ALPHONSE TANGA PRADEEP.

X
BDS – CRRI
VMSDC
DENTAL IMPLANT AND PERIODONTAL CONSIDERATIONS
TERMINOLOGY
BIOLOGICAL CONSIDERATIONS
• Soft Tissue Implant Interface
• Bone Implant Interface
BIOMATERIALS USED FOR IMPLANTS
CLASSIFICATION OF IMPLANTS
CLASSIFICATION OF IMPLANT SYSTEMS
TREATMENT PLANNING
HEALING FOLLOWING IMPLANT SURGERY
PERI-IMPLANT COMPLICATIONS AND DISEASES
 Dental implant is an integral component of the oral
implant complex, which also consists of supportive bone,
interposed keratinized and mucosal oral soft tissues and
prosthetic suprastructure.
 A dental implant is a permucosal device that is
biocompatible and biofunctional and is placed on or within
the bone associated with the oral cavity to provide support
for fixed or removable prosthesis.
 Oral implantology is the science and discipline
concerned with the diagnosis, design, insertion,
restoration and for management of alloplastic or
autogenous oral structures to restore the loss of contour,
comfort, function, esthetics, speech and/or health of the
partially or completely edentulous patient.
 Implant surgery is that part of reconstructive surgery
that is concerned with the placement of endosseous,
subperiosteal and transosseous implants for the
restoration and maintenance of mastication and
speech. Such surgery may also eliminate chronic pain
related to nerve dehiscence, preserving remaining
bone structure and prevent the possibility of a
pathologic fracture.
 Osseointegration: Direct structural and functional
connection between ordered living bone and the
surface of the load carrying implant.
BIOLOGICAL CONSIDERATIONS OF IMPLANTS
I. Soft tissue implant interface.
II. Bone implant interface.
Soft Tissue Implant Interface
 The mucosal tissues around intraosseous implants
form a tightly-adherent band consisting of a dense
collagenous lamina propria covered by keratinized
stratified squamous epithelia.
 The implant epithelium junction is analogous to the
junctional epithelium around natural teeth; in that,
the epithelial cells attach to the titanium implant by
means of hemidesmosomes and basal lamina.
 This evidence supports the concept that a viable
biologicseal can exist between the epithelial cells and
the implants.
 A sulcus forms around the implant lined with a
sulcular epithelium that is continuous apically with
the junctional epithelium.
 Collagen fibers are nonattached and run parallel to
theimplant surface, owing to the lack of cementum.
Since endosseous implants are permucosal, the soft
tissue-implant interface should be considered in their
placement and maintenance. This suggests that
epithelium adheres to implant surfaces and has similar
biological features of the epithelium tooth interface.
Bone Implant Interface
 The relationship between endosseous implants and bone
involves mechanisms like:
• Fibro-osseous integration
• Osseointegration and
• Bioactive integration.
 Fibro-osseous Integration
 It is defined as “tissue to implant contact by interposition
of a healthy dense collagenous tissue between the implant
and the bone interface”. Normally, fibro-osseous union
between the implant surface and adjoining alveolar bone is
not desirable because union formed is a weak union. The
formation of fibro-osseous integration is attributed to
proliferation of connective tissue into the interface, which
hampers the osseous integration process.
Osseointegration
 It is defined as a direct structural and functional
connection between ordered living bone and the
surface of the load carrying implant.
Bioactive Integration
 It is defined as the integration which results by a
physiochemical interaction between collagen of bone
and hydroxyapatite crystals of the implants.
BIOMATERIALS USED FOR IMPLANTS
 Metals and Alloys
a. Titanium 100 percent pure Titanium
b. Titanium-Aluminum Titanium 90 percent
Vanadium Aluminum 6 percent, Vanadium 4 percent
c. Cobalt-Chromium Cobalt 66 percent + Chromium
27 percent + Molybdenum 7 percent
d. Stainless steel Iron 70 percent + Chromium 18
percent + Nickel 12 percent
e. Tantalum 100 percent pure
f. Zirconium 100 percent pure
g. Gold 100 percent pure
h. Platinum 100 percent pure
Inert Ceramics
a. Aluminum oxide (Al2O3)
• Polycrystalline
• Single crystal.
b. Zirconium oxide zircona.
c. Titanium oxide.
