DR.

Ahmed Halim Ayoub

Tips and tricks in dental

implants
Course revision
By
Dr. Ahmed Halim Ayoub

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Introduction to dental implants:

! Osseointegration: direct structural and functional contact between
implant surface and bone.
! Requirements of osseointegration:
(a) Material: titanium: titanium oxides in implant surface: osteo
conductivity( similar to hydroxyapatite) also zircon can be used but
titanium has superior mechanical properties.
(b) Minimal trauma.
(c) No space between implant and bone.
(d) Implants and tools must be sterile.
(e) Period of undisturbed healing.
! Surface treatment (increase surface area for better bone contact).
(a) HA coat.
(b) Titanium plasma sprayed associated with bone reposition and failure.
(c) Acid etch.
(d) SLA : combination between acid etching and sand blasting.
(e) Sand blasting.
Note: roughness increase not only the surface area but also the
osteoblastic activity.
! Main components:
Implant abutment crown
● Implant abutment interface screw loosening.
● External hex / external connection.
● Flat interface between implant and abutment.
Gap formation bacterial colonization crestal bone resorption.
● Internal connection.
● Platform switch. ADV: Reduce crestal bone resorption as much as I can./
formation of thick colar bone of keratinized mucosa under the abutment to avoid
entry of bacteria./ soft tissue hemi-desmosomal connection.

! Platform switching and marginal bone level alterations: the result of

randomized controlled trail. Amount of bone resorption. Platform switch.
! Evolution of marginal bone loss of dental implants with internal or external
connections and it`s association with other variables.
A systemic review:
Osteointgrated dental implants with internal connections exhibited lower
marginal bone loss than implants with external connections. This inding is
mainly the result of the platform switching concept, which is more
frequently found in implants with internal connections.

Abutments: straight / Angled ( up tp 25 degrees, more than this will produce

high forces and lead to failure ).
! Advantges of dental implants:
1) Preservation of tooth structure.
Implant single crowns had the lowest failure rate at 27%.

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The long-term survival of ixed bridge has been reported to be 87%

at 10 years and 69% at 15 years.
2) Preservation if bone.

There is a close relationship between the tooth and the alveolar process throughout life.

Bone requires stimulation to maintain it's form and density, when tooth is lost the
stimulation of the residual bone causes a decrease in trabeculae and bone density in the
areas with loss in height and width of bone. Greater loss was diminished in the maxilla than
in the mandible.

3) Prevision of additional support (lip support for example with

implant retained over-dentures).
4) Resistance to disease: implants have added advantage in that they
are not susceptible to dental caries and can preserve adjacent teeth.

! Disadvantages:
1) Surgery.
2) Prolonged healing period.
3) Expensive.

! Uses:
1) Replacing missing teeth.
2) Ears and eyes.
3) Attach bone anchoring hearing aids.
4) Joint replacement.
5) Orthodontics.

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Patient selection
Patient selection plays a very important role in success rate.

Medical examination

Light smoker < 10 cigarettes per day deal with him as a non-smoker.

Heavy smoker >10 cigarettes per day (only until 1.5 pack) if more than 2 packs don`t
do implants due to liability of periodontal disease.

● Physician consultation.
● Heavy smoking hinders implant success rate.
● Decrease calcium deposition in bone
● Healing takes more time
● Higher liability of periodontal diseases.
● Slower wound healing.
● Decrease incidence of peri-implantitis.
● In lammation in gingiva
● Patient should cease smoking at least I week prior and weeks after the implant
surgery.
● Radiation therapy: Wait for 6 months after therapy - Risk of osteonecrosis.
● Bisphosphonate stop bone formation.
● Impaired bone and soft tissue healing.
● Reduction in implant success.
● Refer to physician for consultation.

● Chemotherapy:
1. Refer to physician for consultation.
2. No adverse effects were reported with endo-osseus implants.

● Osteoporosis: Primary stability issues.

● In maxilla needs more implants but no problems in the mandible as it affects
maxilla especially posterior maxilla.
● More time for bone healing.
● Use all your skills to get good primary stability.
● Psychological problem: Annoying patient's attitude. (The dentist should meet the
mind before the mouth of the patient).
● Bleeding disorder: Refer to physician.
● Diabetes: Avoid uncontrolled and nearly controlled diabetic patient due to risk for
post-operative infections, healing problems, in lammatory gingival changes, peri-
implantitis, in lammation and increased alveolar ridge bone loss.
●
● Accumulative blood sugar level test.

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● Controlled HbA1C if <7 proceed but consider the possibility for low success
rate.
● If >7 don't proceed.

● Any bone pathology

● Long term Corticosteroids: Strong anti in lammatory
● In lammation is the start of healing which is suppressed by this drug.
● Age of the patient: < 15 in females and <18 in males contraindicated because of
growth.

● NO absolute contra-indication but a risky condition.

● May cause delayed healing, reduce bone quality and increase bone loss.

● Laboratory evaluation:

● Complete blood count.

● Fasting blood sugar: recently HbA1c

● T3 and free T4: Anesthesia”

● Serum Ca.

● Serum vitamin D ( essential for calcium deposition).

● If <10 refer to physician for consultation.

● Cholesterol level free radicals affects osseointegration.

