SURGICAL ASPECTS AND RECENT ADVANCES OF

DENTAL IMPLANTS

By Dr Pulak MishraFinal year PG

MEDICAL USES HISTORY TECHNIQUE PLANNING GENERAL CONSIDERATIONS BIOPHOSPHONATE DRUGS MAIN SURGICAL PROCEDURES ADDITIONAL SURGICAL PROCEDURES

1. HARD TISSUE MANAGEMENT2. SOFT TISSUE MANAGEMENT CONCLUSION REFERENCES

CONTENTS

A dental implant (also known as an endosseous implant or fixture) is a surgical component that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor.

The basis for modern dental implants is a biologic process called osseointegration where materials, such as titanium, form an intimate bond to bone. The implant fixture is first placed, so that it is likely to osseointegrate, then a dental prosthetic is added.

A variable amount of healing time is required for osseointegration before either the dental prosthetic (a tooth, bridge or denture) is attached to the implant or an abutment is placed which will hold a dental prosthetic.

The risks and complications related to implant therapy are divided into those that occur during surgery (such as excessive bleeding or nerve injury), those that occur in the first six months (such as infection and failure to osseointegrate) and those that occur long-term (such as peri implantitis and mechanical failures).

In the presence of healthy tissues, a well integrated implant with appropriate biomechanical loads can have 5-year plus survival rates from 93 to 98 percent. and 10 to 15 year lifespans for the prosthetic teeth.

Implants have evolved into three basic types:

1. Root form implants; the most common type of implant indicated for all uses.

 2. Zygoma implant; a long implant that can anchor to the cheek bone by

passing through the maxillary sinus to retain a complete upper denture when bone is absent.

3. Small diameter implants are implants of low diameter with one piece construction (implant and abutment) that are sometimes used for denture retention or orthodontic anchorage.

 Techniques used to plan implants To help the surgeon position the implants a guide is made (usually out of

acrylic) to show the desired position and angulation of the implants.

Planning

Sometimes the final position and restoration of the teeth will be simulated on plaster models to help determine the number and position of implants needed.

CT scans can be loaded to CAD/CAM software to create a simulation of the desired treatment. Virtual implants are then placed and a stent created on a 3D printer from the data.

Main surgical procedures

FIRST STAGE SURGERY

Fixture installation is done in the first stage surgery. The operator must have a thorough knowledge of fixture installation procedures and detailed knowledge of instrumentation use during this first surgery.

The first stage surgery consists of five events, listed as follows

1. Surgical incision of gingiva and mucoperiosteal flap reflection2. Drilling and countersinking procedures3. Tapping procedure4. Fixture installation and cover screw placement.5. Soft tissue re-adaptation and suture procedures.

An area with a single missing tooth

An incision is made across the gingiva, and the flap of tissue is reflected to show the bone of the jaw.

Once the bone is exposed, a series of drills create and gradually enlarge a site (called an osteotomy) for the implant to be placed.

The implant fixture is turned into the osteotomy. Ideally, it is completely covered by bone and has no movement within the bone.

A healing abutment is attached to the implant fixture, and the flap of gingiva is sutured around the healing abutment.

The incision line is marked on the crestal ridge between the canine regions. The surgical incision is made with a no. 15 blade and cut through mucosal tissue along the same line.

Blade is angled towards the basal body of the mandible.

When the muscle fibers have been dissected in the direction of the crestal ridge, the periosteum can be cut.

The periosteum is cut carefully 5.0 mm below the crestal ridge between the canine regions but not near the mental foramina.  

SURGICAL INCISION AND SOFT TISSUE REFLECTION

Use of any of the drilling instruments requires copious saline irrigation. Two methods for irrigation include use of sterile syringes or use of irrigation equipment provided for the System

During drilling, the bur is moved in an up-and-down motion into the prepared site to help remove residual bone and maintain adequate cooling as deep into the site as possible.

DRILLING AND COUNTERSINKING PROCEDURES

Use of 2.0 mm Twist Drill

The 2.0 mm diameter twist drill is used to enlarge the fixture site.

Initially fixture site is prepared closest to the midline. The direction can be checked with the surgical splint for labiolingual orientation, but the mesiodistal orientation should be perpendicular to the alveolar crest.

After the twist drill has been used, a direction indicator into the prepared site is inserted.

Next, the most distal site on the left with the 2.0 mm diameter twist drill is prepared.

Use of pilot drill After placement of all direction indicators into prepared

sites, use the pilot drill to enlarge the site from 2.0 mm to 3.0 mm diameter.

After pilot drilling is finished, the fixture site is enlarged with a 3.0 mm diameter twist drill. This procedure is important for preparing the fixture site to the proper depth.

If the quality of cortical bone is hard and dense, drilling can generate heat with detrimental side effects.

If the quality is low with low density, the length may be increased to engage cortical bone.

After using 3.0 mm twist drill in the first site. The direction indicator is inserted into the prepared site.

Use of Countersink After all fixture sites have been enlarged with

either the 3.0 or 3.15 mm twist drills, the countersink procedure is done to all fixture sites to achieve a fixture and cover screw height level with the alveolar bone.

If a short 7.0 mm fixture is to be used, the short countersink should be used for this procedure.

After completion of drilling with the high speed motor, each fixture site should be checked with the depth gauge to establish final fixture length.

Tapping procedures Tapping is the procedure of creating threads into the

fixture site and requires careful technique and profuse irrigation. These procedures are completed using the low speed handpiece to avoid heat generation in bone.

Attach the screw tap to the hand-piece connector.

Begin tapping the fixture sites from the distal most left site and check using the direction indicators for parallelism.

Do not apply pressure while the threading procedure is being done and continue profuse irrigation.

After tapping procedure is completed on one fixture site, fixture installation should follow immediately.

Fixture Installation The fixture is in a titanium cylinder case, then removed with

titanium forceps and placed into the titanium organizer.

Next, attach a fixture mount to the fixture using the open-ended wrench and long screwdriver.

The fixture is initally installed without irrigation until the horizontal hole of the fixture has threaded into the site and is not visible. In this manner, saline is prevented from being pressed into the narrow space adjacent to the fixture.

At the time of the second surgery, mobility is a reliable test for osseointegration.

Position the explorer near probable fixture sites and insert through the tissues. Change the explorer position slightly to make contact with the cover screw through attached gingiva.

A surgical incision is made approximately five millimeters in length to locate the center of the cover screw. A periosteal elevator is used to reflect the flap and expose all cover screws.

When a cover screw is located, the punch blade needle is inserted into the cover screw center hole, pushed apically, and rotated to cut tissues circumferentially.

THE SECOND STAGE SURGERY

Removal of the cover screw When the cover screw is exposed, use either a short or long screw driver to

unscrew the cover screw.

After removing the cover screw, use the punch blade to cut and remove excess periosteum.

All excess soft or hard tissue should be removed prior to seating the abutment, otherwise the connection between the fixture and abutment will be incorrect.

Abutment connection Use the depth gauge to measure the depth of tissue between the fixture

head and gingival margin. Abutment lengths are available in various lengths, 3.0, 4.0, 5.5, 7.0, 8.5, and 10.0 mm.

In the maxilla, the abutment selected should be at the same height or one millimeter higher than the gingival margin. This is important for esthetic and functional speech purposes.

In the mandible, the abutment selected should be one to two millimeters higher than the gingival margin.

The gingival height changes may require changing the abutment lengths prior to prosthetic treatment.

