Overivew of Implantology Flashcards
Dental implant
An artificial tooth root placed in the jaw
to hold a replacement tooth or bridge
Dental implant
An implant is a 3-piece component
- Crown: extra-gingival
- Abutment: transmucosal
- Implant Body: endosseous portion
Types of Implant
(2)
Bone level vs Tissue level
Shapes and platform
Tissue Level Implants
(4)
- Connect at soft
tissue level - Smooth neck
shapes the soft
tissue - One-stage implant
surgery
Bone Level Implants
(4)
- Connect at bone
- Allows customized
and angled
abutments - Esthetic zone
- Allows two-stage
implant surgery
Shapes
(2)
Straight: cylindrical
Tapered: conical
Straight: cylindrical
(3)
- Increased Surface Area
- Greater Force Transfer
- Most Common Design
Tapered: conical
(3)
- Complex osteotomy sites
- Root proximity
- Bone concavity
Platform
(3)
Narrow—Standard—Wide platform
3.5mm 4.5mm
Platform Switching
The influence of Microgap at two-part implants
Microgap
* Inflammatory cell infiltrate was
consistently present at the level of
the interface between the two
components, the bone crest was
consistently located — mm
apical of the microgap.
* Inflammatory Infiltrate was due to —
1-1.5
bacterial contamination
Platform switching is the
concept of
placing an
narrower abutment on the
wider implant to preserve
alveolar bone levels at the
crest of a dental implant
Platform Switching
It reduces per-implant bone resorption at the —
and maintains the —
bone crest
supracrestal attachment
It reduces per-implant bone resorption at the bone crest
and maintains the supracrestal attachment
* — distance of implant-abutment junction from the crestal bone
* Limits possible interface of bone with —
* Shifts the inflammatory cell infiltrate — and away from the
adjacent crestal bone
Increases
micro-movements
inward
Surface Properties
(2)
Surface characteristic and roughness
Surface chemistry and surface free energy (SFE)
Enhance
cell adhesion
to get better
—
osseointegration
Roughness
(Macro & Micro)
(2)
- Texture
- Machined
Substractive
(2)
- Sandblast
- Acid-etch
Additive
(2)
- Oxidation
- Coating
The roughness of an implant is
measured by the
Sa value
(representing the mean height of peaks and pits of the surface)
- 4 groups of roughness value
(Sa) implants are commercially
available
- Smooth (< 0.5 μm)
- Minimally rough (0.5-1.0 μm)
- Moderately rough (1.0-2.0 μm)
- Rough (> 2.0 μm)
In general, the rougher the
implant, the higher its’
Sa value
(in um), the easier for bacterial
adhesion, the less efficacy of
biofilm treatments
Smooth vs Rough Surfaces
Microbial adhesion can occur on any implant surface,
regardless of the degree of
surface roughness
Surface Chemistry And
Surface Free Energy (SFE)
* SFE is the interaction
between the
force of
cohesion and the force
of the adhesion that
determines whether or
not wetting occurs.
Surface Chemistry and
Surface Free Energy (SFE)
* — technique
* Different material,
implant design with
characteristics contribute
to the
Sessile drop
SFE and cell/
bacterial adhesion.
increase:
Surface roughness
Surface free energy
material factors
Surface characteristics
Surface chemistry
porosity, corrosion behavior, composition of
the surface materials
increase cell adhesion and bacterial adhesion
Which design of the implant
aims to reduce the peri-implant
crestal bone resorption?
A. Tissue level implant
B. Tapered shape implant
C. Sandblast treated rough surface implant
D. Platform switch implant
D. Platform switch implant
Implant Therapy
“A successful implant must present no
(6)
mobility, no peri-implant radiolucency,
bone loss less than 0.2 mm per year
after the first year of loading, and no
persistent pain, discomfort or
infection.”
