the thing supported.
An abutment provides support for the crown (or several
crowns i.e. a bridge). It is also the interface between the
crown and the implant.
Rotation (twist) is controlled by lugs shaped on the
abutments stem. These lugs restrict the abutments rotational
placement to set incremental steps. Different manufactures
use different systems with more or less adjustments.

Older style abutments use external loading with the newer styles tending towards the stronger
internal loading fitment. Numerous designs are available from many companies
Materials Used: Titanium.
Considerations: Shape, angle, length, and platform
size.

IMPLANT OR FIXTURE
1 An insert (tissue, a substance, a device, etc.) into the body.
“a prosthetic device made of alloplastic material implanted into the oral tissues beneath the
mucosal or/and periosteal layer, and on/or within the bone to provide retention and support for
a fixed or removable dental prosthesis” gpt8
An implant provides the anchor or foundation for a restoration. It is screwed into the bone of
the jaw providing a fixed platform on which an abutment can be screwed.
Bone tissue can grow around the implant regenerating and
strengthening the jaw reducing the bone loss whichoccurs when natural teeth are lost.
Implants come in many different lengths, shapes (e.g. tapered), and widths (or platform
size). Each manufacturer has their own implant designs which have unique features.
These unique features require both dentist and technician toadhere strictly to the individual
manufacturer’s procedures and guidelines when placing and constructing implant borne
prosthetics..
Materials Used: Titanium.
Considerations: Mostly medical including bone suitability and spacing issues. A

IMPRESSION COPING
Impression copings are used by the dentist to replicate the position of the implant in the
patient’s mouth. The dentist screws the impression coping to the real implant and then,
using a specific impression technique, takes an impression of the dentition. The impression
technique can be “open” or “closed”:
Materials Used: Titanium, plastic, and anodized
aluminium
Considerations: Correct placement (to prevent
impression material creeping between
surfaces and to ensure correct location for abutment).
Ensure all parts are dispatched
(impression, coping(s), screws, and analogues).

ANALOGUE OR IMPLANT REPLICA
Analogues are used by laboratory technicians to replicate implants and their position in a
patient’s mouth.
A model of the patient’s dentition is cast using an impression. The analogue, screwed onto the
impression coping, is set into the plaster model during casting.
They provide an exact fixed reference platform (a replica of the position of the implant) from
which the technician can place and shape the abutment and build the crown or bridge.
Materials Used: Stainless steel
(sometimes brass)
Considerations:
Ensuring all parts are
dispatched
(impression, coping(s),
screws, and
analogues).

RETENTIVE ANCHORS
Retentive anchors come in various types of design: Ball Abutment (with retaining clip),
Magnetic Abutment (with retaining magnet) and Tower Abutment (“Locator®” which
comes with a retaining clip).
All come in two main parts: The shaped abutment part and the ‘female’ which clips over it
(known as a Matrix).
Once the anchor abutments are screwed into the implants, they provide support for a full or a
partial denture (which are clipped on). This provides a very stable platform and prevents
unwanted movement of the prosthesis.
Materials Used: Titanium and gold (with
plastic matrices or magnetic material)
Considerations: Mostly medical
including bone suitability and spacing
issues (vertical
height). A consultation with a dental
professional is required.

MECHANISM OF IMPLANT INTEGRATION
• The present surge in the use of implants was initiated by Branemark (1952)………..
• Described the relationship between titanium and bone for which they coined the term
osseointegration

DEFINITIONS
The word osseointegration consists of “OS” the Latin word for bone and “integration” derived
from Latin word meaning the state of being combined into a complete whole.
“Direct structural and functional connection between ordered, living bone and surface of a load
carrying implant”.
American Academy of Implant Dentistry defined it as “contact established without interposition
of non bone tissue between normal remodeled bone and on implant entailing a sustained
transfer and distribution of load from the implant to and within bone tissue”.

HISTORICAL REVIEW OF
OSSEOINTEGRATION
• The concept of osseointegration was developed and the term was coined by Dr. Per-Ingvar
Branemark,
• Professor at the institute for Applied Biotechnology, University of Goteborg, Sweden.
• Initial concept of osseointegration stemmed from vital microscopic studies of microcirculation
in bone repair mechanisms.
• Titanium chamber was surgically inserted into the tibia of of a rabbit.
• It was considered the best material for artificial tooth root replacement.

• Many studies followed involving titanium implants being placed into jaws of dogs.
• Direct bone anchorage has been shown to be very strong. A force of over 100kg was applied to
dislodge an implant.
• Based on such a consequence the foundation for Osseo integration and the Branemark implant
system was established in 1952.
• Studies on humans were conducted by means of an implant optical titanium chamber in a twin
pedicle skin tube on the inside of the left upper arm of volunteers.
• Tissue reactions were studied in long term experiments.
• All this lead to the treatment of first edentulous patient in 1965.
History of Branemark system categorized in three stages
Early stage (1965-1968)
Developmental stage (1968-1971)
Production stage (1971 – present)

