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Basic Surgical Techniques for
Endosseous Implant Placement
Bilozetskyi Ivan
 Dental implant is
an artificial titanium
fixture
which is placed
surgically into the
jaw bone to
substitute for a missing
tooth and its root(s).
WHAT IS A DENTAL IMPLANT?
In 1952, Professor Per-Ingvar Branemark,
a Swedish surgeon, while conducting research
into the healing patterns of bone tissue, accidentally
discovered that when pure titanium comes into
direct contact with the living bone tissue, the two
literally grow together to form a permanent
biological adhesion. He named this phenomenon
"osseointegration".
History of Dental Implants
All current implant
designs are
modifications of this
initial design
First Implant Design by Branemark
STEP 1: INITIAL SURGERY
STEP 2: OSSEOINTEGRATION PERIOD
STEP 3: ABUTMENT CONNECTION
STEP 4: FINAL PROSTHETIC
RESTORATION
Surgical Procedure
Fibro-osseous integration
• Fibroosseous integration
– “tissue to implant contact with dense collagenous
tissue between the implant and bone”
• Seen in earlier implant systems.
• Initially good success rates but extremely
poor long term success.
• Considered a “failure” by todays standards
Dental  implants. surgical stages
Osseointegration
• Success Rates >90%
• Histologic definition
– “direct connection between living bone and load-
bearing endosseous implants at the light
microscopic level.”
• 4 factors that influence:
Biocompatible material
Implant adapted to prepared site
Atraumatic surgery
Undisturbed healing phase
Soft-tissue to implant interface
• Successful implants have an
– Unbroken, perimucosal seal between the soft
tissue and the implant abutment surface.
• Connect similarly to natural teeth-some
differences.
– Epithelium attaches to surface of titanium much
like a natural tooth through a basal lamina and the
formation of hemidesmosomes.
Soft-tissue to implant interface
• Connection differs at the connective tissue
level.
• Natural tooth Sharpies fibers extent from the
bundle bone of the lamina dura and insert into
the cementum of the tooth root surface
• Implant: No Cementum or Fiber insertion.
Hence the Epithelial surface attachment is
IMPORTANT
Dental  implants. surgical stages
Subperiosteal
Transmandibular Implant
Dental  implants. surgical stages
Dental  implants. surgical stages
Blade Implant
Endosteal Implants
The “Parts”
• Implant body-fixture
• Abutment (gingival/temporary healing vs.
final)
• Prosthetics
Clinical Components
abutment
Team Approach
• A surgical – prosthodontic consultation is
done prior to implant placement to address:
– soft-tissue management
– surgical sequence
– healing time
– need for ridge and soft-tissue augmentation
Clinical Assessment
• Assess the CC and Expectations
• Review all restorative options:
– Risks and Benefits
• Select option that meets functional and
esthetic requirements
Patient Evaluation
• Medical history
– vascular disease
– immunodeficiency
– diabetes mellitus
– tobacco use
– bisphosphonate use
History of Implant Site
• Factors regarding loss of tooth being replaced
– When?
– How?
– Why?
• Factors that may affect hard and soft tissues:
– Traumatic injuries
– Failed endodontic procedures
– Periodontal disease
• Clinical exam may identify ridge deficiencies
Surgical Phase- Treatment Planning
• Evaluation of Implant Site
• Radiographic Evaluation
• Bone Height, Bone Width and Anatomic
considerations
Basic Principles
• Soft/ hard tissue graft bed
• Existing occlusion/ dentition
• Simultaneous vs. delayed reconstruction
Smile Line
• One of the most influencing factors of any
prosthodontic restoration
• If no gingival shows then the soft tissue
quality, quantity and contours are less
important
• Patient counseling on treatment
expectations is critical
Anatomic Considerations
• Ridge relationship
• Attached tissue
• Interarch clearance
• Inferior alveolar nerve
• Maxillary sinus
• Floor of nose
Radiological/Imaging Studies
• Periapical radiographs
• Panoramic radiograph
• Site specific tomograms
• CAT scan (Denta-scan, cone beam CT)
Width of Space and Diameter of Implant
Attention must be paid to both the coronal and
interradicular spaces
Dental  implants. surgical stages
A case against routine CT
• Expense
• Time consuming process
• Use of radiographic template/proper fit
requires DDS present
• Contemporary panoramic units have
tomographic capabilities
• Usually adds no additional data over
standard database
Dental  implants. surgical stages
Dental  implants. surgical stages
Image Distortion
Anatomic Limitations
Buccal Plate 0.5mm
Lingual Plate 1.0 mm
Maxillary Sinus 1.0 mm
Nasal Cavity 1.0mm
Incisive canal Avoid
Interimplant distance 1-1.5mm
Inferior alveolar canal 2.0mm
Mental nerve 5mm from foramen
Inferior border 1 mm
Adjacent to natural tooth 0.5mm
Dental Implant Surgery Phase I
• Aseptic technique
• Minimal heat generation
– slow sharp drills
– internal irrigation?
