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7/15/2017
1
“BY FAILING TO PREPARE,
YOU ARE PREPARING TO
FAIL.”
- Benjamin Franklin
IMPLANTS IN
POSTERIOR MANDIBLE
PRESENTED BY:
APURVA THAMPI
7/15/2017
2
CONTENTS
• Introduction
• Anatomy of mandible
• Need for implants
• Diagnosis and treatment planning
• Factors affecting implant placement
• Prosthetic considerations
• Surgical considerations
• Implant protected occlusion
• Recent advances
• Conclusion
• References
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Part I
Part II
Part III
ANATOMY
7/15/2017
4
ANATOMY OF THE MANDIBLE
EXTRA-ORAL PALPABLE FEATURES
• Symphysis
• Inferior border of mandible
• Pre-massetric notch
• Gonial angle
• Lateral pole of condyle
• Coronoid process
INTRA ORAL PALPABLE FEATURES
• Retromolar triangle
• Mental foramen
• Torus mandibularis
• Genial tubercles
Coronoid
process
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5
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
MUSCLE ATTACHMENTS TO THE MANDIBLE
Lingual or
medial Buccal or facial
7/15/20176
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
• Mylohyoid
• Genioglossus
• Medial
pterygoid
• Lateral pterygoid
• Temporalis
• Mentalis
• Buccinator
• Masseter
LINGUAL OR MEDIAL ATTACHMENTS - Mylohyoid
Mylohyoid
muscle
Origin Insertion
Mylohyoid line
of mandible
Posterior fibres
– body of hyoid
bone
Middle and
anterior fibres
median raphae
beween
mandible and
hyoid bone
Nerve supply :
Nerve to mylohyoid
Actions :
• Elevates floor if the mouth
during first stage of
deglutition
• Helps in depression of
mandible, and elevation of
hyoid bone
7/15/20177
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
7/15/2017
8
ORIGIN
INSERTION
IN SEVERELY RESORBED MANDIBULAR RIDGES….
• Mylohyoid muscle approximates the crest of the ridge  injury to the muscle
7/15/20179
Swelling of
sublingual
space or
submandib
ular space
complica
tions
Ecchymosis
of the floor
of the mouth
Infection
abcess 
cellulitis
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
LINGUAL OR MEDIAL ATTACHMENTS -
Genioglossus
Genioglossus
7/15/201710
Origin Insertion
Superior genial
tubercle
Anterior
: dorsal surface
of the tongue
from root to
tip
Posterior
: body of the
hyoid bone
Nerve supply :
Hypoglossal nerve
(cranial nerve XII)
Actions :
• Protrudes the
tongue
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
7/15/2017
11
IN A RESORBED MANDIBLE….
• Postioned at the crest of the mandibular ridge – divison C and D bone
7/15/201712
A portion may
be reflected
from genial
tubercle
Avoid injury
during
impression
making
B D Chaurasia's Human Anatomy, Volume 3 4th ed
Contemporary implant dentistry Carl E Misch, 3rd ed
LINGUAL OR MEDIAL ATTACHMENTS – Medial
pterygoid
Medial
pterygoid
7/15/201713
Origin Insertion
Superficial
head :
tuberosity of
maxilla and
adjoining
bone
Roughened
area on the
medial
surface of the
angle - ramus
on mandible
Deep head :
medial
surface of
lateral
pterygoid
plate and
adjoining
process of
palatine bone
Nerve supply : nerve
to medial pterygoid –
branch of main trunk
of mandibular nerve
Action :
• Elevates mandible
• Helps protrude
mandible
• Right MP with left LP
turn the chin side to
side
7/15/2017
14
DURING SURGICAL PROCEDURES….
• MP bounds the pterygomandibular space medially
7/15/201715
LINGUAL AND MEDIAL ATTACHMENTS – Lateral
pterygoid
Lateral
pterygoid
7/15/201716
Origin Insertion
Upper head :
infratemporal
surface and
crest of
greater wing
of sphenoid
Pterygoid
fovea –
anterior
surface of
neck of
mandible
Lower head:
lateral surface
of lateral
pterygoid
plate
Antr margin
of articular
disc and
capsule of
TMJ
Nerve supply : a
branch from
anterior division of
mandibular nerve
Actions:
• Depress mandible
• LP and MP protrude
mandible
• Grinding movements
7/15/2017
17
• Rarely involved in surgery for implants
7/15/201718
LINGUAL OR MEDIAL ATTACHMENTS - Temporalis
Temporalis
7/15/201719
Origin Insertion
Temporal
fossa
excluding
zygomatic
bone
Margins of
the deep
surface of
the coronoid
process
Temporal
fascia
Anterior
border of
ramus of
mandible
Nerve supply :
Two deep temporal
branches from the
anterior division of the
mandibular nerve
Actions :
• Elevates mandible
• Posterior fibres retract
the protruded mandible
• Helps in side to side
grinding movement
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20
• Temporalis tendon fascial complex – retromolar triangle
• Surgical exposure  post op pain
• Incisions for subperiosteal implants or harvesting bone from EOR or ramus 
below insertions of muscle
7/15/201721
BUCCAL OR FACIAL MUSCLE ATTACHMENTS -
Mentalis
Mentalis
7/15/201722
Origin Insertion
Periosteum of
the mental
tubercles and
sides of
mental
eminence
Skin of the
chin;
superiorly
interdigitate
with
orbicularis
oris
7/15/2017
23
DURING SURGICAL PROCEDURES….
Avoid complete
reflection of the
muscle  “witch’s
chin”
If completely
detached to expose
symphysis  elastic
bandage applied
externally to chin (4
days)
Alternatively , leave
proximal portion
attached to the
bone and reflect
the distal portion.
Approximation
done with
absorbable sutures
7/15/201724
BUCCAL OR FACIAL MUSCLE ATTACHMENTS -
Buccinator
7/15/201725
Buccinator
Origin Insertion
Lateral surfaces of
the alveolar
process of
maxilla, maxillary
tuberosity,
pterygoid
hamulus and
mandible in the
area of the molars
Upper and
lowerfibres blend
with that of the
Orbicularis Oris in
th eupper and
lower lip
Central fibres
decussate at the
modiolus – at the
nagl of the mouth
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DURING SURGICAL PROCEDURES………
Episodic pain and swelling at the site of origin of transaction muscle – after heavy
mastication or bruxism
No exudate or purulence
Responds to heat application
7/15/201727
BUCCAL OR FACIAL MUSCLE ATTACHMENTS -
Masseter
7/15/201728
Masseter
Origin Insertions
Superficial :
antr 2/3rd of
lower border of
zygomatic arech
Lower poart of
lateral surface
of ramus
Middle : antr
2/3rd of deep
surface and
postr 1/3rd of
lower border of
zygomatic arch
Middle part of
ramus
Deep : deep
surface of
zygomatic arch
Upper part of
ramus and
coronoid
process of
mandible
Nerve supply :
Massetric nerve
(branch of antr
division of
mandibular nerve
Actions :
Elevates
mandible
7/15/2017
29
DURING SURGICAL PROCEDURES….
