Rationale for Dental Implants

Outline:
i.

Anatomical Consequences of
ii. During a one-stage surgical approach: Edentulism
iii. the immediate restoration approach(loading): a. Anatomical
b. esthetic Consequences
viii.
c. Decreased Performance of Complete
8. diagnosis
Dentures:
a. systemic evaluation
ii.
b. dental evaluation
iii.
Rehabilitation Option for Missed
c. radiographic evaluation
Teeth
i. objectives
a. Fixed Partial Dentures
ii. types
b. Removable denture (partial / complete)
1. PA
c. Single-Tooth Implants
2. Panorama
iv.
3. CT
v.
Dental Implants
4. CBCT
1. The Historical Development and Types
9. Bone density
i. subperiosteal implants: ix.9.
Bone volume classification
ii. the transosseous implant
iii. endosseous implants
x.Implant failure
iv. the blade implant
xi.Choice of implant
v. the root-form or cylindrical implant
vi.
xii.
Guideline for key implant
2. Composition
3. Shapes
position: - (very imp)
4. Implant Retention
5. Osteointegration
1 No cantilevers
6. Parts
2 No three adjacent pontics
a. Fixture
3 Canine-molar rule
i. Crest module
4 Arch dynamics
ii. Body
xiii.
iii. Apex
b. Abutment.
10. TTT plan
c. Connecting screw.
xiv.
Timing & TTT sequence: vii.
7. Stages
xv.
Surgical technique: i. The two-stage surgical process
xvi.

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

29.
30.
31.
32.
33. I) Consequences of Edentulism (tooth loss)
34.
1)Anatomical
35.
Cut section of mandible: 36.There are six different stages of resorption in the
anterior mandible.
37. Stage 1 the tooth and surrounding alveolar
process and basal bone.
38. Stages II and III the initial residual ridge after
tooth loss.
39.Stages IV to VI continuous loss in length of anterior residual bone till leaving
only basal bone
40.
41.
So how to maintain!?!?!
42.Traditional work :-complete denture construction(not
stimulate bone remodellingresorbing
43.Need relining & rebasing to restore vertical
dimension weight on ridge more accelerate bone
resorption .
44.
45.Consequences on the Bony Structures
1. A tooth is necessary to the development of alveolar bone, and stimulation of this
bone is required to maintain its density and volume. A removable denture
(complete or partial) does not stimulate and maintain bone; rather, it accelerates
bone loss. GRF
46.
As The load from mastication is transferred to the bone surface only, not the
whole bone. As a result, blood supply is reduced and total bone volume loss occurs.

2. Hence the traditional method of tooth replacement often affects bone loss in a
manner not sufficiently considered by the doctor and the patient, the doctor
should inform the patient that a denture replaces more bone and soft tissue than
teeth, and every 5 years a reline or new denture is suggested to replace the
additional bone loss by atrophy > so inter-arch space for implant retained
removable prosthesis must be at least 12 mm
47.
Figure: 48. After the initial extraction of teeth, the average first-year
bone loss is more than 4 mm in height and 30% in crestal bone
width. Although the rate of bone loss is slower after the first
year, the bone loss is continuous throughout life.
49.

50.

55.

51.
52.
53.
54.
2)Esthetic Consequences: - (even e complete denture

but after longer time)

1. Decreased facial height & Loss of labiomental angle
2. Deepening of vertical lines in lip and face
3. Chin rotates forwardgives a prognathic appearance
4. Loss of tone in muscles of facial expression
5. Thinning of vermillion border of the lips from loss of muscle
tone
6. Deepening of nasolabial groove
7. columella-philtrum angle
8. length of maxillary lip, so less teeth show at rest and
smilingages the smile
56.
57. 3) Decreased Performance of Complete Dentures: 58. Negative Effects of RPD
1. Bite force is decreased from
200 psi to 50 psi (pound per
square inch) &Ill-fitting
denture wearers have reduced
bite force to 6 psi
2. Masticatory efficiency
3. limited Food selection
4. More drugs are necessary to
treat gastrointestinal

59. Problems with RPD

1. Low survival rate60% at 4 years
2. 10-year survival rate is 35%
3. Repair of abutment teeth rate=60%
at 5 years and 80% at 10 years
4. mobility, plaque, bleeding upon
probing, and caries of abutment
teeth
5. 44% abutment tooth loss within 10
years
6. Accelerated bone loss in edentulous

disorders
5. The life span may be

region if wearing RPD

decreased
6. Healthy food intake is
decreased
60. Advantages of Implant-Supported Prostheses: 1. Maintain bone volume and density
2. Restore and maintain occlusal vertical
dimension, facial esthetic (muscle
tone)
3. Improve esthetic (teeth positioned for
appearance)
4. versus decreasing denture movement)
5. Improve phonetics & occlusion

6. Improve/regain oral proprioception

(occlusal awareness)
7. prosthesis success and survival rate
8. Improve masticatory performance
9. maintain muscles of mastication and
facial expression
10. size of prosthesis (eliminate
flanges , palatal covering gag
reflex)

11.

Provide fixed versus removable

prostheses
12. stability and retention of
removable prostheses
13. No need to alter adjacent teeth
14. psychological health
15.

16.

II)Rehabilitation option for

missed teeth
17.
The posterior regions of the mouth often require the replacement of a single tooth
mainly the first molars GRF
1. They are the first permanent tooth to erupt in the mouth
2. They are often the first teeth lost as a result of decay, failed endodontic
therapy or fracture
18. The options are
1. Fixed Partial Dentures
2. Removable denture (partial / complete)
3. Single-Tooth Implants
19.

20.
21.

1)Fixed Partial Dentures: The most common choice to replace a posterior single tooth is a three-unit

fixed partial denture (FPD).

22.