Age of the patient:

● Osseointegration has no age limits.

● Problems with young age before age of 15 in females and 18 in males.
● Implants are ankylosed.
● Submerging of implants in jaw.
● Relocation of implant site.
● Interference with normal growth of the jaws.

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Clinical examination

● Mucosal lesions and characters:

o Edentulous gingival tissue should be free of in lammations and lesions.
o Unfavorable frenum and muscle attachment.
o Keretenized tissue.

● Inter-arch space.
o There should be 7-12mm of vertical space for ixed complete dentures or over
dentures.(minimum of 5mm for retention of abutment and 2 mm for
restoration).

● Mesic-distal dimensions:
o At least 6-7mm of mesiodistal space should be available between adjacent teeth
for surgical access in placing an implant.
o Smallest implant is 3mm +1.5 mm distal = 6mm minimum.
o Buccal 2mm, palatal 1-2mm.
o In anterior spaces mesially and distally should be minimally 2mm to preserve
bone and papilla.
o What if you didn't preserve the bone?
o Pressure on bone that lead to bone resorption.
o Pressure on the pulp that may need RCT.
o Implant will not be placed in center of occlusion or central fossa and that may
cause a lot of problems in the prosthetic phase.

o Special considerations:
1. Missing maxillary central and lateral a space of 12 mm.
2mm 3mm 2mm 7mm
2 implants 4mm (minimally 3-5mm) 8mm.
2. Implants on the central and cantilever for lateral + rest on the canine.

● Oral hygiene maintenance: patient should poses both the dexterity and the desire to
maintain oral hygiene.
● Mucosal type: Thick or thin.
● Inter-arch space: minimum 7mm clear between gingiva and opposing.
● Abutment length 5mm, 1mm for metal and 1mm for porcelain.
● Minimum buccolingual width 5mm.
● Upper anterior 2mm labially is a must.
● Smile line: Papilla restoration is of great concern in anterior zone.
It's important to determine how much of the teeth and soft tissue is visible during
maximum smile.
● Parafunctional habits require increase in the number of implants.
● Teeth mobility: mobility of adjacent teeth should be assessed labially using a mirror
and a periodontal probe.
● Periodontal pockets: Jeopardise success of adjacent implants.

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" Never do implant beside a periodontally compromised tooth to avoid

migration of bacteria from pocket to implant which may cause infection and
lead to failure.
" All patients who are compromised periodontally should be assessed and
should reserve periodontal therapy before implant treatment is started.

● Intra and extra oral photographs (medico-legal).

● Tooth wear: the three components of teeth wear ( attrition- abrasion- erosion).are
used to provide an indication of the degree of parafunctional as well as the typical
occlusal loads that the patient would have expected ( always increase number and
width of implants/night guards are important).

Non initiated tip with saline can provide good sterilization of bone before implant
placement.

Radiographic examination

● Anatomical landmarks
● Bone density

Panorama: Not the best.

CBCT: 3D image although it's not always real.

● Sometimes you ind no bone in X-ray although clinically there is bone

Diagnostic cast

To check:

" Inter-arch space.

" Arch relationship.
" Diagnostic wax-up replacing missing teeth to evaluate occlusal table.
" Making a stent.

● Waxing up

Any discussion with the patient before placing the implant is considered a treatment
plan.

Any discussion with the patient after placing the implant is considered an excuse.

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TREATMENT PLANING
a) Prosthodontics option
1. Single implant
2. Fixed bridge (implant ixed restoration)
3. Over-denture

b) Temporary planning
a) Complete denture: Relief and relining by tissue conditioner
b) Removable partial denture
c) Resin bonded bridge (Maryland)
d) Transitional implant one-piece temporary narrow implant placed
between permanent implants for a ixed restoration then we remove
it after 2 months. -makes patient satis ied-

c) Dimensional implant placement

1. Implant width: determined by:

-mesiodistal width measured intraoral using graduated probe or

Endodontic ile or Extra-oral with CBCT.

- Buccolingual width composed of (B.one + soft tissue) measured

using Bone caliber or CBCT

● Suitable diameter for different teeth:

● Upper Anterior 3.5 – 4 mm
● Lower Anterior 3 – 3.5 mm
● Upper Premolar 4 – 4.5 mm
● Lower Premolar 3.5 mm
● Upper Molar 4.5mm – in inity
● Lower molar 4.5 mm – in inity

D) Implant position

Note: implant position should be at center of occlusion of the future restoration.