Can be easily reflected –
ramus extension needed
for subperiosteal implants
Space between massetric
fascia and the muscle –
massetric space – infection
– mypsitis and trismus
7/15/201730
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION OF LOWER JAW
Inferior alveolar nerve Lingual nerve Nerve to mylohyoid Long buccal nerve
7/15/201731
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – Inferior alveolar nerve
Infratemporal fossa
Inferior border of
inferior head of lateral
pterygoid
Mandibular foramen
(medial aspect of
ramus)
Mandibular canal
Splits into mental and
incisive nerves at PM
region
Exits canal through
mental foramen
7/15/201732
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – Inferior alveolar nerve (contd)
• Mental foramen closer to crest of the ridge
• Avoid injury during reflection
• CBCTs, MRIs and conventional radiographic methods can be used to locate the
position
In a resorbed ridge….
• Tenderness
• Increase in amount of fibrous tissue around implant
If implant is in contact
with these structures
7/15/201733
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – Lingual nerve
Infratemporal fossa
Inferior border of
inferior head of lateral
pterygoid plate
Anterior to IAN
Between ramus and
medial pterygoid
Oral cavity – above
postr edge of
mylohyoid muscle
Third molar region –
medial to retromolar
pad
7/15/201734
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – Lingual nerve (contd…)
• lateral to retromolar padIncisions
• with periosteal elevator in constant contact with boneMucosal reflection
• ipsilateral paraesthesia , anaesthesia of innervated mucosa,
loss of taste, reduction of salivary secretion
Improper reflection
7/15/201735
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – NERVE TO MYLOHYOID
Motor branch of IAN
Given off before
mandibular foramen
groove on the medial
surface of
mandibular ramus
Submandibular
triangle
Postr border of
mylohyoid muscle
With submental
artery
Outer belly of
diagastric
7/15/201736
Contemporary implant dentistry Carl E Misch, 3rd ed
INNERVATION – LONG BUCCAL NERVE
Sensory branch
Between 2 heads of
lateral pterygoid
Medial to medial
temporalis tendon
Cheek mucosa,
alveolar mucosa,
attached gingiva
Buccinator
Level of external
oblique
7/15/201737
Contemporary implant dentistry Carl E Misch, 3rd ed
BLOOD SUPPLY
7/15/201738
Common
carotid artery
External carotid
aretry
Arch of aorta -
right
Brachiocephalic
artery - left
Contemporary implant dentistry Carl E Misch, 3rd ed
BLOOD SUPPLY
• Circulation is centrifugal
• Medullary region – nutrient arteries – large vessels that pass through bone
7/15/201739
Communicates
with vessels
supplying to
muscles and soft
tissues
Anastomoses with
fibrous layer of
periosteum
Periosteal plexus
Numerous vessels
are given off at
right angles
Reaches cortical
bone through
Volkmann’s canals
Endosteal or
medullary plexus
Contemporary implant dentistry Carl E Misch, 3rd ed
BLOOD SUPPLY - Mandible
Mesial
aspect of
ramus
Mandibular
canal
Body of
mandible
premolar
region
Two
terminal
branches
7/15/201740
Inferioralveolarartery
Downwards and
forwards Mental
Exits body of mandible
through mental foramen
Incisive
Medially anastomoses with
the arteries on the opp side
Contemporary implant dentistry Carl E Misch, 3rd ed
BLOOD SUPPLY – Changes with age
Direction of circulation may reverse with age
Susceptible to arterosclerotic changes  narrow and tortuous
Absence of flow may be associated with tooth extraction
Limitationof reflection may improve blood supply  complicates primary closure
7/15/201741
Contemporary implant dentistry Carl E Misch, 3rd ed
IMPLANT ZONES OF THE JAW
FIZ - 1
• Premaxilla
region
• Till 1st premolars
on either side
• Traumatic zone
FIZ-2
• Sinus zone
• Base of
maxillary sinus
• Based on
degree of sinus
pneumatization
FIZ – 3
• Inter-foraminal
zone
• Symphyseal
• Grafts are
usually
harvested
FIZ - 4
• Ischaemic zone
• 2nd premolar to
retromolar pad
7/15/201742
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
220.