After connecting the abutment to the fixture, the percussion sound is checked for clarity. When the sound is clear, direct bone anchorage is present. When the sound has a dull quality, this may be indicative of soft tissue interposed between the abutment and fixture.

When direct bone anchorage is questionable, design of the prosthesis should be conservative.

Radiographic examination is necessary to verify abutment position on the fixture.

If the position is not accurate, the radiograph reveals a space between the abutment and fixture seen as a translucent area.

When this occurs, repeat abutment connection procedures and verify with another radiograph

There are different approaches to placement dental implants after tooth extraction. The approaches are:

1. Immediate post-extraction implant placement.2. Delayed immediate post-extraction implant placement (two weeks to

three months after extraction).3. Late implantation (three months or more after tooth extraction).  There are also various options for when to attach teeth to dental

implants, classified into:1. Immediate loading procedure.2. Early loading (one week to twelve weeks).3. Delayed loading (over three months)

Timing of implants after extraction of teeth

One-stage, two-stage surgery After an implant is placed, the internal components are covered with either

a healing abutment, or a cover screw.

A healing abutment passes through the mucosa, and the surrounding mucosa is adapted around it.

After an integration period, a second surgery is required to reflect the mucosa and place a healing abutment.

In the early stages of implant development (1970−1990), implant systems used a two-stage approach, believing that it improved the odds of initial implant survival. Subsequent research suggests that no difference in implant survival existed between one-stage and two-stage surgeries

When tissue is deficient or mutilated by the loss of teeth, implants are placed and allowed to osseointegrate, then the gingiva is surgically moved around the healing abutments.

The down-side of a two-stage technique is the need for additional surgery and compromise of circulation to the tissue due to repeated surgeries. 

Additional surgical procedures

Hard tissue reconstruction

Three common procedures are: 1. The sinus lift2. Lateral alveolar augmentation (increase in the width

of a site)3. Vertical alveolar augmentation (increase in the height

of a site)

There are many well-documented approaches for augmentation of the maxillary sinus in preparation for implant therapy. These approaches range from very simple to complex.

SINUS LIFT AND AUGMENTATION

1. In its simplest form, the Le Fort I osteotomy is an aggressive and necessary for the patient with severe maxillary atrophy.

The accomplishment of maxillary down fracture allows the surgeon unparalleled access to the maxilla. From this vantage, cortico-cancellous grafting in large volumes proceeds unimpeded.

In addition, simultaneous maxillary advancement for the severely deficient maxilla permits a better dental relationship for prosthetic treatment planning. In most circumstances, dental implants can also be placed at the same time, with primary stability afforded by block cortical bone grafting.

2. The lateral approach, which is used far more often, is essentially a variation of the classic Caldwell-Luc technique for access to the maxillary sinus.

This approach permits the implant surgeon to gain access to the inferior aspect and floor of the sinus. An incision is made at the height of the crestal bone with releasing incisions as needed posteriorly or anteriorly to reduce flap tension.

An osteotomy is created in the lateral maxillary sinus wall. The lateral maxillary wall is then either fractured medially off a superior ‘‘hinge’’ or pushed bodily into the sinus.

The mobilized lateral maxillary wall segment forms a ‘‘roof’’ under which grafting can proceed along the maxillary sinus floor as necessary.

For primary stability of the implants requires approximately 4 mm of bone height. I

3. Other approaches to the maxillary sinus can be made through the lateral nasal wall or through the alveolus.

The nasal approach is primarily an antrostomy, which is an approach used by oral and maxillofacial surgeons as well as otolaryngologists for the management of sinus pathology.

Augmentation of the sinus through the alveolus can be performed through an osteotome technique whereby progressively larger osteotomes are ‘‘tapped’’ through the alveolus into the sinus floor, ostensibly pushing bone superiorly and therefore creating vertical height through the implant site.

(A) A typical maxillary sinus augmentation case begins with imaging, measurement, and diagnosis.

(B) After incision, flap reflection, sinus mucosa lift and implant placement, the augmentation material can be packed around the implant.

(C) The flap is replaced and incision closed.

(D) An image confirms appropriate implant placement and adequate sinus augmentation. 

If bone width is inadequate it can be regrown using either artificial or cadevaric bone pieces to act as a scaffold for natural bone to grow around.

When a greater amount of bone is needed, it can be taken from another site (commonly the back of the bottom jaw) and transplanted to the implant site.

Bone grafting is necessary when there is a lack of bone.

A general treatment goal is to have a minimum of 10 mm in bone height, and 6 mm in width. Alternatively, bone defects are graded from A to D (A=10+ mm of bone, B=7–9 mm, C=4–6 mm and D=0–3 mm) where an implant's likelihood of osseointegrating is related to the grade of bone.

To achieve an adequate width and height of bone, various bone grafting techniques have been developed.

The most frequently used is called guided bone graft augmentation where a defect is filled with either natural (harvested or autograft) bone or allograft (donor bone or synthetic bone substitute), covered with a semi-permeable membrane and allowed to heal. During the healing phase, natural bone replaces the graft forming a new bony base for the implant.

PERIIMPLANT SOFT TISSUE MANAGEMENT

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Timing in relation to soft tissue management. Soft tissue management before implant placement Optimizing keratinized tissues Socket seal techniques Modified socket seal surgery

TOPICS COVERED

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Soft tissue management in delayed implant placementMucoperiosteal flap design:- The classic vestibular approach- Crestal approach:- Preservative interproximal papilla incision Modified elden-mejchar technique

Soft tissue management in immediate implant placement:- Palatally rotated flap Buccal rotated flap Rehermanplasty Pedicle island flap Guided tissue regeneration

Socket seal template technique the use of soft tissue managment Flapless technique for implant placement Mucoperiosteal flap closure in critical conditions

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Soft tissue management at the time of abutment connection:- Bulking keratinized or connective tissues facially. Scalloping the keratinized tissues Limiting the incision to the keratinized tissues Preserving intact interproximal papillae and Using connective tissue grafts in conjunction with second stage surgery

Soft tissue management postabutment connection Onlay grafting Inlay grafting Connective tissue pouch procedures

Gingival recontouring techniques Use of provisional restorations Soft tissue procedures for reconstruction of the interimplant papillae

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Osseous regenerative methods for interimplant papillae Noninvasive methods for papillary reconstruction Prosthetic solutions for papillary creation Other methods for papillary reconstruction

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Collar does not receive any blood supply from a surrounding periodontal ligament or any other vessels.

It acquires a fibrous connective tissue band around its collar that is more dense and acellular.

Very fragile nature of the oral mucosa makes its ability to withstand excessive clinical manipulations unpredictable, which can lead sometimes to asymmetrical final implant prostheses.

Peri-implant soft tissue

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Allen et al.1985 identified three categories of ridge defects in relation to the healthy soft tissue margins:

(a) mild, a defect of less than 3 mm(b) moderate, a defect of 3-6 mm and (c) severe, a defect greater than 6 mm.

Seibert and Salama ,1996 classified volumetric deformity changes of the edentulous ridge into three general categories:

Class I:-buccolingual loss of tissue with normal ridge height in an apicocoronal dimension

Class II:-apicocoronal loss of tissue with normal ridge width in a buccolingual dimension and

Class III:- combination of buccolingual and apicocoronal loss of tissue, resulting in loss of normal ridge height and width.

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Soft tissue correction of a deficient edentulous ridge is best performed before implant placement; this can help improve aesthetics, phonetics, and oral hygiene maintenance.