Disadvantages: -

1. 10-year survival rate is 50%

2. removing sound tooth structure and crowning two or more teeth risk of
decay and endodontic therapy (destructive). GRF
a. 80% of teeth adjacent to missing teeth need no or minimal restoration
before preparation
b. And after insertion, due to caries (most common cause of FPD failure),
Up to 15% of abutment teeth for an FPD require endodontic therapy,
compared with 3% of non-abutment teeth that have crown preparations.
full coverage restoration abutments bridge

.23
.24

3. Even if the abutment is endodontic ally treated there is bone loss GRF
a. As natural teeth embedded in bone mastication and occlusion force
on bone remodelling bone maintenance .
b. But after extraction advanced bone loss 4 mm height + 25 % during
1st year of extraction ) accelerated bone loss continue throughout life .
25.
26. 2)Single-Tooth Implants
27. Advantages
28. improved
1. 10-year success rates (above 97%

badly destructed .% optimal endodontic ttt success rate is ( 60 : 80 )

immediate implant

.29

2.
3.
4.
5.
30.

ability to clean the proximal surfaces of the adjacent teeth

esthetics of adjacent teeth
Psychological advantage as improve taste, phonetics, no gag reflex.
maintenance of bone in the edentulous site (Decrease amount of bone loss (1st
year=0.2mm & every year=0.1 mm)
Decreased

6. risk of caries of adjacent teeth

7. risk of endodontic problems on adjacent teeth
8. cold or contact sensitivity of adjacent teeth (compared to prepared abutments
(finish line leakage)
9. abutment tooth loss.
31. N.B: 32. Even when teeth adjacent to the missing tooth require crowns, an implant is
the treatment of choice GRF
33. because single crowns on teeth adjacent to implants have fewer
complications and increased longevity compared with abutments for a three-unit
fixed partial denture.
34. Dis advantages of implant: - Economic (extra cost), but on long run is
cheaper
35.
36. III)Dental Implant
37.

1)The Historical Development of Dental Implants

Chinese and Japanese (who used bamboo wedges to fill the sockets)
Egyptians (who used precious materials to replace missing teeth),
The first endosseous implant is Mayan origin from sea shells and
placed in the mandible achieving chemical (e chemical composition

like bone) and mechanical retention.

the young Brnemark studying blood flow in vivo by placing a
titanium chamber in the femur of a rabbit; over time, the chamber
became firmly attached to the bone and could not be extracted due to
bone ingrowth from neighbouring bone. This phenomenon later
described as osteointegration (OI).

38.
39. The implants fall roughly into two major categories:
1. subperiosteal implants: 1. site (extra osseous)
40. rest on alveolar bone beneath the gingiva and usually not attached to
the severely resorbed jawbone for which these implants were designed)
2. technique
41. :incision impression of bone pouring cast of ridgemake metal
framework and rods extended from it 2nd visit oral surgeon open again
inserting framework suture e rods emerging from gingivaover-denture
placement .
42.
3. heals by fibro-integration (fibrous tissue attach to metal) not Osseointegration.
4. disadvantage: - failure due to

43.

fibro-integration on mastication rocking subperiosteal infection pus

removal .

44.
45.

N.B: - in now-days used implants, healing by fibro-integration is a sign

of failure.
46.
47.

48.
49.
50.

2. the transosseous implant

1. Site (intraosseous)
51. penetrates the entire jaw and emerges below the jaw,
where it is secured), extending from lower border till alveolar
crest
52.
2. heal by osteointegration.
3. done by submental incision /endosteal
4. disadvantages: 1. infection on bone.
2. trauma during insertion +approximate rods ( force
distribution)+resorbed ridge= pathological fracture
53.
3. endosseous implants
1. placed within the alveolar bone
2. technique:
54. crestal incisions longitudinal tunnel preparation extended rods from
plate (2 posterior and 2 anterior)overdenture .
3. Variations: 55.
A) the blade implant
1. thin, elongated, flat device designed to be secured in narrow, even
knife-edged alveolar bone)
2. disadvantages: 1. elongated preparation > destruction near nerve
& vessels > bleeding & infection
2. not restore missed single tooth (need more than
1 tooth space as its elongated)
56.

58.
59.

57.
B) the root-form or cylindrical implant (now-days used)
resembles an actual tooth root
2)implant composition:

made of titanium alloy (as the pure titanium is soft metal, so alloy
strengthen it and maintain biocompatibility of titanium).

60.

adv. Of Titanium

1. light in weight, biocompatible, no corrosion

2. when exposed to atmosphere, oxidation of surface layer which lead to
formation of titanium dioxide, which stimulate osteoblast to make
61.

osteointegration around implant

so after preparation, avoid touch the implant to avoid scratch the layer
of titanium dioxide.

62.
63.
64.
65.
66.

3)shapes: -

1. Threated (screw type) form (acc. To implant position, use either:

a) Tapered in case of knife edge ridge .(less size destruction)
b) Parallel wall in case of broad sufficient ridge (inserting by pressing) (high
surface area)

2. Cylindrical (press fit) with no threads

67. The Most common is screw type GRF
1. as roughness mechanical retention and surface area(TiO2) exposed
to bone osteointegration by 40 : 50 % in high successful implant
68. why not 100 %, ?!

a. As the bone contains cancellous bone filled e soft tissue (bone

marrow& blood cells) so bone implant contact reaches 40: 50 %
b. It in purely dense bone till reach 50 : 55 % and in cancellous
bone to reach 25:30 %

73.

69.
2. Easy insertion
screwing facilitate its insertion as tapered is self-tapping (create
space for the threads)
if preparation isnt sufficient (10 mm) and implant 11 mm, the
screwing creates this 1 mm during inserted.
70.
3. primary stability at first day and high osteointegration
71.
(primary stability means highly successful implant),
72. without 1ry stability micro motion fibrous tissue formation not
bone formation fibrointegration failure .
4)Implant retention

1. Macroretention: a. Mechanical: - By

1) Sandblasting during manufacture

threaded form.
b. Chemical :- acid etching > porosity
2. Microretention: -

||

2)

74. Hydroxyapatite or plasma spray on surface stimulate

osteoblasts osteointegration .
75.

5)Osteointegration: -

1. Def:
76.
Direct structural and functional connection between living bone and
surface of load-carrying implant without interpositioning connective tissue
77. Load-carrying means under function & no Connective tissue is detected by absence of radiographic margin
78.

2. it is histological term not clinical (detected by microscope only)

79.
3. the accurate clinical term: rigid fixed. the accurate radiographic description =
absence of radiographic margin
80.

4. phases: 1. Osteoinductive phase: due to trauma during inserting implantrelease of bone

morphogenetic protein stimulate osteoblast for bone deposition .
occurs in 1 month.
2. Osteoconductive phase: thin layer of osteoid bone (immature woven bone) formed.
occur in 3 months
so implant put under load at least after 3-4 months to become rigid

fixed to allow calcification of bone. (acc. To in maxilla or mandible)

3. Osteoadaptive phase: Alv. bone resorption (in micron) During mastication & equal bone deposition (bone

remodeling) at rest
but in parafunctional habit > increase amount of bone destruction.
81.
82.

