Dental Implant Surgery - Zaid Hamdoon

Dental Implant Zaid Hamdoon PhD-MSc, MFDS RCS Dip-Dent Imp Edinburgh dr_zaid_hamdoon  Objectives and outcome 1-History and development The relationship between implant (foreign body)and 2-Osseointegration the living structure (bone and soft tissue)...

Dental Implant Zaid Hamdoon PhD-MSc, MFDS RCS Dip-Dent Imp Edinburgh dr_zaid_hamdoon  Objectives and outcome 1-History and development The relationship between implant (foreign body)and 2-Osseointegration the living structure (bone and soft tissue) 3-Principles to achieve osseointegration 4-Components of dental implants 5-Marco implant design 6-Micro implant design Includes coating that enhances surface topography 7-Tools in dental implants 8-Bone quantity and quality 9-Tremant plant in dental implant  Definition A prosthetic device of alloplastic material implanted into the oral tissues beneath the mucosa and or periosteal layer. Alloplastc is synthetic not natural material like auto transplant where u take a tooth from an individual to another , can be metal (titanium) or non metal (zirconia) to place on bone or inside bone or under periosteum and is used as a base for prosthesis.  History of Dental Implant Before 1000 BC Intraosseous implantation of animal teeth and artificial teeth carved out of ivory or shells were found in ancient Middle East Implantology not restricted to teeth and South America. Facial prosthesis like maxillofacial prosthesis, orbital prosthesis, nasal prosthesis , ear prosthesis for congenital deformity or surgically removed, mini implant on bone. Magnetic maxillofacial prosthesis in joint , and osseointegration plays a role.  Era of early 20th century 1913 hollow basket iridoplatinium acrilick crown wires (Greenfield) by near our moder implant. mechanical interlock radioplatinum which is kind of wire which has Latticed-cage design mechanical and biological problems Perforated and comes in two pieces a base and a crown  Era of early 20th century 1949 Goldberg and Gershkoff developed the subperiosteal implant Because of mobility and loss of retention of the denture subperiosteal implant was developed where they open a flap, take impression and construct cobalt frame and stitch it over. This gets its retention mechanically from the undercuts of the bone and of the periosteum. Both bone undercuts and periosteum will by function cause instability so this helps for a short term not long term and thus it’s abandoned but now it’s back in the market because of advances of technology CAD/CAM and CBCT where with these you can send the lab and it manufactures a frame with a hole to place a mini screw called Osseo synthetic screw open flap takes impression of the bone construct metal frame that goes beyond the periosteum then make another flap to place it so all is mechanical and it is invasives procedure, this subperiosteal implant disappear but now it is coming back cuz of the moder tech we have cat cam cbtc we dont need to open flap to take impression of the bone we can take xray and from it we can visually construct metal frame which can fit nicly so we need only one flap just to place our frame (1) second at that time we used cobalt chromium but know we have titanium which is more expted by the tissuse biocompactable in past we can only cement the crowns kow we cement screw (prosthitic diversity) u can extend the frame up to the zygomatic bone nasal bone in the max in the mandible so On the bone but sub still it is invasive procedure so what are periosteal the indications for it ? 1- when ever there is advance bone resp in mand or max and the medical dr or the health of the pat doesnt allow us to doo bone grapht 2-not veseable the convintain screw implant is not vesable do to resp old age medical cond bon qal and qunt , insufiecent bone hight and density pt refused bone grapt it is advance proc required GA and advance fald to place the frame Modern subperiosteal implant are back in the market due to the fact that material has developed where titanium is used instead of cobalt chromium and secondly because there’s no need to do 2 surgeries for impression and construct frame where only digital impression and 3d xray CBCT for construction of the framework that comes with mini screws, being a good choice as a fixed implant for completely edentulous cases with severe atrophy. Transosteal Implants there is metal plated and other screw going inside the bone so mechanically is good it can retain good denture support stability at the same time there is good support for the metal cuz it goes through and through all the way to the boton in area btw the mental foramen this area is the savest to place the implant cuz we dont have major BV or Ns, but the main issue with this tech is that it is invisve dring within the bone can weaking the mand