CONCEPT OF RELATIVE ISCHAEMIA
Arterial supply –
centripetal –
depnds on the
external musculo
skeletal periosteal
source
Age causes
deficiency of
vascularization –
bone atrophy
Loss of teeth an
dlack of function
 degree of
cebtral arterial
pullback
May cause
relative ischaemia
of posterior
mandible and its
alveolar process
Compromises
bone repair and
growth –
osseointegration
– early implant
failures
7/15/201743
Contemporary implant dentistry Carl E Misch, 3rd ed
NEED FOR POSTERIOR TOOTH REPLACEMENT WITH
IMPLANTS
Molars – first permanent tooth to
erupt and first to get decayed
Decay , failed
endodontic therapy or
fracture
Longevity of FPD is
doubtful – survival
limitations
Caries and endo
failures, long term perio
health - common
7/15/201744
Contemporary implant dentistry Carl E Misch, 3rd ed
COMPARISION BETWEEN FPD AND IMPLANTS
FIXED PARTIAL DENTURES
• Estimated life span – 10 yrs (50 %
survival)
• Caries is most common reason for
failure
• Abutments may require endo therapy
IMPLANTS
• High success rate – 97% for 10 years
• Decreased risk of caries for adjacent
tooth
• Improved ability to clean
• Decreased abutment tooth loss
• Psychological advantage
7/15/2017
45
Contemporary implant dentistry Carl E Misch, 3rd ed
DIAGNOSIS AND TREATMENT PLANNING
7/15/2017
46
TREATMENT PLANNING CONSIDERATION
Available bone Available space Existing prosthesis
Natural tooth
adjacent to implant
site
Occlusal
considerations
Implant number and
position
Implant size Type of prosthesis
7/15/201747
Contemporary implant dentistry Carl E Misch, 3rd ed
AVAILABLE BONE- - DIVISIONS OF AVAILABLE
BONE
DivisionAbone
Width > 6mm
Height > 12mm
MD length >7mm
Angulation of occlusal load <25 degrees
CHS ≤15mm
7/15/201748
Contemporary implant dentistry Carl E Misch, 3rd ed
DIVISIONS OF AVAILABLE BONE
DivisionBbone
2.5 to 6mm wide (B+ : 4-6mm ; B-w : 2.5 to 4mm)
Height > 12mm
MD length > 6mm
Angulation < 20 degrees
CHS < 15mm
7/15/201749
Contemporary implant dentistry Carl E Misch, 3rd ed
DIVISION OF AVAILABLE BONE
DivisionCbone
Width (C-w): 0 to 2.5mm
Height (C-h) <12mm
Angulation of occlusal load (C-a bone)
>30 degrees
CHS >15mm
7/15/201750
Contemporary implant dentistry Carl E Misch, 3rd ed
AVAILABLE BONE – DIVISIONS OF AVAILABLE BONE
DivisionDbone
Severe atrophy
Basal bone loss
Flat maxilla
Pencil thin mandible
>20mm crown height
7/15/201751
Contemporary implant dentistry Carl E Misch, 3rd ed
AVAILABLE BONE –
BONE DENSITY
(MISCH IN 1988)
Bone density Description Tactile analogue Typical anatomic
location
D1 Dense cortical Oak / maple wood Anterior mandible
D2 Porous cortical and
coarse trabecular
White pine or spruce
wood
Anterior mandible
Posterior mandible
Anterior maxilla
D3 Porous cortical (thin)
and fine
Balsa wood Anterior maxilla
Posterior maxilla
Posterior mandible
D4 Fine trabecular Styrofoam Posterior maxilla
Contemporary implant dentistry Carl E Misch, 3rd ed
AVAILABLE SPACE
Mesio-distal
Bucco-lingual
Occluso-gingival
7/15/201753
Jivraj, S., and W. Chee. "Treatment planning of implants in posterior quadrants."
British dental journal 201.1 (2006): 13-23.
AVAILABLE SPACE : Mesio-distal
Allow
development of
occlusion and
embrasure forms
Depends on the
type and number
of tooth being
replaced
7/15/201754
Implant should be
1.5 mm away from
adjacent teeth
3mm away from
an adjacent
implant
Wider diameter
implant for
molars
Guidelines while evaluting M-D space
Contemporary implant dentistry Carl E Misch, 3rd ed
AVAILABLE SPACE : MESIO-DISTAL
7/15/201755
“CEJ – 2mm is a good
anatomic location to assess
the average size of a tooth
root and thus determine the
optimal implant size for
replacing the tooth.”
7/15/2017
56
AVAILABLE SPACE – Bucco- lingual
Minimum 6 mm bone present for a 4mm
implant and 7mm for a 5mm implant
Screw access –towards centre of occlusal
surface
Implants should be place in the correct
angulation
7/15/201757
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
AVAILABLE SPACE – Occluso-gingival
Adequate space
for restoration Adequate osseous
volume
7/15/201758
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
AVAILABLE SPACE – Occluso-gingival : Adequate
space for restoration
Premolar and molar – 10mm space between residual ridge and opposing occlusion
Missing tooth for long time
• Supraeruption and drifting
Minimal compromise
• Enameloplasty
• Orthodontic intrusion of teeth
• Elective endodontics, crown lengthening and preparation
• Extraction (short root trunk)
7/15/201759
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
CONSEQUENCES OF EXCESSIVE CROWN HEIGHT
SPACE
Excessive when
greater than
15mm
Vertical
cantilever – force
magnifier –
lateral forces
Forces
concentrated on
crestal 7-9mm
Greater the load
– greater tensile
and compressive
stress
7/15/201760
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
HOW TO DECREASE STRESS DUE TO EXCESSIVE
CHS?
Shorten cantilever
Minimize buccal and lingual offset
forces
More implants, bigger diameter
Maximize surface area
7/15/201761
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
I. AVAILABLE SPACE – Occluso-gingival
: Adequate osseous volume
Initially  unfavourable implant superstructure ratio  crestal bone loss
Anatomic landmarks should be evaluated
Diameter - wider implants
• Improved stability
• Greater surface are
• Improved force distribution
Implant needs to be placed slightly deeper – proper emergence profile
Placement of 2 implants in the molar position
7/15/201762 Standard protocol
• 7.5 mm bone – 6mm
implant
• 8.5 mm – 7mm
implant
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
EXISTING PROSTHESIS
Opposing soft
tissue supported
RPD – underlying
bone remodels –
modifies occlusal
conditions
Esthetic desires –
reasons for
dissactifaction
Pontic regions may
require CT grafts
7/15/201763
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
NATURAL TEETH OPPOSING IMPLANT SITE
Teeth
adjacent
to
implant
site
Abutment options
Extract/ maintain
Transitional abutments
Adjacent bone anatomy
7/15/201764
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
ABUTMENT OPTIONS
Natural tooth abutments of FPDs
– undergo failures
• Caries
• Endodontic failures
• Unretained restorations
Implants supported abutments
• More implants – enhances
bone-implant interface
• Increases amount of forces on
the abutment screws
7/15/201765
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
TRANSITIONAL ABUTMENTS
Lengthy
treatments
Allows bone
regeneration
Protect
edentulous
implant site
Extracted –
ideal implant
site
7/15/201766
Full arch rehabilitation
• Complete denture – dramatic
changes
• Asymtomatic teeth retained – fixed
temporary prosthesis
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
ADJACENT BONE ANATOMY
Graft the site if inadequate in width
Cantilever a ontic from two or more
natural teeth
Fabricate a prosthesis with one
pontic connecting implant and the
other a tooth
7/15/201767
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
OCCLUSAL CONSIDERATION
Maximum intercuspation
• Complete intercuspation of the opposing teeth independent of the condylar
position, sometimes regarded as the best fir of teeth regardless of condylar position
Centric occlusion
• Occlusion of opposing teeth when the mandible is in centric relation
7/15/201768
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
OCCLUSAL CONSIDERATIONS
Correction of occlusion
before treatment
Eliminate deflective tooth
contacts – evaluation of
noxious effects
7/15/201769
Selective
odontoplasty
Restoration
with a crown
Extraction of
offending
tooth
How?What?