1. Impression – Cast – waxing up – (night gaur/bleaching tray) – drilling the holes –

surgical guide / stent (70 LE cost)
● This helps you determine the correct location NOT
Angulation

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2. CAD/ CAM surgical guide (3D scanning + CBCT) – 1000 LE with one Hole, extra hole
200 LE
● help you determine Location AND Angulation (very
accurate)
● Place the drill through the sleeve

E) Implant position

● Distance from crest of the ridge to the nearest anatomical landmark

F) Implant Number

● For posterior teeth – each tooth replaced by 1 implant

● For Anterior teeth - may reduce the number of implants
● Full maxillary ixed bridge 7 - 8 implants
● Full mandibular ixed bridge 6 -7 implants
● Maxillary over denture 4 implants
● Mandibular overdenture 2 implants
● Opposing occlusion by natural dentition
● Parafunctional habits

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Basic Surgical protocol

a) Clinical consideration
● Dense bone ( type 1&2 ) – mostly in Mandible Anterior and posterior ,
Requires careful attention to drilling with adequate irrigation in order
not to overheat the bone.
● Weak blood supply (little bleeding) associated with decreased healing.
● Care should be taken to debride the osteotomy site from bone debris and
to widen the site to the manufacturer’s recommended diameter prior to
tapping the site
● Placing implant into too tight site can lead to failure due to pressure
necrosis
● Irrigation with a cooled saline
● Change the drill when they become blunt depend on manufacturer
recommendation
● Countersink – pro ile drill – bone tap – multi pro ile
● Intermittent pressure

● Soft bone (type 3 &4) – main problem is primary stability

● Requires a modi ication of the drilling protocol
● Care must be taken to under prepare the osteotomy site
● Over preparation or inadvertent implant angulation changes can
preclude placement of the implant
● Using osteotome technique can also help initial stabilization by
compressing the site with drilling
● Tapered implant has an advantage in softer bone due to wedging effect at
the time of placement

b) Anatomical consideration
● Mandible
● Inferior dental canal 2mm away - ID canal sometimes has
anterior extension, but this is very rare, and it can be
revealed by CBCT.
● Mental foramen 3 mm away
(A) Submandibular fossa - between the 2nd and 3rd molar there is an undercut in the ridge
which if found in 10% only of the population and can correspond to the following problems:
-No osteointegration.
-Terminal branch of the facial artery might get injured.
● (B) Terminal branch of facial artery { A&B } dangerous
zone
Palpated lingually or seen in CBCT
● Direct the implant labially away from this anatomical
landmark
● Direct the implant labially away from this anatomical land mark

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● Maxilla
-Maxillary sinus - sinus has air under pressure, so after extraction sinus
pneumatization takes place where resorption takes place from sinus towards the
oral cavity.
-The sinus is usually surrounded by cortical bone, so when we drill near by the
sinus and we encounter hard cortical bone this is our outmost level of drilling to avoid sinus
perforation.
-Treatment options:
1-Rely on short length and large diameter implant 6/7mm.
2-Change implant position.
3-Sinus lifting.
● Incisive canal at midline – Nasal loor has very thick
cortical lining and is open (NO pneumatization)
NO implant should be placed at the midline mostly. 18-20
mm from crest of the ridge
● Bone Quality
- In upper anterior (severe horizontal bone resorption
following extraction) – very hard and complex cases
Note: sometimes in rare cases IAN continuous anteriorly with the branch even after it loops
back to enter the mental foramen , so closely and carefully on the x-ray measure it during
placing an implant in premolar or anterior region

c) Implant position

1. Anterior maxilla and mandible

-Slightly palatal to arti icial teeth (cingulum of adjacent teeth)
- corresponding to missing teeth
- Multiple implants should be parallel
2. Posterior maxilla and mandible
-same direction as occlusal force
- in center of occlusal surface (central fossa)
- on tripod design (offset con iguration)- biomechanics and force
distribution

d) Implant surgery
1. Preoperative patient preparation:

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Medical history- vital signs (pulse / heart rate / temperature /

respiration)
2. Instrumentation
Prepare all instrument required for the surgery
3. Anesthesia and Analysis
Nerve block – in iltration – general in iltration
4. Mucoperiosteal lap
-in edentulous patient incision done palatal to keep large part ot
tissue un traumatized and the sutured part be behind the implant (to
prevent infection)
- lap should be distally placed for a good visibility
- concave part of the periosteal elevator towards the bone
- movement is (pushing –rotate – lift bone off –remove)

5. Sequential drilling
1. Pilot drill / round bur
2. Paralleling pin
3. With increasing drill (color coded)
- incrementally widen the osteotomy without creating excess
heat
- used to widen the diameter of the osteotomy after the depth has
been established with a starter drill
- we use progressive widen drills stopping at one with a diameter
less than implant
- verifying depth after each drill
4. Implant insertion (open it near to the patient mouth/ don touch
cheeks)
-We use the mount to insert the implant and never touch it with
ingers or gloves
- we may need to use the ratchet or wrench then screw driver
insertion

Golden role: Place the implant parallel and 1mm palatal or lingual to the natural tooth
position to facilitate correction in prothesis.

Rules of the lap:

● Base wider than the margins to maintain adequate blood supply.