Calcium Phosphate Ceramics
Calcium phosphate.
Bioactive and Biodegradable Ceramics
a. Hydroxyapatite.
b. Tricalcium phosphate.
c. Bioglass.
d. Ceramic.
e. Calcium aluminates.
f. Carbon.
g. Carbon silicon.
h. Polycrystalline glassy carbon.
Polymers
 a. Polymethyl methacrylate.
 b. Polytetrafluoroethylene.
 c. Polyethylene.
 d. Polyethylene tetraphthalate.
 e. Polypropylene.
 f. Polyoxymethylene.
 g. Silicone rubber.
 h. Polysulfone.
CLASSIFICATION OF IMPLANTS
Implants are classified based on:
1. Shape and form and
2. Surface characteristics.
Based on the Shape and Form
1. Endosteal.
2. Subperiosteal.
3. Transosteal.
4. Intramucosal inserts/submucosal
implants/subdermal implants.
5. Endodontic stabilizer.
With regard to shape, it is possible to distinguish between:
a. Post or root form implants—Exhibiting rotation
symmetry.
b. Blade implants—Extension implants.
The post or root implant designs can be of the following
types:
1. Solid tapering types.
2. Solid cylinder type.
3. Pin type.
4. Screw-shaped implant type.
5. Basket design.
6. Hollow cylinder design.
The blade implant designs can be of following types:
1. Conventional blade design.
2. Vented blade design.
Based on Surface Characteristics
1. Titanium plasma—sprayed coating.
2. Sand blasting—surface etching.
3. Laser induced surface roughening.
4. Hydroxyapatite coating.
CLASSIFICATION OF IMPLANT SYSTEMS
1. Branemark implant system (Nobel Biocare System).
2. International team for implantology (ITI) system.
3. Implant innovations systems.
4. Astra-dental implant system.
5. IMZ implant system (Interpore IMZ).
6. Corevent system.
7. Sterioss system.
8. Stryker implant system.
9. Endosteal hollow basket system.
TREATMENT PLANNING
Clinical Assessment
Selection of cases for implants is based on the:
I. Age limitations for case selection.
II. Anatomic prerequisites:
1. Resorptive process.
2. Soft tissue situation.
3. Available bone.
4. Mandibular canal.
5. Height of bone.
6. Width of bone.
7. Bone shape (contour).
8. Length of bone.
9. Implant crown relationship.
10. Maxillary sinuses.
The Absolute Requirements for Treating Implant
Patients
1. Have an acceptable patient.
2. Implant made of biocompatible material.
3. Be durable.
4. Have proper surface quality.
5. Have acceptable socket created in bone.
6. Have surgical procedure properly done.
7. Have healing completed with acceptable bone
interface.
8. Have healing period without pathological stress.
9. Have normal implant function without
pathological stress.
Indications for Implant Therapy
A. The edentulous patient:
• Edentulous mandible
• Edentulous maxilla.
B. The partially-edentulous patient:
• Free end edentulous situation
• Multiple missing teeth.
C. Single tooth loss.
Absolute Contraindications for Implant Treatment
1. Uncontrolled-diabetes mellitus.
2. Long-term immunosuppressant drug therapy.
3. Diseases of connective tissue.
4. Blood dyscrasias and coagulopathies.
5. Regional malignancy.
6. Metastatic disease.
7. Previous radiation to the jaws that might lead to
postsurgical osteoradionecrosis.
8. Alcohol or drug addiction.
9. Severe psychologic disorders.
Intraoral Contraindications
This includes:
1. Unfavorable interarch relationships.
2. Problematic occlusal and functional relationships.
3. Pathologic considerations in alveolar bone,
example, fibro-osseous disease.
4. Pathologic alteration of the oral mucosa, example,
cysts, infections.
5. Xerostomia.
6. Macroglossia.
7. Unrestored teeth—poor oral hygiene.
Radiographs
Radiographs used in dental implants are panoramic
radiographs. However, this technique has certain inherent
problems that have to be taken into consideration like
distortion of spatial relationships. In order to eliminate
thedistortion problems panoramic radiographs and their
use of templates with incorporated metal spheres have
been demonstrated.