TMJ conditions
Tooth sensitivity
Tooth mobility
Fractures or abfractions
Porcelain fracture
When?
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
IMPLANT NUMBER AND POSITION
Number of implants is dependent on bone quantity and quality
Inadequate bone volume – grafts
2 implants for molars
Position should aim at the elimination of cantilevers
Multiple missing teeth must be replaced with staggard implant
effect)
7/15/201770
25lb
25lb
PRINCIPLES OF IMPLANT POSITIONING
Vertical positioning of implants in the bone
Buccolingual positioning in bone
Mesio-distal positioning in bone
Trajectory or angulation of implant
7/15/201771
Babbush, Charles A., et al. Dental implants: the art and science. Elsevier Health
Sciences, 2010.
VERTICAL POSITIONING OF IMPLANTS IN BONE
7/15/201772
Babbush, Charles A., et al. Dental implants: the art and science. Elsevier Health
Sciences, 2010.
Chronic inflammation
– absence of good
biologic health
Full reconstruction –
prosthetic platform is
imm below gingival
crest – plaque
accumulation
Implant placed above
the gingival crest –
exposed – unesthetic
Biologic width determines
the vertical
placement of implants 
placement of implant
3mm below the crest of
gingiva
BUCCOLINGUAL POSITIONING IN BONE
• Buccal and lingual bones are responsible for supporting the overlying gingiva
• Placed too labially breakdown of buccal bone
7/15/201773
MESIO-DISTAL POSITIONING IN BONE
7/15/201774
Ideal anatomic distance between 2
implants
•
𝒘𝒊𝒅𝒕𝒉 𝒐𝒇 𝒕𝒐𝒐𝒕𝒉 𝟏
𝟐
+
𝒘𝒊𝒅𝒕𝒉 𝒐𝒇 𝒕𝒐𝒐𝒕𝒉 𝟐
𝟐
Distance between implant and natural tooth
• R1 + 2mm
ANGULATION OF IMPLANT
• Implants are best loaded vertically  placed perpendicular to the plane of
occlusion
7/15/201775
IMPLANT SIZE
Increased length –
provides
resistance to
torqueing forces
and increases BIC
Short implants –
higher failure rate
after loading
Softer bone
requires longer
implants
Wider implants –
greater BIC
0.25mm increase
in implant
diameter – 5%tp
10% increase in
SA
7/15/201776
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
TYPE OF PROSTHESIS
Screw
retained VS
cement
retained
Splinted or
non-splinted
Abutment
level VS
implant level
7/15/201777
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
SCREW RETAINED VS CEMENT RETAINED
Retrievablility is the key  facilitates
individual implant evaluation, soft
tissue inspection and any necessary
prosthesis modifications
Influenced by the tooth position
7/15/201778
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
SPLINTED VS NON SPLINTED
Multiple implants should always be splinted
Reduces the incidence of screw loosening
Manipulation of stress distribution
Better retention of prosthesis
Sectioning and soldering may be required to improve fit
7/15/201779
Contemporary implant dentistry Carl E Misch, 3rd ed
Tolstunov, Len. "Implant zones of the jaws: implant location and
related success rate." Journal of Oral Implantology 33.4 (2007): 211-
PROSTHETIC OPTIONS
7/15/2017
80
SEQUELAE OF PARTIAL EDENTULISM
Aesthetics Speech Drifting and tilting
Supra-erupted
teeth
Overloading of
remaining teeth
Loss of masticatory
efficiency
Loss of vertical
dimension
Mandibular
deviation
Loss of alveolar
bone
Combination
syndrome
7/15/201781
ALTERNATIVE OPTIONS FOR PARTIAL EDENTULISM
Removable partial denture
Resin bonded prosthesis
Fixed partial denture
Implant prosthesis
7/15/201782
MAINTENANCE OF POSTERIOR SPACE :
To replace or not to replace, that is the question.
• 90% masticatory efficiency  anterior to mesial half of mandibular 1st molar
7/15/201783
To prevent:
• Tipping
• Extrusion
• Increased plaque
accumulation
• Caries
• Periodontal
disease
• Collapse of
integrityof the arch
Why??
To replace or not to replace, that is the question….
Not in esthetic zone
More often exhibits
occlusal interferences
during excursions
Higher and less
predictable location of
mandibular canal
Less dense bone
Submandibular fossa
depth greater – angulation
of bone to occlusal plane
greater
Limited to infavorable
crown height space for
cement retention
Limited access for occlusal
screw placement
7/15/201784
To replace or not to replace, that is the question….
Limited access for
correct implant body
placement
Implant placed more
buccal than maxillary
tooth
Hygiene access more
difficult
Cheek biting more
common
Greater mandibular
flexure
Mandibular molars when
present moves forward;
intra tooth space limited
7/15/201785
CONTRAINDICATIONS FOR POSTERIOR IMPLANT
PLACEMENT
Inadequate bone volume
• Faciopalatal <5mm
• Mesiodistal <6.5 for a >3.5mm diameter implant
Moderate to advanced mobility of two to four adjacent teeth
Limited time for patient treatment
7/15/201786
PROSTHODONTIC CLASSIFICATION FOR IMPLANT
PROSTHESIS DESIGN
Type Definition
FP-1 Fixed prosthesis- replaces only the crown
FP-2 Replaces the crown and a portion of the root;
crown contour appears normal in the occlusal
half but is elongated or hyper-contoured in
the gingival half
FP-3 Replaces missing crowns and gingival colour
and portion of the edentulous site; prosthesis
most often used denture teeth and acrylic
gingiva but maybe porcelain to metal
RP-4 Overdenture supported completely by
implant
RP-5 Overdenture supported by both soft tissue
and implant
7/15/201787
7/15/2017
88
FP-1 FP-2 FP-3
FP-1 FP-2 FP-3
SURGICAL GUIDELINES
Posterior single tooth implant placement
7/15/2017
89
7/15/201790
BIBLIOGRAPHY
• B D Chaurasia's Human Anatomy, Volume 3 4th ed
• Contemporary implant dentistry Carl E Misch, 3rd ed
• Tolstunov, Len. "Implant zones of the jaws: implant location and related
success rate." Journal of Oral Implantology 33.4 (2007): 211-220.
