BASICS IN DENTAL IMPLANT

IMPLANT AND ITS COMPONENTS

1. Implant Surgery From Basics to Advance

2. History What is Implant? Why Implant? Bone Biology Bone cells Osseointegration Points to remember Implant v/s Natural tooth One stage vs Two stage Patient Selection Indications Contraindications Diagnosis and treatment planning Implant Planning Anatomic Considerations Available bone Principles of implant positioning Vertical positioning of the implant Crown height Available bone height Buccolingual positioning Available bone width Mesiodistal positioning Rule of 1,2,3 & 7 Angulation of implants Available bone angulation Missing teeth number Abutment position Implant design Implant size Available bone Implant placement Surgical Procedure Flapless Technique Flap Raised Technique Suturing the flap Post operative Instructions Abutment number Key areas covered

3. History 3 Throughout the history of civilization, significant value has been seen in the presence of a complete set of teeth, both for functional and aesthetic reasons. As early as 2000 BC, early versions of dental implants were used in the civilization of ancient China. Eg. Carved bamboo pegs. In the 18th century, experiments started with gold and alloys to make implants. These did not prove to be very successful primarily due to rejection of the foreign body dental implant . In order for the implant to be successful, the replacement tooth and the bone need to fuse together. In 1952 as a part of a research by Dr. Per-Ingvar Branemark’s team surgically implanted titanium metal pods containing optical devices, into the lower legs of rabbits to study the healing process within their bones. But when they tried to remove the metal-framed optics from the bone, he famously discovered that the bone and titanium had become virtually inseparable . Almost immediately it occurred to Dr. Branemark that there could be useful applications for this discovery of osseointegration.

4. History Dr. Branemark came up with a way to implant four pieces of titanium into the patient’s lower jaw.  Until his death 4 decades later the patient used those 4 titanium implants to successfully anchor a lower denture.  Today Dr. Branemark is known as “the father of the modern dental Implantology” Dr. Branemark is known as “the father of the modern dental Implantology” The first titanium dental implant was placed in a human volunteer in 1965, Dr Branemark . 4

5. What is Implant

6. What is Implant? An artificial dental root that is surgically inserted into the jaw bone & that can be used by the dentist as platform for prosthesis. 6

7. 7 Why Implant? To avoid tooth preparation and possible sequelae. No need for connectors between pontic and abutment teeth. Avoids mechanical risks of conventional bridges. Denture retention and support. FPD RPD CD

8. 8 What is Implant?

9. Bone Biology

10. 10 Bone Biology A successful treatment in dental Implantology requires the maintenance of the implant health over long periods of time such that the implant continues to improve the function of the prosthesis. Bones in our body are living tissue. They have their own blood vessels and are made of living cells, which help them to grow and to repair themselves. Bones are composed of two types of tissue : A hard outer layer called cortical (compact) bone, which is strong, dense and tough. A spongy inner layer called trabecular (cancellous) bone. This network of trabeculae is lighter and less dense than compact bone.

11. 11 Cells and composition of Bones Bone is composed of: Bone forming cells (osteoblasts & osteocytes) Bone resorbing cells (osteoclasts) Nonmineral matrix of collagen and non-collagenous proteins (osteoid) Inorganic mineral salts deposited within the matrix Cells in our bones are responsible for bone production, maintenance and modeling: Osteoblasts Osteocytes Osteoclasts

12. 12 Bone matrix and Types of Bones Osteoid is comprised of type I collagen ~94% and non-collagenous proteins. The hardness and rigidity of bone is due to the presence of mineral salt in the osteoid matrix, which is a crystalline complex of calcium and phosphate (hydroxyapatite). Calcified bone contains about 25% organic matrix ( 2-5% of which are cells), 5% water and 70% inorganic mineral (hydroxyapatite). Two types of bone can be identified according to the pattern of collagen forming the osteoid: Woven bone  Lamellar bone  Virtually all bone in the healthy mature adult is lamellar bone.

