1. Chapter 53
Dental Implants

2. What is an implant?
A “root replica” or a “root form” implant is a titanium fixture inserted in the jaw to act as a tooth root and anchors a restoration (single crown, bridge, or denture)
The final restoration looks, feels, & functions like a natural tooth

3. Dental Implant
Discuss the healing times for each stage of the procedure.

4. Why an Implant?
They replace missing tooth roots and form a stable foundation for replacement teeth that look, feel and function like natural teeth.
Dental implants also help preserve the remaining bone by providing the stimulation previously provided by the natural tooth roots & prevent future bone loss.
Bone that disappears when a tooth is removed can only be replaced with a bone graft.

5. Indications for Implants
Replace one or more teeth as single units
Support a bridge and eliminate the need for a partial denture
Provide support for a denture, making it more comfortable
Prevent bone loss and gum recession
Enhance patient confidence in smiling/speaking
Improve overall psychological health
Improve esthetic appearance of the teeth and mouth
Most patients find that having a full lower denture can be a “mouthful”—implants are a good option.
Implants have a 90% success rate.
Requires heavy commitment on the patient’s part.
If a patient is only missing tooth #19 in the lower arch, would he or she be better suited for an implant or a fixed bridge? (Answers may vary.)

6. Advantages to Implants
Maintain Anatomy:
If you have missing teeth, the bone begins to shrink over time. Unhealthy bone loss can make your jaw line recede and change your facial structure and cause drifting & shifting of the other natural teeth.
Dental implants can help prevent deterioration of the jawbone so your face retains its natural shape.

7. Advantages to Implants
Keep your healthy teeth
In many cases, a better long-term alternative to bridgework, dental implants eliminate the need to grind down healthy teeth when replacing one or more adjacent teeth. Your own natural healthy teeth are not compromised.

8. Advantages to Implants
Security:
Securely anchored dental implants do not slip or move. This eliminates some of the key problems of dentures, including poor fit, gum irritation and pain from exposed nerves. The result is superior comfort, reliability, and freedom from embarrassment.

9. Contraindications to Dental Implants
The financial investment is greater
Treatment can take several months to complete
An implant may loosen and require replacement
Implant procedures may be emotionally challenging for some patients
Bruxism is a significant component of failed implants
The risk for infection is much greater with an implant than with a fixed bridge.
Patients with diseases of the cardiovascular, respiratory, and gastrointestinal systems are not good candidates for implants.
Patients with seriously compromised immune systems and other diseases that may slow the healing process are not good candidates.
Would a patient who is HIV-positive be a good candidate for implants? (No)
Would a patient who is undergoing chemotherapy be a good candidate for implants? (No)

10. The Dental Implant Patient
Psychological evaluation
The dentist assesses the patient's attitude, ability to cooperate during complex procedures, and overall outlook on dental treatment
Dental examination
The dentist evaluates the condition of the teeth, soft tissues, areas of attached and unattached tissue, and the height and width of the edentulous alveolar bone ridge
Psychological Evaluation: Is the patient ready for this involved procedure? Does the patient have a realistic expectation of the implants? (These are all questions to ask.)
Would a patient who is looking for a “quick fix” be a good candidate for an implant? (No)
Would a patient who has severe periodontal disease be a good candidate for an implant? (No)

11. The Dental Implant Patient
Medical history and evaluation
The dentist assesses any existing medical conditions that could worsen as a result of the stress of implant surgery
Specialized radiographs and imaging
Periapical, panoramic, and cephalometric radiographs, as well as tomograms, are needed to evaluate the height, width, and quality of bone
Diagnostic casts and surgical stents
A surgical stent is made
A medical evaluation should be done on all patients, regardless of the procedure.
What is a panoramic radiograph? (Shows the entire dentition in one radiograph)
What is a cephalometric radiograph? (Used to study the bone and tissue structure of the head)
What is a tomogram? (Imaging of one section of the body while blurring images from structures in another plane)
A surgical stent is made of clear plastic; it is used as a guide for the dentist to place the implant in the correct area.

12. Preparation for Implants
Informed consent
The consent form should advise and educate the patient about:
Background information on implants
Complications of implant surgery
Prognosis
Time frame
Home care
Follow-up appointments
What background information would you give to the patient? (The procedure can be 90% successful if the patient is cooperative.)
What complications can arise from having implants placed? (Greater risk of infection)
What is the prognosis? (It can be 90% successful if the patient is cooperative and there are no complications.)

13. Surgical Preparation for Implants
Implant surgery must be completed under strict surgical sterile conditions with sterile instrumentation
The head is draped, and a sterile surgical drape is applied to the circumoral area, leaving only the mouth exposed
It is recommended that the implant team consist of at least three persons: the clinician, the surgical dental assistant, and the nonsterile circulating assistant
The patient’s mouth is rinsed with what? (0.1% chlorhexidine)
How is the implant retrieved from its packaging during surgery? (Just before placement, the inner vial is opened and the implant is allowed to slide [untouched] onto a sterile surface.)

14. Initial Placement
The practitioner places the dental implant into your jaw (1&2)
The healing period for dental implants varies depending on the location and the health of the bone.
It can be as little as 6 weeks or as much as four months.
During this time, osseointegration takes place
The bone will heal & bond to the surface of the implant

15. Prosthetic Placement & Loading
A minor procedure creates an opening through which your artificial tooth will emerge
Once the implant is biologically attached to the bone, an abutment is inserted inside the implant. (3)
A restoration is created to fit on the abutment (4)
The restoration is ready to be “loaded” – establishing chewing force

16. Implant Materials
Implants are made of a bio- compatible material called titanium, which cannot decay

17. Types of Dental Implants
Endosteal implant
The most common placed type of implant
Subperiosteal implant
Placed under the periosteum and on top of bone
Transosteal implant
Inserted through the inferior border of the mandible
Which type of implant is most commonly placed? (The endosteal implant, also known as the tooth form implant, is the most commonly placed.)