Three-month waiting period for the soft tissue to stabilize before selecting the final abutment. (Small and Tarnow 1997)

The majority of the recession occurred within the first three months, and 80% of all sites exhibited recession on the buccal surface.

It is therefore recommended to allow three months time for the tissue to stabilize and mature before either selecting a final abutment or making a final impression in order to avoid any unpredictable tissue behavior around the final prosthesis

TIMING IN RELATION TO SOFTTISSUE MANAGEMENT

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Two to four months before the first-stage implant placement surgery takes place.

Soft Tissue Management beforeImplant Placement

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This technique provides sufficient keratinized mucosa for a soft tissue closure procedure on top of the implant.

This new regenerated tissue subsequently minimizes surgical trauma that occurs due to attempts to achieve primary closure in immediate

implant placement.

OPTIMIZING KERATINIZED TISSUES

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Technique

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First described by Landsberg and Bichacho 1997

Preserves the integrity of the alveolar ridge and inhibits apical epithelial migration into the socket.

SOCKET SEAL TECHNIQUES

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Technique

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The soft tissue graft is prone to thinning, necrosis, and infection, due to the poor blood supply to the graft.

It generally does not come to possess the same texture or color as the surrounding soft tissues.

Shortcomings

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Modified by Misch et al.

Enhance the quantity and quality of bone and soft tissue.

To preserve the original biological architecture of the alveolar ridge at the place of tooth extraction.

MODIFIED SOCKET SEAL SURGERY

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It is preferably performed when the socket walls are intact.

In this technique, a composite graft, consisting of epithelial tissue, connective tissue, periosteum,

cortical bone, and cancellous bone, is harvested from the tuberosity area to fill and seal the socket

Technique

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Technique

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Technique

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Technique

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Postoperative View

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It merges and blends with the adjacent keratinized tissues after completion of the healing process.

The autogenous bone is found to be more predictable for bone regenerative procedures.

Advantage

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Misch et al 1999 have also used platelet-derived growth factor (PDGF) from the patient's own blood that

functions as a chemoattractant for mesenchymal cells to enhance bone formation rate.

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Nonsubmerged implant are preferred as they do not

require a second-stage surgery because the access to the

implant is maintained above the soft tissue from the time of

its placement.

Buser et al 1990 stated that osseointegration showed high predictability in the one-stage,

nonsubmerged surgical protocol; this referred to the

elimination of the subgingival implant-abutment

connections.

Soft Tissue Management duringImplant Placement

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Mucoperiosteal Flap Design:- The classic vestibular approach- First described by Branemark et al 1998

The objective of this design is to position the incision line away from the head of the implants.

The design involves a horizontal incision in the vestibular mucosa parallel to the gingival margin.

A lingually or palatally pedicled mucoperiosteal flap is next obtained through two vertical incisions.

Disadvantages:-severe postoperative edema and compromised blood supply to the site accompanied by an inflammatory reaction .

SOFT TISSUE MANAGEMENT IN DELAYED IMPLANT PLACEMENT

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Crestal approach:- It is simple, does not require professional surgical experience.

Can be easily sutured, offers faster healing, does not compromise the blood supply to the site and

Exhibits a mild inflammatory reaction.

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Favors aesthetics because the preservation of the papillae stabilizes the adjacent margins of the implant-supported prosthesis, reduces postoperative soft tissue recession, and reduces the tendency for marginal bone loss.

lessened tendency to lacerate the interdental papillae during surgery.

The preservative interproximal papilla flap design allows better flap adaptation upon closure

Preservative Interproximal Papilla Incision

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Preservative Interproximal Papilla Incision

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Introduced by Nemkovesky et al 2000.

Achieving primary closure on top of an immediate implant without modifying or altering the buccal contour of keratinized mucosa.

A palatal pedicle flap is rotated towards the buccal mucosa to cover the socket orifice

SOFT TISSUE MANAGEMENT IN IMMEDIATE IMPLANT PLACEMENT

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Palatally Rotated Flap

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Becker and Becker 1990 developed the buccal rotated flap technique

The technique can achieve a complete tension-free closure without creating any mucoginigival discrepancies.

Becker and Becker originally recommended a split thickness flap from the tooth adjacent to the donor tooth to cover the exposed bone on the donor tooth itself.

Buccal Rotated Flap

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Technique

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Most common method among clinicians for primary soft tissue closure in the oral cavity.

Rehermanplasty

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Technique

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The flapless, immediate placement technique is utilized to maintain the natural soft tissue contours, preserve alveolar ridge integrity, and avoid additional soft tissue trauma by raising a mucoperiosteal flap Preservation of the delicate vascular network adjacent to implant. (Al-Ansari BH and Morris RR 1998)

FLAPLESS TECHNIQUE FOR IMPLANT PLACEMENT

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No absolute necessity for either bone augmentation or primary flap closure when placing implants in freshly extracted sites.

The flapless approach is still a blind surgical procedure

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Two basic surgical protocols are used to expose the implant head at the second-stage surgery:-

Reflecting a mucoperiosteal flap next to the implant to be restored.

Soft tissue punching technique.

Soft Tissue Management at the Timeof Abutment Connection

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Bulking keratinized or connective tissues facially.

Scalloping the keratinized tissues

limiting the incision to the keratinized tissues

preserving intact interproximal papillae and

using connective tissue grafts in conjunction with second stage surgery.

RULES OF SECOND-STAGE SURGERY

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Develop the future biological width & to compensate for any postoperative soft tissue remodeling or gingival recession.

Bulking Keratinized or Connective Tissues Facially

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This method ensures tighter adaptation of the soft tissue to the abutment (Herrel et al 2001):-

Reducing the tendency for developing a dead space and

Minimizing any possible soft tissue marginal discrepancy around the abutment.

Scalloping the Keratinized Tissues

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Modified roll therapy

Using Connective Tissue Grafts in Conjunction with Second-Stage Surgery

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These techniques originally aimed at increasing the width of

keratinized tissues, treating mucogingival defects, and arresting gingival recession

around natural teeth.

Onlay soft tissue grafting may be performed prior to implant

placement or after connection of the final abutment, to improve the integrity of soft tissue contours, stabilize soft tissue margins, and

treat minor deficiencies.

Onlay Grafting

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Technique

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Color and texture mismatch between the graft and the surrounding tissues (tire patch appearance)

Difficulty of graft adaptation to the recipient site.

Graft mobility due to hematoma formation, graft shrinkage (approximately 30%) from its original size after healing is complete and

Difficulty of achieving proper adherence of the graft to titanium abutments, which has caused some clinicians to abandon this grafting procedure after the abutment connection.

A recent development in onlay grafting procedures is the introduction of the acellular dermal matrix.

Grafting with autogenous tissue or freeze-dried skin can be an accepted method for increasing and/or restoring the width of attached gingiva.

Drawbacks and complications

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The technique of using inlay grafting showed success and predictability in treating one-, two-, and three-dimensional soft tissue defects around natural teeth and dental implants. .

This technique is now used routinely by many clinicians to enhance soft tissue profile with implant-supported dental restorations.

Connective tissue grafts are applied clinically in two different forms: (1) a graft composed solely of connective tissue or (2) a graft composed of connective tissue that has an epithelial rim.

Inlay Grafting

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The inlay grafts have an advantage over the onlay grafts because they combine the characters of the soft tissue autograft and the pedicle flap procedure.

This combination doubles the blood supply to the graft, thus increasing its chances of survival

Inlay grafts attain the same color and texture of the tissues surrounding the recipient site after healing has occurred

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Technique

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It is used to correct confined minor ridge deficiencies, where the color and surface characteristics of the area after grafting should not differ from the original tissue character .