13. 13 Bone modeling & Remodeling Modeling is when bone resorption and bone formation occur on separate surfaces. An example of this process is during long bone increases in length and diameter. Bone modeling occurs during birth to adulthood and is responsible for gain in skeletal mass and changes in skeletal form. Remodeling is the replacement of old tissue by new bone tissue. This mainly occurs in the adult skeleton to maintain bone mass. This process involves the coupling of bone formation and bone resorption and consists of five phases: Activation Resorption Reversal Formation: osteoblasts synthesize new bone matrix Quiescence: osteoblasts become resting bone lining cells on the newly formed bone surface

14. Osseointegration

15. 15 Osseo Integration Osseo Integration is defined as a histological structural and functional direct contact between bone and bone marrow with titanium-based implants without fibrous tissue. The osteotomy site should heal with intramembranous ossification without cartilage tissue formation. Bone in contact with the implant surface undergoes morphological remodeling as adaptation to stress and mechanical loading. The turnover of peri-implant mature bone in Osseo integrated implants is confirmed by the presence of medullary or marrow spaces containing osteoclasts, osteoblasts, mesenchymal cells and lymphatic/blood vessels next to the implant surface.

16. 16 Osseo Integration The mechanisms by which end osseous Implants become integrated in the bone can be subdivided into three separate phenomena. They are: Osteo Conduction De novo bone formation Bone remodeling To obtain implant osseointegration, primary mechanical stability of the implant is essential, especially in one-stage surgical procedures. Primary mechanical stability consists of rigid fixation between the implant and the host bone cavity with no micro-motion of the implant or minimal distortional strains. Excessive implant motion or poor implant stability results in tensile and shear motions, stimulating a fibrous membrane formation around the implant and causing displacement at the bone-implant interface, thus inhibiting osseointegration and leading to aseptic loosening and failure of the implant

17. 17 Osseo Integration The successful outcome of any implant procedure is mainly dependent on the interrelationship of the various components. Biocompatibility of the implant material Implant surface & designs The status of the implant bed The surgical technique per se The undisturbed healing phase Loading conditions Once activated; osseointegration follows a common, biologically determined program that is subdivided into 3 stages: Incorporation by woven bone formation Adaptation of bone mass to load (lamellar and parallel-fibered bone deposition) Adaptation of bone structure to load (bone remodeling).

18. Osseointegration is also a measure of implant stability, which can occur at two different stages: primary and secondary. Primary stability of an implant mainly comes from mechanical engagement with compact bone. Secondary stability, on other hand, offer biological stability through bone regeneration and remodeling. of an implant. Osseo Integration Many methods have been tried to clinically demonstrate osseointegration of an implanted alloplastic material. These are : Performing a clinical mobility test Radiographs demonstrating a apparently direct contact between bone and implant have been cited as evidence of osseointegration. The use of a metal instrument to tap the implant and analyze the transmitted sound may, in theory, be used to indicate a proper osseointegration. Clinical application of RFA includes establishing a relationship between exposed implant length and resonance values or ISQ values. 18

19. 20 Points to remember Titanium is an ideal material for dental implants. Titanium is biologically inert; thus, it does not trigger foreign body reactions. Implant placement kits include designated drills that are used in sequence to remove the bone as traumatically as possible. Implant insertion is performed in accordance with the normal practices of aseptic surgery. Limiting thermal damage requires using sharp dental implant drills run at very low speeds and providing copious cooling irrigation. Ideally, once inserted, the implant should have minimal movement while bone is allowed to biologically adhere to the implant surface. The primary (initial) stability of an implant at the time of placement depends on the nature of the bone. Cortical bone provides more primary stability than cancellous bone. Maxilla in general has more spongy bone.

20. 21 Points to remember Lekholm and Zarb , 1985 Misch , 1988

21. Implant v/s Natural tooth

22. 23 Implant v/s Natural tooth

23. 24 Implant v/s Natural tooth

24. 25 COMPONENTS 1.Fixtures/Implants 2.Abutments Healing Basic Custom 3.Gold cylinders 4.Analogs/Replicas Abutment Fixture 5.Impression copings 6.Connection Armamentarium Screw drivers Guide pins

25. 26 Titanium Different Configurations Threaded and Non-threaded Cylindrical and Tapered Different surfaces Machined surface Enhanced surface Different Widths Narrow, Regular, wide platforms. Different heads External and Internal Fixture

26. 27 Healing abutment Basic abutment Standard abutment Estheticone abutment Angulated abutment Mirus cone abutment Multiunit abutment Custom made abutments Abutments

27. 28 Conical abutment Hexed connection to fixture Collar width 1,2,3 mm Improves esthetic potential of restoration Seating of the abutment must be verified with an x-ray. Design of abutment allows up to 30° non parallelism of fixtures. Basic Abutments ESTHETICONE ABUTMENTS

28. 29 Corrects screw access for mal-aligned implants, but doesn’t improve implant loading. Internal 12 positions on bottom matches hex on fixture to prevent rotation and give multiple angle correction possibilities. Can be difficult to use aesthetically. Angulated abutments

