Dental Implant
Dr. Abdulrahman Hunaish Dr. Khalil Alkamel
PhD, Oral & Maxillofacial Surgery Msc, Oral & Maxillofacial Surgery
• Contemporary Oral & maxillofacial surgery
5th Edition chapter 14 page 253-287
Contents
• Basic surgical techniques
Complications
Implant Placement
Clinical implant
components
Implant prosthetic
options
Advanced surgical
techniques
Special situations
BASIC SURGICAL TECHNIQUE
Before implant placement
• A traumatic extraction
• Socket preservation
• Interim prosthesis design
• Timing of implant placement
Atraumatic Extraction
• An intact socket is critical to achieve full bony
regeneration.
• Atraumatic extraction with a periotome preserves the
contour and integrity of this bone.
Socket Preservation
• To lessen the time between extraction and implant
placement, reconstruction of the socket may be
considered.
• A number of alloplastic and allogeneic grafts or xenografts
are available.
• If the socket is reconstructed with a graft, as little as 2
months is an adequate waiting period before implant
placement. During this time the overlying soft tissue
heals, and primary closure is easier at the time of implant
placement.
Timing of Implant Placement
• Although a period of 2 to 6 months following extraction
can aid in improved bone quality, longer delay may
result in bone resorption.
• Implant placement produces functional stresses in the
bone that helps maintain contour and bulk.
• In the absence of a natural tooth or an implant, bone
will resorb. Excessive resorption may necessitate
grafting procedures before an implant can be placed.
IMPLANT PLACEMENT
Patient preparation
Soft tissue incision
Preparation of the implant site
Implant placement surgical procedure
Post operative care
Uncovering techniques
Abutment placements
Complications
Patient preparation
• Implant surgery can be performed with local anesthesia.
• The use of conscious sedation is often beneficial.
• Preoperative antibiotic prophylaxis is usually recommended.
* oral dose of 2 g penicillin V 1 hour preoperatively
* or an intravenous dose of 1 million units penicillin G
immediately preoperatively
* 600 mg clindamycin orally or intravenously.
• No postoperative antibiotic administration is necessary.
• The patient can rinse with 15mL 0.12% chlorhexidine
gluconate (Peridex) for 30 seconds immediately
• before the start of surgery.
Soft tissue incision
Soft tissue incision
The incision should:
1- be designed to allow convenient retraction of the
soft tissue
2- preserve or increase the quantity of attached
tissue and preserve local soft tissue esthetics.
3- be placed slightly palatal in the anterior maxilla,
especially when esthetics is of concern, because it
preserves facial contour and soft tissue bulk.
4- preserve the adjacent papilla especially in the
esthetic zone.
Soft tissue incision
• The closed technique uses a tissue punch to gain access
only to the crestal bone, and relies on the surgeon's
ability to determine bone morphology without direct
visualization and works best with wide, uniform ridges.
• An open approach is more predictable but also more
invasive
• When the quantity of attached tissue is adequate and
the underlying bone is expected to be of adequate
width, a simple crestal incision is the incision of choice
Implant placement
• Once the implant site is prepared, a surgical
guide or stent is placed intra orally, and a
small round bur or spiral drill is used to mark
the implant sites.
• The stent is then removed, and the sites are
checked for their appropriate facio-lingual
location.
• The site is then
marked to a depth
of 1-2mm, breaking
through the cortical
bone
• A small spiral drill, usually 2
mm in diameter and marked to
indicate appropriate depth is
used at onset to establish the
depth and align the axis of the
implant recipient site.
• This drill may be externally or
internally irrigated and used at
a speed of 800-2000 rpm with
copious irrigation to prevent
over heating the bone.
• The next step is to use a series
of drills to systemically widen
the size to accommodate the
selected size of the implant.
Implants can be screwed in place by a handpiece
at very low speeds (15-20rpm) or by hand.
Healing cap Closure
Postoperative care
• Radiograph
• Analgesics
• 0.12% chlorhexidine gluconate rinses for 2
weeks
• Evaluated weekly for 2-3 weeks for soft tissue
healing.
• Dentures relined with a soft liner after 1 week
Uncovering – Tissue Punch
Requirements
- adequate attached tissue
- implant can be palpated
• Advantages
- least traumatic
- periosteum not reflected – less bone resorption
- early impressions are possible
• Disadvantages
- sacrifice of attached tissue
- unable to visualize bone
- unable to visualize implant & superstructure interface
Uncovering – Tissue punch
Uncovering – Crestal Incision
• Advantages
- does not require implants to be palpable
- easy access
- minimal trauma
- able to visualize bone
- able to visualize implant & superstructure
interface
• Disadvantage
- periosteum reflected – may lead to bone
resorption
Uncovering – Apically
Repositioned Flap
Advantage
- improves vestibular depth & attached tissue
• Disadvantages
- longer healing time
- bone loss as a result of reflection of periosteum
- technically more difficult
Apically repositioned flap
Abutment placement
After the implant is exposed, either the
implant abutment or a temporary healing
abutment is placed.