The procedure is indicated when the alveolar defect is not large in size.

"closed connective tissue grafting procedure" because the graft is totally embedded under the soft tissues,

Connective Tissue Pouch Procedures

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Technique

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Gingival recontouring techniques are plastic surgical procedures used to reshape or refine peri-implant soft tissues

They are usually performed after the implant is restored.

The techniques require a favorable keratinized tissue condition, in terms of quality and quantity.

Gingival Recontouring Techniques

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Resurfacing by laser is widely used by plastic surgeons because:- it has been shown to control the depth of tissue removal better than any other

traditional method it allows for precise tissue trimming it offers a bloodless field and it emits less heat generation to the underlying tissues than do rotary instruments.

COSMETIC LASER RESURFACING

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Electrosurgery can be used to remove the excess bulky gingival contours or smoothen tissue scars, as is done in laser resurfacing.

Tissue warming due to the heat emitted from the electrodes sometimes delays healing.

This method should be applied with caution because there is an increased risk of implant failure if the electrode contacts the implant surface.

ELECTROSURGICAL SCULPTURING

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Minor plastic surgical procedures known as gingivoplasty can be used to treat undesirable aesthetic gingival contours, provided a sufficient amount of keratinized tissue is present.

It is usually limited to patients with the thick flat tissue biotype

It is used when final maturation of the soft tissue around the implant-supported restoration has occurred.

The procedure entails removal of the excessive facial gingival tissues using either a sharp scalpel or a high-speed diamond bur.

GINGIVOPLASTY

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Implant-supported provisional restoration is considered an important tool for reshaping and profiling the periimplant soft tissues without performing any surgical intervention after the

second-stage surgery is completed and soft tissue is healed.

It is considered the most important factor responsible for a natural appearance of implant-

supported restorations.

stimulates periimplant tissues to attain the same configuration and dimensions as missing original

natural soft tissue contours.

USE OF PROVISIONAL RESTORATIONS

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The presence of the interproximal papillae around implant supported

restorations allows symmetrical soft tissue margins and a state of

harmony between natural and dental implant components.

The slightest change in the level of the interproximal papillae around dental implants due to pathologic

reasons or poor soft tissue handling during implant treatment can lead to major aesthetic and phonetic

complications.

THE REAL PAPILLAE

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Interimplant papillae have a connective tissue fiber orientation,they have a high percentage of collagen fibers with fewer fibroblasts, and attain a less adequate blood supply because of the absence of the periodontal ligament.

This makes the interimplant papillae more like scar tissue, which may complicate any attempts for surgical repair or reconstruction.

When the interimplant papilla is missing or does not totally fill the embrasure space, the condition looks like and is called a black triangle.

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Nordland et al. have classified the clinical condition of the interdental papillae according to their marginal level.

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Tarnow et al. developed a useful classification for clinically identifying the predictability of the presence of interdental papillae:-

•They concluded that when the measurement from the contact point of the natural tooth to the crest of the bone was 5 mm or less, the papilla was present almost 100% of the time

•when the distance was 6 mm, the papilla was present 56% of the time

•when the distance was 7 mm or more, the papilla was present in only 27% of the time or less

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Salama et al. proposed another interesting classification that furnished a prognostic classification system for the peri-implant papillae.

class I-A cases:- no need to increase the alveolar ridge contour in vertical or horizontal dimensions.

Class II-B:-- A proper soft tissue augmentation technique can be of utmost importance in class II-B cases

Abutment installation has been performed using the tissue-punch technique

Surgical technique to restore a papilla-like tissue between implants

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Management

Class III-C Bone grafting aims at restoring adequate support for the

implant and soft tissue.

The subsequent clinical situation should approach class II-B and then class I-A after performing soft tissue augmentation.

Class IV-D vertical dimension of the future implant site has been

markedly altered.

Bone resorption and soft tissue collapse require major surgical reconstruction prior to implant placement 100

Bone grafting

Orthodontic eruption of the ridge

Segmental osteotomy.

Distraction osteogenesis.

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Soft Tissue Procedures for Reconstruction of the Interimplant Papillae

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Beagle's technique entails a palatal pedicle flap that is folded and tied on itself on the facial side in order to increase the height of the interimplant papilla.

This method did not attain a high success rate because of the compromised blood supply of the smallsized pedicle

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Alternatively, Han and Takei described a technique that makes use of a pedicle graft with a semilunar incision and total coronal displacement of the gingival unit.

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Azzi et al. employed a connective tissue graft to be placed on the defective area then tucked under buccal and palatal flaps, thus providing the graft with an adequate blood supply .

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The interimplant papilla regenerative template is a carrier fabricated from pure titanium.

It acts as a housing that supports the bone-grafting material on the alveolar ridge, and it is placed between two implants to regenerate an osseous foundation for the interimplant papilla.

The template is to be placed at the time of implant insertion, therefore eliminating the need for any additional surgical procedure.

Other advantages of the template are that it carries and protects the bone graft material and also separates the bone-grafting mix from the undesired fibroblast and epithelial cells, which favors graft predictability.

Osseous Regenerative Methods for Interimplant Papillae

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The use of the template requires a space of not less than 3 mm between two adjacent implants.

After the implants are inserted, the interimplant bone is decorticated, to provide sufficient blood supply to the graft.

use of 100% autogenous chips can provide a more predictable clinical outcome.

The template is then placed on the ridge with its two perforated ends facing the alveolar ridge.

Two GBR fixation pins are fitted into the perforated ends of the template to stabilize the template and secure it in place.

Soft tissue closure can be performed

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used to improve aesthetic and phonetic problems associated with losing interimplant papillae.

Papillary illusions are yet another method used to modify the final prosthesis :-

By moving the contact area in an apical direction.

Thus making the gingival embrasures smaller in size and giving the impression that the interimplant papilla fills most of the gingival embrasure space.

Prosthetic Solutions for Papillary Creation

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Jemt observed that the peri-implant papillae can regenerate without any clinical manipulation of the soft tissue to some extent one to three years after completing the implant therapy.

He reasoned that plaque accumulation in the proximal areas causes gingival inflammation and hyperplasia, which sequentially leads to overgrowth of the papilla to fill the interproximal space.

Scaling and root planing also may induce proliferation of the gingival tissues .

This can lead to regeneration of the interdental papilla after nine months time.

Creeping of the interdental papilla around the root surface is not clinically predictable in many clinical conditions.

Noninvasive Methods for Papillary Reconstruction

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Soft tissue ballooning concept has been investigated as a technique for developing a subgingival tissue space that can be filled later with any commercially available silicon material or bone cement.

Also, titanium papilla inserts were inserted subgingivally to regain the shape of the interimplant papilla.

Unfortunately, the delicate nature of the oral mucosa did not allow any success for these trials.

The current thought is to use mini osteodistraction devices to increase bone height in the future interimplant papilla areas, or to distract all of the bone segment that will receive the implants to a higher level than the CEJ of the adjacent teeth.

This method is still under investigation because the construction of mini osteodistractors will be expensive and the treatment time will be doubled, which is considered a handicapping factor

Other Methods for Papillary Reconstruction

RECENT ADVANCES IN DENTAL IMPLANTOLOGY

Contents

Advanced diagnostic methods Advances in implant materials. Advanced surgical techniques. Changing concepts in implant dentistry. Conclusion.