6)Parts of implant

1. Fixture
a. Crest module
b. Body
c. Apex
2. Abutment.
3. Connecting screw.
83.
84.

N.B: Criteria of successful fixture: -

1. Made of Titanium
2. Threaded type (high in bone implant contact)
threads & interstitial spaces
86. 1)fixture
87. a. Crest module: 1. Def:
88.
The portion designed to retain the prosthetic
component in a one-piece or two-piece implant system
representing the transition zone from the implant body
design to the transosteal region of the implant at the
crest of the ridge.

.85

89.
2. Function: bacterial invasion. (e.g., smoother to
impair plaque retention if crestal bone loss
occurs). Its smoother dimension varies greatly
from one system to another (0.5 to 5 mm).
90.
3. An anti-rotation feature also is included on the
platform (external hex) or extends within the
implant body (internal hexagonal, Morse taper or
cone screw, internal grooves or cam tube, and pin
slots, basket) but not weakens the metal.,

91.

92.
Has connection between abutment and fixture
either:

a. internal connection Abutment enter in the fixture

b. external connection abutment contain the fixture
93.
4. cervical collar When the crest module is smooth, polished metal,
94.has no threads (smooth collar) GRF

the implant losses 0.1 mm/year .when 1st thread appear plaque accumulationgingivitispus
periodontal pocket periodontitis bone resorption perimplantitis failure .
So if theres rough part, remove it by bur then smoothen it by rubber cups

95. As

96.
97.
98.

b. Body: -

1. Material (TI alloy)

2. Roughness (Threads)
3. Has Anti-rotational features
99.
Hole through which osteointegration form within it also increase surface
area within implant.
100.
4. A threaded type is primarily designed to BIC and to the stresses at the
interface during occlusal loading.
C) apex: 101. blunt not sharp GRF
1. to avoid penetration or injury to maxillary sinus in case of pneumanization of
sinus
2. to stop at osteotomy site that you prepared.
102.
103. 2)Abutments: 1. Def:
104.

2.

the portion of the implant that supports or retains a prosthesis or implant

superstructure.

categories

105. A) according to the method by which the prosthesis

or super-structure is retained to the abutment)
106. 1)Built in abutment (one piece/stage abutment): 107. Implant and abutment is one piece (no
connecting screw)
108.
109. 2)Separate abutment (most common)
110.
a) Custom made: 111.
Its neck is standard (for connection e fixture) and you can only modify
the coronal part (diameter, width, configuration, bulkiness)
112.
It has metallic neck e plastic coronal part that you modify e wax then
send it to lab. To fabricate it
113.
B) prefabricated
114.
its already prepared with finish line e minimal modifications allowed.
Its either
115.
1) screwed: - uses a screw to retain the prosthesis or superstructure
116.
2) cementable: - uses dental cement to retain the
prosthesis or superstructure.
117.
3) abutment type: uses an attachment device to
retain a removable prosthesis (such as an O-ring attachment
ball &socket, locator, magnetic,).
118.
119. In case of: 120. FPD > cementable.
121. Crown or FBD > screwed.
122. Overdenture(RPD) > ball and socket.
123.
124. The abutment for cement/ screw/attachment may be
screwed or cemented into the implant fixture, but this
aspect is not delineated within the generic terminology.
125.

screwed abutment need high technique and used in case

of limited inter-arch distance on contrast cementable abutment

can't be used in this case.

126.
127. B) acc. to axial relationship between the implant body and the abutment. (in each
of the three abutment types)
1. Straight
2. Angled abutment.

1. As when you place fixture at a specific angle and

you have to counteract this angulation
2. mainly in esthetic zone like ant. Maxilla to allow
space for crown insertion
128.
129. N.B: Healing abutment(temporary): 1. Inserted for 2 weeks before final abutment (shorter
than the final)
2. Function: Its diameter is wider than abutment induce papilla formation 0gingiva
heal with divergence create emergence profile replace e final abutment .
130.
131. Many manufacturers classify the prosthesis as: fixed whenever cement retains the prostheses (either the dentist or

pt. can manually remove it)

fixed/removable when screws retain a fixed prosthesis (the dentist

can but pt. cant)

removable when the restoration is removed by the patient (e.g.
magnetic or ball and socket in overdenture.

132.
133.

134. 3)screw: 1. Copper screw: in two stage procedure.

2. Abutment screw in connecting screw.
3. Gold screw in screwed type abutment. (crown retaining screw to abutment or
implant)
135.

N.B: -

136.

Most common implant now is extra-osseous - root form, threaded, screwed type.

137.

GRF: - threaded advantage over cylindrical is high

1. High BIC & easy insertion primary stability no micro-motion .

2. stress on bone > amount bone resorption implant durability .
138.

139. type according to stages (for the two-piece implant systems)

140. A) The two-stage surgical process: 1. places the implant body below the soft tissue, until
the initial bone healing has occurred. (the fixture is
closed by cover screw to prevent bone, soft tissue, or debris from
invading the abutment connection area)

2. During a second-stage surgery, the soft tissues are

reflected to attach a permucosal element or abutment.
141.
(healing submerged, then uncover it by surgery),
142.

143. B) During a one-stage surgical approach: 1. the implant body and the permucosal abutment above the soft tissue are
both placed until initial bone maturation has occurred.
2. The abutment of the implant then replaces the permucosal element without the
need for a secondary soft tissue surgery. (implant is not submerged & crown is
away from occlusion)
144. (implant with permucosal healing, no uncovering surgery) (not
submerged)
145. C)The immediate restoration approach(loading): 146.
147.

places the implant body and the prosthetic abutment at the initial surgery.
A restoration is then attached to the abutment (out of occlusal contacts in partially

edentulous patients).

148. 8. diagnosis: -

149. A) systemic evaluation: 150.

1)Diabetes Mellitus: -

151.

1) Well controlled D.M is not contra-indicated.

152.

2) Uncontrolled diabetes is contra-indicated for implant GRF

1. Excessive alveolar bone resorption (difficult to get rigid fixation)

2. Gingival bleeding and ulceration.

153.
154.