● Distal extension.
● Implant should be away from incision line.
● Direction of drilling is very critical.
● While drilling for posterior teeth make sure you are centered over the central fossa.
● Tripod (3points): 2 on a line and 1 on another line. *
● Drilling

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● Cortical drill: usually pointed and may be rounded / speed 1200 - 1500 RPM and
has to be associated with cooling. It cuts in the cortical bone and provides the sense
of drop from enamel to dentine.
● Cortical drill can be used without cooling in case the speed is 100 RPM.
● Pilot drill: It establishes initial length (full depth).
● Intermittent pressure is used to enable the irrigant to go inside the osteotomy site
while cutting.
● Don't rest while drilling to avoid change in direction of drill (cutting in an arc ) and
make sure movement is shoulder and not wrist.
● Parallel pin usually inserted in osteotomy site to check parallelism if not available
use a drill instead.
● Direction change in hard bone is extremely dif icult while easy in soft in soft bone
and usually can be done following pilot drill where the drilled whole is still small.
● Stopper is added to rest on bone at the desired length thus facilitating drilling.
● We increase the size of osteotomy site by width increasing drills to avoid heat
generation (speed 600 - 700 RPM ), but they never give depth it is only estimated by
the pilot driller.
● Sometimes we encounter soft bone in the mandible.
● The higher the pressure and torque the more will be the postoperative pain and failure
rate as well.
● 3/4 the implant should be screwed manually, and the rest of the implant aided by the
ratchet / torque wrench.
● Bone tap / countersink ( inal drill for hard bone ): It facilitate implant screwing with
less pressure on the bone through troughing in the osteotomy site with its sharp
threads.
● Self taping implants: Create its own way through the bone.
● Acceptable torque range 30-50 N.

How to determine bone density?

● Location: Upper/ Lower - Anterior/Posterior.

● X-ray: Radiolucent / radiopaque.
● Never touch implant by your hand.
● Screwing the implant without proceeding apically will widen the osteotomy site, so stop
screwing, remove the implant and continue drilling.
● After screwing the implant the implant holder/mount is removed.
● Before placing the cover screw it's preferred to add 2 drops of chlorohexidine gel inside
the implant to kill bacteria, but it is believed that this is a theoretical action that won't
matter if not taken.
● Two stage surgery implant is also called submerged/bone level implant.
● Non submerged implant where the healing abutment/gingival former is placed.
● No mucosal seal against bacteria or for graft protection.
● Patient's tongue may jeopardize implant stability.

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● Silk suture is usually removed after a maximum of 10 days as it provides a very good
medium for bacteria to grow on. On the other hand mono ilament suture does not let
bacteria accumulate on besides being a resorbable suture.
● Postoperative instructions are the same as in any surgery.

Bone expansion:
Primary stability in soft bone.
No. of cells, hardness of bone.
1. Osteotomes: pushing the bone trabeculae into spaces.

First two: pointed (cut apically).

The rest: blunt ( expansion, modules of elasticity of the bone, primary stability of the implant).
● Disadvantages:
Chipping of the bone.
Formation of simple slightly conical cavities in the jaws which doesn't provide a reliable bed
for the ixation results in dif iculty in the osseo-integration.
Complete deterioration of the dental base can occur, which requires extensive repair.
The appearance of a hammed and the shock of the hammer in the metal resulting in fear of
the patients and vertigo.

● Advantages:
No heat generation.

2. Bone expanders (non-traumatic expanders).

Threads: screwing instead of tapping.

Sequentially used in a rotation motion (not tapping).
Same theory as the bone method pushing into the intertrabecular spaces increases modulus of
elasticity, create space for the implant, better primary stability.
● The theory:

3D lateral condensation of bone trabeculae creating a dense wall of bone around the implant thus
improving the primary stability and osteointegration.
● Note: irst you have to remove the irst layer (cortical plate) with the pilot drill then use the
expanders (work only in the trabeculae bone).
● Note: expanders have laser marks to determine length during use.
● Note: they can be used by hand or wrench, but better with hand for better tactile sensation.
Color coded corresponding to the color of the implant diameters.
● Note: some surgical kits contain both the drills and the expanders with a corresponding
color coding as the implant.
● Combination method in D3 bone and not D4 bone done all by expanders.
● Start by drilling sequential until two drills before the implant size.
● The last two diameter to prepare the remaining diameter until the corresponding implant
diameter (better primary stability, less heat generation).
● Combination between drilling and expansion.
● Less crestal bone resorption.
● D3 bone: combination method.
● D4 bone: A-Z expansion.

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● First you have to do ridge mapping with the bone caliper or using the cone beam CT, the
minimum width for expansion 4mm less than 4mm bone splitting.
● Be aware of the yellow color codes.
● Always make sure that implant is moving apically when it`s below the gum level.

To make sure the implant is moved apically:

1) Apical pressure.
2) The 2 yellow color codes.

● Expansion soft bone (mainly in maxilla or recent expansion socket in the

mandible).
● No heat generation, no bone cutting, better primary stability.
● Expanders increase bone width by about 2-3mm expanders only from
4-6mm.
● Drill expanders: for short drills.
● Sockets: wear woven bone.
● Contraindicated for lapless bone undercuts.
● Strengthen the weakened wall of the implant.
● Remove the depression of dehiscence drilling.
● Preserve bone.
● Don't use expanders without double cooling.
● Expanders are blunt: expand don't cut.
● No heat generation, no need for cooling.

3- Densah drills “osseodensi ication drills”

-densifying crest in osseodensi ication mode for compaction autografting.
-clockwise cw is the cutting direction and counterclockwise is the non-cutting direction for bone
expansion.
-motorized bone expanders 1300-1500 rpm -> more possibility for heat generation and cracks
Ridge wider neobiotech anther motorized expander.
Motorized less control than hand in lapless surgery.
Probing mesially, distally, buccally, lingually to make sure the implant is 2 mm below the crest of the
ridge.
Speed reduction contra-angle 1/20
20.000 RPM from motor

● 1981 - Invention of osteotome.