Classification Advances in diagnostic imaging

◦ Zonography◦ Cone beam Computed tomography(CBCT)◦ Microtomograph ◦ Multi slice helical CT◦ Dentascan ◦ Interactive CT

Advances in implant design◦ Mini implants◦ Transitional implants◦ One-piece implants.

• Advances in Implant materials-Ceramics-Carbon and polymers- Hyrdoxyapatite- Bone morphogenic proteins- Plasma spraying

Advances in implant design and surface in commerically available brands:◦ Biohorizon ◦ Nobel biocare◦ Astra tech◦ Straumann

Softwares simplifying treatment planning and surgical procedures◦ Simplant ◦ NobelGuide◦ NobelClinician◦ Image guided surgeries

CAD/CAM in implant dentistry.

Changing concepts in implant dentistry-All on 4 concept-Tooth in an hour concept-Rescue implant concept

Thank you

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Reference• Clinical periodontology by Carranza - 9th edition

• Clinical Periodontology and Implant Dentistry by Jan Lindhe- 4th edition

• Atlas of cosmetic and reconstructive periodontal surgery by Edward s. Cohen- 3RD edition

• Practical Periodontal Plastic Surgery by Dibart S and Karima M- 1st edition

• Critical decisions in periodontology.Halls-4rth Edition

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Management of inter-dental/ inter-implant papilla.Zetu L, Wang H-L. J Clin Periodontol 2005; 32: 831–839

Soft tissue enhancement around dental implants. PATRICK PALACCI & HESSAM NOWZARI. Periodontology 2000, Vol. 47, 2008, 113–132

Free Gingival Grafting to Increase the Zone of Keratinized Tissue around Implants.( Yadav A et al International Journal of Oral Implantology and Clinical Research, May-August 2011;2(2):117-120

Guided Bone Regeneration Using Injectable Vascular Endothelial Growth Factor Delivery Gel.Darnell Kaigler et al. J Periodontol 2013;84:230-238

Soft Tissue Biology and Management in Implant Dentistry.Yeung Stephen C H.

Guided Bone Regeneration: biological principle and therapeutic applications. Retzepi M, Donos. N Clin. Oral Impl. Res. 21, 2010; 567–576.

Text book of RECONSTRUCTIVE AESTHETIC IMPLANT SURGERY. Abd El Salam El Askary

ADVANCES IN IMAGING/DIAGNOSTIC MODALITIES

ADVANCES IN PANORAMIC IMAGING ZONOGRAPHY

A modification of the panoramic x-ray machine for making cross sectional images of the jaws.

The tomographic layer is approximately 5mm.

For appreciation of spatial relationship between the critical structures and the implant site.

Zonography

Limitations:

Tomographic layers relatively thick .

Adjacent structures blurring and superimposition.

Not useful for determining the differences in bone density or for identifying disease at implant site.

Tomography

Tomography is the generic name formed by the greek words ‘tomo’(slice) and ‘graphy’(picture).

Enables visualization of a section of patient’s anatomy by blurring other regions above and below the site of interest.

For dental implant patients, high quality complex motion tomography is required.

Computed tomography (CT)

Computed tomography (CT) is a digital and mathematical imaging technique that creates tomographic sections.

With latest CT scanners, images with sectional thickness of 0.25 mm can be obtained .

This can be useful for determining the implant site in terms of bone density, and location to adjacent anatomic structures.

Recent advances in Computed Tomography(CT)

Cone beam CT: It uses a cone beam and reconstructs the image in any

direction using special software. It gives all the information of a CT but, at 1/8th the radiation

dose and at a lower cost.

Software is used to display and visualize the anatomy in a way that is clinically meaningful.

The manufacturers of CBCT scanners offer software that is capable of multiplanar reformations .

Third-party software …….Simplant……..

SAGGITAL CT AXIAL CT

CROSS SECTIONAL VIEW OF MAXILLA AND MANDIBLE

Recent advances in Computed Tomography(CT)

Microtomograph: Modification of CT, it is specially useful in acquiring serial

sections of bone implant interface. Multi slice helical CT: The rapid volumetric data acquisition. The speed was further

increased by multislice CT, and offers higher accuracy of images as compared to CT.

Dentascan

DentaScan imaging provides programmed reformation, organization and display of the imaging study.

The radiologist simply indicates the curvature of the mandibular or maxillary arch

The computer is programmed to generate referenced cross sectional and tangential/panoramic images of the alveolus along with 3-D images of the arch.

The cross sectional and panoramic images are spaced 1mm apart and enable accurate preprosthetic treatment planning.

Limitations 1. Images may not be of true size and require

compensation for magnification.

2. Determination of bone quality requires use of the imaging computer or workstation.

3. Hard copy dentascan images only include a limited range of the diagnostic gray scale of the study.

4. Tilt of the patients head during the examination is critical

Interactive computed tomography(ICT)

This technique enables transfer of the imaging study to the clinician as a computer file….

The clinician’s computer becomes a diagnostic radiologic workstation with tools……….

An important feature of ICT is that the clinician and radiologist can perform “electronic surgery” (ES)……

With an appropriately designed diagnostic template, ES can be performed to develop the patient’s treatment plan electronically in 3 dimensions.

ES and ICT enable the development of 3 dimensional treatment plan…..

Transfer of the plan to the patient at the time of surgery can be accomplished by……

It can also be accomplished by the production of the computer generated, three-dimensional stereotactic surgical templates from the digital ICT and ES data.

Limitations of ICT:

Refinement and exact orientation of the implant positions is difficult and cumbersome.

Executing the plan may be difficult for the surgical team.

ADVANCES IN IMPLANT MATERIALS,FORM, SHAPE AND

SURFACE TOPOGRAPHY

Mini implants/transitional implants.

One -piece implants

Modifications in surface topography(coatings)

Materials used for fabrication of implants.

MINI IMPLANTS

Mini dental implants (MDIs) are small diameter dental implants.

Are sometimes referred to as SDIs (small diameter implants), as well as NDIs (narrow body implants).

Diameter less than three millimetres (3mm.)

MINI IMPLANT DESIGN

Diameter of 1.8mm to 2.9mm.

Various lengths.

Multiple tip, thread, body and head designs are available

Thread designs vary from thin to thick and thread spacing is

also variable.

Square, rectangular, or o-ball heads are common.

MINI IMPLANT -indications Endentulous patients that have loose

lower dentures.

Where extensive surgery required for conventional implants is contraindicated due to medical or age constraints.

Healing time is decreased.

Lower costs

Fixed crown and bridge….

Proper case selection is critical but the available literature has demonstrated success that rivals standard implants.

Transitional stabilization

PROCEDURE Available in 6 lengths: 6, 8, 10,13, 15 & 18

Typically inserted directly through the overlying gums and into the bone beneath

No need to surgically cut and raise flap

A single minimally invasive surgery is needed for insertion of MDI implants

Immediate loading done due to self tapping design.

PROCEDURE Each of the tiny implants is

held in finger driver that inserts the implant and also acts as screw driver.

Next a winged wrench is used to tighten the implant

Possible to provide mini implant treatment in single dental office visit.

 TRANSITIONAL IMPLANTS

Diameter ranges -1.8 to 2.8 mm

Length -7mm to 14mm.

Fabricated with pure titanium in a single body with treated surface.

Primary function is to absorb masticatory stress during healing phase

Advantages

Provisionalisation of fully and partially edentulous jaws

Undisturbed healing of bone grafts

Immediate loading not possible but patient insists for fixed

transitional prosthesis

Effective way to generate aesthetic transitional appliances

Allows evaluation of phonetics and function.