3) Sign and symptoms: 155.

gingivitis & gingival recession first thread of implant appear(rough
surface) plaque accumulation periodontal pocket & horizontal abscessbone
loss .

156.

4) laboratory finding:
157.

Glycosylated hemoglobin test:

158.
Detect glucose level within last 3:4 moths (life span of RBCs) normally =
around 7
159.
160.

if its range 7: 8 = semi controlled, if >8 = uncontrolled.

5) Antibiotic therapy at the time of surgery.

161. 2) Smoking: -

1. Heavy smoker (>20/day) is absolute contraindicated to implant while

<20/day absolute contra-indicated .
2. When to ask the patient to stop smoking?!
162. Before surgery by 3 weeks and during healing period (3: 4 months
after surgery) why?!!
163.

As nicotine interfere with blood supply reduce blood supply , reduce oxygen
tension , immune cells retard healing fibrointegration of implant

3. Perimplantitis is frequent.
164. 3)Osteoporosis: -

Relative contraindicated due to BIC .

Sol. :- control case(ca blood level) + number of implant +

surface area to BIC .

165. 4) Immunocompromised: 166. 1st) Most common immunocompromised in America and Africa is AIDS but in Egypt is
diabetic.
167.
169.

Healing is retarded, and socket is prone to dry socket GRF

due to atherosclerosis(deposition of on intima of blood vessel) blood flow
immune cells and oxygen tension .
2nd) organ transplant due to immunosuppressive drugs (to avoid organ rejection).

170.

3) Radiotherapy to oral and maxillofacial region only is contraindicated, during 1st 2 years

168.

after exposure to avoid osteoradionecrosis

171.

This is acc. To 1) site of radiation E.g. on thorax (not C.I) while on thorax (without barriers) may be CI

172.
173.

2) barrier usage (not C.I)

5) Psychological patient is contraindicated > uncooperative /not

tolerate multiple visits/mainly no oral hygiene.

174.

175. B) Dental evaluation: 176. I) General: 177.

178.
TTT them
179.
180.
181.
182.
183.
184.
185.
186.
187.
188.
189.
190.

1) Traditional radiographic survey as panorama 1st step

To evaluate site of surgery, cysts, remaining root or pneumanization of sinus &
2) Periodontal charting: Good gingival condition to avoid entrapment of calculus in surgical site.
3) Caries detection: Filling of decayed teeth, replacing defective restoration.
4) Control of diseases prior to implant placement (to avoid inflammation)
5)Oral hygiene level: - indicative of future care of the implant hygiene
Remove calculus, bacteria, infection, inflammation, motivation to oral hygiene.
6) No implant treatment without full patient co-operation.

191. Intra-oral: 192.

2)Arch shape and size & number of implant needed, bone volume, size of space,

completely edentulous pt.

193. 3)Occlusion
194.

must be well diagnosed to evaluate the type of occlusion class 1 or 2 or 3.

195.
Presence of attrition or General wear facets on teeth indicate presence of
parafunctional habitocclusal guarded usually needed .

196.

4) Esthetic evaluation: - smile line analysis is critical for maxillary anterior

implants.
197. 5) Inter-arch space: - (very important)
198.

Its the space bt opposing cusp to the edentulous ridge to be occupied by abutment

199.
200.

For fixed implant support: in posterior region: cementable abutment= minimal 7 mm

201.

screwed abutment if < 7 mm

202.
in anterior area: 8: 10 mm is necessary GRF as angled abutment
may be used which is more in length.
203.

For implant retained removable prosthesis at least 12 mm. why?!

204. As It occupy = fixture, abutment (neck = thickness of gingiva) > ball >
housing in fitting surface of denture > acrylic part > teeth.
205.
In case of over-eruption of antagonist and periodontal affected > extraction of
upper and lower implant or restoration by fixed prosthesis.
206. 6) Adjacent teeth: 207.

*For single tooth implant

208.
-at least 7 mm M-D are necessary from CEJ of
mesial tooth to CEJ of distal tooth (1.5 mm of bone M+1.5
mm of bone D+ 4 mm diameter of crest)
209. -At least 6 mm Bucco-lingual (for 1 mm buccally
+1 mm lingually + 4 mm diameter of implant)
210.

*In case of 2 neighboring implant: - (3 mm required)

1.5 mm for each implant to enhance osteointegration

211.

N.B: -

212. A) The implant dimension in question is the size of the

crest module, not the implant body dimension.
213.
For example, a 4.1-mm crest module (on a
3.75-mm implant body) needs 7.1 mm of mesiodistal crestal Bone.
214.
215. B) During implant diameter selection, keep in mind that keeping it away from natural
tooth by 1.5 mm,
216.

1 mm for bone + 0.5 mm for PDL. otherwise:

1. encroachment of periodontal ligament of neighboring teeth no osteointegration.

2. resorption of bone between implant and neighboring tooth > pocket formation >
peri-implantitis > implant failure.

217.
C) number of implant surface area force dissipating
capacity healing of bone and success rate .
218.

219. 7)Diagnostic cast, waxing up for: -

1. surgical template construction

2. to evaluate opposing tooth, inter-arch space and occlusion.
220.
221. 8)tissue health: -

1. Whether gingiva is healthy or ulcerated.

2. Insert implants only in keratinized mucosa it can withstand force and load
222.

but non. k. mucosa(easily ulcerated ) failure of implant as it can't withstand

force gingival recession pocketing and it is.

223. 9)palpation: 224.

palpation of the ridge during examination to feel presence of bony exostosis or

undercut (D.t tooth inclination) as present in lower second molar near lingual pouch, or
labial undercut of upper anterior teeth region.
225. 10) Ridge Mapping (historical)
226.

It is a clinical measurement of soft tissue at several corona-cervical level to assess

bone width.
227.