29. 30 Mirus cone abutment Shorter height than estheticone abutment Allows greater degree of non-parallelism with fixture placement up to 40°. Multi unit abutment. Same dimensions as mirus cone No hex under abutment to facilitate placement Only for bridges. Mirus cone & Multi Unit abutment

30. 31 UCLA Abutments Hexed-Engaging Non-Hexed-Non Engaging. Easy abutment Prepable Titanium Cemented final restorations Straight esthetic Angled esthetic Ceramic Cemented final restoration Screw retained Procera Titanium Alumina Zirconia. Custom abutment types

31. 32 UCLA Abutments Original UCLA Abutment was a plastic castable pattern. Improved consistency of fit was developed with the introduction of a precast and machined abutment with a waxing sleeve. Two types Hexed –for single tooth Non-hexed –for bridges. Custom abutments

32. 33 When inter arch space is limited When the fixture angulation is not acceptable Follows contours of the soft tissue Conventional restorative technique UCLA TYPE ABUTMENT :wax /invest/cast

33. 34 Predefined margin Snap on impression cap available. Easy abutment

34. 35 Analogs allow the accurate transfer of a facsimile of the intraoral component to a working model. Abutment analog Fixture analog Analog / Replicas

35. 36 Abutment level Fixture level Linked impression copings. Impression copings

36. 37 Open tray copings Pick up copings Square copings Closed tray copings Transfer copings Tapered copings. Impression copings

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38. 39 Screw drivers

39. 40 Torque drivers

40. 41 One stage vs Two stage

41. 42 One stage vs Two stage

42. 43

43. Patient Selection

44. 45 Patient Selection Restore dental aesthetics. Restore lost dental function Space maintenance and occlusal stability Orthodontic anchorage Convenience and comfort Bone preservation and prevention of disuse atrophy after tooth loss. Indications Contraindications Poorly controlled diabetes Immunosuppression Untreated periodontal disease Radiotherapy to the jaw bone Untreated intraoral pathology or malignancy Smoking Uncontrolled drug or alcohol use (abuse) Uncontrolled psychiatric disorders Recent myocardial infarction (MI) or cerebrovascular accident (CVA) Intravenous bisphosphonate therapy Bruxism

45. 46 Diagnosis and treatment planning Patients presenting complaint and expectations Medical history Dental and social history Extra-oral examination including lip and smile lines Intra-oral examination including full periodontal charting Bone mapping Diagnostic imaging Photography Written treatment plan and cost estimate Patient education and informed consent

46. Implant Planning

47. 50 Surgical Stent Preparation

48. 51 Anatomic Considerations Anterior Mandible – more cortical bone and denser cancellous bone – higher implant success as compared to thinner cortical bone and loose cancellous marrow as in Posterior Maxilla. After tooth loss resorption of ridge results in crestal bone thinning and changes in angulations of the ridge. Posterior maxilla – Close approximation of maxillary sinus. Posterior mandible – implants placed usually shorter, do not engage cortical bone and must support increased biomechanically occlusal force once loaded. Hence slightly increased integration time is beneficial. Also more implants than usual should be placed when using short implants (8-10mm) to withstand occlusal load. Resorption pattern of maxilla - constriction Resorption pattern of mandible – flaring of angles. Premolar area – implant placement anterior to mental foramen. Nerve may be as much as 3 mm anterior to foramen.

49. 52 Anatomic Considerations

50. 53 Available bone It is the amount of bone in the edentulous area considered for implantation. Width Height Length Angulation Crown/implant ratio Measured in :

51. Principles of Implant Positioning

52. 55 Principles of Implant Positioning ALWAYS PROSTHETIC DRIVEN X X X

53. 56 Principles of Implant Positioning Four factors must be correctly addressed to achieve both optimal esthetic results and biologic health. Vertical positioning of implant in the bone Buccolingual positioning of implant in the bone Mesiodistal placement of implant in the bone Trajectory or angle of the implant

54. 57 Vertical positioning of the implant In esthetically demanding situations, implants must be placed below the crest of gingiva at a level that respects biologic health and provides proper emergence profile. But this is no longer acceptable as it led to frequent perforations on inferior cortical bone. Earlier it was suggested that implant be placed more than 5 mm below the crest of gingiva but such placements resulted in the failure of implant.

