Implantology & Bone Grafting

By

Dr. Hamouda Mahmoud Hamouda

(BDs),(MSc),OMFS
Assistant Lecturer, Oral & Maxillofacial Surgery
 Dental Implant
• Dental Implant are endosteal alloplastic biologically compatible
material that is surgically inserted into an edentulous ridge to serve
as a foundation for a prosthetic restoration.
 Indications for implant placement:
1. Single tooth replacement to avoid reduction of
abutments.
2. Partially edentulous arch to support short or long
span fixed prosthesis.
3. Totally edentulous arch to support overdentures.
4. Anchorage for orthodontic tooth movements to
retract molars instead of head gears.
5. A cooperative patient and good oral hygiene.
 Objectives of Dental Implant
• Replacement of the missing tooth.
• Restore function, mastication and occlusion.
• Restore esthetics.
• Maintain health and integrity of dental arch ( bone
& soft tissue).
• Support the treatment of problems related to
Temporomandibular Joint (TMJ)
 Osseointegration
• Osseointegration was discovered by a Swedish orthopedic surgeon
called "Branemark" during his study on microvascular circulation, where
he was transplanting a lens within a metal housing made of titanium into
the tibia of rabbits to examine the blood circulation of the rabbit, After he
finished his examination, he failed to remove the metal housing from the
bone of the rabbit, and called this strong connection between the metal
& bone "Osseointegration".
• Osseointegration is "a histological term that means; a direct structural
and functional connection between living bone and the surface of
implant, is critical for implant stability, and is considered a necessary
for implant loading and long-term clinical success of dental implant.
• The corresponding clinical term of osseointegration is "Clinically stable
implant".
Osseointegration
 Factors affecting osseointegration
Patient selection:
• Systemic conditions. Ex. Diabetes
• Local factors e.g. soft tissue quality, type of bone, occlusion, habits, oral hygiene.
Type & surface treatment of the implant. Maybe need to soft tissue or bone graft to perform implant
Surgical technique: e.g. excess pressure, overheating, lack of primary stability,
presence of infection.
Healing period: (3 to 6 months) We don’t give enough time to osseointegration process
Prosthetic management.
Patient assessment is very important to detect any problem leading to excessive force or loading , ex.bruxism
• Premature loading.
• Excessive loading e.g. high load (bruxism) or direction (improper inclination of the
abutment).
Maintenance.
Skills of operator. Ex.overheating
 Types of implants
I) Subperiosteal Implants:
• This type consists of a non-osseointegrated framework resting on jaw
bone directly beneath the mucoperiosteum.
• The frame has posts that penetrate the mucosa into the oral cavity to
support an overdenture.
 Types of implants
II) Transosseous Implants:
• This type of implant is used only in mandibular symphyseal region.
• The implant consists of a plate that rests on the inferior border of the
mandible & two posts that penetrate the whole thickness of bone to
project into the oral cavity to support an overdenture & other posts that
partially penetrate the mandible to fix the implant to the bone.
 Types of implants
III) Endososseous Implants:
• It is the most common type of implant used nowadays.
• The implant is placed into bone of both mandible & maxilla.
• The endosseous implants conform more or less to the shape of the
tooth root, that’s why it is called “Root form”.
They maybe:
Blade-vent form.
Screw root form.
Cylinder root form.
Combination root form.
 ix Components of implants
1. Fixture (Implant body): Part of implant that is inserted inside the
bone.
• They are made of pure titanium or titanium alloy (titanium-
aluminum- vanadium), because it is biocompatible, light in weight and
corrosion resistant which is most probably due to the oxide layer formed
over its surface immediately after it is exposed to the air.

Surface treatment technologies to improve osseointegration

 Components of implants
2. Healing screw (Cover screw):
• It is a cover to the implant body to prevent the ingrowth of bone, soft
tissues or debris inside the implant body after stage I surgery.