IMPLANT-BONE INTERFACE
There are two basic theories regarding the bone-implant interface
I. Fibro-osseous integration supported by Linkow (1970), James (1975), and Weiss
(1986)
In 1986, the American Academy of Implant Dentistry defined fibrous integration as “tissue-
to-implant contact with healthy dense collagenous tissue between the implant and bone”
In this theory, collagen fibers function similarly to Sharpey’s fibers in natural dentition. The
fibers affect bone remodelling where tension is created under optimal loading conditions
(Weiss, 1986).
It is not accepted now as no sharpey’s fibers are present between the bones and implant
so it is difficult to transmit the loads. Therefore, bone remodeling cannot be expected to
occur in fibro-osseous integration.
II. Osseointegration supported by Branemark (1985)
This was first described by strock as early as 1939 and more recently by Brenamark et al
in 1952. Branemark theorizes that the implant must be protected and completely out of
function, as he envisions a period of healing of at least 1 year, in which new bone is
formed close to the immobile resting implant.
Meffert, et al (1987) redefined and subdivided osseointegration into
•Adaptive osseointegration : has osseous tissue approximating the surface of the
implant without apparent soft tissue interface at the light microscopic level
•Biointegration: is a direct biochemical bone surface attachment confirmed at the
electron microscopic level.

Biological Considerations for Osseointegration
Bone implant interface
•When compared to compact bone spongy bone has less density and hardness is not a stable
base for primary fixture fixation.
•In the mandible the spongy bone is more dense than maxilla.
•With primary fixation in compact bone, osseointegration in the maxilla require a longer healing
period.
Bone remodeling
•Osseointegration requires new bone formation around the fixture. A process resulting from
remodeling within bone tissue.
•Osteoblastic and osteoclastic activity helps maintain blood calcium without change in quantity
of bone.
•To maintain a constant level of bone remodeling there should be proper local stimulation,
crucial levels of thyroid hormone, calcitonin and vitamin D.
•Occlusion or occlusal force stimulus are both important to optimal bone remodeling.

Foreign body reaction
•Organization or an antigen antibody reaction occurs when a foreign body is present in the body.
•This reaction occurs in the presence of a protein but with implant materials devoid of proteins no
antigen antibody reaction
•When titanium is used no foreign body reaction are seen.
•The implant material is an important factor for Osseo integration to occur.

BIOLOGICAL PROCESS OF IMPLANT
OSSEOINTEGRATION
• The healing process of implant system is similar to primary bone
healing.
• Titanium dental implants show three stages of healing.
OSTEOPHYLLIC STAGE
• When a implant is placed into the cancellous marrow space
blood is initially present between implant and bone.
• Only a small amount of bone is in contact with the
implant surface; the rest is exposed to extracellular fluids.
• Generalized inflammatory response to the surgical insult.

• By the end of first week, inflammatory cells are responding to foreign antigens.
• Vascular ingrowth from the surrounding vital tissues begins by third day.
• A mature vascular network forms by 3 weeks.
• Ossification also begins during the first week and the initial response observed in the migration of
osteoblasts from the trabacular bone which can be due to the release of BMP’s.
• The osteophyllic phase lasts about 1 month
OSTEOCONDUCTIVE PHASE
• Once they reach the implant, the bone cells spread along the metal surface laying down osteoid.
• Initially this is an immature connective tissue matrix and bone deposited is a thin layer of woven
bone called foot plate.
• Fibro-cartilaginous callus is eventually remodelled
into bone callus.
• This process occurs during the next 3 months
• Four months after implant placement the maximum surface
area is covered by bone.

OSTEOADAPTIVE PHASE
•The final phase begins approximately 4 months after implant placement.
•Once loaded implants do not gain or loose bone contact but the foot plates thicken in response
and some reorientation of the vascular pattern may be seen.
•Grafted bone integrates to a higher degree than the natural host bone to the implant.
•To achieve optimal results an osseointegration period of 4 months is recommended for implants
in graft bone and 4 to 8 months for implant placed in normal bone.

FACTORS INFLUENCING
OSSEOINTEGRATION
• Biomaterial for dental implant
• Surface composition and structure
• Implant design
• Heat
• Contamination
• Primary stability or initial stability
• Bone quality
• Epithelial down growth
• Loading

1.Biomaterial for dental implant
Implants must not induce a host immune response Titanium and certain calcium-phosphate
ceramics are biocompatible and do not stimulate a foreign body rejection reaction.
II Surface composition and structure
•It is thought that cp Ti owes its ability to form an osseointegrated interface to the tough and
relatively inert oxide layer, which forms very rapidly on its surface.
•This surface has been described as osseoconductive, that is, conducive to bone formation
• Other substrates also have this property and may also stimulate bone formation, a property
known as osseoinduction
III Implant Design
•The vast majority of commercially available implants claiming osseointegration status are
cylindrical in shape.
•Their design may be threaded or else lack similar microscopic retentive/stabilization aspects

IV Heat
•Heating of bone to a temperature in excess of 47°C during implant surgery can result in cell
death and denaturation of collagen.
•As a result, osseointegration may not occur, instead the implant becomes surrounded by a
fibrous capsule and the shear strength of the implant-host interface is significantly reduced
V Contamination
•Contamination of the implant site by organic and inorganic debris can prejudice the
achievement of osseointegration.
•Material such as necrotic tissue, bacteria, chemical reagents and debris from drills can all be
harmful in this respect.
VI. Primary stability or Initial stability
•It is known that where an implant fits tightly into its osteotomy site then osseointegration is
more likely to occur.
•This is often referred to as primary stability, and where an implant body has this attribute when
first placed failure is less probable.
•This property is related to the quality of fit of the implant, its shape, and bone morphology and
density.