Steps: -

1. Take alginate impression and pour it with stone.

2. Cut cross section of the cast at edentulous area and measure thickness of cross section
which Is equal to thickness of bone and soft tissue.
3. Anesthetize the edentulous area and insert endodontic file on soft tissue and repeat
measurement at different coronal level starting 2 mm apical to crest and every 3 mm
from buccal and lingual sides.
4. Apply measurements on sectioned stone then join points with line to assess osseous
profile.
228. N.b: - length of the ridge mesiodistal and height from crest of the ridge to lower
border can't be determined by ridge mapping only by radiograph. (& CAD-CAM)

229. C) Radiographic examination: 230.

Types of Imaging Modalities

1. Periapical
radiography
(analog)
2. Panoramic
radiography
(analog)
3. Occlusal
radiography
(analog)

4. Cephalometric
radiography
(analog)
5. Tomographic
radiography
6. Computed
tomography (3-D)
7. Magnetic resonance
imaging (3-D)

8. Interactive
computed
tomography (3-D)
9.

Objectives of Preprosthetic Imaging

1. Identify

5. Determine

disease
2. Determine

implant
position
6. Determine

bone quality
3. Determine

implant

bone quantity
4. Determine

orientation

bone density
1.)

Periapical Radiographic Images Radiographic Images

7. Advantages
1. Low radiation dose (compared to panorama)
2. Minimal magnification with proper alignment and
positioning in relation to panorama.
3. High resolution
4. Inexpensive
8. Limitations
1. Distortion and magnification minimized by
parralling technique .
2. Minimal site evaluation (so used in 1 or 2
implants only-neighboring tooth may ve curved
roots toward set)

3. Difficulty in film placement (e.g. D.t gagging

reflex)
4. Technique sensitive: - Change angulation leads to long or short ridge >>
misleading to bone length.
5. Lack of cross-sectional imaging
9.
10.
Indications
1. Evaluation of small edentulous spaces
2. Alignment and orientation during surgery
3. Recall/maintenance evaluation. panorama
11.
12.2)Digital periapical radiograph: 13. Film(sensor) is connected to direct USB on computer.
14.
16.

Advantages :1.
No processing

15.
24.

17.

2.

Fast

the sensor and the position of the

18.

3.

High resolution.

connecting cord.

19.

4.

Can evaluate density

25.

of bone

disadvantage
the size and thickness of

These features make the

positioning

20.

5.

Film can be stored,

26.

of the sensor more difficult

transported.

in some sites such as those

21.

6.

Used in recall visits.

adjacent to tori or a tapered arch

22.

7.

Low radiation

form in the region of the canines

exposure.

(Table 3-1).28

23. 8.
Excellent quality
27.3)Panoramic Radiographic Images: 28.

the most used diagnostic modality in implant dentistry. However, for

quantitative presurgical implant imaging, panoramic radiography is not the

most diagnostic.
29.

Advantages

1. Easy identification of opposing landmarks

2. Initial assessment of vertical height of bone
3. Convenience, ease, and speed in performance in most dental offices
4. Evaluation of gross anatomy of the jaws and any related pathologic findings
5. Can estimate bone quality (dense or porous) without identification of its level.
6. Locate anatomic limitation " nerve bundles, mental foramen, sinus lining "
30.
31.Disadvantages :- 2D not 3D
1. Its use alone can lead to errors in estimating or determining bone width.
2. Superimposition or overlapping of structures can result in poor image quality.
3. The presence of metallic restorations, metal frameworks, or base metal implants
can cause metallic artifacts and streaking to appear on the image.
4. Non-uniform magnificationinaccurate length )(main problem) (not on
dentition or resorbed alveolar ridge)
32. To simulate the accuracy, make 1:1 dimension or subtract 2 mm
(magnified error)
33.
34.Evaluation of degree of distortion.
35.

a) Radiographic template: -

1. Guiding grooves or holes are placed with flat plane surfaces in potential
implant sites, with radiopaque metallic ball bearings of known diameter
luted over placement sites on the stent.
2. On the panoramic image, the metallic spheres will
appear suspended over potential implant sites.
3. The distortion factor=actual diameter of the sphere /
its diameter on the radiograph
4. The true height of the residual ridge at the site can be
36.

calculated on the radiograph

by measuring the distance from the ridge crest to the inferior border of

the mandible in the symphysis region, or the inferior aspect of the maxillary
sinus in the maxilla) and multiplying this result by the distortion factor.

37.

In brief: true height of the residual ridge = radiographic height /

distortion factor.
5. This information helps in selecting the correct implant length.

38.

When the radiographic TTT planning completed, the ball bearings are removed

and the stent is cut out and grooved for implant surgery.(Surgical template)

39.B) Transparent sheet: There are variant sheets differing in magnification degree (e.
g100:150 /100:125)
they are placed over the panoramic x-ray to help calculate
the area that the implant would occupy in a particular site.
thus choosing the appropriate length & width
40.
41.4) Computed tomography(3-D)
42. Advantages
1. rapidly processed and highly detailed images, e possible reconstruction.
2. No superimposition, distortion or magnifications seen, as other radiographic
procedures (e.g., panoramic radiographs).
3. Automatic calculation of bone height and width and precise estimation of
available bone.
4. Information pertaining to the quality of the cancellous bone and the thickness
of the cortical plates is available (D1 or D2 or D3 or D4.)
5. Various views (sagittal, axial, coronal)
43.Indications:

1.Interactive treatment planning

2.Determination of bone density
3.Vital structure location determination
4.Subperiosteal implant fabrication
5.Determination of pathology
6.Preplanning for bone augmentation
7.Cross reference
44.

45.
46.5)Cone Beam CT (CBCT)
More used e more advantages than C.T.
1. Low radiation dose.
2. resolution , exposure time 36 seconds on contrast of medial C.T 10
min > more safe .
47.

function

1. Provide lateral cephalometric, panorama, cross sections & 3D images so:

o Used in orthodontics, endodontics, implant and plastic surgery.
2. C, T derived template could successfully treat completely edentulous case using
flapless tech
3. Digital subtraction radiography to view bone gain and loss.
4. Interactive software allows to place dental implant virtually & construct precise
guide and final prosthesis for delivery during implant placement.
5. give 3D soft tissue and 3D bony window.
48.Comparison of Medical Spiral Scanners and Cone Beam

49.

1. Scanning time
2. Radiation
exposure

50.

MEDICAL

CT
52.

10 min

54.

4. Exposed field
5. Scatter
6. Positioning

(CBCT)
53.
55.

56.

3. Scan

51. CONE BEAM

Multiple

slices
58.
One arch
at a time
60.
62.

36 sec

57. One rotation

59. Both arches
simultaneously
61.

Very

technique
sensitive
64.

63.