18. Lithium disilicate on titanium base
Abutment Materials
Abutments can be made of titanium, zirconium, & lithium disilicate
Lithium disilicate on titanium base
titanium
zirconium

19. Endosteal Implants
Also known as osseointegrated implants, these implants are surgically placed in the bone
Implants and abutment screws are commonly made from titanium because of its compatibility with bone and oral tissues
Titanium implants can be coated with hydroxyapatite
Endosteal implants have three components:
Titanium implant
Titanium abutment screw
Abutment post or cylinder
Osseo = bone.
A titanium implant is placed in the bone during the first stage of the procedure.
A titanium abutment screw is screwed onto the implant during the second stage of the procedure—osseointegration must be complete.
The abutment attaches to the tooth or the denture.
Titanium is very strong and is a compatible material for the oral cavity.
Informed consent must be obtained before the start of treatment.

20. Endosteal Implants Osseointegration
In this process, the living jawbone naturally grows around the implanted dental supports
It refers to the bond that is developed between living bone and the surface of the implant fixture
The bond between living bone and the dental implant.
How long is the osseointegration process? (Between 3 and 6 months)
Used to support removable dentures, fixed bridges, and single-tooth implants.

21. Procedure Process of an Endosteal Implant
First surgery
The implant fixture is placed in receptor sites in the jawbone at predetermined locations
The mucosa is sutured over the fixtures
A period of 3 to 6 months is required to permit the fixture to osseointegrate, or bond to the bone
The patient must be extremely careful during this stage not to cause any trauma to the mucosa.
Strict sterile conditions are enforced during this procedure.
What would the surgical area be irrigated with? (Sterile saline solution)
Implants to be inserted should be sterilized before placement.
Be sure that the patient has signed an informed-consent form before starting procedure.
Surgical techniques vary from patient to patient.

22. Procedure Process of an Endosteal Implant
Second surgery
The implant fixture is exposed and the abutment screw is connected to the anchor
The implant protrudes through the mucosa and connects the fixture to the prosthesis
The patient begins the restorative phase
When the fixture is exposed, tissue is reflected away from the implant.
What is the time frame between the first surgery and the second surgery? (3 to 6 months)
Strict sterile conditions are enforced during the procedure.
What would the surgical area be irrigated with? (Sterile saline solution)
Surgical techniques vary from patient to patient.
The restorative phase is placement of a final crown, bridge, or partial or full denture.

23. Subperiosteal Implant
With this type of implant, a metal frame is placed under the periosteum but on top of the bone
Indicated for patients who do not have sufficient alveolar ridge remaining to support the endosteal-type implant
Two surgical procedures are required for this type of implant
Not placed in the bone like an endosteal implant.
Most commonly used in patients with insufficient alveolar ridges.
Most commonly used on the mandibular arch.
Why wouldn’t this type of implant be used on the maxillary arch? (It is easier to replicate the alveolar bone on the mandible than that on the maxilla.)

24. Subperiosteal Implant Full-Arch Denture Prosthesis
Requires a two-step surgical procedure; varies from patient to patient.
From Newman M, Takei T, Klokkevold P, Carranza F, editors: Carranza’s clinical periodontology, ed 11, St Louis, 2012, Saunders.

25. Procedure Process of a Subperiosteal Implant
First surgery
The alveolar ridge is exposed and impressions are taken
The tissue is repositioned over the ridge and sutured back into place
The impression is sent to the laboratory, where a metal frame with posts is fabricated
Which patients are good candidates for subperiosteal implants? (Those with insufficient alveolar ridges)
Sterile surgical conditions are enforced during the procedure.

26. Procedure Process of a Subperiosteal Implant
Second surgery
The alveolar ridge is surgically exposed
The metal frame is placed over the ridge
With the frame in place, the tissues are repositioned and sutured into place
Requires 3 to 6 months of healing time between the first and second surgeries.
Sterile surgical conditions are enforced during the procedure.

27. Transosteal Implant
These implants are primarily used in patients with severely resorbed ridges
The implant is inserted through the inferior border of the mandible and into the edentulous area
The most common type is the transmandibular staple implant.
It is used when there are no other options for the patient.

28. Maintenance of Dental Implants
Home care devices
Toothbrushes (manual or electric)
Single-tufted toothbrushes
Partial denture clasp brushes
Interproximal brushes
Dental implant floss
Floss
The success of implants depends on good home care.
Complete instruction on home care devices is important.
Patients should keep up with their regular recall visits.

29. Maintenance of Dental Implants Appointments
Routine office visits
Patients should be scheduled at regular intervals for:
Examinations
Radiographs
Prophylaxis
Removal of fixed components
Replacement of components
Relines and remakes as recommended
The success of implants depends on regular recall appointments.
Patients should understand that these implants need to be cleaned thoroughly—just like natural teeth.

30. How long do implants last?
Modern dental implants have been maintained in individual cases for more than twenty years.
The life of the implant varies with factors of patient health (diabetes, HIV, metabolic bone disease), patient habits (smoking, oral hygiene) and structural overload.
It is impossible to predict exactly how long an implant will last, it is not uncommon to have success rates over 95% in the field of dental implants.