3. Healing abutment:
• It extends the implant above the gingiva by 1mm to help the gingiva to
heal around the implant after stage II surgery.
 Components of implants
4. Abutment (Suprastructure): Part of the implant that supports &/or
retains a prosthesis.
Types of abutments:
Abutments for screw retention
• Uses a screw to retain the prosthesis
Abutment for cement retention
• Uses cement to retain the prosthesis
Abutment for attachments
• Uses an attachment device to retain a removable prosthesis, such as
an O-ring attachment, ball & socket attachments and bar attachments.
Ex.over denture
 Components of implants
• Each of the three abutment types maybe further classified as
Straight or Angled abutments, describing the axial relationship
between the implant body and the abutment. The most commonly
used angle abutments are 150 & 250, & they are usually used in the
anterior maxillary region.
• Also Zirconium abutments are available to be used in esthetic
areas.
 Components of implants
5. Transfer coping: are precisely machined from titanium alloy and
attached to the implant fixture by a titanium screw or guide pin. Each
transfer coping is specific to the restorative platform of the seated
implant, as well as the impression technique and desired emergence
profile, It is used to transfer an analog in an impression.

6. Implant analog: It is exactly similar to the implant & it is used in the

fabrication of the master cast to replicate the implant.
Transfer coping
 Preparation for dental Implant surgery
1) Make sure you have a complete Implant surgical kit which should include:
Pilot drill (some systems) or Starter drill (other systems)
Depth drills
Width increasing drills (some systems) or Intermediate drills:
Parallel pins
Crestal bone drill (Counter sink)
Bone tap
Screwdriver Manual or by hand piece
Ratchet
2) Availability of enough number of implants:
3) Availability of a reducing handpiece: A speed reducing handpiece is recommended as
drilling requires 500-800 rpm, while bone tapping & implant insertion requires 25 rpm.
4) Availability of of motor: Characterized by its high torque, & built-in pump for external &
internal irrigation.
Dental implant surgical kit
Dental implant drills
 Factors influencing a successful
implant
Proper patient assessment and treatment plan.
Proper surgical technique.
Proper prosthetic assessment.
Proper implant maintenance.

Patient assessment and treatment plan:

1. Medical history.
2. Dental history.
3. Complete oral & dental examination.
4. Radiographic examination.
5. Mounting of diagnostic casts.
 Factors influencing a successful
implant
Oral & dental examination:
• Ridge size & contour.
• Soft tissue quality & quantity (atleast 3mm height of attached gingiva
should be present.
• Vestibular depth.
• Available space (Interarch space atleast 6-7mm & mesiodistal space
atleast 6-7 mm).
• Condition of opposing & adjacent dentition.
• Parafunctional habits.
• Oral hygiene.
• Presence of bony tori that may be used as a source of bone grafting
material.
 Factors influencing a successful implant
Radiographic examination: Radiographic examinations are used to
determine:
1. The surrounding vital structures (inferior alveolar nerve, mental nerve,
maxillary sinus or nasal cavity )
2. Any bone pathologies.
3. The available bone quantity (bone width & height).
4. The available bone quality (bone density).
5. The adjacent teeth.
 Factors influencing a successful implant
Radiographic examinations include:
• i) Intraoral radiographs: (Periapical & occlusal views)
• ii) Extraoral radiographs: (Panorama & Cone Beam Computed
Tomography (CBCT)
• Panorama is the most commonly used radiograph but it has the disadv.
of magnification.
• Cone Beam Computed Tomography (CBCT):They are superior in
identification of vital structures, calculation of distance
measurements and determination of bone density.
Cone Beam Computed Tomography (CBCT)
Cone Beam Computed Tomography (CBCT)
 Anatomic considerations during implant
placement
• i) At least 2 mm should be present between the implant & the inferior
alveolar canal.
• ii) At least 1 mm should be present between the implant & the max. sinus
or nasal cavity.
• iii) At least 5 mm should be present anterior to the anterior border of the
mental foramen, to avoid the inferior alveolar nerve looping if present.
• iv) At least 1 mm should be present between the implant and the inferior
border of the mandible.
• v) At least 1-1.5 mm should be present betw. the implant & the buccal or
lingual plates of bone. (So the minimal permissible buccolingual bone
width for implant placement is 6 mm, if bone width is deficient then bone
graft is done first)
• vi) At least 3 mm should be present between adjacent implants.
Surgical stents
 Types of bone quality
• The bone density maybe determined by tactile sense during surgery,
the anatomic location, or radiographic evaluation (CT).
1) D1 bone: Dense cortical bone .
• Usually found in the anterior mandible.
• Difficult to drill because it is so dense, thus bone may become
overheated & slow impaired healing may result.
• Best type of bone in terms of osseointegration & healing,
• However, due to its poor blood supply the healing process is very slow.
• Best type of bone regarding initial implant stability.
• Suitable for immediate loading.
2) D2 bone: Thick layer of cortical bone surrounding a core of dense
trabecular bone
• Usually found in the anterior mandible, posterior mandible, &
anterior maxilla
• Most preferred type of bone since it provides good initial implant
stability.
• Suitable for immediate loading
3) D3 bone: Thin layer of cortical bone surrounding a core of dense
trabecular bone
• Usually found in the posterior mandible, anterior maxilla & posterior
maxilla
• Provides good initial implant stability
4) D4 bone: Very thin layer of cortical bone (maybe absent) surrounding
a core of loose trabecular bone
• Usually found in the posterior maxilla.
• Worst type of bone as it neither provides initial implant stability nor
allow immediate loading.
• To overcome the lack of initial implant stability with this type of bone,
sequential osteotomes are used instead of the sequential drills, where
they condense the loose trabecular bone instead of cutting it.
• Therefore it more or less changes the D4 bone around the implant to D3
bone.
5) D5 bone: Regenerated bone (Bone like tissue): mostly need bone
graft.
 Implant techniques
I) Delayed implantation:
• Implant inserted in a healed extraction site, after at least 9-12
months from extraction.
Disadvantage:
• It allows bone loss to occur after extraction
II) Immediate implantation: Implant inserted immediately into fresh extraction
site
Advantages:
• It decreases the amount of bone loss that takes place after extraction (i.e Bone
preservation)
• It allows for rapid restoration construction.
• It provides better esthetics.
• Natural gingival scalloping.
• Better healing potential that is usually present after extraction (i.e It benefits
from socket healing phenomenon)
• Tooth angulation guide
• Less surgical procedures
Rules:
• Absence of infection
• Atraumatic extraction (its better to use a periotome)
• Avoid heat generation.
• Drill parallel to long axis of tooth.
• Always put the implants towards the palatal plate of bone.
Periotome
III) Delayed-immediate implantation:
• Implant inserted in extraction site after 2-8 weeks of
extraction.
Indications:
• Periodontally affected teeth.
• Presence of pus.
IV) Immediate loading:
• Implant is inserted & the abutment is immediately loaded over the
implant, then a final restoration is constructed.
V) Early progressive loading (Immediate-esthetic restoration):
• Implant is inserted & the abutment is immediately loaded over the
implant, then impressions are taken to fabricate a temporary acrylic
crown that is made to be out of occlusion & patient is instructed to eat
soft diet.
• A final restoration is constructed to replace the temporary restoration
at the end of the healing period.
VI) Delayed loading:
• A healing period of 3-4 months in the lower jaw & 6-8 months in the
upper jaw is recommended for osseointegration to occur, and then a
final restoration is loaded on the implant.
 Approaches of surgery
a) Two-stage surgery:
• A flap is reflected , then the implant is inserted & covered
by a healing screw, and then the flap is sutured back (1st
stage surgery).
• After the healing period; the healing screw is exposed &
removed & a healing abutment is placed instead to allow
healing of the gingiva around the implant (2nd stage
surgery).
• After 2-3 weeks from placement of the healing abutments,
impressions are taken inorder to construct the final
restoration.
Two-stage surgery
 Approaches of surgery
b) One-stage surgery:
• Healing abutment (Transmucosal abutment) is placed
after insertion of the implant (i.e no healing screw is
placed) & it's left in place during the entire healing
period.
• Has the advantages of better soft tissue healing &
esthetic outcome, in addition to the lack of a second
stage surgery.
One-stage surgery
 Flapless technique
• A flapless technique done by using a punch drill that cuts
by its end only to remove the soft tissues over the implant
site.
Flapless technique has:
• advantages; less time is required, no sutures are done,
atraumatic procedure, & fewer postoperative pain
&swelling
• Disadvantages: requires an experienced operator.
Flapless technique
Flapless technique
 Residual ridge resorption
• Residual ridge resorption (RRR): It is a changes of alveolar ridge as
a result of tooth extractions. It is a chronic, progressive and
irreversible condition
Classification of Residual Ridge Resorption