• Jivraj, S., and W. Chee. "Treatment planning of implants in posterior
quadrants." British dental journal 201.1 (2006): 13-23.
7/15/201791
• KOIS, JOHN C. "Altering gingival levels: the restorative connection part I: biologic
variables." Journal of Esthetic and Restorative Dentistry 6.1 (1994): 3-7.
7/15/201792

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Treatment planning in posterior mandible

  • 1. 7/15/2017 1 “BY FAILING TO PREPARE, YOU ARE PREPARING TO FAIL.” - Benjamin Franklin
  • 2. IMPLANTS IN POSTERIOR MANDIBLE PRESENTED BY: APURVA THAMPI 7/15/2017 2
  • 3. CONTENTS • Introduction • Anatomy of mandible • Need for implants • Diagnosis and treatment planning • Factors affecting implant placement • Prosthetic considerations • Surgical considerations • Implant protected occlusion • Recent advances • Conclusion • References 7/15/2017 3 Part I Part II Part III
  • 5. ANATOMY OF THE MANDIBLE EXTRA-ORAL PALPABLE FEATURES • Symphysis • Inferior border of mandible • Pre-massetric notch • Gonial angle • Lateral pole of condyle • Coronoid process INTRA ORAL PALPABLE FEATURES • Retromolar triangle • Mental foramen • Torus mandibularis • Genial tubercles Coronoid process 7/15/2017 5 B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed
  • 6. MUSCLE ATTACHMENTS TO THE MANDIBLE Lingual or medial Buccal or facial 7/15/20176 B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed • Mylohyoid • Genioglossus • Medial pterygoid • Lateral pterygoid • Temporalis • Mentalis • Buccinator • Masseter
  • 7. LINGUAL OR MEDIAL ATTACHMENTS - Mylohyoid Mylohyoid muscle Origin Insertion Mylohyoid line of mandible Posterior fibres – body of hyoid bone Middle and anterior fibres median raphae beween mandible and hyoid bone Nerve supply : Nerve to mylohyoid Actions : • Elevates floor if the mouth during first stage of deglutition • Helps in depression of mandible, and elevation of hyoid bone 7/15/20177 B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed
  • 9. IN SEVERELY RESORBED MANDIBULAR RIDGES…. • Mylohyoid muscle approximates the crest of the ridge  injury to the muscle 7/15/20179 Swelling of sublingual space or submandib ular space complica tions Ecchymosis of the floor of the mouth Infection abcess  cellulitis B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed
  • 10. LINGUAL OR MEDIAL ATTACHMENTS - Genioglossus Genioglossus 7/15/201710 Origin Insertion Superior genial tubercle Anterior : dorsal surface of the tongue from root to tip Posterior : body of the hyoid bone Nerve supply : Hypoglossal nerve (cranial nerve XII) Actions : • Protrudes the tongue B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed
  • 12. IN A RESORBED MANDIBLE…. • Postioned at the crest of the mandibular ridge – divison C and D bone 7/15/201712 A portion may be reflected from genial tubercle Avoid injury during impression making B D Chaurasia's Human Anatomy, Volume 3 4th ed Contemporary implant dentistry Carl E Misch, 3rd ed
  • 13. LINGUAL OR MEDIAL ATTACHMENTS – Medial pterygoid Medial pterygoid 7/15/201713 Origin Insertion Superficial head : tuberosity of maxilla and adjoining bone Roughened area on the medial surface of the angle - ramus on mandible Deep head : medial surface of lateral pterygoid plate and adjoining process of palatine bone Nerve supply : nerve to medial pterygoid – branch of main trunk of mandibular nerve Action : • Elevates mandible • Helps protrude mandible • Right MP with left LP turn the chin side to side
  • 15. DURING SURGICAL PROCEDURES…. • MP bounds the pterygomandibular space medially 7/15/201715
  • 16. LINGUAL AND MEDIAL ATTACHMENTS – Lateral pterygoid Lateral pterygoid 7/15/201716 Origin Insertion Upper head : infratemporal surface and crest of greater wing of sphenoid Pterygoid fovea – anterior surface of neck of mandible Lower head: lateral surface of lateral pterygoid plate Antr margin of articular disc and capsule of TMJ Nerve supply : a branch from anterior division of mandibular nerve Actions: • Depress mandible • LP and MP protrude mandible • Grinding movements
  • 18. • Rarely involved in surgery for implants 7/15/201718
  • 19. LINGUAL OR MEDIAL ATTACHMENTS - Temporalis Temporalis 7/15/201719 Origin Insertion Temporal fossa excluding zygomatic bone Margins of the deep surface of the coronoid process Temporal fascia Anterior border of ramus of mandible Nerve supply : Two deep temporal branches from the anterior division of the mandibular nerve Actions : • Elevates mandible • Posterior fibres retract the protruded mandible • Helps in side to side grinding movement
  • 21. • Temporalis tendon fascial complex – retromolar triangle • Surgical exposure  post op pain • Incisions for subperiosteal implants or harvesting bone from EOR or ramus  below insertions of muscle 7/15/201721
  • 22. BUCCAL OR FACIAL MUSCLE ATTACHMENTS - Mentalis Mentalis 7/15/201722 Origin Insertion Periosteum of the mental tubercles and sides of mental eminence Skin of the chin; superiorly interdigitate with orbicularis oris
  • 24. DURING SURGICAL PROCEDURES…. Avoid complete reflection of the muscle  “witch’s chin” If completely detached to expose symphysis  elastic bandage applied externally to chin (4 days) Alternatively , leave proximal portion attached to the bone and reflect the distal portion. Approximation done with absorbable sutures 7/15/201724
  • 25. BUCCAL OR FACIAL MUSCLE ATTACHMENTS - Buccinator 7/15/201725 Buccinator Origin Insertion Lateral surfaces of the alveolar process of maxilla, maxillary tuberosity, pterygoid hamulus and mandible in the area of the molars Upper and lowerfibres blend with that of the Orbicularis Oris in th eupper and lower lip Central fibres decussate at the modiolus – at the nagl of the mouth
  • 27. DURING SURGICAL PROCEDURES……… Episodic pain and swelling at the site of origin of transaction muscle – after heavy mastication or bruxism No exudate or purulence Responds to heat application 7/15/201727
  • 28. BUCCAL OR FACIAL MUSCLE ATTACHMENTS - Masseter 7/15/201728 Masseter Origin Insertions Superficial : antr 2/3rd of lower border of zygomatic arech Lower poart of lateral surface of ramus Middle : antr 2/3rd of deep surface and postr 1/3rd of lower border of zygomatic arch Middle part of ramus Deep : deep surface of zygomatic arch Upper part of ramus and coronoid process of mandible Nerve supply : Massetric nerve (branch of antr division of mandibular nerve Actions : Elevates mandible