● The irst 2 are pointed to expand apically, then expand laterally.
● Advantages:
● Condensation of bone.
● Improve bone quality around the implant.
● Exerts compression on the implant, so improve the primary stability.
● No bone removal.
● No heat generation.
● In 1994 its success rate was 98.8%.
● Drawbacks:
● Fracture of bony part.
● Complete deterioration of the alveolar ridge.
● Severe headache.
● Usually performed under general anesthesia.

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● 1996 - Garcia in cooperation with microdent launched the so called "Non traumatic
expander kit".
● Its threads are rounded not sharp to avoid bone cutting.
● It works in alveolar bone not cortical.
● Expander kit is universal.

Steps of expansion:

● Cortical drill.
● Expanders are color coded as endodontic iles ( yellow, red, blue, green &
black ).
● each expander is left about 10 seconds in situ for bone remodeling.
● Widen with expanders till osteotomy suits the desirable implant diameter.
● No need for lap, just a crestal incision.
● Eddy Paltie - Lateral condensation --> Improve bone density --> Better primary stability.
● In case of emergency situation where the adjacent teeth are rotated providing no space
for proper implant positioning and no time for orthodontic alignment the best option is
tapered implant.

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Flapless Surgery
● When the tooth is in its place it receives blood supply from:
1. Periodontal ligament
2. Periosteum
3. Few blood capillaries inside the bone
● After extraction PDL disappears and periosteum becomes the main blood supply
source:
● Arterial: 80%
● Venous: 100%

Thus, it's preferable not to raise a lap as the periosteum takes about 3 weeks for
revascularity to take place - a period during which bone resorption can occur.

● Majority of the post-operative complications including pain, edema, .. etc. is the

consequence of raising lap.
● We cannot open lingual lap.

Advantages of lap-less surgery:

● Less operative time

● faster healing
● Less post-operative complications
● Less resorption
● No scar tissue formation

Disadvantages of lap-less surgery:

Blind surgery
●
Bone map (CBCT - Caliber ) is a must.
●
● V-shaped bone in the x-ray demonstrates horizontal resorption.
● Bone caliber measurements are done in 3 points:
● 1st point at the crest to determine the implant diameter.
● 2nd and 3rd points to avoid any bony defects.
● N.B. If the bone is pyramidal, it is a straightforward case.
● Don't do immediate loading without taking whole cost.

Disadvantage of one-piece implant:

● No angled abutments for correction of parallelism problems.

● Epithelial tissue inclusion is of no concern in lap-less surgery.

● Tissue punch has to be always sharp to avoid tissue laceration and corresponding pain.

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How to detect level of implant in relation to the bone?

● Periapical x-ray
● Using a probe move from bone surface to implant if it hits the implant then the
implant needs to move further apically - if the probe drops then the implant is
below bone level.
● Bone sounding - to check if there is and defect/ perforation after drilling.

Conclusion: Flapless surgery is a predictable surgery when patient selection and surgical
techniques are well chosen.

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Immediate placement
● Healing after extraction (bone formation at the base of the socket and bone resorption
at the crest), thus implant can stop bone resorption.
● 60% of the bone resorb in the irst 3 years following extraction.
● Success rate of immediate placement = delayed placement.
● No need for surgical stent as implants are placed in the same position as the natural
teeth.

● Immediate Implant placement offers success rates that are strongly evidenced in the
Literature; results are equal to that of the delayed implant placement modes

Since the extraction socket is totally visible the surgeon can better determine the
appropriate alignment and Parallelism relative to the adjacent and opposing
residual dentition

The result is better implant position, which in turn ensures better inal function and
esthetics.

The ELIAN Classi ication of Extraction Sockets:

Type I Socket. The facial soft tissue and buccal plate of bone are at normal levels in
relation to the cementoenamel junction of the pre-extracted tooth and remain intact
post extraction. Favorable for an immediate implant.

• Type II Socket. Facial soft tissue is present but the buccal plate is partially missing
following extraction of the tooth. (Resorption of buccal bone less than 4mm # Palatal
positioning of the implants + bone grafting as long as there is enough thickness of
soft tissue).

• Type III Socket. The facial soft tissue and the buccal plate of bone are both
markedly reduced after tooth extraction. (Extract $ Soft tissue closure of socket $
Grafting $then implant placement).

Type I % Always Immediate Placement.

Type II % Immediate in most cases and might need grafting simultaneously.
Type III % Extract and wait for soft tissue healing the grafting then delayed implant
placement after bone formation.

● TYPE II and III would need augmentation procedures.

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Other classi ication is Sagittal root position (SRP) classi ication.

Class I: the root is positioned against the labial cortical plate.

Class II: the root is centered in the middle of the alveolar housing without engaging
either labial or palatal cortical plates at the apical one-third of the root.
Class III: the root is positioned against the palatal cortical plate.
Class IV: at least two-thirds of the root is engaging both labial and palatal cortical
plates.

How to avoid future bone resorption?

● Stop squeezing the socket as it destroys the ridge if further implant placement is
needed.
● Socket preservation (Place bone graft in socket after extraction, this will correspond
to further bone formation ).