VII Bone quality
• It is a function of bone density, anatomy and volume, and has been described using a number of
indices.
•The classifications of Lekholm & Zarb and of Cawood & Howell are widely used to describe bone
quality and quantity.
•The former relates to the thickness and density of cortical and Cancellous bone,
• and the latter to the amount of bone resorption.
• Bone volume does not by itself influence osseointegration, but is an important determinant of
implant placement
VIII Epithelial down growth
•Early implant designs were often associated with down growth of oral epithelium, which eventually
exteriorized the device.
•When the newer generation of cp Ti devices was introduced great care was taken to prevent this
by initially covering the implant body with oral mucosa while osseointegration occurred.
•The implant body was then exposed and a superstructure added, since it was known that the
osseointegrated interface was resistant to epithelial down growth

IX Loading schemes
•Delayed loading: The prosthesis is attached at the second procedure after a conventional
healing period of 3 to 6 months 8, 23.
•Early loading: The prosthesis is attached during a second procedure, earlier than the
conventional healing period of 3 to 6 months. Time of loading should be stated in days to weeks
8, 23.
•Immediate / Direct loading: The prosthesis is attached to the implants the same day the
implants are placed.

SUCCESS CRITERIA FOR OSSEO
INTEGRATED IMPLANTS
• Durability
• Bone loss
• Gingival health
• Pocket depth
• Effect of adjacent teeth
• Functions
• Esthetics
• Presence of infection
• Intrusion on the mandibular canal
• Patient emotional and psychological attitude

REVISED CRITERIA FOR IMPLANT
SUCCESS
• Individual unattached implant is immobile when tested clinically.
• No evidence of peri implant radiolucency is present as assessed on an undistorted radiograph.
• Mean vertical bone loss is less than 0.2 mm after 1st year of service.
• No persistent pain, discomfort or infection.
• A success rate of 85% at the end of a 5-year observation period and 80% at the end of a 10-
year period are minimum levels of success.

CLINICAL APPLICATIONS OF
OSSEOINTEGRATION

FUTURISTIC CONCEPTS OF
OSSEOINTEGRATION
OSSEOPERCEPTION
The interaction between the osseointegrated fixture bone tissue, receptor systems and nervous
system has to be studied.
“Owing to the nature of osseointegration it is not easy to dissect the system
of anchorage from the clinical level down to the molecular level or even the
real interface which is still largely a mystery”
- Branemark

DIAGNOSIS AND TREATMENT PLANNING
IN COMPLETE DENTURE

‘’The most important factor to be kept in mind is that treatment with implant is a prosthetically
driven restorative management.’’
•So successful implant therapy requires systematic thorough and meticulous planning and sound
clinical judgment to determine the ultimate prognosis.
•Like any other diagnostic procedures in dentistry, proper history and physical examination, form
the two basic methods of diagnosis.
•So the diagnostic procedures should comprise a complete and detailed medical and dental history,
the vital signs and thorough clinical examination of the head and neck with special emphasis on the
oral cavity and a laboratory workup.
•The initial consultation is the first step in determining whether a patient qualifies for a
reconstructive procedure.
•The evaluation of the patients should be carried out in a way similar to the screening admission
procedure conducted with the patient who is entering the hospital
•The evaluation must be performed in an orderly and precise fashion on a routine basis. The hard
and soft tissue should be evaluated as to both quality and quantity.

Combining the above information will enable us to categorize patients into one the five basic
classifications of presurgical risk as formulated by the AMERICAN SOCIETY OF
ANESTHESIOLOGY
ASA Class 1 :
Normal healthy patient
ASA Class 2 :
Patient with mild systemic disorder
ASA Class 3 :
patient with systemic disease that limits activity but is not incapacitating
ASA Class 4 :
patient with incapacitating disorder
ASA Class 5 :
patient who may die within the next 24 hours
Most of the patients who seek implant reconstruction fall into Class I and Class II and sometimes
Class III. Class IV and Class V are not appropriate candidates for implant management. Class III
patients require preparatory measures such as stabilizing or controlling the disease before implant
surgery can be considered.