Cost effective.

Contraindications Depth of supporting bone is less than 10mm with insufficient

cortical bone to provide implant stabilization.

Patients with excessive bruxism.

When placement of sufficient number of transitional implants

is not possible…..

Should be used with caution : Placed 1.5 to 2.5 mm from

definitive implants….

COMMERCIALLY AVAILABLE TRANSITIONAL IMPLANT SYSTEMS Immediate Provisional Implant System –IPI (Nobel

Biocare)

Modular Transitional Implant System -MTI (Dentatus)

TRN/ TRI Implants (Hi Tec implants)

 ONE PIECE IMPLANTS

Abutment and implant body in one piece and not separate

Material: Titanium Alloy – Ti-6Al-4V Diameter: 3.0mm Lengths: 12, 15 and 18mm.

Maximum Strength - Minimum Profile. Minimal Surgery - Maximum Esthetics. Availability : Biohorizon 3.0 , Nobel direct ,

Zimmer’s one piece implant.

INDICATIONS

The long-term treatment of missing maxillary laterals and mandibular incisors.

For treatment of spaces that cannot be handled with larger two-piece implants….

Also used for overdentures.

Biologic width Around One- And Two-Piece Titanium Implants.

Histometrically examined peri-implant soft tissue dimensions

Conclusion: Gingival margin (GM) is located more coronally and Biologic Width (BW) dimensions are more similar to natural teeth around one-piece nonsubmerged implants compared to either two-piece nonsubmerged or two-piece submerged implants.

Clinical Oral Implants Research 2001, 12: 559–571.

Hermann J. S, Cochran D. L., Buser D., Schenk R. K. and Schoolfield J. D

 SURFACE MODIFICATIONS

Increase possibility of rigid fixation Promote higher percentage of bone – implant contact Proven to increase bone bonding strength

Three general techniques used to modify surfaces:  - Add material, - Remove material - Change the material already present.

Addition Thick coatings - sol-gel and plasma-spraying

Thin film coatings (sub-micron) - vapor deposition techniques, where the coating material condenses onto a surface from a vapor.

The three basic vapor deposition techniques are: i. evaporation, ii. sputtering and iii. chemical vapor deposition.

Removal of material from surfaces

Glow discharge treatment

Sputter-etching.

Changed without addition or removal of material by use of laser and electron beam thermal treatments.

Ion implantation can be used to add material to surfaces, modify coatings, and change microstructures

 Surface modification for

metallic implants

These treatments include passivation, anodization, ion implantation, and texturing.

PASSIVATION Purpose: enhancing the oxide layer present and creating a

surface less likely to break down and release metallic ions in service.

Passivation of a surface with the action of an electric current is known as ANODIZATION….resulting in much thicker oxide layers…..

IMPORTANT for highly roughened surfaces, since the increased surface area has the potential for greater release of metallic ions into the surrounding tissue.

Surface texturing of an implant is done to increase the surface area and provide a greater potential for interlocking with bone.

Blasting with aluminum oxide or other ceramic particulate materials, plasma spraying with titanium and acid etching.

Recently, a resorbable ceramic-blasting material has been developed…….

Ceramic implant surface

High-strength ceramics used for implants are very inert in the body and exhibit minimal ion release.

Aluminum oxide is regarded by many as the standard inert material……..

The ionic ceramic surface is in a high oxidation state, thermodynamically stable and hydrophilic

Minimal ion release has been noted for aluminum oxide or zirconium oxide under normal conditions.

Coatings may also include biologic coatings such as proteoglycans, bone morphogenic proteins and growth factors

Zirconia Zirconia (Zr02) is a ceramic material used

in implantology because:

Biocompatibility(bio inert) Esthetics (because its colour is similar to the teeth), and Mechanical properties, which are better than alumina. High resistance to corrosion, flexion, and fracture Contact with bone and soft tissue similar to that observed in

titanium implants It can be used to produce a entire implant or as a coating.

Carbon and Polymeric implant surfaces

Carbon has been shown to exhibit an inert and biocompatible surface when exposed to blood or tissue.

The carbon structure used for dental implants is known as turbostratic and is a modified graphite structure.

Polymeric surfaces are not commonly seen for dental implants.

Designed to act as a shock absorber, but this polymeric element requires periodic replacement due to wear.

Surface enhancers

Bioactive surface coating Plasma spray - titanium - hydroxyapatite Sand blasted Acid etched

Hydroxyapatite

Properties of HA composites is highly dependent on the particle size and morphology of the HA filler.

HA of sufficient fineness should be developed.

RF induction suspension plasma spraying with a wet suspension of HA.

NanoTite ion beam modification of titanium surface Modified with a thin 1 micron thickness of calcium phosphate

with HA- like chemistry for bone enhancement

Ion beam deposition

Loaded HA Coated And Grit Blasted Titanium Implants

Comparative study of bone response to HA-coated titanium surface and two titanium surfaces.

He found that bone formation and maturation clearly occurred at a faster rate and earlier periods on HA coated implants than on non-coated implants, they are stable both in vivo and in vitro.

He concluded that HA-coated dental implant results in superior bone bonding, earlier biointegration, and better maintenance of crestal bone than titanium surfaces.

Int J Oral Maxillofac Implants 1989,4:219-225

Block MS, Finger IM, Fontenot MG, Kent JN

Red Blood Cell And Platelet Interaction With Titanium Implant Surfaces

The influence of the micro-roughened surface, produced by dual acid-etching (DAE) of machined commercially pure titanium, on initial blood cell/implant interactions .

Micro-roughened DAE implant surfaces showed, qualitative, more platelets than machined surfaces, while the textured glass surfaces demonstrated increased platelet aggregation.

They believed that these early blood cell/implant interactions may play a key role in the osteoconduction stage of peri-implant bone healing response to micro-roughened implants.

Clini Oral Implants Res 2000,Dec 11(6);530-9

Park JY, Davies JE

The Advantages Of Coated Titanium Implant Prepared By Radiofrequency Sputtering From

Hydroxyapatite

Investigated and compared the healing rates of bone around commercially pure titanium implants and titanium implants sputter-coated from a hydroxyapatite target.

Histologic analysis of the bone-implant interface demonstrated that coated implants had nearly twice the percentage of direct bone contact compared with non coated implants.

Accelerate the healing of bone at the implant interface.

J Prosth Dent 1992(1);93-100

David R. Cooley, Adrian F. Van Dellen DVM, John O. Burgess and A. Stewart Windele

Bone Reaction Adjacent To Microplasma Sprayed Capo4 Coated Oral Implants Subjected To Occlusal Load, An Experimental Study In The Dog ; Short Term Results

Investigated, in a mandibular dog model, bone biological properties and the occlusal loading effects of titanium implants provided with newly developed microplasma-sprayed CaP coatings.

Functional loading of MPS CaP coatings induces a favorable bone response.

Clinical Oral Implants Res 2010

R. Junker  , P. J. D. Manders  , J. Wolke  , Y. Borisov and J. A. Jansen 

Bone Formation Of Titanium Porous Oxides (TiUnite ) Oral Implants In Type IV

Bone

Evaluated the local bone formation and osseointegration at TPO- modified implants in type IV bone.