Not as

critical

65.6)Interactive Computed Tomography(ICT)

a) It 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 a personal computer.
b) Regions of the patients anatomy can be selected for display normally, with
magnification, facilitating the appreciation of anatomy, structures, or disease.
c) the dentist and radiologist can perform electronic surgery (ES) (not real) by
selecting and placing arbitrary-sized implants that simulate root form implants in
the images. GRF
.66
67.ES: when theres insufficient available bone such as the maxillary sinus, the amount of
bone need may be determined

1. to develop the patients 3-D treatment plan electronically

in. that is integrated with the patients anatomy and
visualize it before surgery for approval or modification.
2. ICT enables the determination of bone quality adjacent to
the prospective implant sites with the number and size of
implants accurately determined,
3. the dentist can determine the characteristics of the
implants accurately before surgery.
4. Electronic implants can be placed at arbitrary positions and
orientations with respect to each other, the alveolus, critical
structures (the mandibular canal and mental foramen), and the
prospective occlusion and esthetics.
68.
69.
70. CT

N.B: with its 2-D and 3-D reconstruction capabilities,

is currently the most useful radiograph for TTT

planning in implantology, especially with multiple implant sites

71.
72.
73. 3-D bone models: 1. specialized software generate 3-D imaging that can be viewed from any angle and
surface, or sliced panoramic views and vertical cross-sectional images of the jaw,
encompassing the entire arch of the alveolar ridge.
2. then makes life-size (i.e., 1: 1 ratio) 3-D images that show bone width, height, and
depth at the proposed implant site
3. The dimensions of the residual ridges and bone height relative to critical anatomical
structures can be measured directly from the scan.
74.

75.

Surgical template/ Precise

template.

76. Definition: 77.A stent is a clear resin duplicate of the diagnostic wax-up of
the patients denture, which provides information regarding
optimum implant sites and desired angulation of the prosthesis.
78.Fabrication:

1. a prosthesis that is fabricated and duplicated in acrylic

resin to serve as a scanning template.
2. the clinician obtains the panoramic radiograph with a
Radiographic stent in place
3. Axial images from a CT scan are transferred to software
that provides real 3-D information to determine implant
position &size and any anatomical complications.
4. The scanning template is drilled to reflect the planning
and is used as a drilling and placement guide during surgery.
79.
80.Computer milled

1.The Axial images from a CT scan can be transferred to software that provides
real 3-D information to determine implant position, size and any anatomical
complications.
81.
2.Using (CAD)/(CAM) techniques such as stereo lithographic rapid
prototyping, to build surgical guides to aid in the precision of implant
placement.
82.
template impression .83
flap accurate measurements
84.

Avoid

1.manual errors especially in difficult areas

2.guessworkaccurate dimension without injury to vital structure
1.flapless surgery, prosthesis preparation before surgery
2.used for immediate loading,

3.avoidance of critical anatomical structures,

85. Function: -

1. establish the position, angle, and depth of the implant.

2. positioner template reduce errors associated with perforating the mandible.
3. enabled precise placement in otherwise contraindicated anatomical sites, as well
as elimination of manual errors.
86.
87.Recently the use of cone beam tomography is instead of the relatively expensive and high
radiation producing CT Enabling transfer of the preoperative implant axis planned on 3-D imagery
to a surgical template.

4.flapless surgery, prosthesis preparation before surgery

5.used for immediate loading,
6.avoidance of critical anatomical structures,
7.and elimination of errors associated with manual placement of implants.
8.acrylic template that shows the contour of the future prosthesis,
9.angulation of the future implant,
10.soft tissue thickness.

88.

89. Interactive treatment planning: the ability to reconstruct 3-D images allows for interactive placement of
simulated root-form implants in the reformatted images.
it is possible to know exactly, simultaneously in all 3-D, how each
implant affects the patients oral anatomy.
o The clinician is able to prepare and evaluate several treatment plans
before surgery and to select the one best suited for the patient so no
unwelcome surprises are noted at the time of surgery and prosthetic
restoration.
90. Cross-referencing
91.Limitations
92. Cost
93. Technique sensitive
94.Indications
95.an interactive imaging program allows CT images to place dental implants
virtually and construct a precise guide splint and final prosthesis for delivery
during implant placement.
96.The guide splint and final prosthesis were returned to the clinical site for
implant placement, and an implant map was provided for each patient,
indicating diameter and length of implants and abutments.
97.The prosthesis was delivered after flapless surgery.
98.this interactive computer imaging system can allow precise planning for
implant position, and that images can be used successfully for guide splint and
final prosthetic fabrication.
99.
100.Splinting action of multiple implants:

a. surface area

b. surface TTT

c.
d.
e. 8. Bone Quality: f.Its difficult to detect it by normal x-ray
g. Instead, known by
1. Tactile sensation during drilling
2. CBCT (the only provider of
quantative analysis(HFU)
h.
i.
D
e

j.

field

units(H

U)

k.Character of bone

l.

Site

q.

Lower

t
y
m.
D
1
r.
D
2
w.
D
3
ab.
D
4

o.primarily dense cortical bone

p.no spongy bone

n.

anterior. >
difficult .
v.
Anterior

s.
1250

t.Thick cortical bone

u.Thin spongy bone
y.cortical crest is thinner & porous
z.main mass is fine trabecular bone

x.
850
ac.
350

within
ad.almost no crestal cortical bone.
ae.The fine trabecular bone

maxilla. >
aa.

mandible. >
easy
af.

Posterior
maxilla. >

composes almost all of the total

difficult

volume of bone.
aj.

*Socket
after

ag.
D

easy
Posterior

ah.

ai.

extraction
ak. *Immediate
implant can be
used .

al.Treatment plane depend on bone density as: am. D1

an.* heat generation during drilling in deep pocket necrosis & resorption replaced by fibrous
tissue > fibrointegration > surgical failure .
ao.
*low blood supply > retarded healing
ap.
aq.how to avoid: -

1. Incremental drilling(gradual in diameter) (up and down)coolant reaching drill depth &
removing debris
2. Use refrigerated saline.
3. Use of sharp drill.
ar.Under drilling must be avoided as strain in bone from compression lead to
pressure necrosis of bone around implant healing by fibrointegration delayed
failure
as.