and cuz fracture , it needs GA and the placme of metal plate needs submental incision and open an external flap that will leaves a scar now disappearing (through and through) Goes from the crest of the ridge till the inferior cortex of the mandible and thus extraoral flap is needed. With this technique it’s good to have stable implant but with the limitation of the extraoral incision, it’s an invasive technique where you’ll drill through and can end up with a submental scar and needs GA. It’s helpful when you want to provide fixed or removable denture in severely atrophied mandible. However with the recent implantology, we can place all on four, meaning 4 implants can be placed on the mandible and the mini screws that can go from cortex till medullary bone becoming less invasive  wide but thin implant with perforation so the bone can go into it , it is useful in case of sever H resorption not V like a knife edge ridge Linkows’ Blade-Vent Implants we need to cut the bone very dilicant if the surgon not experiant surgon can only replace large are not single tooth , it needs like distal extention or full denture Linkow’s blade implant is made from titanium but instead of a screw it’s a blade implant with perforations. It’s successful but is technique sensitive where to place a blade you have to make a cut in the form of a drill and that cuts a lot of bone and is invasive. Placing an implant with angulation can make prosthetic problem in the future. Thus, endosseous screw implants are better option because of their simplicity compared to transosteal implants and blade implants the dr personaly love it ! cus only limited indication and it needs it is not screw so we need humar takh takh takh to place it so it bother the pt patient DR so very limited in used so lets recap! 1-subperiosteal implant it started but it feed down now it come back cuz of the modern tech 2- trans-osseous implant was good option for sever bone resorption but now we have Brånemark Era replacement end osseous implant incase of sever resorption then we have onther altarnative which is modersub 3- brade vade in sever Hr but has limitation so it used clinicly is limited The father of Modern dental implant He’s an so his orthopedic not dentist! surgeon  Brånemark Era He was doing a research about tibia of the rabbit and experimenting healing of bone after fracture by placement of screw. By the end of the experiment he found out that it’s hard to remove and that a proper osseous integration has been developed between bone and the screw that was made from titanium. Brånemark began extensive experimental studies in 1952 on the microscopic circulation of bone marrow healing  so the key succuss of the modern dental implant is the used of the right material and then after is the right design so the material is for the biology and the design for the mechanic so biomechanics Brånemark Protocol Based on animal studies and clinical trials done for 15 years the protocol was published indicating success of titanium material in screw implants 1-A trumatic surgery = less heat genertion the heat is the Anami of bone 2 Non loading (3-6months) 3Compatable material (titanium alloy) based on his accidantal finding imp 4-Good primary stability (30-45 N/cm) represent the ressistent of the retention Successful implant surgery needs to be atraumatic, when you reflect the flap don’t compromise the blood supply, not generating heat during drilling inside bone. If 47 degrees reached for 2 mm this causes irreversible bone damage, if 45C for 2 min this will cause reversible bone damage. Any trauma to bone will cause necrosis but can either be reversible or irreversible depending on the degree of heat, where anything less than 47 it’s reversible whereas more than that will be irreversible and lose bone and the implant. irriversable bone necrosis so implant will fail Implant placed in the socket and is covered with the gum, no crown prosthesis will be placed immediately otherwise this will cause micromovement of the implant, an thus it must be kept for 3 months if in the mandible (dense bone) and 6 months if in maxilla (softer bone) , if bone augmentation or sinus lifting was needed with the implant this will need more than 6 months because of complex form of healing. 3-6 months for conventional implants however any modifications like the mentioned will need more than 6 months Screw type implant is used, when inside the bone it makes resistance and torque achieving torque measured by torque meter ratchet (30-45). We can make immediate loading meaning the screw and crown are placed immediately if the primary stability torque was 40-45 N/cm but this is against Branmark protocol and way too advanced.  