  • 30. DURING SURGICAL PROCEDURES…. Can be easily reflected – ramus extension needed for subperiosteal implants Space between massetric fascia and the muscle – massetric space – infection – mypsitis and trismus 7/15/201730 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 31. INNERVATION OF LOWER JAW Inferior alveolar nerve Lingual nerve Nerve to mylohyoid Long buccal nerve 7/15/201731 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 32. INNERVATION – Inferior alveolar nerve Infratemporal fossa Inferior border of inferior head of lateral pterygoid Mandibular foramen (medial aspect of ramus) Mandibular canal Splits into mental and incisive nerves at PM region Exits canal through mental foramen 7/15/201732 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 33. INNERVATION – Inferior alveolar nerve (contd) • Mental foramen closer to crest of the ridge • Avoid injury during reflection • CBCTs, MRIs and conventional radiographic methods can be used to locate the position In a resorbed ridge…. • Tenderness • Increase in amount of fibrous tissue around implant If implant is in contact with these structures 7/15/201733 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 34. INNERVATION – Lingual nerve Infratemporal fossa Inferior border of inferior head of lateral pterygoid plate Anterior to IAN Between ramus and medial pterygoid Oral cavity – above postr edge of mylohyoid muscle Third molar region – medial to retromolar pad 7/15/201734 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 35. INNERVATION – Lingual nerve (contd…) • lateral to retromolar padIncisions • with periosteal elevator in constant contact with boneMucosal reflection • ipsilateral paraesthesia , anaesthesia of innervated mucosa, loss of taste, reduction of salivary secretion Improper reflection 7/15/201735 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 36. INNERVATION – NERVE TO MYLOHYOID Motor branch of IAN Given off before mandibular foramen groove on the medial surface of mandibular ramus Submandibular triangle Postr border of mylohyoid muscle With submental artery Outer belly of diagastric 7/15/201736 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 37. INNERVATION – LONG BUCCAL NERVE Sensory branch Between 2 heads of lateral pterygoid Medial to medial temporalis tendon Cheek mucosa, alveolar mucosa, attached gingiva Buccinator Level of external oblique 7/15/201737 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 38. BLOOD SUPPLY 7/15/201738 Common carotid artery External carotid aretry Arch of aorta - right Brachiocephalic artery - left Contemporary implant dentistry Carl E Misch, 3rd ed
  • 39. BLOOD SUPPLY • Circulation is centrifugal • Medullary region – nutrient arteries – large vessels that pass through bone 7/15/201739 Communicates with vessels supplying to muscles and soft tissues Anastomoses with fibrous layer of periosteum Periosteal plexus Numerous vessels are given off at right angles Reaches cortical bone through Volkmann’s canals Endosteal or medullary plexus Contemporary implant dentistry Carl E Misch, 3rd ed
  • 40. BLOOD SUPPLY - Mandible Mesial aspect of ramus Mandibular canal Body of mandible premolar region Two terminal branches 7/15/201740 Inferioralveolarartery Downwards and forwards Mental Exits body of mandible through mental foramen Incisive Medially anastomoses with the arteries on the opp side Contemporary implant dentistry Carl E Misch, 3rd ed
  • 41. BLOOD SUPPLY – Changes with age Direction of circulation may reverse with age Susceptible to arterosclerotic changes  narrow and tortuous Absence of flow may be associated with tooth extraction Limitationof reflection may improve blood supply  complicates primary closure 7/15/201741 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 42. IMPLANT ZONES OF THE JAW FIZ - 1 • Premaxilla region • Till 1st premolars on either side • Traumatic zone FIZ-2 • Sinus zone • Base of maxillary sinus • Based on degree of sinus pneumatization FIZ – 3 • Inter-foraminal zone • Symphyseal • Grafts are usually harvested FIZ - 4 • Ischaemic zone • 2nd premolar to retromolar pad 7/15/201742 Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211- 220.
  • 43. CONCEPT OF RELATIVE ISCHAEMIA Arterial supply – centripetal – depnds on the external musculo skeletal periosteal source Age causes deficiency of vascularization – bone atrophy Loss of teeth an dlack of function  degree of cebtral arterial pullback May cause relative ischaemia of posterior mandible and its alveolar process Compromises bone repair and growth – osseointegration – early implant failures 7/15/201743 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 44. NEED FOR POSTERIOR TOOTH REPLACEMENT WITH IMPLANTS Molars – first permanent tooth to erupt and first to get decayed Decay , failed endodontic therapy or fracture Longevity of FPD is doubtful – survival limitations Caries and endo failures, long term perio health - common 7/15/201744 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 45. COMPARISION BETWEEN FPD AND IMPLANTS FIXED PARTIAL DENTURES • Estimated life span – 10 yrs (50 % survival) • Caries is most common reason for failure • Abutments may require endo therapy IMPLANTS • High success rate – 97% for 10 years • Decreased risk of caries for adjacent tooth • Improved ability to clean • Decreased abutment tooth loss • Psychological advantage 7/15/2017 45 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 46. DIAGNOSIS AND TREATMENT PLANNING 7/15/2017 46
  • 47. TREATMENT PLANNING CONSIDERATION Available bone Available space Existing prosthesis Natural tooth adjacent to implant site Occlusal considerations Implant number and position Implant size Type of prosthesis 7/15/201747 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 48. AVAILABLE BONE- - DIVISIONS OF AVAILABLE BONE DivisionAbone Width > 6mm Height > 12mm MD length >7mm Angulation of occlusal load <25 degrees CHS ≤15mm 7/15/201748 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 49. DIVISIONS OF AVAILABLE BONE DivisionBbone 2.5 to 6mm wide (B+ : 4-6mm ; B-w : 2.5 to 4mm) Height > 12mm MD length > 6mm Angulation < 20 degrees CHS < 15mm 7/15/201749 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 50. DIVISION OF AVAILABLE BONE DivisionCbone Width (C-w): 0 to 2.5mm Height (C-h) <12mm Angulation of occlusal load (C-a bone) >30 degrees CHS >15mm 7/15/201750 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 51. AVAILABLE BONE – DIVISIONS OF AVAILABLE BONE DivisionDbone Severe atrophy Basal bone loss Flat maxilla Pencil thin mandible >20mm crown height 7/15/201751 Contemporary implant dentistry Carl E Misch, 3rd ed
  • 52. AVAILABLE BONE – BONE DENSITY (MISCH IN 1988) Bone density Description Tactile analogue Typical anatomic location D1 Dense cortical Oak / maple wood Anterior mandible D2 Porous cortical and coarse trabecular White pine or spruce wood Anterior mandible Posterior mandible Anterior maxilla D3 Porous cortical (thin) and fine Balsa wood Anterior maxilla Posterior maxilla Posterior mandible D4 Fine trabecular Styrofoam Posterior maxilla Contemporary implant dentistry Carl E Misch, 3rd ed
  • 53. AVAILABLE SPACE Mesio-distal Bucco-lingual Occluso-gingival 7/15/201753 Jivraj, S., and W. Chee. "Treatment planning of implants in posterior quadrants." British dental journal 201.1 (2006): 13-23.