Anatomy
Landmarks to consider during implant placement
(4)
- Inferior Alveolar Canal/Mental Foramen
- Incisive Foramen
- Maxillary Sinus/Nasal Cavity
- Lingual undercut
Inferior Alveolar Canal
And Mental Foramen
Premolar and molar areas of the mandible
A loop of the nerve can be found to extend —.
Safety zone of – from the mental foramen and
- from the IAN is recommended.
mesially
3mm
2mm
Inferior Alveolar Canal
And Mental Foramen
Ways to detect IAN/mental foramen:
* Periapical films:
* Panoramic films:
* CT scans :
75% to 46.8% accuracy
94% to 49% accuracy
most accurate way to detect
Inferior Alveolar Canal
And Mental Foramen
Ways to detect IAN/mental foramen:
- CT scans : most accurate way to detect
Incisive Canal
(2) are Important
Size and location
Maxillary Sinus/Nasal Cavity
Sinus augmentation
Direct sinus lifting:
Indirect sinus lifting:
less than 4mm residual bone height
more than 4mm residual bone height
Maxillary Sinus/Nasal Cavity
— technique
Direct/lateral window
Maxillary Sinus/Nasal Cavity
Indirect/osteotome technique/crestal approach/transalveolar approach
Lingual Undercut
(2)
- Perforating the lingual plate during preparation of the implant
site can result in extensive and even life-threatening bleeding. - Proper planning and considering reflect a lingual flap to
visualize the ridge.
Bone Requirements
Osseointegration
“A direct functional and structural connection
between living bone and the implant surface.”
Bone Requirements
The stability of the bone at the time of implant
placement is critical to the successful osseointegration.
- Quantity:
- Quality:
related to the degree
of bone loss or bone resorption
present
related to the degree
of bone density present
Type 1: hard and dense like oak wood (D1)
(3)
- Less blood supply than other types (compact bone)
- Takes longer for an implant to integrate
- Found in the mandible
Type 2: consistency of pine wood (D2)
(1)
- Thick layer of compact bone surrounds a core of
dense, trabecular bone
Type 3: consistency of balsa wood (D3)
- Thin layer of cortical bone surrounds a core of
dense trabecular bone
Type 4: consistency of Styrofoam (D4)
(2)
- Thin layer of cortical bone surrounds a core of low
density trabecular bone - Commonly found in posterior maxilla
Concepts of Placement
(3)
Prosthetically-driven implant placement
Hard tissue management
Soft tissue management
Prosthetically-driven Implant
Placement
(4)
Safety/ Function/ Value/ Esthetics
Three Dimensional Position
Mesiodistal
* At least — mm between teeth and implant
* At least — mm between 2 adjacent implants
1.5
3
Three Dimensional Position
No social distance:
can’t restore, no access to clean, bone loss,
peri-implantitis
Buccolingual:
* Significantly greater resorption and gingival recession when the
ridge width —
* Anterior region: at least – mm of buccal bone thickness
* Posterior region: at least – mm buccal bone and – mm lingual
bone thickness is acceptable
< 2 mm.
2
1
1
Coronal-apical*
* —mm from adjacent CEJ
* It is recommended to place bone level implants —.
3-4
subcrestally
Placing #30 implant, what
anatomy and three-dimensional
position need to be considered?
A. Leave at least 1mm buccal bone and 1mm lingual bone
thickness is acceptable, ideally 2mm each.
B. When using tissue level implant, the platform should be
place subcrestally 3mm from the adjacent teeth CEJ
C. Leave at least 1mm distance from adjacent teeth and
1.5mm from adjacent implant
D. Leave at least 5 mm distance away from IAN.
A. Leave at least 1mm buccal bone and 1mm lingual bone
thickness is acceptable, ideally 2mm each.