Original Brånemark system Original is Pure and uncoated but future 1 Screw-shaped modifications done to surface not titanium alloy topography added to make it rough and 2Implant made of pure titanium. stimulate bone formation now there is bigger and smaller 3-Outer diameter of 3.7 mm Almost like the premolar 4 Length of 10 mm. nearly as then length of the root of the premolar length In the market it’s mostly taper but the original one was 5Cylindrical in shape cylindrical 6-External hex The attachment of the implant with the abutment but currently we use the internal hex  New Era in dental implant Term given by branmark other scientist like (idk) call it functional ankylosis Osseointegration Bone to metal Screw with crown functioning with no pain or pus Direct structural & functional connection between living bone & surface of a load-carrying implant. this allows the crown or the bridge to function around the screw without caussing bone necrosis 1-Hemi-desmosome like structures 2-No connective tissue insertion btw the implant and the bone only hemi-D like struct so that means there are no mobility in the implant unlike normal 3-No Sharpey’s fiber teeth where there is physiological mobility from the PDL we have fix No pdl meaning there’s no physiologic movement of the implant instead a solid relationship making it diff from conventional fixed and removable prosthetic as it deals with natural teeth having cementum mobility and occlusion , however in implants there’s concrete relationship between bone and implant  Important to understand limitations of the implant and for MCQs Implants versus natural teeth the biological consideration will be different 1 Hypocellular (less healing capacity) 2Hypovascular (bleeding is less reliable sign of inflammation) the key feature of the natural tooth is the PDL which contain variable cells and BV which imp for healing and defense bv for nuitration and healing ,so less of healing and more inflamation suspactibility , when bacteria come aroound the implant is more prone to cuss perimplantities 3 No shock absorption (no adaptive) so why we have high incidense of perimplantities than periodontiris ? cuz of the inhereted problem of the 4Connective tissue parallel to implant hypovascurality and hypoceralaty cant recognize the magnitude of the 5-No innervation no proprioception force cant tell what they are eating at certain stage cuz we still have osteoreceptive in the bone but not propi 6Fulcrum when lateral force applied like in PDL so the feeling will be different (Tooth=Apical, Implant=Crestal) 7 Axial mobility of implant (3-5 Microns) microscobic insignevents due to the bone elasticity not the movement btw bone and implant so cuz of bone movment  It’s hypocellular because of no cementum or PDL thus less healing capacity of implant and thus more inflammation than in natural teeth blood, periosteum and tissues give blood to tooth but in implants it’s bone and implant with little soft tissue and little blood supply affecting the healing capacity. periodontitis in natural dentition lead to bleeding however in peri implantitis it’s with minimal bleeding and thus cannot use bleeding index as a reliable way to assess it’s only reliable in periodontitis. No PDL= no shock absorption and if there’s enormous force the implant will either disintegrate or fracture of the abutment or the screw No CT that is parallel to the implants in area of junctional epithelium whereas in teeth CT runs perpendicular No proprioception receptor a patient wearing full arch implant cannot tell magnitude or direction of the force only little osteoreceptors and not as powerful as proprioception. This is important in occlusion patient cannot tell if any high spots are there. If you apply force on natural tooth , force will go apically because of PDL whereas in implants force is applied to the crest of the implant and it’s the most important part of the implant (crestal part) so design and bone level here is important it make early bone resorption around implant at higher risk the fulcrum in NT is in the J btw middle third and apical third, while in implant is it at the neck so that why all the bone resorption in implant is happen around the neck mainly due to biomechanics force to implant stress in the neck 6-Probing depth 2-3m for teeth versus 4mm or more for implant why we do percussion over the implant ? 