  • 54. AVAILABLE SPACE : Mesio-distal Allow development of occlusion and embrasure forms Depends on the type and number of tooth being replaced 7/15/201754 Implant should be 1.5 mm away from adjacent teeth 3mm away from an adjacent implant Wider diameter implant for molars Guidelines while evaluting M-D space Contemporary implant dentistry Carl E Misch, 3rd ed
  • 55. AVAILABLE SPACE : MESIO-DISTAL 7/15/201755 “CEJ – 2mm is a good anatomic location to assess the average size of a tooth root and thus determine the optimal implant size for replacing the tooth.”
  • 57. AVAILABLE SPACE – Bucco- lingual Minimum 6 mm bone present for a 4mm implant and 7mm for a 5mm implant Screw access –towards centre of occlusal surface Implants should be place in the correct angulation 7/15/201757 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 58. AVAILABLE SPACE – Occluso-gingival Adequate space for restoration Adequate osseous volume 7/15/201758 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 59. AVAILABLE SPACE – Occluso-gingival : Adequate space for restoration Premolar and molar – 10mm space between residual ridge and opposing occlusion Missing tooth for long time • Supraeruption and drifting Minimal compromise • Enameloplasty • Orthodontic intrusion of teeth • Elective endodontics, crown lengthening and preparation • Extraction (short root trunk) 7/15/201759 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 60. CONSEQUENCES OF EXCESSIVE CROWN HEIGHT SPACE Excessive when greater than 15mm Vertical cantilever – force magnifier – lateral forces Forces concentrated on crestal 7-9mm Greater the load – greater tensile and compressive stress 7/15/201760 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 61. HOW TO DECREASE STRESS DUE TO EXCESSIVE CHS? Shorten cantilever Minimize buccal and lingual offset forces More implants, bigger diameter Maximize surface area 7/15/201761 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 62. I. AVAILABLE SPACE – Occluso-gingival : Adequate osseous volume Initially  unfavourable implant superstructure ratio  crestal bone loss Anatomic landmarks should be evaluated Diameter - wider implants • Improved stability • Greater surface are • Improved force distribution Implant needs to be placed slightly deeper – proper emergence profile Placement of 2 implants in the molar position 7/15/201762 Standard protocol • 7.5 mm bone – 6mm implant • 8.5 mm – 7mm implant Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 63. EXISTING PROSTHESIS Opposing soft tissue supported RPD – underlying bone remodels – modifies occlusal conditions Esthetic desires – reasons for dissactifaction Pontic regions may require CT grafts 7/15/201763 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 64. NATURAL TEETH OPPOSING IMPLANT SITE Teeth adjacent to implant site Abutment options Extract/ maintain Transitional abutments Adjacent bone anatomy 7/15/201764 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 65. ABUTMENT OPTIONS Natural tooth abutments of FPDs – undergo failures • Caries • Endodontic failures • Unretained restorations Implants supported abutments • More implants – enhances bone-implant interface • Increases amount of forces on the abutment screws 7/15/201765 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 66. TRANSITIONAL ABUTMENTS Lengthy treatments Allows bone regeneration Protect edentulous implant site Extracted – ideal implant site 7/15/201766 Full arch rehabilitation • Complete denture – dramatic changes • Asymtomatic teeth retained – fixed temporary prosthesis Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 67. ADJACENT BONE ANATOMY Graft the site if inadequate in width Cantilever a ontic from two or more natural teeth Fabricate a prosthesis with one pontic connecting implant and the other a tooth 7/15/201767 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 68. OCCLUSAL CONSIDERATION Maximum intercuspation • Complete intercuspation of the opposing teeth independent of the condylar position, sometimes regarded as the best fir of teeth regardless of condylar position Centric occlusion • Occlusion of opposing teeth when the mandible is in centric relation 7/15/201768 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 69. OCCLUSAL CONSIDERATIONS Correction of occlusion before treatment Eliminate deflective tooth contacts – evaluation of noxious effects 7/15/201769 Selective odontoplasty Restoration with a crown Extraction of offending tooth How?What? TMJ conditions Tooth sensitivity Tooth mobility Fractures or abfractions Porcelain fracture When? Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 70. IMPLANT NUMBER AND POSITION Number of implants is dependent on bone quantity and quality Inadequate bone volume – grafts 2 implants for molars Position should aim at the elimination of cantilevers Multiple missing teeth must be replaced with staggard implant effect) 7/15/201770 25lb 25lb
  • 71. PRINCIPLES OF IMPLANT POSITIONING Vertical positioning of implants in the bone Buccolingual positioning in bone Mesio-distal positioning in bone Trajectory or angulation of implant 7/15/201771 Babbush, Charles A., et al. Dental implants: the art and science. Elsevier Health Sciences, 2010.