Reasons beyond fast anterior zone bone resorption?

● Buccal bone of upper anterior is very thin and it is called bundle bone.
● It receives its blood supply from the periodontium which resorb after extraction
leaving no blood supply, Thus graft in this zone is of prime importance to initiate
bone formation.

Types of graft:

● Autogenous: From same patient.

● Allograft: From different human source/ Human tissue bank.
● Xenograft: As bovine bone.
● Alloplastic: Synthetic, it's not preferred around the implant because
● It's very hard and may break around the implant affecting its stability as well.
● Needs long wait time to form bone which is about a year.
● Does not provide strong bone structure.

● Before extraction decide whether the tooth of concern is a strategic one or not and if so
immediate replacement is very important.
● For bone graft to form bone it must be surrounded by bony walls.
● Big defects are better left for bone to form after extraction + delayed implant placement.
● Primary stability is usually achieved through drilling into more depth than the
corresponding tooth length.

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How to remove fractured root tip?

1. Periotome
2. Piezosurgery tip
3. Luxator ( Between periotome and elevator )
● All of which aim to destroy the pdl without expanding the buccal plate of bone.

Contraindications of immediate placement:

● If there is acute infection, extract, clean the ield, prescribe an antibiotic and never
put implant.
● If there is no buccal plate of bone --> no immediate placement --> Socket
preservation.
● Low sinus level.

Advantages

1. Less operative time.

2. Bone preservation.
3. Faster healing.
4. Proper positioning.
5. Better acceptance by the patient.
6. Better osteointegration.

N.B. You cannot stop bone resorption, you can only reduce it.

Disadvantages

1. Decreased primary stability.

2. High skill needed.

Steps of immediate placement:

1. Chlorohexidine and antibiotic prescription.

2. Atraumatic extraction.
3. Never touch buccal plate of bone.
4. curettage with sharp curette to remove granulation tissue and pdl ibers making
sure that implant will be in direct contact with bone not pdl.
● If the gap is > 2mm : put graft.
● If the gap is < 2mm : leave it with no need for graft.
● In case of upper or lower 6: we can put implant in the interradicular bone only if thick.
● Instead of putting graft around the implant in the socket of molars, we can squeeze the
bone around the implant.
● The upper premolar usually has oval socket, thus graft is usually placed buccal and
palatal to the implant.
● In this condition, implant is placed 2-3 mm below ridge crest on the level of future bone.

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The buccal bone thickness can give an indication of future resorption

● If thick --> less resorption.

● If thin --> more resorption.

After 6 months from extraction

● Horizontal resorption: 3.8 mm.

● Vertical resorption: 1.25 mm.

Titanium mesh (solid membrane)

● Is added particularly in the anterior zone to counteract strong muscular action to make
sure the graft is stable. Usually place in large defects and ixed by screws.
● Bleeding bone is a vital bone formed within this mesh.

Conclusion

● Immediate placement has survival rate.

● Gaps may heal alone.
● Chronic infection is not an absolute contraindication.

Immediate Loading

-Immediate loading with the permanent restoration (PFM or Zirconia) in functional

occlusion at the same day of implant placement.

-Progressive loading is similar to immediate loading but describes the placement of a

provisional restoration.

• The prosthesis for progressive loading is made of a resilient material (Acrylic or

PMMA) that is fabricated out of occlusion and splinted to the neighboring teeth
with composite to distribute the forces.

• Progressive loading provides instant functioning as well as esthetically pleasing

result.

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• It is theorized that placing load on the bone surrounding the implant progressively
provides a better guarantee of implant survival; however, at the present time, little
evidence support this concept.

! Which is better progressive or immediate loading?

& Immediate is better in cases of full arch large cases because of:

Splinting of implants together (with a PFM bridge for example) helps

to distribute the forces.

& In progressive loading:

The material used (Acrylic or PMMA) doesn’t provide the needed amount of
splinting and still permit some of the implants to be under excessive forces.

Out of occlusion -> less forces.

Splinted with composite -> more distribution.

& So, both Immediate and Progressive loading are good for healing.

' Still, progressive loading has the following two advantages:

1. The weight of the metal in the inal PFM adds extra forces on
the implants.

2. In case of failures the expenses of the provisional are a lot

less.

& Either immediate or progressive loading both require extensive preparations

and precautions.

! A study compared the success of immediate and delayed loading by comparing the
histology of both with regards to osseointegration.

' When speaking about osseointegration we have to consider two

factors:

1. Bone Implant Contact %

2. Bone Density around the implant.

( Bone-Implant Contact %

Results after 3 years:

Immediate/Progressive loading < Delayed Loading ( the amount of bone

increases with time leading to more bone formation around the implant)

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( Bone Density:

Immediate/Progressive loading > Delayed loading

Alveolar bone is a functional bone -> amount of bone formation

increases under forces of mastication.

So, Immediate/Progressive loading is a predictable procedure.