1- succus criteria of the implant is that it is not mobile so to check the mobility 2-osentigation if u hear very solid sound this is the osteointgration if u hear dull that is not osteotegration 7-Junctional epithelium originates from adjacent epithelium in dental implant Not from PDL like in natural teeth  Why Titanium? Why not gold? No corrosion but it’s expensive ,it’s soft and malleable, and cannot withstand occlusal forces unlike titanium it’s light Corrosion resistance is imp for biocompatibility particles if corrosion happen will stimulate immunological reaction and implant is rejected. the cuss of HIGH biocomp and it is dianamic Oxide layer is a protective layer that changes throughout function hence the name and this makes implants stable for 20 years or more. 1 Light weight so not put much weight in the mand cytokinin will destroy 2 Biocompatible 3 Corrosion resistant 4Dynamic oxide layer 5-Strong 6-Low-priced Original Barnamark implant was machined screw form Like zirconia implants it has bacteria that can stimulate bone formation but is susceptible for fracture Polymers for TMJ surgery but not anymore it’s bio tolerable but can still stimulate an immunologic reaction. Ceramic=Bioactive can stimulate bone formation Polymers=Biotolerable still exepted Titanium=Bioinert (Biocompatible) cant provokes any reaction of the body at the same time cant stimulate any bone formation so, the difference between bioactive and bioinert? the Bioactive is also a Bioinert but with sti  Development Modifications and development to branmark original implant include : CBCT is mainly market because of dental implant not wisdom tooth. 1-Fixture design (Macro design) 2-Surface coating (Micro design) manipulating the loading to 1 month by making the coating rough stimulate the bone 3-Implant abutment connection formation which is the plate form 4-Techniques, bone and membranes 5-Imaging  Macro design of implant fixture Component of two piece implant A generic language for endosteal implants was developed by Misch in 1992.. Developed a common language with terminologies. Component of two piece implant 1 FixureImplant body 2Cover screw Close inner side of implant 3-Healing cap Healing abutment 4-Abutment Prosthetic part crown or denture 5-Transfer coping Element for impression taking (open or closed tray technique) 6-Analogue Replica of implant in lab in stainless steel form not screwed represent only inner side of implant  Cover Screw Flat and small otherwise it will impinge tissue and will open the flap. Its main function is to prevent soft tissue, bacteria, debris to go inside the implant during the healing time Hole inside for the abutment and the hole is covered by a cover screw  after 3-6m i open the flap agian flat prevent to create gingival soft cuf a nice profile , tissues emergence profile injury during healing to recreate the papilla After 3- 6 months we remove the cover screw and then place the healing cap that goes above the gum.by 2mm The first screw (cover screw) has to be of low profile small and flat and under the gum. The second screw is the healing abutment that I above the gum and is important to create emergence profile, shape the gum and to be like natural teeth.  Healing abutment Following branmark protocol, After 3-6 months we open flap see the cover screw remove it and place the second screw (healing cap) bigger 2-4 mm above gingiva to create papilla and we don’t want soft tissue to cover it so we don’t have to cut it and you need to make sure it doesn’t interfere with the occlusion away from opposing tooth. after 2-3week of placing ??? mm above the tissue  Healing caps Different shapes and heights reflecting different implant position. Lower CI= small for small emergence profile in conical shape Molars= wide The thickness of the gum is another factor more in premolar than in molar /more in smokers, this is why there’s diff width, shape and height. Selected according to anatomical areas and soft tissue thickness. non anotomical 1,5 mm 2,0 mm 3,0 mm 4,5 mm anatomical have merges to recreate the papilla 2,0 mm 3,5 mm 3,5 mm 5 mm  Transfer coping in dental after finish of the implant u will take an impression Leave healing cap implant for 3-4 weeks until soft tissue heals then take impression with transfer coping , if short one we go it goes inside the for closed tray implant and then technique and if we scew it ten the try will be placed it’s long that is here open tray once we take the technique. impression the Impressions in transfer coping will come out with it dental implants has low error because of transfer coping. Dental implant abutment You send impression to the lab and the lab decide on the abutment needed, they come in different material titanium(high resistance) or zirconia in case of anterior teeth (has limitation of fracture), different designs if straight implant use straight abutment , if angled like anteriors you use angled abutments. Alveolar bone is not on the same plane of the abutment in anteriors where they’re proclined. For dentures we use ball and socket , locator for denture type of implants that is removable not fixed.  