Other Radiographic Procedures Employed These are:
1. Periapical dental radiographs.
2. Rast-O-Pan bite blocks.
3. Lateral cephalometric radiograph.
4. Occlusal radiograph.
5. Tomography
6.Computed tomography
Surgical Procedures
Most threaded endosseous implants can be placed either in
one stage (or) two stages.
One-stage: Endosseous Implant Surgery
In this procedure the coronal portion stays exposed
through gingiva during the healing period. For example,
ITI system, TG Implant of 3i system and Life core single–
stage system.
One stage endosseous implant surgery:
In this implant surgery, the implant (or) healing abutment
protrudes about 2 to 3 mm from the bone crest and the
flaps are adapted around the implant. In posterior areas of
the mouth the flap is thinned and sometimes placed
apically to increase the zone of keratinized attached
gingiva.
Surgical Technique
Flap design and incisons:
The flap design is always a crestal incision bisecting the
existing keratinized tissue. The soft tissue is not thinned
in anterior or other esthetic areas of the mouth to prevent
the metal collar from showing, full- thickness flaps are
elevated buccally and lingually.
Placement of the implant: The implant site preparation to
place implants in one stage surgery is identical to principles
of two-stage except, implants or healing abutment is
placed in such a way that head of implant protrudes about
2 to 3 mm from the bone crest.
Closure of the flap: The keratinized edges of the flap are
tied with independent sutures around the implant, when
keratinized tissue is abundant, scalloping around the
implant provides better flap adaptation.
Surgical steps in implant placement. (A) Initial incision placed (B)
Reflection of flap (C) Osteotomy procedure at implant site (D)
Checking for parallelism of implant (E) Placement of implant (F)
Repositioning of flap and placement of sutures
Advantages and disadvantages of one stage implant
surgery.
Advantages:
a. Mucogingival management around the implant is
easier.
b. Patient comfort increases because less surgeries
are involved.
c. Esthetic management is easier in many cases.
Disadvantage:
If extensive bone loss occurs at the implant site.
Vertical bone augmentation is necessary, and or bone
quality is poor then two-stage surgical approach is
recommended.
Two-stage: Endosseous Implant Surgery
In the two-stage implant surgical approach, the first stage
ends by suturing the soft tissues over the implant so that it
remains excluded from the oral cavity.
In the mandible, the implants are left undisturbed for 2 to 3
months, whereas in the maxilla, they remain covered for
approximately 4 to 6 months because of slower healing due
to less dense bone. During this period, the healing bone
makes direct contact with the implant surface
(osseointegration) and sometimes grows to its occlusal
surface, even covering it.
In second-stage surgery, the buried implant is uncovered
and a titanium abutment is connected to allow access to
the implant from the oral cavity. The restorative dentist
then proceeds with the prosthodontic aspects of the
implant therapy.
HEALING FOLLOWING IMPLANT SURGERY
If the space between an implant and its osseous bed is
narrow, bone formation is comparable to primary
healing after a bone fracture, because no callus is
formed. Direct bridging via lamellar bone occurs, at a
rate of about 1 m/day.
Healing of implants with a wide space around them is
comparable to secondary healing of a bone fracture, as
bone formation occurs via formation of a fibrous and
bony callus, at about 50 to 100 μm/day. The temporal
sequence is woven bone with subsequent remodeling
into lamellar bone.
During preparation of the implant bed, periosteal
intracortical and endosteal blood vessels are damaged.
As a result blood accumulates in peri-implant space,
with a loose attachment of fibrin on the surfaces of
both bone and implant. This hematoma will be
remodeled by proliferating tissue with new capillaries
and fibrous collagen connective tissue in 7 to 14 days.
New bone formation can occur directly in the vicinity
of the implant depending upon the degree of its
stability. Implant instability influences cell
differentiation and therefore also bone formation. So
the implant stability is an absolute requirement for all
types of implants with adequate blood supply.