55. 58 Crown height This affects the appearance of the final prosthesis. It is measured from the occlusal or incisal plane to the crest of the ridge. Affects the amount of moment of force on the implant and the surrounding crestal bone during occlusal loading.

56. 59 Crown height It’s a vertical cantilever or lever that magnifies any lateral or cantilever forces. Greater the crown height ,the greater the moment of the force under lateral loads For every 1 mm increase force increase may be up to 20%. Crown height increases as the bone height decreases so more number of implants to be inserted. Minimum crown height needed for a fixed implant prosthesis should be 8 mm. Crown height space is related directly to the crown height of the prosthesis which is greater in anterior regions of the mouth. If too much crown height space is present before placement then  autogenous or membrane grafts to be used to increase the vertical bone height

57. 60 Available bone height Minimum height of available is in part related to density of available bone. More dense bone Less dense and weaker bone Shorter implants( 8mm ) Longer implants( 12mm ) Anterior regions limited between nares and inferior border of the mandible. Maxillary canine eminences region offers greatest height of available bone than any other maxillary anterior sites. Greater bone height in max 1st premolar than the 2nd premolar. Mandibular premolar anterior to foramen provides greatest vertical column of bone.

58. 61 Available bone height Maxillary canine eminences region offers greatest height of available bone than any other maxillary anterior sites. Greater bone height in max 1st premolar than the 2nd premolar. Mandibular premolar anterior to foramen provides greatest vertical column of bone. Initial anterior maxillary available bone height is less than the mandibular available bone height. Angle’s class II have shorter mandibular heights. Angle’s class III exhibit greatest heights. Panoramic radiographs are still the most common method for preliminary determination of available bone height.

59. 62 Buccolingual positioning Extremely important for placement of implants in crown and bridge restorations in areas demanding high esthetics. Must be positioned far enough buccally to provide proper esthetics but it must not invade or compromise the thin plate of buccal bone.

60. 63 Available bone width Is measured between the facial and lingual plates at the crest of the potential implant site. Root form implants of 4mm crestal diameter usually require more than 6 mm of bone width to ensure sufficient bone thickness and blood supply around the implant. These dimensions provide more than 1mm bone on each side of the implant at the crest. Crest of the ridge is supported by wider base which has a triangular cross section an osteoplasty can provide a greater width although of reduced height This is untrue in case of anterior maxilla as edentulous ridge exhibits labial concavity. The ideal implant width for a single tooth replacement or multiple adjacent implants often is related to “the natural tooth being replaced”

61. 64 Mesiodistal positioning One of the most important factors to be considered while placing implants. The greater the number of teeth replaced with implants the greater the esthetic challenge.

62. 65 Rule of 1,2,3 & 7 07 03 02 01 A rule has been suggested to guide in the placement of implants: Bucco- lingually 1 mm of bone is present after implant placement Distance between tooth and implant in mm. Distance between implant and implant in mm Distance between crest of bone and opposing tooth.

63. Angulation of implants

64. 67 Angulation of implants It is generally accepted that implants are best loaded vertically. This suggests implants should be angled perpendicular to plane of occlusion. Bone of maxilla and mandible are not always perpendicular to plane of occlusion especially in mandibular posterior and maxillary anterior regions Angled abutments to correct angulation off the perpendicular are acceptable. Forces are tensile, compressive and shearing to the implant system. Bone is strongest to compressive,30% weak to tensile and 65% weak to shearing forces.

65. 68 Available bone angulation Mandibular roots flare so crowns are lingually inclined in posterior regions & labially inclined in anterior region. Alveolar bone angulation represents the root trajectories in relation to occlusal plane. In posterior mandible submandibular fossa mandates implant placement with increasing Angulation as it progresses distally 15,20,25 degrees and so on. The distance from the centre of the most anterior implant to the line joining the distal aspect of the two most distal implants is called the Anteroposterior or A-P spread. Indicates the amount of cantilever that can be planned. As a rule when 5 anterior implants are planned in the anterior mandible for prosthesis support the cantilevered posterior section of the restoration should not exceed 2.5 times the A-P spread.

66. 69 Available bone angulation Tapering arch form is preferred for anterior implants supporting posterior cantilevers. Square arch form is preferred when canine and posterior implants are used to support anterior teeth in either arch. Modulus of elasticity is proportional to cube of the diameter of the implant. Greater the modulus of elasticity greater will be the amount of biomechanical mismatch and less likely the bone would be maintained at the interface. This biomechanical mismatch is known as stress shielding. Thus larger diameter should be used with caution.