STILL,

The prognosis of immediately loaded implants placed in,

1. Poor quality bone especially maxilla

2. Areas with simultaneous augmentations (regenerated bone) Has

not been well documented. ~Chipasco 2004

! For achieving perfect immediate loading:

-patient related factors:

1. Patient Selection.

a) the patient should be medically free (DM, Osteoporosis)

b) No bruxism.

c) good inter-arch stability

d) inancial considerations

2. Bone Quality and Quantity.

a) Use Compressive Implants/One-Piece Implants in the maxilla or

extraction sockets. The aggressive threads will help achieve good
primary stability.

b) Use expansion in soft bone to achieve good primary stability.

3. Implant Surface Area.

a) The more the length and diameter increase the better the primary
stability and the more successful the immediate loading. (use wider
implants >3.5mm).

4. Implant Selection.

b) Rough Surface-> better osseointegration.

c) *Wider threads-> better osseointegration.

5. Implant Placement.

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a) Cooling->cold saline double cooling.

b) Respect soft bone as mentioned before.

6. Prosthetic Considerations

a) Totally avoid cantilever-> excessive forces on the implant.

b) Try to splint multiple implants as much as possible.

c) Occlusal table narrow Bucco-lingually.

d) Narrow cusps. Avoid sharp cusps to decrease lateral forces.

7. Post Placement Instructions.

a) Soft diet for 3 months and bite on the other side.

b) Oral hygiene measures; brushing and CHX mouthwash.

NOTES!!

! Primary stability is calculated from the torque wrench N/cm2

-if primary stability > 35N/cm2 (some recommend 40N/cm2) à you can go for
immediate loading.

-if primary stability 10-15N/cm2 à you have to go for delayed loading.

! Number of implants in immediate loading should be increased as much as possible

à to provide more splinting and distribution.

! ELASTIC DEFORMITY OF DENTAL IMPLANTS

• In Two-Piece Implants:

-even in implants with platform switch (internal connection), under

forces of masticationà Deformation within the elastic limit à Space
creation à Entrance of saliva and bacteria àPeri-implant mucositis
and Peri-implantitis.

• For these problems came the idea of One-Piece Implants:

-No connection à No space creation under elastic deformity + No

screw loosening problems

So, Compressive Implants are better in progressive loading cases

(Two-Piece implants can still be used).

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Compressive Implants
-They have a variety of lengths and diameters.

-They have a “Bendable Abutment” until 20-25degree à to achieve the right angulation.

-Manufactured in a way that it can be bent but just in one direction with special tools.

-Don’t insert the implant with excessive primary stability >40N/cm2 à this will lead to
fracture during bending.

-Easy placement à just 1-2 drills then the implant is inserted.

-There are 3 Drills:

a) Short drill for cortical bone.

b) Small drill for 3-3.5mm implants.

c) Large drill for 4-4.5 and 5mm implants.

-Increase the number of implants, one for each tooth and splint them together. Avoid
bridges.

-Always check occlusion for high points. High points in immediate/progressive loading will
lead to failure.

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Soft Tissue Management

Alternative name: Implant exposure in Second Stage Surgery
after Osseointegration (3-6 months) $ Soft tissue management )*+, Impression.

- At the time of implant uncovering the implantologist encounters the challenge of

maintaining or improving the conditions of the implant that was placed several
months ago.
- Emergence Pro ile: Pro ile of the restoration as it emerges from the gingiva. Neck of
restoration + surrounding soft tissue.
- Biological Constant: 2mm of epithelium + 1mm of connective tissue.
- Biological Width: Alveolar bone, PDL iber, Implant surface, junctional epithelium.
- Thinning or destruction of the biological constant will lead to bone resorption
around the dental implant.
- In thin gingival biotype: 1mm thickness bone will undergo at least 2mm of
resorption to recreate a 3mm space for biological constant.
- Gingival biotype during implant placement is important - Connective tissue grafts.
- The effect of inter implant distance on the height of inter-implant bone crest:
The biologic width around implants has been well documented in the literature.
Once an implant in uncovered, vertical bone loss of 1.5 to 2mm is evidenced apical to
the newly established implant abutment interface.
- The technique chosen for uncovering will depend on the characteristics of the
tissue that overlies the implants:
1- the amount of attached gingiva
2- The thickness of overlying mucosa.
3- The presence or the absence of interdental papilla.

2nd Surgery Technique

1. Excisional Technique
2. Incisional Technique

- In some situations, the cover screw exposes itself completely or partially to the oral
cavity perhaps eliminating the need for second surgery.
- If the cover screw is not kept plaque-free during the healing period, the implant
could eventually be lost.
- In some cases, the implant head can be seen or palpated throughout the soft tissue,
if not, there is always the help of X-ray ilms and remaining teeth or other anatomical
sites that can be used as a reference for locating the implant. Or we can use the
surgical stent used to place the implant.

1. Excisional Technique:
- For thick gingival biotype.
- Blade – Punch – Electro surgery – Diode laser. Any of which are used to remove soft
tissue uncovering the implant to place a healing abutment which should be left fro 3
weeks in esthetic zone and 2 weeks in non-esthetic zone.
- Used when the gingival tissue over the implant will be removed and discarded

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- Electrosurgical instruments as well as high speed motors should be avoided as the

implant can be harmed as it is dif icult to control these methods.
-NOTE: Excisional techniques are ideal only when there is suf icient attached
gingival tissue around the head of the implant.