EXTRA ORAL EXAMINATION
SMILE LINE
The” LARS” factors as described by Ahmed, provides information for determining the appropriate
display of the maxillary anterior teeth. These factors are : lip length(short, medium, large), age
(elderly typically show less of maxillary and more of mandibular teeth), race(patients of African
descent frequently display less of the maxillary anterior teeth than Caucasian patients) , and
sex(females generally show twice as much of the maxillary incisors as males)

TMJ :
•Dysfunction
• Maximal opening
• Deviation
• Unrestricted mandibular movements
FACIAL ASYMMETRY…
MUSCLES OF MASTICATION
LYMPH NODES

INTRA ORAL EXAMINTION
JAW OPENING :
HYGIENE

PRESENCE OF LESIONS / ABSCESS
INTER ARCH RELATIONS
May be hazardous in combination with functional risks

INTER ARCH DISTANCE
Ideal inter arch space :
7 mm – posterior
8 – 10 mm – anterior
12 mm – removable prosthesis
Increased space
• Results from vertical loss of alveolar bone and soft
tissues.
• Increased space makes the placement of removable
prosthesis easier.
• In fixed restorations increased space makes –
Replacement teeth elongated. – Placement of gingival
tone materials
– Increased crown height increased moment of force
on implants increased risk of component and material
fracture.

Management of increased Interarch space.
• May be decreased by addition of onlay grafts before implant placement.
– Autogenous and /or membrane grafts.
– Alloplastic grafts
• It improves – – – – –
Crown –implant ratio
Esthetics
Permits wider implant selection.
 Benefit of increased surface area.
Improves hygiene condition.
Lack of Interarch space
• Results from
– migration of the opposing natural dentition into the edentulous space.
– History of tooth abrasion,attrition and skeletal insufficiencies
– Even when the opposing teeth are extracted or missing the Interarch space is
still less as the alveolar process has followed the teeth.
• Consequences. – – – –
Decreased abutment height
Inadequate retention.
Inadequate bulk for esthetics and strength
Poor hygiene conditions.

Management of less Interarch space.
1.Surgical reduction of tuberosities.
2.Osteoplasty and /or soft tissue reduction of implant region
3.Selective grinding
4.Prosthodontic restorations
5.Endodontic therapy

CLASSIFICATION OF PARTIALLY EDENTULOUS ARCHES (MISCH AND JUDY)
CLASS I Partially edentulous arch with bilateral edentulous areas posterior to remaining natural teeth.
DIVISION “A”
1.edentulous areas have abundant bone height more than 10 mm and length more than 7mm for
endosteal implant.
2.direction of load is within 30 degrees of implant body access.
3.crown implant ratio is less than 1.
4.root form implants and independent prostheses are often indicated
DIVISION “B”
1.Edentulous areas have moderate available bone width (2.5-5 mm) and at least adequate bone height
more than (10mm and length 15mm)
2.Direction of load is within 20 degrees of implant axis.
3.Crown implant ratio is less than 1
4.Surgical options include osteoplasty, small diameter implants
and /or augmentation.

DIVISION “C”
1.Edentulous area have inadequate available bone for endosteal implants with a
predictable result because of two little bone width( C-w), length ,height (C-h) or angulation
of load.
2.Crown implant ratio is more than 1
3.Surgical options for (C-w) includes osteoplasty or augmentation;
for C-h subperiosteal implants or augmentation.
4.Root forms may be considered with augmentation
and or nerve repositioning.
DIVISION “D”
1.Edentulous areas have severely resorbed ridges involving
a portion of the basal or cortical supporting bone
2.Crown implant ratio is more than 5
3.Surgical options usually require augmentation
before implants can be inserted.

CLASS II: Partially edentulous arch with unilateral edentulous areas posterior to remaining
teeth .
DIVISION A - D are same as for CLASS I

CLASS III: partially edentulous arch with unilateral edentulous areas with natural teeth remaining
anterior and posterior

CLASS IV: partially edentulous arch with edentulous area anterior to remaining natural teeth
and crosses the midline

CLASSIFICATION OF COMPLETELY EDENTULOUS ARCHES
The edentulous jaw is divided into three regions. In the mandible the right and left posterior section s extend
from the mental foramen to the retro molar pad and the anterior area is located between the mental
foramina.
TYPE I: here the division of bone is similar in all three anatomic segments. Therefore four
different categories of type I arches are present.
Type I division “A” ridge has abundant bone (division A) in all three sections
The patient may use as many root forms as needed and wherever desired to support the
final prosthesis.

Type I division B ridge has adequate bone in all three sections in which to place narrow
diameter root form implants.

Type I division C-w ridge have inadequate bone width for implantation. Ti can be converted to C-h ridge
by osteoplasty.
Type I division C-h ridge do not present all the essential requirement for predictable long-term implant
support for fixed prosthesis

Type I division D ridge offers the greatest challenge and implant failure at the time of placement or
after many years may result in mandibular fracture oro nasal fistula.

TYPE II: the posterior section s of bone is similar but differ from anterior segments. The most common
arches in this category present less bone in posterior region s than in anterior segment
TYPE III: here the posterior section of the maxilla or mandible differs from each other.

BONE EVALUATION
Available bone : is the amount of bone in the edentulous area considered for implantation
it is measured in :
 width
 height
 length
 angulation
 crown : implant

BONE CLASSIFICATION:
CLASISFICAITON BY LINKOW AND CHERCHEVE (1970):
CLASS I : Consists of evenly spaced trabeculae with small cancelated spaces. This is ideal bone type.
CLASS II: Has slightly larger cancellated spaces with less uniformity of the osseous pattern
CLASS III: Large marrow filled spaces exists between bone trabeculae.
For Linkow Class III bone results in a loose fitting implant. Class II bone is satisfactory for implants
and Class I bone provides a very satisfactory foundation for implant prosthesis.