– external cooling
Dental Implant Surgery Phase I
• Adequate time for integration
• Adequate recipient site
– soft tissue
– bone
• Kind & Gentle technique
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
1. Chlorhexidine
2. Analgesics
+/- antibiotics
Disposition
Implant placement 3 months after menton bone
grafting
Dental  implants. surgical stages
Dental  implants. surgical stages
Exposure of Implant during
Placement
Dental  implants. surgical stages
Dental  implants. surgical stages
Summer’s Osteotomes
Limitations to Implant placement in the
Maxilla
• Ridge width
• Ridge height
• Bone quality
Surgical Solutions to Anatomical
Limitations
Onlay Bone Graft Sinus Lift
Summers, RB. A New concept in Maxillary
Implant Surgery: The Osteotome technique.
Compendium. 15(2): 152, 154-6
• Ridge expansion technique
– 3-4 mm of crestal alveolar width
required
• Sinus floor elevation technique
– 8-9 mm of alveolar bone height
required in order to place a 13 mm
implant
(4-5 mm sinus floor elevation)
Dental  implants. surgical stages
Introduction
Ridge expansion technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– sequenced tapered osteotomes.
– ridge expansion (displacement) versus
bone removal.
• Final drill coincident with the final
implant size (sometimes not
necessary)
Dental  implants. surgical stages
Introduction
Sinus floor elevation technique
• 1.6 mm pilot hole
• Summers osteotome # 1-4
– Sinus floor microfractured superiorly
– Sinus floor can be elevated 4-5 mm
– May backfill with bone allograft/alloplast
• Final drill coincident with final
implant size
Dental  implants. surgical stages
Surgical Technique
Dental  implants. surgical stages
A. Rake, K. Andreasen, S. Rake, J. Swift A Retrospective
Analysis of Osteointegration in the Maxilla Utilizing an
Osteotome Technique versus a Sequential Drilling
Technique, 1999 AAOMS Abstract
• 155 maxillary implants in 84 patients restored
for at least 6 months
– 57 were placed utilizing the osteotome technique
– 98 were placed utilizing the drilling technique
• One implant failed of the 98 in the drill group
• None of the implants had failed of the 57 in the
osteotome group
Stage II Surgery Preoperative
Considerations
• 3-6 months after stage I
Stage II Surgery Preoperative
Considerations
• Done under local anesthesia
• Pre-op medications
– Chlorhexidine rinse
Dental  implants. surgical stages
Dental  implants. surgical stages
Placement of
healing abutment
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
Dental  implants. surgical stages
• The failing implant is very difficult to treat
• Traumatic surgical manipulation with
initial instability of implant increases risk
of failure
• Implant success is only as good as the
prosthodontic reconstruction
conclusions

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Dental implants. surgical stages

  • 1. Basic Surgical Techniques for Endosseous Implant Placement Bilozetskyi Ivan
  • 2.  Dental implant is an artificial titanium fixture which is placed surgically into the jaw bone to substitute for a missing tooth and its root(s). WHAT IS A DENTAL IMPLANT?
  • 3. In 1952, Professor Per-Ingvar Branemark, a Swedish surgeon, while conducting research into the healing patterns of bone tissue, accidentally discovered that when pure titanium comes into direct contact with the living bone tissue, the two literally grow together to form a permanent biological adhesion. He named this phenomenon "osseointegration". History of Dental Implants
  • 4. All current implant designs are modifications of this initial design First Implant Design by Branemark
  • 5. STEP 1: INITIAL SURGERY STEP 2: OSSEOINTEGRATION PERIOD STEP 3: ABUTMENT CONNECTION STEP 4: FINAL PROSTHETIC RESTORATION Surgical Procedure
  • 6. Fibro-osseous integration • Fibroosseous integration – “tissue to implant contact with dense collagenous tissue between the implant and bone” • Seen in earlier implant systems. • Initially good success rates but extremely poor long term success. • Considered a “failure” by todays standards
  • 8. Osseointegration • Success Rates >90% • Histologic definition – “direct connection between living bone and load- bearing endosseous implants at the light microscopic level.” • 4 factors that influence: Biocompatible material Implant adapted to prepared site Atraumatic surgery Undisturbed healing phase
  • 9. Soft-tissue to implant interface • Successful implants have an – Unbroken, perimucosal seal between the soft tissue and the implant abutment surface. • Connect similarly to natural teeth-some differences. – Epithelium attaches to surface of titanium much like a natural tooth through a basal lamina and the formation of hemidesmosomes.