● Thick gingival biotype: Red in color, Highly vascularized

● Thin gingival biotype: pinkish white, very thin, re lecting the color of underlying
bone
2. Incisional Techniques: for thin gingival biotype
*Preserve the soft tissue at the implant site
Can be performed with several methods:
1- Mid-crestal incision
on crest of the ridge, suture in between the healing abutments Thickness of
keratinized gingiva around the healing abutments.
2- The X or Y incision Technique (or +)
over the bulge of the cover screw healing abutment NO Suture band of
keratinized tissue around the healing abutment.
3- Pallaci Technique Microsurgery. Dif icult.
4- Preservation of the Papilla Technique
- Mid-crestal Incision.
- Re lection of the buccal lap and stretching it palataly.
- Midline incision separating the buccal lap into two halves.
- Suturing of the two parts around the healing abutment (in the midline of the 2
parts to the stable palatal lap.
5- Vertical Mid-crestal Incision
- One Bucco palatal / ligual incision.
- Re lection of the two mesial and distal parts.
- Removal of the cover screw.
- Healing abutment for 1 week Soft tissue expansion mesially and distally.
- The replace the narrow healing abutment with a wide healing abutment Further
Pressure mesially and distally Creation of the papilla.

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Failures in Dental Implants

! Most common failures:

1) Loss of integration

2) Biomechanical failure

3) Positional failure

4) Soft tissue failure

o Loss of Integration:

' The cause of failure is after placement of the prosthesis:

1) High Point

2) Crown/Implant ratio à the most common cause;

There should be correspondence between the diameter of the implant and

the tooth to be restored

' Etiology of failure:

1) Improper patient selection

2) Improper implant selection

3) Improper surgical placement

a) Over pressure/heat.

b) No primary stability

4) Prosthetic Problems:

a) Crown/implant ratio

b) High points

c) Premature loading

d) Few number of implants carrying large prosthesis

Note: 1) and 3) will cause early failure.

' Delayed Failure:

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-progressive or continuous bone loss is a sign of potential implant

failure. However, it’s dif icult or impossible to establish agreement
between researchers/clinicians as to what level of bone destruction
constitutes failure. Therefore, most implants described as failures are
those that have been removed from the mouth.

' Peri-Implant Disease (Implant Failure):

-in lammatory process in the tissues surrounding an implant.

1. Peri-implant Mucositis:

Reversible in lammatory process in the soft tissue surrounding a functional implant

that could eventually progress to peri-implantitis.

• Causes:

1-Poor oral hygiene.

2-Poor prosthesis design that collects food.

2. Peri-implantitis:

In lammatory process additionally characterized by loss of peri-implant bone. à

You have to interfere.

• Causes:

1-Labial positioning of the implant à resorption of labial plate of

bone.

2-Poor implant placement à implants placed too close to each other

or a single implant carrying a cantilever.

3-Prosthesis related causes:

A. open contacts.

B. high points.

C. external connection.

• Peri-implantitis à the main reason for late implant loss.

1-immune systemà poor/excellent?

2-early edentulism/multiple disease.

3-history of periodontal disease.

4-poor oral hygiene.

5-smoker lifestyle.

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6-overloaded implants.

• Bone loss or infection due to self-tapping implants/surgical

technique?

-bone compression.

-overheating.

àRevival of latent infection. (Main reason for early loss)

-After extraction of infected teeth without adequate debridement à

after a while, infection surrounds itself with sclerotic margin at the
site of the apex surrounded by necrotic bone. After a while, during
implant placement, if over compression/heating à reactivation of
the infection à early loss/failure.

-Bacteria can persist at the site of the former apex in apparently

healed sites and they may be shielded from the host defense
mechanism by a sclerotic margin.

-bacteria can persist as a contaminant in apparently healed alveolar

bone following extraction of teeth with apical radicular pathosis

• Treatment of peri-implantitis:

1-Amoxicillin + Chlorhexidine MW 3days before the surgery.

2-Irrigation with 0.2% Chlorhexidine for 1min after meticulous

debridement of implant surface from the granulation tissue.
(Mechanical)

3-Cleaning of implant surface with citric acid 40% for 1min with a
cotton then left for another 1min then profuse saline irrigation.
(Chemical)

4-Tetracycline paste for 2minutes then cleaning with saline.

(Biological)

5-Calcium hydroxide powder application on implantàhighly

alkalineàkills acidic bacteria.

6-Application of bone graft + membrane over the implant surface.

7-Other alternatives:

A.Titanium brushàused on the implant motoràinstead of citric

acid, but only after removal of granulation tissue.

B.Diode laser on the peri-implantitis mode à instead of or as an

adjunct to calcium hydroxide.

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o Positional Failure:

-The implant is Osseointegrated but won’t be able to carry a prosthesis.

• - Surviving Implants:

-Implants that remain in function but do not match the criteria for success.

• Caused by:

1-poor abutment planning.

2-poor surgical execution.

-the most common errors seen in these types of cases are implants placed in the
interproximal areas and/or differing depths of implant placement.

-if the implant is not placed prosthetically (ie; at the center of occlusion)à this will lead to a
cantilever design à bone resorption. The solution to this problem is to reduce the size of
the crown and make another crown/bridge on the adjacent tooth to close the space.

The end.

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