CLASSIFICATION BY LEKHOLM AND ZARB (1985):
QUALITY I bone comprises homogenous compact bone.
QUALITY II bone has a thick layer of compact bone surrounding a core of dense
trabecular bone.
QUALITY III bone has a thin layer of cortical bone surrounding dense trabecular bone of
favorable strength.
QUALITY IV bone has a thin layer of cortical bone surrounding a core of low density
trabecular bone.

Bone density is determined by tactile sense during surgery,its general location or by radiographic
bone evaluation
Bone density(MISCH 1999) is determined clinically using CT determination, as
follows:
D1: > 1250 Hounsfiled units (DENSE CORTICAL)
D2: 850 – 1250 Hounsfiled units(POROUS CORTICAL)
D3: 350 – 850 Hounsfield units(COURSE TRABECULAR)
D4: < 150-350 Hounsfield units (FINE TRABECULAR)
D5: < 150 Hounsfield units (IMMATURE, NON MINERALIZED BONE

DIVISIONS OF AVAILABLE BONE
Division A : forms soon after the tooth extraction
Division B : 25 % - I yr & 40 % - 3 yr

Division C : deficient in one / more dimensions
Division D : long term bone resorption

EVALUATION OF NATURAL TEETH ADJACENT TO IMPLANTS :
Mobility :
clinical assessment of tooth mobility : 0 – 4
Healthy posteriors & canine : 0 – horizontal clinical
mobility
Healthy posteriors : 0 – vertical mobility
Healthy incisor teeth -: 1 – clinical mobility , range being :
90 -108 µm
So when the natural abutment exhibits clinical mobility :
• place additional implant to avoid inclusion of natural
abutment
• splint additional natural abutments – 0 clinical mobility
Crown ; Ratio :
Pt with h/o Pdl disease – inc C : R – no mobility
splinting is indicated / occlusal schemes modified to protect the abutment – horizontal
stress
Most ideal – 1 : 2
More common – 1 : 1.5
Minimum requirement – 1 : 1

Tooth position :
when adjacent are missing for a long time , abutment may be –
drifted / tipped / tilted / rotated / extruded
Treatment may be : coronoplasty
crown preparation
RCT
orthodontic movement
Caries :
restored even though the teeth will be restored with crown
if endo therapy is necessary – obturation should be
completed
Root configuration :
Tapered / fused roots / blunted apices – e.g. of decreased ability to with stand the occlusal
forces
dilacerated / curved roots – improve the prosthodontic support
roots with circular configuration – not good prosthodontic abutment

Root surface area :
greater the root surface area…
teeth affected by Pdl disease…
Endodontic evaluation :
if the pulpal / Endodontic status is questionable
Periodontal evaluation :
dental prophylaxis & OHI
tetracycline local delivery is indicated
Occlusal evaluation

ESTHETIC RISK FACTORS
GINGIVAL FACTORS
SMILE LINE
GINGIVAL QUALITY
PAPILLAE OF ADJACENT TEETH

DENTAL FACTORS
FORM OF NATURAL TEETH
POSITION OF INTERDENTAL CONTACT
Greater than 5 mm - bone margin
SHAPE OF INTERDENTAL CONTACT
Larger –smaller is papillary space

BONE FACTOR
ADJACENT IMPLANT
VESTIBULAR CONCAVITY
VESTIBULAR BONE RESORPTION
PROXIMAL BONY PEAKS / SEPTA

PATIENT FACTORS
Esthetic requirements
Hygiene level

DIAGNOSTIC IMAGING
IMAGING OBJECTIVES
Can be organised into 3 phases:
 Pre prosthetic implant imaging
 Surgical & interventional implant imaging
 Post prosthetic implant imaging
PRE PROSTHETIC IMAGING
OBJECTIVES
• Identify disease
• Determination of bone quality
• Determination of bone quantity
• Determine implant position
• Determine implant orientation

SURGICAL AND INTERVENTIONAL IMPLANT IMAGING
It assists in the surgical and prosthetic intervention of the patient
OBJECTIVES
1) Evaluate the surgery sites during and immediately after surgery.
2) Assist in the optimal position and orientation of the dental implants
3) Evaluate the healing and integration phase of implant surgery.
4) Ensure abutment position and prosthesis fabrication are correct.
POSTPROSTHETIC IMPLANT IMAGING
It commences just after the prosthesis placement and continues as long as the
implants remain in the jaws
OBJECTIVES
1.Evaluate the long term maintenance of implant rigid fixation and function.
2.Evaluate crestal bone levels
3.Evaluate the implant