Analogue lab replica of the implant represent implant inner geometry, interiorly the implant has something we call it the hex In the lab represent implant geometry as the platform and the inner x , no need to pay attention to the screw design. Inner side of the implant and the surrounding tissue is the only thing we want to register and accordingly we’ll construct the crown. Made of stainless steel non screw , it’s lab form not used in patients mouth and for multiple use without concern to cross infection. so when u use hexagonal implant uur analog should be the same they make the analog of stainless steel actually it dosnt matter it won't goes to the pt mouth so cheaper Implant Body i dont want to screw it or locate the apex ect so Most commonly used dental implant don't care about the outer only inner the platform and the helix is the internal hex however the original form was the external hex. Internal hex the neck part Where all force is External hex concentrated neck of implant crestal part Tapered or cylindrical apical part , pointed or blunt, screwed or non screwed. To be safer they use the blunt so it doesn’t injure a vital structure like a nerve Collar Smooth Surface (bone level) Placement of the implant relative to the bone. At the level of the bone = implant bone level ( gum covers this implant) Soft tissue level implant=neck of the implant will be with the level of the gum during the surgery  Soft tissue versus bone level implant (Indications??) above the alveolar bone with the level of gum Advantages of soft tissue implants Secondly, in soft tissue ? implants with level of In subgingival implants those that gum you don’t need to are with the level of the bone will open a flap after 3-6 have the microgap between the months to place abutment and implant will become healing cap and only under the gum causing bacterial one surgery is needed proliferation under the gum, more no need for re entry. inflammation. Thus by soft tissue implants the microgap is pushed upwards from subgingival to gingival level to decrease chances of inflammation. Bone level implant Soft tissue implant  so who's better in case of health and bacteria contamination ? the soft so less periimplantities Bone level implant Soft tissue implant Preserve bone Smooth part below crest inside bone even the bone level implant can be supra or sub crestal level  Soft tissue level implant At time of surgery neck of implant with the level of the gum so microgap is away from subgingival area less inflammation and less peri implantitis and no need for second gingival surgery , no additional trauma and more preservation of bone Limitations and disadvantages of this the contamination due to wound healing were implant is exposed and this can possibly cause early implant infection ,trauma of implant that can cause micromovement of the implant and dis integration , implant displacement which can cause aesthetic problem. Recession in tissue will cause implant exposure and lead to unaesthetic appearance which cannot be corrected. the only solution for it is to do bone or soft tissue implant or just remove it However in bone level implant the neck and the no need to re-open a flap and place the abutment (the crown)so it is less invasive platform is away from the soft tissue even with recession it will never expose or cause any aesthetic SO we dont placed soft implant in esthetics area problem.  Types of root form body There are three primary types of root form body Original was cylindrical or parallel 1 Cylinder (Parallel walled) walled meaning same diameter from crest module to apex 2Taper or conical (Immediate insertion) 3- Combination. To mimic the root of natural teeth to only remove thin from alveolar bone and thus taper is the most commonly used. Immediate insertion is when we want to preserve the tissues , after gentle extraction if the buccal bone and palatal are intact and there was no infection in the area an implant can be placed immediately, if we do so a taper implant has to be selected otherwise if cylindrical is selected you’ll end up with dehiscence in that area pus will form and it’s hard to detect. fenestration perforate the bpne cuss pus perimplan but in the apical area Cylinder versus taper  Thread design (Shape) Modern implants are threaded screws to help engage bone The more attachment to the 1-Bone engagement bone as surface area increases so bone implant contact ratio VIC and the 2-Primary stability more the ration the more successful is the implant. 3-Increase surface area No PDL thus we rely to threads 4-Force distribution toareengage , smooth implants not stable and no force distribution.  easier insertion Most commonly used one can cut bone and achieve good stability. Quicker and smoother V-shaped insertion compared to Buttress rest The V-shaped threaded screw has the longest history of clinical use  Good primary stability = use the V shaped Good secondary stability and force distribution =square is ur choice Less engaging to the bone in terms of Revers Buttress Square primary stability. Different insertion from v shaped which is quicker and smoother.  