Bone density(D4) bone strength(spongy)

bone

1y stability microfracture of

load ( delayed ) failure

D4 best in healing

at.how to avoid: au. the strain(force/ area) to bone by implant :

by priority)

( arranged

1. Surface area ( threads &roughness)

2. Number:
av.Each tooth is replaced by 1 implant
aw.In parafunctional habit1 implant for each buccal ??
3. width(e.g. diameter by 0.5 mm is more efficient than length 0.5 mm)
4. length
5. design (threaded & cylindrical)
6. surface condition

ax. these factors BIC osteointegration

ay.

n.b:

az.d1 difficult surgical preparation

ba.d4 implant loss
bb.
bc.
bd.

How to avoid: -

be. under drilling ( 2 4 ) bone compaction lateral condensation of

bone bone strength

bf.

osteointegration

9. Bone volume classification: - (from A to E)

1. Division A (Abundant Bone) similar to that of day of extraction

2. Division B (Barely Sufficient Bone)

3. Division C (Compromised Bone)
4. Division D (Deficient atrophic Bone)
bg.
bh.
bi.
bj.9. Failure of implant: bk. 2 types
bl.Immediate(surgical)
bm.

Delayed

bn.

bo.Treatment Plans
Bone density/Treatment plan
Stress = Force/Area
bp.Decrease Bone density means increase Implant area
bq. Implant number firstly not diameter.
br. Implant width.
bs. Implant length.
bt. Implant design.
bu. Implant surface condition.
bv.As the bone density decreases, the strength of the bone also decreases. To decrease the incidence of
microfracture of bone, the strain to the bone should be reduced.
bw.implant number firstly not diameter.
Stress may also be reduced by increasing the functional area over which the

force is applied.
Increasing implant number is an excellent way to reduce stress by increasing
functional loading area.
Three implants rather than two may decrease applied implant moments in half
and bone reaction forces by two thirds, depending on implant position and size.
An implant prosthesis with normal patient forces in the bone should have at
least one implant per tooth. In the molar region, two implants for each missing molar

may be appropriate.
bx. Implant width.
by.Why width before length: bz.As mastication force transmitted through implant over first 9 mm, after it stress dissipating to bone
as surface area increase for example (increasing width by .5 mm increase surface area more than
increasing .5mm of implant length)
ca.The width of the implant may decrease stress by increasing the surface area.
cb. This may also reduce the length requirement. For every 0.5 mm increase in width, there is an
increased surface area between 10% and 15% for a cylinder implant, and even
cc.more difference is found with threaded-implant body designs.
cd. Implant length.
ce. Implant design: cf. . Implants designed for D4 bone should have the greatest surface area.
cg. For example, a classic V-thread screw design has 30% more surface area than a cylinder implant.
ch. A thread design with more threads has more surface area than one with fewer threads.

ci.

The deeper the thread depth in the implant body, the more functional surface area for the bone

implant contact.
cj. An implant body designed for the soft bone should have more and deeper threads than an
ck.implant body designed for hard bone.
cl. A D1 implant, may be designed for easy surgical placement, as the strains under load are
minimized, but the surgical failure rates are greater.
cm.Implant surface condition
Coatings or the surface condition on an implant body can increase the boneimplant contact percentage and therefore the functional surface area.
A rougher surface is strongly suggested in soft bone and has resulted in
improved short-term survival rates when compared with machined titanium.
the roughest surfaces are most often used in only softer bone types.
In brief, increasing BIC factors, to increase osteointegration.
cn.N.B: -

o Bone density difficult to be categorized from plain x-ray.

o Bone density known by > tactile sensation during drilling and CBCT.
o Only C.T provides quantative analysis via housefield unit.
co.
cp. Choice of implants: cq.1)Diameter (most important)
1. The wider the implant , the BIC .
2. At least 1 mm of buccal and1 mm lingual bone must remain around implant diameter.
3. Maximum diameter of implant in 8 mm bone width = (8 1 - 1) = 6 mm
4. The ideal implant size in the posterior maxilla depends on four criteria: 1 The implant dimension should correspond to the natural tooth (2 mm below the CEJ).
2 The implant should be at least 1.5 mm from the adjacent teeth.
3 The implant should be at least 3 mm from an adjacent implant.
4 The implant should be at least 4 mm in diameter.
cr.
cs.2)Implant length: 1. Measured from crest of the ridge to vital structure below (ant: nasal cavity, inferior alveolar nerve)
2. If measured on panorama subtract 2 mm from it (magnification error) while on CT, its accurate.
3. Minimum length is 9.5 or 10 mm while the optimum is 12 mm
1. If less than 9 mm ( 7 mm ) stress over it and surface area .
2. If more than 12 mm even e abundant bone:
1. longer implant doesnt provide additional retention of distribution of stress as they found
that force disseminated at the level of 7: 10 mm and not transmitted to the apex.
2. heat generation occur with subsequent failure.
ct.
3. Except D4, more than 12 mm length is required GRF
1. to enhance primary stability
2. cooling is not critical due to presence of soft bone )no heat generation
cu.
4. In D1, it's contraindicated to use long implant as no coolant system can reach to the long depth of
implant.
4. For posterior mandible estimate 2 mm at least from mandibular nerve.
5. In premolar region implant length should be 4 mm away from mental foramen.
cv. Note:
cw.Pterygoid /zygomatic /tuberosity implant >???
cx.Long implants (13:16)

cy.
cz.3)Implant surface area (S.A): 1. Rough surface is recommended S.A enhance BIC .
2. Its Selected acc. to bone quality , the the soft bone , the (S.A) is recommended .
3. Either by: sandblasting, plasma spray or both
da.4)Implant position: 1. It Should Be Centralized in occlusion
2. For posterior teeth, implant long axis should emerge from the center of
occlusal surface
a. to withstand compressive stress
b. if placed buccally > subjected to lateral force.

bridg
e

db.As implant can withstand compressive force not

lateral force.

3.

For anterior teeth, implant in place of cingulum.

dc.
dd.
de.
df.
5
6

Guideline for key implant position: - (very imp)

No cantilevers
No three adjacent pontics

7
8

Canine-molar rule
Arch dynamics

9
101)No cantilevers
1. Def Cantilever is fixed prosthesis at one end only
2. Cause: they are force magnifiers to the implants, abutment screws,

Torque

cement or prosthesis screws, and implant-bone interface.--> torque or

lever action on the mesial surface of terminal implant bone
resorption around implant loss of osteointegration failure .
3. Avoidance:
a. the ideal key implant positions should include the terminal
abutment positions when adjacent teeth are missing.
b. To enforce the rule of no cantilever, the key implant positions when one or two adjacent teeth
are missing indicate one implant per tooth.
4. n.b The only permissible case is to replace an out-of-occlusion lateral incisor (pontic without implant)
(only for esthetics)

11

2.