PERIAPICAL
Indications:
•Evaluation of small edentulous spaces ,
Eg: in case of single tooth replacement
•Alignment and orientation of implants during surgery
•Recall/maintenance evaluations
Advantage
• Amount of bone loss and peri- implantitis can be
visualized
• Subtle variations in bone activity is clearly seen
• Minimal magnification with high resolution
• They are easy to obtain in the dental clinics.
Disadvantages
• They are susceptible to unpredictable magnification of anatomic structures, which does not allow
reliable imaging.
• Distortion is particularly accentuated in edentulous areas, where missing teeth and resorption of the
alveolus necessitate film placement at significant angulation
• The periapical image is limited by the size of film being used
• Often, it is not possible to image the entire height of the remaining alveolar ridge, and when extensive
mesial-distal areas need to be evaluated, multiple periapical films are required

DIGITAL RADIOGRAPHY
• Process wherein the film is replaced by a sensor that collects the data
• The analog information received is then interpreted by specialized software and an image is
formulated by a computer monitor
• The resultant image can be modified in terms of gray scale, brightness, contrast, inversion and
color enhancement
• Computerised software programs like Dexisimplant are available that allowing for calibration of
magnified images , ensuring accurate measurements
Advantages
• Less radiation
• Superior resolution
• Instantaneous speed of image formation is highly useful
during surgical placement of implants and the
prosthetic verification of component placement
Disadvantage
Size and thickness of the film and position of the
connecting cord sometimes makes film placement difficult
in some sites , such as those adjacent to tori or in case of
tapered arch form in the region of canines

OCCLUSAL
Maxillary occlusal radiograph
Mandibular - orthognal projection
Limitations…
•Degree of mineralisation is not determined
•Spatial relationship b/w critical structures is lost
•Rarely indicated in implant dentistry

PANORAMIC RADIOGRAPH
• They display image slices through the jaws by producing a single image of the maxilla and mandible
and their supporting structures in a frontal plane
• The image receptor is either the radiograph film or can also be a digital storage phosphor plate or
a digital charge – coupled device receptor
Indications
• Indicated when multiple implant placements are planned.
• Initial assessment of vertical height of bone
• Evaluation of gross anatomy of the jaws and any related pathologic findings
Advantages:
• They display anatomic structures like nasal cavity,
maxillary sinus, inferior alveolar canal and mental foramen.
• Convenience, ease and speed in performance dental office
Disadvantages
• The resolution is lesser when compared to intraoral radiograph.
• Cross sectional view is not demonstrated and is of little use in depicting the spatial
relationship between the structures
• A10-20% image magnification occurs, which is non uniform. This magnification is undesirable for both
implant selection and implant site assessments.
• Geometric distortion and overlapping of images of teeth can occur
• Overlapping of anterior region by vertebral column occurs.

CEPHALOMETRIC
It makes cross sectional image – alveolus of both maxilla & mandible in
mid-sagital plane
It displays
•Spatial relationship of occlusion - length , angulation , & geometry of
the alveolus
•Width of the bone in symphysis region
•Relationship b/w buccal cortex & the roots of the anterior teeth
Can help to evaluate :
• loss of VD
• skeletal arch interrelation ship
• Anterior crown : implant
• anterior tooth position in prosthesis

TOMOGRAPHY
• Tomographic units produce cross-sectional slices of the jaws that can be as thin as 1 mm and are
suitable for pre- and post-implant assessment
• This technique enables the visualization of patient’s anatomy by blurring regions above and below
the section of interest.
Conventional tomography :
Types : linear , complex , spiral
Computed tomography ( CT ) :
Sir Hounsfield ( 1972 ); is a digital & mathematical
imaging technique
Produces 3 dimensional axial images

COMPUTERISED TOMOGRAPHY
• CT is a digital imaging technique, which can generate 3D images using a very narrow “fan
beam” that rotates around the patient, acquiring one thin slice (image) with each revolution
• It was first applied successfully in implantology in the 1980s.
• It allows clinicians to visualize the bony architecture, nerves, joints, sinuses and other
structures much more completely than traditional flat radiographs
• CT scans have been shown to be very accurate with the magnification effect, the same for both
the anterior and posterior area, from a range of 0% to 6% in
Advantages
Negligible magnification
High contrast image
3 dimensional bone models
Interactive treatment planning
Disadvantages
High dose of radiation
Technique – sensitive

DENTASCAN
DentaScan is a computed tomography (CT) software program that allows the mandible and maxilla to be
imaged in three planes: axial, panoramic and cross-sectional.
Data acquisition time for maxilla or mandible is about 15 min.
INTERACTIVE COMPUTED TOMOGRAPHY
This technique enables the radiologist to transfer the imaging study to the practitioner as a
computer file and enables the practitioner to view and interact with the imaging study on their own
computer

It helps to measure the length and the width of the alveolus, measure bone quality and change the
window and level of the grayscale of the study to enhance the perception of critical structures
An important feature of ICT is that the dentist and radiologist can perform electronic surgery (ES) by
selecting and placing arbitrary-sized cylinders that simulate root form implants in the images.
With an appropriately designed diagnostic template, ES
can be performed to develop the patient’s treatment plan
electronically in 3D
ES and ICT enable the development of a 3D treatment
plan that is integrated with the patient’s anatomy and can
be visualized before surgery