  • 72. VERTICAL POSITIONING OF IMPLANTS IN BONE 7/15/201772 Babbush, Charles A., et al. Dental implants: the art and science. Elsevier Health Sciences, 2010. Chronic inflammation – absence of good biologic health Full reconstruction – prosthetic platform is imm below gingival crest – plaque accumulation Implant placed above the gingival crest – exposed – unesthetic Biologic width determines the vertical placement of implants  placement of implant 3mm below the crest of gingiva
  • 73. BUCCOLINGUAL POSITIONING IN BONE • Buccal and lingual bones are responsible for supporting the overlying gingiva • Placed too labially breakdown of buccal bone 7/15/201773
  • 74. MESIO-DISTAL POSITIONING IN BONE 7/15/201774 Ideal anatomic distance between 2 implants • 𝒘𝒊𝒅𝒕𝒉 𝒐𝒇 𝒕𝒐𝒐𝒕𝒉 𝟏 𝟐 + 𝒘𝒊𝒅𝒕𝒉 𝒐𝒇 𝒕𝒐𝒐𝒕𝒉 𝟐 𝟐 Distance between implant and natural tooth • R1 + 2mm
  • 75. ANGULATION OF IMPLANT • Implants are best loaded vertically  placed perpendicular to the plane of occlusion 7/15/201775
  • 76. IMPLANT SIZE Increased length – provides resistance to torqueing forces and increases BIC Short implants – higher failure rate after loading Softer bone requires longer implants Wider implants – greater BIC 0.25mm increase in implant diameter – 5%tp 10% increase in SA 7/15/201776 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 77. TYPE OF PROSTHESIS Screw retained VS cement retained Splinted or non-splinted Abutment level VS implant level 7/15/201777 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 78. SCREW RETAINED VS CEMENT RETAINED Retrievablility is the key  facilitates individual implant evaluation, soft tissue inspection and any necessary prosthesis modifications Influenced by the tooth position 7/15/201778 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 79. SPLINTED VS NON SPLINTED Multiple implants should always be splinted Reduces the incidence of screw loosening Manipulation of stress distribution Better retention of prosthesis Sectioning and soldering may be required to improve fit 7/15/201779 Contemporary implant dentistry Carl E Misch, 3rd ed Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-
  • 81. SEQUELAE OF PARTIAL EDENTULISM Aesthetics Speech Drifting and tilting Supra-erupted teeth Overloading of remaining teeth Loss of masticatory efficiency Loss of vertical dimension Mandibular deviation Loss of alveolar bone Combination syndrome 7/15/201781
  • 82. ALTERNATIVE OPTIONS FOR PARTIAL EDENTULISM Removable partial denture Resin bonded prosthesis Fixed partial denture Implant prosthesis 7/15/201782
  • 83. MAINTENANCE OF POSTERIOR SPACE : To replace or not to replace, that is the question. • 90% masticatory efficiency  anterior to mesial half of mandibular 1st molar 7/15/201783 To prevent: • Tipping • Extrusion • Increased plaque accumulation • Caries • Periodontal disease • Collapse of integrityof the arch Why??
  • 84. To replace or not to replace, that is the question…. Not in esthetic zone More often exhibits occlusal interferences during excursions Higher and less predictable location of mandibular canal Less dense bone Submandibular fossa depth greater – angulation of bone to occlusal plane greater Limited to infavorable crown height space for cement retention Limited access for occlusal screw placement 7/15/201784
  • 85. To replace or not to replace, that is the question…. Limited access for correct implant body placement Implant placed more buccal than maxillary tooth Hygiene access more difficult Cheek biting more common Greater mandibular flexure Mandibular molars when present moves forward; intra tooth space limited 7/15/201785
  • 86. CONTRAINDICATIONS FOR POSTERIOR IMPLANT PLACEMENT Inadequate bone volume • Faciopalatal <5mm • Mesiodistal <6.5 for a >3.5mm diameter implant Moderate to advanced mobility of two to four adjacent teeth Limited time for patient treatment 7/15/201786
  • 87. PROSTHODONTIC CLASSIFICATION FOR IMPLANT PROSTHESIS DESIGN Type Definition FP-1 Fixed prosthesis- replaces only the crown FP-2 Replaces the crown and a portion of the root; crown contour appears normal in the occlusal half but is elongated or hyper-contoured in the gingival half FP-3 Replaces missing crowns and gingival colour and portion of the edentulous site; prosthesis most often used denture teeth and acrylic gingiva but maybe porcelain to metal RP-4 Overdenture supported completely by implant RP-5 Overdenture supported by both soft tissue and implant 7/15/201787
  • 89. SURGICAL GUIDELINES Posterior single tooth implant placement 7/15/2017 89
  • 91. BIBLIOGRAPHY • B D Chaurasia's Human Anatomy, Volume 3 4th ed • Contemporary implant dentistry Carl E Misch, 3rd ed • Tolstunov, Len. "Implant zones of the jaws: implant location and related success rate." Journal of Oral Implantology 33.4 (2007): 211-220. • Jivraj, S., and W. Chee. "Treatment planning of implants in posterior quadrants." British dental journal 201.1 (2006): 13-23. 7/15/201791
  • 92. • KOIS, JOHN C. "Altering gingival levels: the restorative connection part I: biologic variables." Journal of Esthetic and Restorative Dentistry 6.1 (1994): 3-7. 7/15/201792

Editor's Notes

  1. External oblique ridge o the same level as an atrophied ridge
  2. Structures above the mylohyoid are sublingual or intraoral in location and those below are extra oral or sub cutaneous
  3. Insertion : below and behind the mandibular foramen and mylohyoid groove
  4. Pterygomandibular space is entered when the IANB is involved. Infection of this space is dangerous  proximity to the parapharyngeal space and the potential for spread of infection to the mediastinum
  5. FIZ – 2 : vertical bone deficiency
  6. Abutment teeth are more prone to caries when splinted together with pontic - plaque accumulation - reservoir
  7. Molar teeth are wider MD – 2.5 mm away from adjacent tooth
  8. 7mm bare minimum (8-12mm Misch)
  9. Remove restorations during sleep – noxious parafuntion
  10. Studies showed that 6-8 mm shorter implants did not show increased crestal bone loss in comparison to longer 10-12 mm implants
  11. Cantilevers are force magnifiers -
  12. A natural tooth has a gingival sulcus, JE and connective tissue attachment An implant has a sulcus, CT attachment almost till the bone and bone implant contact. Connective tissue attachment serves as a robust mechanism of attachment thereby protecting it from the oral environment – lacking in implants
  13. Apply these measurements to the teeth on the contralateral side and then determine the ideal distance between two implants
  14. Elevated risk of paraesthesia and neurovascular bundle damage during implant surgery
  15. Posterior healthy teeth - 28μm and lateral movement - <78μm – heavy bite force allows movement within physiological limits. Mobile teeth – implant crown will come into contact before the conclusion of adjacent natural teeth movement. – implant bears the load of all the mobile teeth