Result- TPO surface possesses a considerable osteoconductive

potential promoting a high level of implant osseointegration in type IV bone in the posterior maxilla

Clinical Oral Implant Res 2005, Vol 16 Issue 1 ;105-111

Huang YB, Xiropaidis AV, Sorensen RG, Albandar JM, Hall J, Wikesjo UM

Advances in commercially available implant systems

Biohorizon

Nobel biocare

Astra tech

Straumann

BIOHORIZON IMPLANT SYSTEM LASER- LOK TECHNOLOGY Unique surface characteristics Laser-Lok microchannels is a series of cell-sized

circumferential channels that are precisely created using laser ablation technology.

Extremely consistent microchannels that are optimally sized to attach and organize both osteoblasts and fibroblasts.

Includes a repeating nanostructure that maximizes surface area and enables cell pseudopodia and collagen microfibrils to interdigitate with the Laser-Lok surface.

Biologic response : The inhibition of epithelial downgrowth and the attachment of

connective tissue (unlike Sharpey fibers).

This physical attachment produces a biologic seal around the implant that protects and maintains crestal bone health.

More effective than other implant designs in reducing bone loss.

Different than other surface treatments Virtually all dental implant surfaces on the market are grit-

blasted and/or acid-etched.

These manufacturing methods create random surfaces that vary from point to point on the implant……..

The clinical advantage The Laser-Lok surface has been shown in several studies to

offer a clinical advantage over other implant designs to reduce bone loss by 70% .

Latest discoveries Laser-Lok abutments Create a biologic seal.

NOBEL BIOCARE SYSTEM NobelReplace™ Tapered Groovy implant

NobelReplace™ Tapered Groovy implant is shaped to resemble a tooth root.

New and unique grooved threads implant.

Since bone forms more rapidly in the grooves, the Groovy implants integrate faster

Tapered design makes surgical procedure exceptionally simple and predictable – especially for immediate placement after extraction.

INDICATIONS For immediate placement after extraction.

Whenever immediate or early loading is applied.

The Groovy implants are preferred over models without the groove in soft bone conditions.

Advantages of groove pattern Faster integration with grooves Bone formed preferentially within the grooves, compared to

other parts of the implant

Enhanced osseoconductive properties of the grooves and a guiding effect on bone forming cells

Up to 30% increase in stability……

Scanning electron microscopic

images of TiUnite® implant with

a groovy at the thread flank.

NobelReplace™ Tapered Groovy implant on the collar

Grooves extended to the collar of most new implants so they: Increase surface area Increase area for bone to-implant contact

The NobelSpeedy™ implant Features: Parallel walled implant Slightly tapered design TiUnite® surface provides accelerated

osseointegration over machined surface implants .

Narrow tip makes it perfect for flapless surgery

Primary stability at time of implant placement.

Shortening treatment time and speeding recovery.

NobelSpeedy™ implant for flapless surgery The innovative head design makes this implant ideal for

flapless surgery. Head is the same diameter as the implant body… Inspection of the bone margin is impossible when working

flapless…… Preventing the use of countersinks preserves cortical bone.

  NobelSpeedy™ implant for Immediate Function The innovative implant tip is sharp so the implant works as an

osteotome…….

This feature allows variable, and if needed, extensive under-preparation of the site.

The resulting higher initial stability, especially in soft bone, supports immediate function.

The sharp tip also secures a smooth insertion…….

Since the implant cuts through any bone quality it's especially suitable for grafted bone.

The bone graft can be of various density levels, and the ability to under-prepare gives the necessary flexibility when preparing the grafted site.

The implant will cut even in under-prepared block graft sites.

NobelSpeedy™ implant -esthetics The parallel-walled body and innovative head of

NobelSpeedy™ secures flexibility in the final vertical position of the implant, which is important for the emergence profile.

It provides the possibility to increase torque and place the implant further down without repeating the drilling procedure.

Especially important when working with internal connection implants where only 3 positions allow optimal esthetics.

NobelSpeedy™ Replace

Narrow Tip ,Sharper Chamfers Internal Abutment Connection Slightly Tapered TiUnite® all the way up Extremely Short Drill Protocol Grooves on threads Increased initial stability in soft bone

NobelSpeedy™ Groovy

Same benefits as NobelSpeedy™ Replace.

In addition: External Abutment Connection Including Shorty implant

NobelSpeedy™ Shorty (7mm)

NobelActive™ Implant NobelActive™ implants don't cut

through bone like conventional implants, they gently press through it like a corkscrew.

This bone condensing capability delivers high initial stability.

The narrow neck is designed to preserve marginal bone and promote long-lasting soft tissue stability.

The self-drilling ability of NobelActive™ implants allows it to be inserted into sites prepared to a reduced depth.

This is useful where sites are close to vital anatomical structures: the mandibular nerve canal or the maxillary sinus, and nose cavity.

Operator can be confident of accurate placement while having a minimally invasive procedure.

NobelActive™-Advantages Potentially fewer drilling protocol steps, depending on bone

density and quantity .

Minimal osteotomy with minor trauma to bone and surrounding tissues .

High stability in fresh extraction sites and sites with thin sinus floors.

Immediate placement in the esthetic region, even when buccal bone plate is very thin

Excellent stabilization in wide sockets…..

Excellent stabilization in soft bone…

Adjustment to small changes for parallelism – using the self-drilling capacity…..

A narrow neck designed to preserve marginal bone.

Grooves on threads and scientifically proven Tiunite™ surface

NobelSpeedy™ Shorty

Shorty implant (7mm) Narrow Tip Slightly Tapered Grooves on threads The implant for flapless surgery Extremely Short Drill Protocol Immediate Function Increased initial stability in soft bone Optimal Emergence Profile and Esthetics TiUnite® 'all the way up'

NobelPerfect™

NobelPerfect™ is a unique, anatomically designed implant for esthetically demanding areas from premolar to premolar.

The interproximal bone may be preserved …………… height discrepancy between the facial and interproximal…

 The anatomic design and the unique implant surface, TiUnite™, give esthetic support and an effective barrier against the oral cavity.

Scalloped bone apposition area follows three-dimensional osseous contours.

Scalloped soft tissue apposition area allows for the development of the biologic width around the entire neck of the implant.

Scalloped prosthetic table follows three-dimensional soft tissue topography.

The NobelPerfect™ One-Piece implant The NobelPerfect™ One-Piece implant is

machined from a single piece of titanium…..

The scalloped TiUnite surface contour at the implant neck follows the same principles as for the original NobelPerfect™. 

The One-Piece design allows placement flexibility of the implant…

With this design, the soft tissue is supported entirely by the implant body, irrespective of the shape of the osseous ridge.

 NobelDirect Implant

The NobelDirect Groovy implant features a revolutionary new one-piece design that is

user-friendly, cost-effective, biologically sound and esthetically stable. The implant is machined from a single piece of titanium,

incorporating both the implant body and an integral fixed abutment.

 NobelGuide™ Zygoma Implant

Using Brånemark System® Zygoma implants with NobelGuide™ enables use of CT scan data as the basis for surgical planning in a 3D computer environment.

From computer-based planning…one or two Surgical Templates, depending on the nature of the case….flapless surgery.

Immediate Function

Astra Tech implant system

OsseoSpeed™ -chemically modified titanium surface, Providing unique nano scale topography, Stimulates early bone healing and speeds up the bone healing

process.

The result of the micro-roughened titanium surface treated with fluoride is increased bone formation and stronger bone-to-implant bonding.

Astra Tech implant system

MicroThread™ The neck of Astra Tech implants are

designed with MicroThread that has minute threads that offer optimal load distribution and lower stress values.

Astra Tech implant system

Conical Seal Design™ a strong and stable fit

Conical connection below the marginal bone level transfers the load deeper down in the bone…….