DIAGNOSTIC CASTS
• assist in implant site selection & angulation requirements during surgical phase
• surgical template
• one set – permanent record – dentolegal cases
• used for presentations to motivate the patient acceptance of the proposed treatment

• Proper articulation of cast is an essential part of every restorative procedure. By correctly reproducing
the patients occlusal relationship on an articulator proper planning can be accomplished. If the casts
are not related to the condylar axis of the patient before articulator mounting, the accuracy of the bite
record may not be valid.
• All of the occlusal relationship records should be derived form the articulator. Final prosthesis balancing
is accomplished as well, following these articulator-related techniques

DIAGNOSTIC WAX UP
A diagnostic wax up may be begun
The determinants of diagnostic wax up which define the optimum final tooth position are
1.Physiologic occlusal vertical dimension
2.Maxillomandibular relationships
3.Tooth form
4.Embrasure determination for conventional or cantilevered ceramometal restoration.
Once clinically tested, the provisional waxup or trial tooth setup allows the fabrication of diagnostic
template to create a computer profile image (CPI) which transfers prosthetic information regarding
the optimal final tooth position to a multiplanar reformatted computer topography radiograph.
The diagnostic waxup or trail tooth setup must be modified as it relates to oral musculature
support, phonetics, and the of ease oral hygiene procedures.

TREATMENT OPTIONS & TREATMENT
PLANNING

CLASSIFICATION OF PROSTHESIS MOVEMENT
• PM-O
• PM-2
• PM-3
• PM-4
• PM-6
PM-0 – prosthesis rigid – no movt (implant support similar
to FPD).
0-ring attachments (6 directions).
4 0-rings placed on complete arch and prosthesis rests on
the bar- PM-0

PM-2 – prosthesis with hinge motion (2 planes).
Hinge attachment (Dolder bar without a spacer or Hader bar and clip).
PM-3 – prosthesis with an apical and hinge motion.
Dolder bar with spacer and clip

PM-4 – movts in 4 directions.
Rarely used in O.D.
Magnets are used.(no lateral force).
PM-6 – all ranges of prosthesis movt.
O-ring attachment or extra coronal resilient attachment
(ERA).
Implants independent of each other.(no bar)

COMPLETELY EDENTULOUS PROSTHESIS DESIGN
• Pts desires-fixed or removable.
• To assess ideal final prosthetic design-existing anatomy evaluated.
• An axiom of implant Rx is to provide ,most cost effective Rx that will satisfy pts anatomical needs
and personal desires.
• In completely edentulous pt a removable implant supported prosthesis offers several advantages
over a fixed implant restoration
• However some completely edentulous patients require a fixed restoration because of their desire
or because their oral condition makes fabrication of teeth difficult if a super structure and
removable prostheses are planned.
• For eg when pt has abundant bone-implants already placed-lack of crown height space-removable
prosthesis.
• Too often Rx plans for completely edentulous pts-max denture and mand over denture with 2
implants.

• Long term-disservice to pt-parasthesia, facial changes and reduced posterior occlusion on max
prosthesis are to be expected.
• Important to visualize the final restoration at the onset with a fixed implant restoration.
• Individual areas of ideal or key abutment determined.
• A fixed implant restoration-partially or completely edentulous pt.
• Fixed lasts longer.(acrylic teeth wear,attachments replacement-removable prosthesis).
• No food entrapment
Advantages of removable implant-supported prostheses in completely edentulous patient
• Facial esthetics enhanced with labial flanges.
• Prosthesis – removed at night - nocturnal parafunction.
• Fewer implants.
• Less bone augmentation-before implant insertion.
• Shorter RX-no bone augmentation.
• Less expensive.
• Daily home care is easier.

FP-1
•Replace only the anatomical crowns
•Minimal loss of hard and soft tissues
•The volume and position of the residual bone must permit ideal placement of the implant in a
location similar to the root of a natural tooth
•Very similar in size and contour to most traditional fixed prostheses
•Most often desired in the maxillary anterior region

Material
•The restorative material of choice for an FP-1 prosthesis is porcelain to noble-
metal alloy
•Easily be separated and soldered in case of a nonpassive fit at the metal
•try-in
•Noble metals in contact with implants corrode less than nonprecious alloys
•Any history of exudate around a subgingivalbasemetal margin will
•dramatically increase the corrosion effect between the implant and the
•base metal

FP-2
•Restore the anatomical crown and a portion of the root
•The volume and topography of the available bone is more apical (1 to 2 mm below the cement-
enameljunction)
•Incisal edge is in the correct position, but the gingival third of the
•crown is overextended
•Are similar to teeth exhibiting periodontal bone loss and gingival recession
•Prosthetic options in implant dentistry chapter 5
•The patient and the clinician should be aware from the onset
•of treatment that the final prosthetic teeth will appear longerthan healthy natural teeth without
bone loss
Esthetic zone
The esthetic zone of a patient is established during : 1.Smiling in the maxillary arch
high lip line during smiling
2.Speech of sibilant sounds for the mandibular arch
Low lip line during speech