Bony remodeling of the callus is completed after 4 to 6
weeks, thorough activation of the Haversian system,
numerous resorption canals are formed, and the
remodeling process into lamellar bone begins. These
mineralization processes, which transforms the
osteoid into calcified osseous substance, proceed at
about 1 micrometer per day.
Different Phases of Healing
Osseous Healing—Early Phase
Preceded by hemorrhage and formation of a blood
clot, this coagulum consists of fibrin and embedded
blood cells and represents the scaffold for reparative
(granulation) tissue, the coagulum begins to organize
with ingrowth of capillaries and pre-osteoblasts
(centripetal bone growth).
During this early stage, in addition to new bone
formation, the macrophages as well as multinucleated
giant cells appear and recognizes the implant as
foreign body. As bone formation is initiated at the
implant surface, the number of multinucleated giant
cells are reduced.
Osseous Healing—Late Stage
Depending upon the width of the gap between the
implant surface and the osseous bed, direct filling of
the space can occur about 0.2 mm by means of
concentric bony apposition.
Wider spaces will usually be filled within 14 days by a
network of new woven bone, which will be remodeled
in about 2 months into lamellar bone: remnants of the
early woven bone may persist centrally. Direct bony
contact with implant surface ranges from 56 to 85
percent with screw- type implants and 46 to 82
percent with linkow blade implants. Areas of the
implant surface not covered with bone will manifest
adipose cells without an intervening fibrous layer.
PERI-IMPLANT COMPLICATIONS
Despite the long-term predictability of
osseointegrated implants, biologic, biomechanical,
and esthetic complications can occur in a small
percentage of cases.
PERI-IMPLANT DISEASES
Pathologic alterations in the tissues that contact a dental
implant can be placed in the above category.
Types of Peri-implant Diseases
1. Peri-implant mucositis: Inflammatory changes, which
are confined to soft tissue surrounding an implant is
termed as peri-implant mucositis.
2. Peri-implantitis: It is a progressive peri-implant bone
loss in conjunction with soft tissue inflammatory lesion.
Peri-implantitis begins at the coronal portion of the
implant, while the more apical portion of implant remains
osseointegrated. This means that the implant is not
clinically-mobile until late stages when bone loss had
progressed to involve the complete implant surface.
Clinical Features
• Color changes, bleeding upon gentle probing.
• Pocket formation and radiographic bone
destruction.
• Suppuration, calculus build-up and swelling.
• Mobility has been extensively described to detect
early and late failures.
Diagnosis
A number of clinical parameters used to evaluate
periodontal conditions have also been used to assess
peri-implant conditions. These parameters include
evaluation of oral hygiene, peri-implant marginal
tissues, and bone implant interface.
Probing
A successful implant generally allows probe penetration of
approximately 3 to 4 mm and the location of peri-implant
bone level can be expected to be about 1 mm apical to the
position of the probe tip.
Radiographs
Reveal the peri-implant bone status as well as the marginal
bone level. Periapical intraoral radiographs are obtained
instead of OPG (which have lower discrimination power).
Direct imaging may have the potential to replace
conventional radiology.
To diagnose a compromised implant site, soft tissue
measurements using manual or automated probes have
been suggested; careful monitoring of probing depth and
clinical attachment level seems useful in detecting changes
of the peri-implant tissue.
Microbial Monitoring
 It is useful in evaluating the peri-implant health
conditionand microbial composition of a peri-
implantitis site.
Management and Maintenance
Management
Occlusal therapy: When excessive forces are
considered the main etiologic factor for peri-implant
bone loss treatment involves an analysis of fit of the
prosthesis
1.The number and position of implants.
2.Occlusal evaluation.
Change in prosthesis design, improvement of
implant number, position and occlusal equilibration
can contribute to arrest the progression of peri-
implant tissue breakdown.
Anti-infective therapy: The nonsurgical treatment of
peri implantitis involves:
• Local removal of plaque deposits with plastic
instruments and polishing of all accessible surface with
pumice.
• Subgingival irrigation of all peri-implant pockets with
0.12 percent chlorhexidine
• Systemic antimicrobial therapy for 10 consecutive days
• Improved patient compliances with oral hygiene until a
healthy peri-implant site is established.