Hard Tissue Management
* Ridge atrophies:
* Siebert Classification
* Class I:
* Class II:
* Class III:
horizontal and vertical
buccolingual loss of tissue (horizontal)
apicocoronal loss of tissue (vertical)
both loss of tissue
Hard Tissue Management
* Ridge augmentation for atrophic bony ridge
* Bone block technique vs particulate bone graft
* Guided Bone regeneration (GBR):
* Sinus augmentation:
- A surgical procedure that uses barrier membranes with
bone grafts to augment atrophic bony ridge
direct/indirect
Ridge augmentation for atrophic bony ridge
* Longer healing time:
* Post-op complications:
* — expected treatment time line.
3-12 months to be ready for implant
placement, depending on the augmented volume, the graft material and individual healing ability.
membrane exposure, infection,
sinus membrane perforation…etc.
Longer
Dimensional change 6 months post extraction
* Mean horizontal reduction in ridge width:
* Mean vertical reduction in ridge height:
3.8 mm.
1.24 mm.
Hard Tissue Management
Rationales for RIDGE PRESERVATION
* By performing ridge preservation
(3)
- Maintain stable ridge volume to optimize functional and esthetic
outcomes - Simplify treatment procedures following the ridge preservation
- Ready for implant placement at 3-6 months
- Peri-implant mucosa
(1)
- The soft tissue surrounding
dental implants
- Transmucosal
attachment
(1)
- A mucosal seal should prevent
bacterial products reaching
the bone, ensuring the
osteointegration
Soft Tissue Management
* The height of the peri-
implant supracrestal soft
tissue (PST) includes
(3)
* Supracrestal tissue
attachment is roughly —
sulcular epithelium,
junctional epithelium and
supracrestal connective
tissue.
3 mm
(JE 1.88 mm + CT 1.05 mm =
2.93 mm)
Soft Tissue Management
* Soft tissue thickness
greater than – mm is
necessary to prevent peri-
implant soft tissue
dehiscence.
* A minimum of – mm of KT
is necessary to facilitate
proper oral hygiene for peri-
implant health
2
2
Soft Tissue Management
* Free gingival graft
* Primarily gains —
* Connective tissue graft
* Primarily gains —
KT
thickness
Teeth vs Dental Implants
Teeth
(4)
- Periodontal fibers attach from bone to root
in multiple directions - Connective tissue fibers attach to teeth
- Periodontal ligament act as shock absorber
- Blood supply from PDL and periosteum
Teeth vs Dental Implants
Dental Implants
(5)
- Direct bone to implant contact (osseointegration)
- Peri-implant fibers form parallel cuff in a oriented
longitudinal direction - Ankylosis, higher stress at the neck of the screw/implant
- Blood supply by terminal branches of large vessels from
periosteum, fewer capillaries. - Stronger inflammatory response
Peri-implant fibers form parallel cuff in
a oriented longitudinal direction
(3)
- Epithelial cells attached by hemidesmosomes
- Collagen fibers do not insert into the implant but
creates a cuff around the implant creating a
mucosal seal - Prevents bacterial invasion
Stronger inflammatory response
(2)
- Similar to periodontitis, peri-implantitis lesion is
dominated by plasma cells and lymphocytes but
characterized by a larger proportion of
polymorphonuclear leukocytes and macrophages - Area proportions, numbers and densities of
plasma cells, macrophages and neutrophils are
higher in peri-implantitis
- Peri-implant health
Absence of erythema, bleeding on probing, swelling and
suppuration.
- Peri-implant mucositis
An inflammation in absences of continuous marginal peri-
implant bone loss. The clinical sign of inflammation is
bleeding on probing. Additional signs may include
erythema, swelling, and suppuration.”
- Peri-implantitis
A pathological condition occurring in tissues around dental
implants, characterized by inflammation in the peri-implant
mucosa and progressive loss of supporting bone.
Clinical sign of inflammation is detected by bleeding on
probings, while progressive bone loss is identified on
radiographs
Prevalence
* –% for peri-implant mucositis and –% for
peri-implantitis at subject level.
* –% for peri-implant mucositis and
–% for peri-implantitis at implant level
43
22
29.5
9.3-22.1
Baseline X-ray or previous examination data is available
* Presence of
* Increased — compared to previous examinations.