67. 70 Missing teeth number & Abutment number In completely edentulous patients, No of implants in mandible= 5-9 with at least 4 of these placed between mental foramen. No of implants in the maxilla= 6 to 10 with 2-3 implants placed in the premaxilla Abutment number Overall stress on the implant system can be reduced by increasing the surface area to which the force is applied. This is achieved by increasing the number of implants to support the prosthesis. Abutment position This is also related to implant number as 2 or more implants are needed to form a biomechanical tripod that is not a straight line. Suggested that multiple units be placed in a staggered buccal abutment offset.

68. 71 Missing teeth number & Abutment number In completely edentulous patients, No of implants in mandible= 5-9 with at least 4 of these placed between mental foramen. No of implants in the maxilla= 6 to 10 with 2-3 implants placed in the premaxilla Abutment number Overall stress on the implant system can be reduced by increasing the surface area to which the force is applied. This is achieved by increasing the number of implants to support the prosthesis. Abutment position This is also related to implant number as 2 or more implants are needed to form a biomechanical tripod that is not a straight line. Suggested that multiple units be placed in a staggered buccal abutment offset.

69. Implant design and Size

70. 73 Implant Design Implant design may affect surface area more than the increase in the width. A cylindrical implant provides 30% less surface area than a conventional threaded type of implant of the same size. Implants with greater surface area should be selected in situations of poor bone densities and higher stresses.

71. 74 Implant Size An increase in implant length is beneficial for initial stability and overall amount of implant bone interface. The surface area of each implant is related directly to the width of the implant. Wider root form > narrower root form implants. 0.25mm increase in implant diameter 5 to10% increase in surface area. Greater diameter implants increases the surface area at the crest of the ridge, where the stresses are highest.

72. 75 Available bone As a general guideline 2mm of surgical error is maintained between implant and any adjacent landmark especially when the landmark is mandibular canal. Usually the implants have a crest module wider than the body dimension Crestal dimension of bone (where the wider crest module dimension is placed) is usually the narrowest region of the available bone Implant placement Incision Pilot hole - 2– 3mm depth. Inclination of Bur Maxillary - 40-90°. Mandibular - 30-45°. Placed With Minimal Pressure, copious irrigation and intermittent drilling. 50gms – 250 gms of load can be applied immediately.

73. Surgical Procedure

74. 77 Surgical Procedure

75. 78 Flapless Technique

76. 79 Flap Raised Technique Papilla Preserving Single stroke Incision

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83. 86 Suturing the flap The flap is sutured back into place using monofilament suture. The anterior papilla should be secured first. The vertical release is then sutured, followed by the mesial and distal sides of the abutment. These are routine interrupted sutures tied in the same fashion as the first suture described

84. 87 Post operative Instructions Dietary Instructions Antibiotics Analgesics Oral hygiene instructions

85. Recent Advances

86. Osseo densification A new method of biomechanical bone preparation Densah burs are used Bone preservation and condensation OD does not excavate bone Implant placement 89

87. Root is bisected. Buccal 2/3 rd of root is preserved in the socket Periodontium along with bundle bone remain intact. Buccal bone remains intact Socket shield 90

88. Use of smaller diameter abutment on a larger diameter implant collar Preserves crestal bone Platform switching 91

89. Peek Trinia Biohpp Shape memory niti implant Implant materials 92

90. Fewer hypersensitive and allergic reactions Radiolucent,causes few artifacts in MRI. Doesnot have a metallic color (beige color )-more aesthetic apperaence Used as implant body,abutment and superstructure CFR peek ,GFR peek. Peek 93

91. CAD/CAM reinforced polymer Used for core in non-metallic prosthetic restorations ,including implant super structure. Light weight No firing required Biocompatible . Trinia 94

92. PEEK variant Ceramic filler is added in this material Metal free No abrasive for remaining teeth Can be veneered with traditional composites No discoloration High esthetics . BIOHPP 95

93. X PEED- Megagen system Surface coatings 96

94. Shape memory abutments 97

95. Customized 3d printed implants 98

96. TTPHIL-ALL TILT(Tall Tilted Pin Hole Immediate Loading Bicortical engagement of implants Less stress on the bone with reduced chances of bone resorption No cantileverage Tall (16-25mm) tilted (30°-45°).-tall implants more surface area for osseointegration Implants placed in pinhole manner ie,flapless All On Four 99

97. Zygomatic ,Basal, Pterygoid Implants 100