• Conventional hand and ultrasonic instruments are not
suitable for the preparation and detoxification of the
implant surface.
• Irradiation with soft lasers for elimination of bacteria
associated with peri-implantitis has also shown promising
results in the destruction of bacterial cells.
Surgical techniques for treatment of peri-
implantitis:
Once the inflammatory process in the peri-implant
tissue is under control, an attempt may be made to
improve or re-establish osseointegration.
The surgical procedures are modified from techniques
used to treat bone defects around the teeth.
Re-osseointegration: It can be defined as the growth of
new bone in direct contact to the previously
contaminated implant surface without an intervening
band of organized connective tissue.
Maintenance
After surgical intervention, all patients are placed on
a close recall schedule. It is advised to schedule
maintenance visits at least every 3 months. This allows
for monitoring of plaque levels, soft tissue
inflammation, and changes in the levels of bone.
Oral Hygiene Aids
• Toothbrushes with soft, rounded bristles should be
used because the surfaces of the implants are easily
damaged.
• Toothpaste should be only minimally-abrasive; the
tooth- cleaning procedures should be conducted by
rinsing or brushing with chlorhexidine.
• Gauze strips or superfloss are effective for cleaning
interproximally.
• Irrigators can also be used as adjunctive aids.
KEY POINTS
1. A dental implant is a biologic or alloplastic biomaterial
inserted into soft or hard tissues of the mouth for
functional or cosmetic purposes.
2. Osseointegration is a direct structural and functional
connection between ordered living bone and the surface of
the load carrying implant.
3. Soft tissue interface of the implant consists of mucosal
tissues around intraosseous implants which form a tightly
adherent band consisting of dense collagenous lamina
propria covered by stratified squamous keratinizing
epithelium.
4. Bone implant interface is the relationship between
endosseous implants and bone which involves mechanisms
like fibro-osseous integration, osseo-integration and
bioactive integration.
 5. Based on shape and form implants are classified into
Endosteal, subperiosteal, transosteal, submucosal implants
and endodontic stabilizer.
6. Based on surface characteristics implants are classified
into titanium plasma sprayed coating, sandblasting-
surface etching, laser-induced surface roughening and
hydroxyapatite coating.
7. Surgical procedure involves:
a. One-stage endosseous implant surgery.
b. Two-stage endosseous implant surgery.
8. Healing involves two phases:
a. Osseous healing—Early phase.
b. Late stage.
9. Pathologic alterations in the tissues that contact a dental
implant are peri-implant diseases, which are peri-implant
mucositis and peri-implantitis
KNOW MORE ...
- Implant Failure
- Failures in implant therapy can happen sometimes
and this could be due to:
a. Complications that arise during the early phase
following implant insertion—Early implant failures.
b. Complications that arise after the reconstruction of
the implant—late implant failures.
- Causes for Early Implant Failures
1. Improper preparation of the implant site.
2. Bacterial contamination.
3. Improper mechanical stability following implant
insertion.
4. Premature loading of the implant.
- Causes for Late Implant Failures
According to proceedings of the 3rd European
Workshop on Periodontology the late implant failures
could be as a result of:
1. Excessive load.
2. Infection, e.g. periimplant mucositis,
periimplantitis.
BIBLIOGRAPHY
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restorations in partially edentulous patients—a critical
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 3. Berman CL. Osseointegration, complications,
prevention, recognition, treatment. Dent Clin North
Am 1989; 33: 635.
 4. Buser D, Weber HP, Donath K, et al. Soft tissue
reactions to non-submerged implants. J Periodontol
1990; 61: 597.
 5. Ericsson I, Lindhe J. Probing depths at implants and
teeth. J Clin Periodontol 1993; 20: 263.
 6. Jan Lindhe. Clinical Periodontology and Implant
Dentistry, 4th edn, Munksgaard, 2003.
 7. Michael Norton. Dental implants, Quintessence
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 8. Newman, Takei, Carranza. Clinical Periodontology.
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 9. Van Steinberghe D, et al. Survival and success rates
with oral endosseous implants. In Lang NP, Karring T,
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of 3rd European Workshop in Periodontology. Berlin,
Quintessence 1999.
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