Thread width Least significant parameter in implant marco design Length, diameter, threads, width of threads, length of threads all are parts of the macro design  Distance between thread (Pitch) not only the design the screw but also the bone density (effect the primary) effect the stability with is the prim N-cm , so if i hav HDB i hav HS so in mand what desing course or fine ? course caz in dense bone i will inccauter h prim stab which cass pressure necrosis if i exeed 60N-cm this is no no no not healthy Number of threads per unite length An important parameter in the macro design considering threads is he pitch which is the distance from a thread to another. Coarse pitch is with long distances between the threads Fine pitch is with short distances between the threads. Coarse is with quick insertion no need to turn the implant a lot unlike the fine which needs many turns. Fine is with positive influence on implant stability unlike the coarse which negatively affects stability. Fine is good for soft bone like in maxilla , if dense and heavy bone coarse pitch is used. Coarse pitch=quicker insertion of screw but negatively influence implant stability. so if he said he have soft bone which implant u will choose in case of pitch and the thread depth fine and deep dense course and shallow threads Thread depth Distance between the shaft and the outer. The more the depth is , the more aggressive and more engagement to bone. Better stability = deeper threads( like in maxilla a deep thread and fine pitch is needed) Deeper threads seem to have an important effect on the stabilization in poorer bone quality situations.  Body lengths this is the conventional implant inside the alveolar bone more than 16 it goes to the basal bone mainly cortical, so we call them cortically fixed implant or basal implant The body lengths usually range from 8 to 16 mm Length less that 8mm-Short implant, more than 16-Extra long implant Anything shorter is risky and is not conventional and you need to assess its risk, anything longer it doesn’t go to just alveolar bone or basal (Ideal length 12mm) bone instead to pterygoid bone or zygomatic bone Lengths from 5 mm to 56 mm are available we go to the zygoma to have primary stability Long zygomatic implant 50 mm length goes from alveolar to zygomatic bone and engages basal bone and has special indications. Long zygomatic implant 14mm all in four concept in mand 2 straight implant and to angled then we put fixed denture over it  Diameter 1-Narrow (3-3.9mm) 2-Standard (4-4.9mm) Most commonly used 3-Wide (5-6mm) 4-Extra wide (7-9mm) Slim implant less than 3mm (Be careful) Like short implants not recm cuz biomechanically it canoot tolarate that much forces it will breack it is not safe to with special indications use ! unless we put 2 implant and connect them and need risk togather or come in one peaice crown and screw cuz frcture happent in junk neck area the hex assessment. area weather internal or external  Diameter Diameter will be 2 mm away from CEJ. Not less 4 in CI forceful In molars nothing less than 4mm Wider Diameter=Better strength Fracture resistance is better and replicate the diameter of the root  Emergence profile More protected with wider implants and better emergence profile with wide neck. Wider Diameter=Better Esthetic  Slim implants crown is very big called tomato on steak and is unaesthetic Oversize is not acceptable has to be smaller than the size of natural tooth root  No pdl so forces are made axial are most referable , we make forces as axial as possible, anything away from the axis of implant is non axial force called cantilever. A wider implant has less cantilever and is better. any off axess force Wider Diameter=less cantilever and better biomechanics  Platform switching Important in modern Implant has no step Abutment diameter is implants , making the abutment smaller than smaller than the the implant platform of the implant. So that the Reducing the abutment diameter in comparison with the dimeter abutment fits inside of dental implant the platform of the implant. Advantages include: Pushing all inflammatory cells from the central axis of the implant to the inner side to reduce the inflammation and preserve bone to have healthy implant to avoid crestal bone resorption and soft tissue will be preserved. Shift inflammatory cell infiltration to the central axis of the implant and away from the adjacent crestal bone, which is thought to restrict crestal bone reabsorption Platform switching can help prevent crestal bone loss, which is fundamental for the implant’s long-term success and stability. It can also increase the volume of soft tissue around the implant platform, helping to improve the esthetic end result