* Presence of bone loss beyond crestal bone level changes resulting
from —
bleeding and/or suppuration on gentle probing.
probing depth
initial bone remodeling ( ≥2 mm after the 1st year of function)
In the absence of previous examination data :
* Presence of bleeding and/or suppuration on gentle probing.
* Probing depths —
* Bone levels — apical of the most coronal portion of the
intraosseous part of the implant.
≥6 mm
≥3 mm
Diagnosis
Peri-implant Health
(3)
Absence of
Inflammation
No BoP
Bone level change
≤ 2mm
Diagnosis
Peri-implant Mucositis
(4)
Signs of
Inflammation
BoP and/or SoP
↑ PD compared to
baseline
Bone level change
≤ 2mm
Diagnosis
Peri-implantitis
(4)
Signs of
Inflammation
BoP and/or SoP
↑ PD compared to
baseline or ≥6 mm
Bone loss ≥3 mm
Peri-implantitis risk factors/
Indicators
(7)
- Poor plaque control
- Lack of regular maintenance
- Tissue quality: thin phenotype, KT
band, bone deficiency - Iatrogenic factors: malpositioning,
poor design of emergency profile,
inadequate abutment/implant
seating - Excessive cement
- Occlusal overload
- Titanium particles: implant
corrosion, micromovement
Peri-implantitis risk modifiers
(5)
- History of periodontal disease
- Smoking
- DM
- Genetic factors
- systemic condition
- Bacterial colonization
was initiated within
— after implant
placement. - The sequence of
colonization on
dental implants and
biofilm formation is
similar to that of
teeth
30 min
Plaque leads to peri-implant mucositis
(2)
- Plaque accumulation and then reversed
- Histology demonstrated B & T cells infiltration at 21 days
- Peri-implant mucositis may lead to peri-implantitis
- It mirrors the progression of gingivitis to periodontitis
Health to disease
(6)
Pioneer bacteria colonization
Biofilm formation
Congregation of early colonizers
Acquisition of bridging bacteria
Accumulation of keystone pathogens
Dysbiosis+host immune response
Implants in
Fully Edentulous Patients
(4)
- The microbiota is similar
to the mucosal flora on
the adjacent alveolar
ridge - Over 80% were Gram-
positive facultative cocci - Spirochetes were limited
- Fusobacteria/black-
pigmenting Gram-
negative anaerobes were
found infrequently
Implants in
Partially Edentulous Patients
(2)
- The microbiota is similar
to remaining teeth - Higher percentages of
black-pigmenting Gram-
negative anaerobes and
Capnocytophaga
Treat periodontal disease
prior to
implant placement
Surface topography influences biofilm formation
- Exposure of the implant surface may lead to peri-implantitis
Surface roughness
Surface free energy
Cell/ Bacterial adhesion
Regarding the peri-implant
disease, which of the following
statement is incorrect?
A. Plaque leads to peri-implant mucositis, and peri-implant mucositis may
lead to peri-implantitis.
B. The risk of peri-implantitis of the patient with history of periodontal
disease and well-maintained is the same as the patient with healthy
periodontium.
C. The diagnosis of the peri-implant disease relies on probing depth, the
bleeding on probing and/or suppuration, and the change of the crestal bone
compared to the base line.
D. The peri-implantitis demonstrates stronger inflammatory response than
the periodontitis.
Maintenance
(3)
- Provide guidelines for maintaining the long term
health of the dental implant - Focus on both hard and soft tissue stability
around the dental implant - Work as a team— patient are co-therapists in the
maintenance therapy
Maintenance
Oral Hygiene Modification
Interproximal brushes can effectively
penetrate up to 3mm into a gingival
sulcus and may effectively clean a
peri-implant sulcus (Balshi 1986)
Professional Debridement
Scalers made of stainless steel and ultrasonic tips can roughen
the implant surfaces creating scarring and pitting.