Esmi
 Bone Grafting for Bone Defect Repair
• Bone grafting is one of the most commonly used surgical
methods to augment bone regeneration in maxillofacial
surgical procedures.
• Regeneration is defined as reproduction or reconstitution of
a lost or injured part which fully restores the architecture or
function of the part.
• The bone grafting can be categorized according to the donor
into three groups; autologous bone grafts, allogeneic bone
grafts and xenogeneic bone grafts
 Bone Grafting for Bone Defect Repair
• Physiological mechanisms of bone graft healing are:
A- Osteogenesis B- Osteoconduction C- Osteoinduction
Osteogenesis is the ability of the grafting material to produce bone,
osteogenic graft materials contain viable cells with the ability to form
bone (osteoprogenitor cells) or the potential to differentiate into bone
forming cells. ‫املادة تحتوي علي خاليا عظمية تحفز نمو العظم‬
Osteoinduction is the ability of graft material to induce stem cells to
differentiate into mature bone cells.
Osteoconduction is the physical property of the graft to serve as a
scaffold for viable bone healing. Osteoconduction allows for the
ingrowth of neovasculature and the infiltration of osteogenic
precursor cells into the graft site.
 Types of Bone Grafting
Autologous Bone Grafts (autografts) :
• An osseous graft harvested from an anatomic site and
transplanted to another site within the same individuals.
• With the possession of osteoconductive, osteoinductive and
osteogenic properties, an autologous bone graft can integrate into
the host bone more rapidly and completely therefore being
regarded as the gold standard in treating bone defects.
• Drawbacks: including donor site complication and pain, increased
blood loss, increased operative time, potential for donor site
infection and limited volume of material available
Osteogenesis,osteoinduction,osreoconduction‫تتوفر فيه الشروط الثالتة‬
 Types of Bone Grafting
Allogeneic Bone Grafts (allografts): Osteoinductive, osteoconduction
• Allogeneic bone graft refers to bony tissue that is harvested from one
individual and transplanted to a genetically different individual of the same
species. Rejection
Xenogeneic bone grafts (Xenograft):
• Xenografts consist of bone mineral from animals or bone-like minerals
(calcium carbonate) derived from mammalian bones. Bovine derived bone
has been commonly used with or without other sources such as porcine.
• Deproteinized bovine bone is the most common type of grafting material and
is widely used in dentistry because of its similarity to human bone. Proteins in
deproteinized bovine bone have been extracted to avoid immunologic
rejection after implantation
• The advantages of using xenograft as a grafting material are not required a
donor site and reducing morbidity after harvesting and simplifying procedure
 Types of Bone Grafting
Synthetic Bone Grafting (alloplastic): by using synthetic bone grafting
materials as calcium phosphate, hydroxyapatite etc. osteoconduction
• which involve one of important biological properties; osteoconduction.
• Osteoconduction (scaffold) refers to the ability to support the
attachment of osteoblast and osteoprogenitor cells, and allow the
migration and ingrowth of these cells within the three-dimensional
architecture of the graft.
 Growth Factors for Bone Defect Repair
• Most bone graft substitutes, especially synthetic ceramics and
cements, do not possess any osteoinductive property. The ability to
enhance bone healing of those bone substitutes
• Platelet rich fibrin (PRF) was first described in France by Choukroun,
is a second-generation platelet concentrate which contains
platelets and growth factors in the form of fibrin membranes which
promote tissue regeneration and healing.
• The collected blood specimen from patient was placed in the
centrifuge and was allowed to spin immediately in centrifugation
machine for 10 min at 3,000 revolutions per minute (rpm)
Platelet rich fibrin (PRF)
 Bone Grafting Strategies
‫الدكتور قال ماتركزوش عليهم‬
• (1) Guided bone graft augmentation
• (2) Onlay block grafting
• (3) Interposition alveolar bone graft
• (4) Alveolar distraction osteogenesis
• (6) The sinus bone graft
Guided bone graft augmentation
Guided bone graft augmentation
Onlay block grafting
Alveolar distraction osteogenesis
The sinus bone graft
Open Sinus lifting
Closed Sinus lifting
Types of bone

graft

Components of

implant

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