  • 10. Soft-tissue to implant interface • Connection differs at the connective tissue level. • Natural tooth Sharpies fibers extent from the bundle bone of the lamina dura and insert into the cementum of the tooth root surface • Implant: No Cementum or Fiber insertion. Hence the Epithelial surface attachment is IMPORTANT
  • 18. The “Parts” • Implant body-fixture • Abutment (gingival/temporary healing vs. final) • Prosthetics
  • 21. Team Approach • A surgical – prosthodontic consultation is done prior to implant placement to address: – soft-tissue management – surgical sequence – healing time – need for ridge and soft-tissue augmentation
  • 22. Clinical Assessment • Assess the CC and Expectations • Review all restorative options: – Risks and Benefits • Select option that meets functional and esthetic requirements
  • 23. Patient Evaluation • Medical history – vascular disease – immunodeficiency – diabetes mellitus – tobacco use – bisphosphonate use
  • 24. History of Implant Site • Factors regarding loss of tooth being replaced – When? – How? – Why? • Factors that may affect hard and soft tissues: – Traumatic injuries – Failed endodontic procedures – Periodontal disease • Clinical exam may identify ridge deficiencies
  • 25. Surgical Phase- Treatment Planning • Evaluation of Implant Site • Radiographic Evaluation • Bone Height, Bone Width and Anatomic considerations
  • 26. Basic Principles • Soft/ hard tissue graft bed • Existing occlusion/ dentition • Simultaneous vs. delayed reconstruction
  • 27. Smile Line • One of the most influencing factors of any prosthodontic restoration • If no gingival shows then the soft tissue quality, quantity and contours are less important • Patient counseling on treatment expectations is critical
  • 28. Anatomic Considerations • Ridge relationship • Attached tissue • Interarch clearance • Inferior alveolar nerve • Maxillary sinus • Floor of nose
  • 29. Radiological/Imaging Studies • Periapical radiographs • Panoramic radiograph • Site specific tomograms • CAT scan (Denta-scan, cone beam CT)
  • 30. Width of Space and Diameter of Implant Attention must be paid to both the coronal and interradicular spaces
  • 32. A case against routine CT • Expense • Time consuming process • Use of radiographic template/proper fit requires DDS present • Contemporary panoramic units have tomographic capabilities • Usually adds no additional data over standard database
  • 36. Anatomic Limitations Buccal Plate 0.5mm Lingual Plate 1.0 mm Maxillary Sinus 1.0 mm Nasal Cavity 1.0mm Incisive canal Avoid Interimplant distance 1-1.5mm Inferior alveolar canal 2.0mm Mental nerve 5mm from foramen Inferior border 1 mm Adjacent to natural tooth 0.5mm
  • 37. Dental Implant Surgery Phase I • Aseptic technique • Minimal heat generation – slow sharp drills – internal irrigation? – external cooling
  • 38. Dental Implant Surgery Phase I • Adequate time for integration • Adequate recipient site – soft tissue – bone • Kind & Gentle technique
  • 48. 1. Chlorhexidine 2. Analgesics +/- antibiotics Disposition
  • 49. Implant placement 3 months after menton bone grafting
  • 52. Exposure of Implant during Placement
  • 56. Limitations to Implant placement in the Maxilla • Ridge width • Ridge height • Bone quality
  • 57. Surgical Solutions to Anatomical Limitations Onlay Bone Graft Sinus Lift
  • 58. Summers, RB. A New concept in Maxillary Implant Surgery: The Osteotome technique. Compendium. 15(2): 152, 154-6 • Ridge expansion technique – 3-4 mm of crestal alveolar width required • Sinus floor elevation technique – 8-9 mm of alveolar bone height required in order to place a 13 mm implant (4-5 mm sinus floor elevation)
  • 60. Introduction Ridge expansion technique • 1.6 mm pilot hole • Summers osteotome # 1-4 – sequenced tapered osteotomes. – ridge expansion (displacement) versus bone removal. • Final drill coincident with the final implant size (sometimes not necessary)
  • 62. Introduction Sinus floor elevation technique • 1.6 mm pilot hole • Summers osteotome # 1-4 – Sinus floor microfractured superiorly – Sinus floor can be elevated 4-5 mm – May backfill with bone allograft/alloplast • Final drill coincident with final implant size
  • 66. A. Rake, K. Andreasen, S. Rake, J. Swift A Retrospective Analysis of Osteointegration in the Maxilla Utilizing an Osteotome Technique versus a Sequential Drilling Technique, 1999 AAOMS Abstract • 155 maxillary implants in 84 patients restored for at least 6 months – 57 were placed utilizing the osteotome technique – 98 were placed utilizing the drilling technique • One implant failed of the 98 in the drill group • None of the implants had failed of the 57 in the osteotome group
  • 67. Stage II Surgery Preoperative Considerations • 3-6 months after stage I
  • 68. Stage II Surgery Preoperative Considerations • Done under local anesthesia • Pre-op medications – Chlorhexidine rinse
  • 78. • The failing implant is very difficult to treat • Traumatic surgical manipulation with initial instability of implant increases risk of failure • Implant success is only as good as the prosthodontic reconstruction conclusions