Abutments
Complications
• Improper angulation or positioning of the
implants
• Perforation of the inferior border, maxillary
sinus, or the inferior alveolar canal
• Dehiscence of buccocortical or linguocortical
plate
• Mandibular fracture
• Soft tissue wound dehiscence
CLINICAL IMPLANT
COMPONENTS
Implant body
Healing screw
Interim abutment
Abutment
Impression coping
Implant analog
Waxing sleeve
Prosthesis retaining screw
Implant body / fixture
:
Implant body
Dental implant body/fixture is the component
placed within the bone during first-stage surgery.
Threaded/non threaded root form
Made of titanium/titanium alloy with or without
a hydroxyapatite coating
Internally threaded portion that can accept
second stage screw placements
Antirotational feature – internal/external
One-stage & two-stage implants
Healing screw
Interim abutment
- Dome shaped screws placed
after 2nd stage surgery &
before insertion of the
prosthesis.
- Range in length from 2-
10mm.
- Adequate healing for
impressions usually takes 2
weeks after 2nd stage
uncovering.
- in esthetic zones, 3-5 weeks
may be required.
Abutment
Zirconia abutment
Impression coping
• Facilitate transfer of the intraoral location of the
implant or abutment to a similar position on the cast.
Implant analog
• A : fixture analog
• B : abutment analog
Implant analog
Implant analog
IMPLANT PROSTHETIC OPTIONS
-Completely edentulous patients
-Partially edentulous patients
Completely edentulous patients
• Implant & tissue supported overdenture
• All implant supported overdenture
• Complete implant supported fixed prosthesis
Implant & tissue supported
overdenture
Two to four implants
(ideally four) should
be present.
•
All implant supported overdenture
Typically, a minimum of four
implants is required for the
mandible, and six implants
are recommended for the
maxilla
Complete implant supported fixed
prosthesis
Two basic designs:
The first design is a fixed partial denture, which
is either screw retained or cement retained to
six to eight implant abutments.
Complete implant supported fixed
prosthesis
The second design is a hybrid prosthesis, which
utilizes a framework, which accepts acrylic, resin, or
porcelain to create the replacement of the patent’s
missing bone, gingival tissue, and teeth.
Partially edentulous patients
• Free-End Distal Extension:
There are two options in treating the patient missing
terminal posterior teeth:
(1) A single implant placed distal to the most posterior
natural teeth and a fixed prosthesis made to connect
the implant to the natural tooth.
• This situation is associated with a higher incidence of
implant failure because of forces placed on the implant.
(2 ) Alternatively, two or more implants can be placed
posterior to the most distal natural tooth, and an
implant restoration or bridge can be fabricated
Partially edentulous patients
Partially edentulous patients
• Single- Tooth Implant Restorations:
They are indicated in four situations :
(1) Patients with otherwise intact dentition.
(2) Dentition with spaces that would be more complicated to
treat with conventional fixed prosthodontics,
(3) Distally missing teeth when cantilevers or removable partial
dentures are not indicated,.
(4) Patient desire for treatment that will most closely mimic the
missing natural tooth.
Follow-up & maintenance
Recall visits scheduled every 3 months for the
1st year.
The sulcular area should be debrided of
calculus by using plastic or wooden scalers.
Implant mobility should be evaluated.
Bleeding upon probing should be documented.
Framework fit & occlusion should be checked at
recall appointments.
Failing implant
At the time > 18 months
18 months after
/shortly after after stage II
stage II surgery
stage II surgery surgery
Cause not
Excessive bio-
Overheating of identifiable (peri-
mechanical
bone implant bone
forces
loss)
- Initially hygiene
Compromised
Lack of primary maintenance
peri-implant soft
stability - Later surgical
tissue health
intervention
a. implant exposed
surgically
Post-op infection Smoking
b. soft tissue adjacent to
implant surface removed
c. implant surface cleaned
Excessive with hydrogen peroxide &
pressure on the
integrating
citric acid
implant d. tetracycline powder
placed into the bony defect
e. defect reconstructed with
Wound healing graft
problems f. healing for 4 months
Thank you