Reduces peak stresses and thereby preserves the marginal bone.

Seals off the interior of the implant from surrounding tissues, minimizing micro-movements and micro-leakage.

Simplifies maintenance and ensures reliability in all clinical situations.

The tight and precisely fitting implant-abutment relation......

The abutment is self-guiding and the installation procedure is non-traumatic, eliminating the risk of bone damage.

Connective Contour

The Connective Contour™ is the unique contour that is created when you connect the abutment to the implant.

This contour allows for an increased connective soft tissue contact zone both in height and volume…

Sealing off and protecting the marginal bone.

Straumann SLActive implant

Chemical modification to a sandblasted, large-grit, acid-etched (SLA) implant surface.

Hyrdophilicity

Protein adsorption

Enhanced osteoblast activity within the first weeks

Enhanced angiogenesis and bone healing within the first days after contact with the new surface.

More bone apposition on surface

Higher implant stability .

Advantages

This surface reduced the average healing time from 12 weeks (TPS surface) to only 6-8 weeks.

Molecular optimization and the substantial reduction of the average healing time from 6-8 weeks to 3-4 weeks,

Straumann Roxolid Implant Roxolid® is a homogenous metallic alloy composed of the

elements titanium and zirconium. Higher tensile strength compared to pure titanium. Important when small diameter implants are chosen due to

their reduced size. Roxolid® and SLActive® combine high strength with

excellent osseointegration. Roxolid® implants have been used where

3.3mm titanium implants previously were not suitable.

SURGICAL GUIDES Surgi Guides are computer-generated drilling guides that are

fabricated through the process of stereolithography. The SurgiGuide concept is based on the presurgical treatment

planning using SimPlant software for ideal implant positioning.

These successive diameter surgical osteotomy drill guides may be either bone, teeth, or mucosa-borne.

Surgi Guides have metal cylindrical tubes that correspond to the number of desired osteotomy preparations and specific drill diameters.

The diameter of the drilling tube is usually 0.2mm larger than the corresponding drill, thus making angle deviation highly unlikely.

Steps in using SIMPLANT softwareStep 1The scan Connect to the Dental Planit button in

your SimPlant GO software to start a case.

A radiolucent bite index used to stabilize jaws at the time of scanning.

Create an open bite with no overlap in the horizontal plane.

Steps in using SIMPLANT software

Step 1The scan Digital information on the desired tooth-

setup is obtained via the wax-up created on the plaster model.

When your patient has been scanned, your image conversion provider takes an optical scan of the plaster model and wax-up and integrates them with the scanning images.

Steps in using SIMPLANT software The image conversion saves you valuable

time and ensures that the CT images are easy to read.

Exact tooth information – no scatter artefacts.

Desired tooth setup – via the plaster model wax-up (optional).

Soft tissue information – be able to measure mucosa thickness.

Indication of the alveolar nerve –result is EASY verification.

Exact sinus information – 3D representations included.

Steps in using SIMPLANT software Step 2 The planning in

SimPlant® SimPlant file.

3D representations of patient’s anatomy, alveolar nerve, sinuses, plaster model and desired tooth setup.

Plan and communicate

Steps in using SIMPLANT software Step 3 The SurgiGuide®online order

The high resolution optical scan of the plaster model in SimPlant is used to design a perfectly fitting SurgiGuide.

Specialized design team reviews and designs a custom made SurgiGuide which is fabricated with high precision 3D printing process.

Steps in using SIMPLANT software

Step 4 Surgery

SurgiGuide is delivered with the drilling and installation protocol.

Disinfect the SurgiGuide before surgery

NobelGuide

NobelGuide is a complete treatment concept for

Diagnostics, Prosthetic-driven treatment

planning and Guided implant surgery – for

a single missing tooth to an edentulous jaw.

NobelClinician Software NobelClinician Software is the next generation software for Digital diagnostics and Treatment planning.

Through various pre-defined workspaces any DICOM file can be reviewed and analyzed.

NobelClinician Software facilitates team collaboration and comes with an unparalleled ease of use.

NobelClinician Software supports the NobelGuide concept.

3D radiographic data

CAD/CAM in implant dentistry Uses Used in designing of prosthesis Used in milling /fabrication of prosthesis(framework) For milling of abutments.

Advantages: Superior fit Less degree of rotational freedom so more accurate implant

abutment connection.

CAD/CAM

system

Provider Implant restoration type

Restoration material

Procera Nobel Biocare

AbutmentsFixed partial

denture frameworksMilled bars

TitaniumAluminaZirconia

Atlantis Astra Tech

Abutments TitaniumTitanium with gold

coatingZirconia

Encode Biomet 3i Abutments TitaniumTitanium with gold

coating

CAM StructSUR

E

Biomet 3i Milled bars Titanium

CARES Straumann Abutments TitaniumZirconia

Etkon Straumann FrameworksAbutments

ZirconiaTitanium

BioCad BioCad Medical

AbutmentsMilled bars

Titanium

CAD/CAM Custom Implant Abutment Systems

The Procera system (Nobel Biocare) :

Custom abutments in titanium, alumina, and zirconia.

A master cast is developed after making an implant-levelimpression.

Scanned and the custom abutment is designed by a 3d cad pro-gram.

A machined base cylinder isscrewed to the implant analog and the abutment is waxed up.

The pattern is then removed from the master cast and scanned by the Procera scanner.

The design is sent to the production facility for the abutment fabrication.

The abutment can be further digitized, and finally a titanium or ceramic coping isproduced using the same system.

CAD/CAM Custom Implant Framework System

Procera implant partial prostheses are available in zirconia or titanium.

CAD/CAM custom Procera partial prostheses are screw-retained implant-supportedrestorations that can be used with a wide range ofimplant systems.

The zirconia implant prosthesis is available at the implant level, while the titanium implant prosthesis is available at the implant and abutment levels .

Using acrylic resin, a framework pattern is fabricateddirectly on temporary implant cylinders.

The acrylic resin framework pattern is then laser scanned, andthe framework is milled in a CNC-milling machine with 5 degrees of freedom.

CAM StructSURE precision milled bars (Biomet 3i)

Hader and Dolder designs for over-denture bars and primary bars and in fixed hybrid designs.

Technician does not need to wax or resin design the framework; instead, the design is made on-screen with a sophisticated software program.

The Etkon system can produce frameworks up to16 units from a variety of materials, such as zirconia and titanium.

Newer concepts in implant dentistry

All on four

Rescue implant concept

Teeth in an hour concept

ALL ON FOUR -Maxilla and mandible

The All-on-4 for edentulous jaws has been developed to maximize the use of available bone and to allow for Immediate Function

Using only four implants in edentulous jaws…..

All-on-4 using conventional flap procedure with traditional planning and a standardized All-on-4 Guide for predictable and optimal positioning of the implants.

All-on-4 with NobelGuide using flapless technique, computer-based planning and a customized Surgical Template to correctly drill and position the implants.

Zygoma implants

The zygomatic implant is an alternative to bone grafting in extremely resorbed maxilla.

With extremely resorbed maxillas, fixed prosthesis can be provided with four zygomatic implants.

Either a conventional two stage procedure or a one-stage surgical procedure or flapless guided surgery with Nobelguide and immediate function.

Zygoma implants The four zygomatic implants procedure results in Less morbidity, Shorter delays between anatomical reconstruction and

functional rehabilitation Provide immediate or early loading with immediate function.

Four zygomatic implants and a fixed bridge seem to be a valuable technique for the rehabilitation of extremely resorbed maxillas.