• A multiple-unit FP-2 restoration does not require as specific an implant position in the
mesial or distalposition because the cervical contour is not displayed during function
• The implant position may be chosen in relation to bone width, angulation, or hygienic
considerations rather than purely esthetic demands (as compared with the fp-l prosthesis)
• The implant may even be placed in an embrasure between two teeth that often occurs for
mandibular anterior teeth for full-arch fixed restorations
• It should be placed in the correct facial-lingual positionto ensure that contour, hygiene, and
direction of forces are not compromised
Material
The material of choice for an FP-2 prosthesis is precious metal to porcelain

FP-3
•replace the natural teeth crowns and has pink-colored restorative materials to replace a portion of the
soft tissue
•original available bone height has decreased by natural resorption or osteoplasty at thetime of implant
placement
•teeth are unnatural in length
•patient may also have greater esthetic demands
•Patients complain the display of longer teeth even though they must lift or move their lips in unnatural
positions
•greater moment of force is placed on the implant cervicalregions, especially during lateral forces (e.g.,
mandibular excursions or with cantilevered restorations)

There are two approaches for an FP-3 prosthesis:
•a hybrid restoration of denture teeth and acrylic and metal substructure
•a porcelain-metal restoration
•The primary factor that determines the restoration material is the amount of crown
height space
Occlusal vertical <15mm ≥15mm
PORCElAIN –METAL HYBRID

Food impaction or speech problems
Wide open embrasures in the maxillary arch
1. Using a removable soft tissue replacement device
2. Making overcontoured cervical restorations
The maxillary fp-2 or the fp-3 prosthesis is often extended
or juxtaposed to the maxillary soft tissue so that speech is
not impaired. Hygiene is more difficult to control, although
access next to each implant abutment is provided

REMOVABLE PROSTHESES
Two kinds of removable prostheses, based upon support of the restoration:
1. RP-4
2. RP-5
determined by the amount of implant support
The difference in the two categories of removable restoration is not in appearance
Complete removable overdentureshave often been reported with predictability
The removable prosthetic options are primarily overdentures
for the completely edentulous patient

RP-4
•Completely supported by the implants, teeth, or both
•The restoration is rigid when inserted
•A low-profile tissue bar or superstructure that splints the implant abutments
•5 or 6 implants in the mandible
•6 to 8 implants in the maxilla
•More lingual and apical implant placement in comparison with the implant position for a fixed
prosthesis
•Same appearance as an Fp-l, FP-2, or FP-3 restoration
•Improved oral hygiene
•Sleep without the excess forces of nocturnal bruxism on the prosthesis
•The implants in an RP-4 prosthesis (and an FP-2 or FP-3 restoration) should be placed in
the mesiodistal position for the best biomechanical and hygienic situation

RP-5
•combining implant and soft tissue support
•The amount of implant support is variable:
(1) Two anterior implants independent of each other
(2) Two Splinted implants in the canine region to enhance retention
(3) Three splinted implants in the premolar and central incisor areas to provide lateral stability
(4) Implants splinted with a cantilevered bar to reduce soft tissue abrasions and to limit the amount of
soft tissue coverage needed for prosthesis support
•The primary advantage of an RP-5 restoration is the reduced cost
•The clinician and the patient should realize that the bone will continue to resorb in the soft tissue-
borne regions
•Relines and occlusal adjustments every few years
•Bone resorption with RP-5 restorations may occur two to three times faster than the resorption found
with full dentures

CONCLUSION
Treatment planning for implant restorations may at first appear complicated. It
is imperative to consider all treatment options with the patient, and during
detailed planning it may become apparent that an alternative solution is
preferred. In all cases the implant treatment should be part of an overall plan to
ensure health of any remaining teeth. Once the goal or end point has been
established it should be possible to work back to formulate the treatment
sequence. The cost of the proposed treatment plan is also of great relevance.
The greater the number of implants placed, the higher will be the cost and this
may therefore place limits on treatment options.

REFERENCES
• Block & Kent’s Endosseous Implants For Maxillofacial
Reconstruction.
• Elaine Mc Clarence ’s Close to the edge.
• Hubertus Spikerman’s Color atlas of Dental medicine
(Implantology).
• Malvin E. Ring’s Dentistry An Illustrated History.
• Sumiya Hobo’s oseointegration and occlusal rehabilitation.
• Ralph V. McKinney, Jr’s endosteal dental implants.
• ADA council on scientific affairs Dental endosseous implants.
An update. JADA, Vol. 135, January 2004.

• Richard M. Sullivan, Implant Dentistry and the Concept of Osseointegration: A Historical Perspective .(2001)
Journal of the California Dental Association.
• Douglas A. Deporter “simplifying the treatment of edentulousness” JADA Vol 121sept 1996:1343
• Young-Min Kong, Hydroxyapatite-Based Composite for Dental Implants: an In Vivo Removal Torque
Experiment. J Biomed Mater Res (Appl Biomater) 63: 714–721, 2003
• M. A. EL BASTY and I. L. KAMEL.The Development of a Novel Tooth-root Implant Material. J Dent Res
62(6):733-737, June 1983
• Management of atrophic mandibular ridges with Mini dental implant systems- A case report J.IPS;2005;5;158.

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