No three adjacent pontics

1. The abutments face additional force when they must support three
missing teeth, especially in the posterior regions of the mouth all pontic
spans between abutments flex under load.

12
2. So the span of the pontics in the ideal treatment plan should be limited
to 2 teeth (premolars) only
13
3. Molar is considered 2 teeth so should be replaced by 2 pontics
o As a missing tooth span is often related to the missing number
of roots in the mandible and number of buccal roots in the
maxilla. (when terminal abutments are present).
o ex when a 5 & 6 are missing, this span is often treatmentplanned to replace three teeth, rather than two.
14
15
16

173.Canine and First Molar Sites

1. The canine and first molar sites are key positions (must be replaced by implant), especially when
adjacent teeth are missing.
18Thin cortical bone so the canine is supported by canine eminence to withstand masticatory forces.
S.A no destruction
2. So, after placement of terminal abutment, canine and each molar must be replaced by implant

194) Arch dynamics

20An arch may be divided into fi ve segments, similar
to an open pentagon:
211)The two central and two lateral incisors
222 + 3) the canines are independent segments,
234 +5) the premolars and molars on each side form a
segment.
24a key implant position needs to be situated within
each segment.
25e.g.: if the patient is edentulous from 4 to 4, the key
implant positions include

a. the terminal abutments (the two 4),

b. the two canines,
c. either of the central incisor positions
26
27
28These implant positions follow the rules

1. no cantilever,
2. no three adjacent pontics,
3. the canine position,

4. at least one implant in each edentulous

segment of an arch.

5.
6.the maxilla is flexed while the mandible is moving so the mandibular implant supported
bridge moves(every 6 months ) D.t flexure (elevator & depressor MS) so full arch single
bridge is contraindicated 3 or 2 parts ??????
7. n.b:
8.daily normal occlusal contact (during speech, deglutition, mastication <etc.) is 30 min e bite
force=200 newton only while parafunctional habits reaches 8:9 hours e bite force=1000
newton only
9.5) IMPLANT NUMBER: -

10.One of the most efficient methods to S.A& stress is to the implant number.
11. For example, only two implant key positions as terminal abutments for a four-unit
implant prosthesis in the canine and posterior region represent inadequate implant
support, unless
1. patient force factors are low
2. bone density is ideal,
3. implant size is not compromised.
12. In most situations, three implants to replace four missing teeth is an ideal implant
number.
13.When force factors are and bone density is (i.e., posterior maxilla), four
implants to replace four teeth is often appropriate
14.Fully edentulous maxilla: -

1. At least 7 implant,
2. if patient has D4 bone > increase number of implant to counteract deficiency in the bone,
3. if patient has limited thickness of bone & has parafunctional habit > each tooth must be replaced by
implant.
4. If patient need 14 unites: 2 2nd molar right and left . (terminal implant) = (principal implant)
2 1st molar right and left .( key positions)
2 canine right and left .(key positions)
1 central right or left
15.If patient need 12 exclude the 2nd molars.

16.

Ttt plane: -

It need a teamwork of
1. Oral surgeon
2. Restorative (for the crowns)
3. Radiologist (for diagnosis)
4. Periodontists (for continuing maintenance /uses plastic It curates to avoid scratching of implants
5. Prosthodontics

17.For partially edentulous patient.

1. Fixed prosthesis(cementable) (either implant supported or implant tooth supported)

2. Fixed detachable > screw retained abutment
3. Removable > overdenture (ball &socket, magnetic, locator)

18.It may be either

1. Splinted implant(splint implant e bar) > total stress results.

2. Or Separate implant
19.

20.

Timing & TTT sequence: -

21.Q) Optimum time for tooth rehabilitation (dental implant)?!

22.Q) In another way, when bone is observed after extraction in radiograph?!
23.After extractionwoven bone is formed (not appear on x-ray) > maturation and
calcification after 6 : 9 months .
24.So after 6 : 9 months bone formation occurred Delayed implant . is inserted
25.
Notes: Immediate implant: - inserted at the time of extraction.
Early implant: - inserted after 4: 6 weeks of extraction.
Delayed implant: - after 6 months.
26.
1. Fixture
a. 3: 6 months after extraction.
b. But 4:6 months after bone graft.
c. after sinus floor elevation
i. with immediate implant insertion 3: 4 months,
ii. if require bone graft >> insertion of implant >> after 9 months.
2. Abutment insertion
a. after 3: 4 months for osteointegration
27.
3. healing abutment.
a. 2: 3 weeks
28.Theres deference bt loading & insertion
29.Time of loading means the patient can perform mastication on it.
30.So theres immediate insertion &immediate loading
31.Early loading & early insertion
32.

33.
34.

35.
36.
37.Surgical technique : -

1.
2.
3.
4.
5.
6.
7.
8.
9.

Clinical diagnosis by palpation

Design and length selection
Proper aseptic technique.
Routine anesthetic infiltration (even e lower 6)
Incision design
a. Crestal exposure only
b. No bone border exposed except if theres exostosis or undercut
Alveoplasty (smoothening and recontouring of alveolar ridge result from extraction)
Implant handpiece
a. Speed > range from 800 2000 rpm
b. High torque
Irrigation
38.There are 2 types: External or Internal= bur cooled from inside (not used nowadays d.t infection)
Pilot hole preparation then gradual
a. to reach the adequate diameter to prevent heat generation and provide reorientation. ( drilling
sequence and incremental in an and motion )
39.1 then 1.5 then 2 then 2.5 etc

40.
10. Last drilling is the most important one (critical)
11. Post-operative instruction
a. Like after extraction (firm biting on gauze pad 30: 60 min, no hot foods, antibiotics, etc.)
12. Remove stitch after 7 days
13. 2nd surgery: 41.
crestal incision (exposure of implant) after 3: 4 months > then heal abutment
for 2: 3 weeks then final abutment insertion.
14. Impression of the abutment: either
I.
Direct
II.
Indirect (not used anymore)color and analog: outside mouth articulator prepared abutments