brief review of recent advances in implant dentistry

2. Recent advances in
Implantology
Presented by
Pallavi Chavan

3. Introduction
◉The science of implantology is highly dynamic. Ever since its
introduction into the field of dentistry by Dr. Branemark, it has
undergone numerous modifications and improvements.
◉With each improvement and advancement made, implantology
has proved to be a boon in disguise to the society

4. Contents
◉Advances in Diagnostic imaging
◉Recent advances in Implant design
◉Advances in Implant materials
◉Advances in commercially available implant systems
◉Software simplifying treatment planning
◉Recent advances in Implant Abutments
◉Implant -Abutment connection
◉New concepts in Implant rehabilitation
◉Conclusion
◉References

5. Advances in
Diagnostic
Imaging

6. Imaging
Phase 1: Pre-
prosthetic implant
imaging
Phase 2: Surgical
and interventional
implant imaging
Phase 3: Post-
prosthetic implant
imaging
Determines the
• Quantity, quality, and
angulation of bone;
•Relationship of critical
structures to prospective
implant sites
• The presence or absence of
disease at the proposed
surgical sites.
Evaluates the
surgical sites during
and immediately
after surgery
Evaluates the long-term
change
• Crestal bone levels around
each implant
• Changes in mineralization or
bone volume.

7. 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.
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.

8. 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.

9. Computed tomography (CT)
✘CT was invented by Sir Godfrey Hounsfield and was introduced in
1972.
✘Computed tomography (CT) is a digital and mathematical imaging
technique that creates tomographic sections and allows soft tissues
and hard tissues to be visualized simultaneously
✘Ideally, tomographic sections spaced 1 to 2 mm enable evaluation of
implant site and 3D appearance of alveolus
✘With latest CT scanners, images with sectional thickness of 0.25 mm
can be obtained

10. The advantages of CT based systems are
◉Uniform magnification
◉High contrast image with well-defined image layer, free of
blurring
◉Easier identification of bone grafts or hydroxyappatite materials
used to augment maxillary bone in sinus region
◉Multiplanar views
◉Three-dimensional reconstruction
◉Simultaneous study of multiple implant sites
◉Availability of soft tissue for image analysis

11. Disadvantages
◉Limited availability of reconstructive software
◉Higher dose of radiation
◉Lack of understanding of dentists
◉Lack of usefulness for implant interface follow-up because of
metallic streak artifacts
◉Expense

12. Recent advances in Computed Tomography(CT)
Tuned Aperture CT (TACT)
◉Tuned aperture computed tomography (TACT) by Webber is a
relatively simple, faster method for reconstructing tomographic
images
◉It is based on the concept of tomo-synthesis and optical-aperture
theory
◉TACT uses 2-D periapical radiographs acquired from different
projection angles as base images and permits retrospective
generation of longitudinal tomographic slices (TACT-S) lining up in
the Z axis of the area of interest

13. ◉ The overall radiation dose of TACT is not greater than 1 to 2 times
that of a conventional periapical X-ray film.
◉The resolution is stated to be similar with 2-D radiographs.
◉ Artefacts associated with CT, such as starburst patterns seen with
metallic restorations, do not exist with TACT.

14. The big concept!
Cone Bean Computed Tomography

15. Cone Beam Computed Tomography
Fan beam Cone beam

16. ◉Software programs incorporating sophisticated
algorithms including back-filtered projection are applied
to these image data to generate a 3D volumetric data set,
which can be used to provide primary reconstruction
images in 3 orthogonal planes (axial, sagittal and coronal).
◉CBCT is devoted to maxillofacial area to scan and
visualize jaw bone lesions especially cancellous bone
◉It gives all the information of a CT but, at 1/8th the
radiation dose and at a lower cost

17. ◉CBCT is categorized into large, medium, and limited volume units based on the size
of their field of view (FOV)
Large (FOV)
• 15-23 cm
• Maxillofacial
trauma
• Orthodontic
use
• TMJ diseases
Medium FOV
• 10-15 cm
• Mandibulo-
maxillary
imaging
• Pre-implant
planning
• Pathology
Small FOV
• < 10 cm
• Endodontic
applications

18. Advantages of CBCT
◉X-ray beam limitation
◉Image accuracy
◉Rapid scan time: 10–70 seconds
◉Software can be made available to the user
◉Dose reduction :Effective dose is 98% smaller than conventional CT
◉Reduced image artifact

19. 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)

20. • With an appropriately designed diagnostic
template, ES can be performed to develop
the patient’s treatment plan electronically in
3 dimensions.
•Transfer of the plan to the patient at the
time of surgery can be accomplished by
production of the computer generated,
three-dimensional stereotactic surgical
templates

21. 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 helical CT scan takes continuous pictures of the body in a rapid spiral motion,
so that there are no gaps in the pictures collected.

22. Recent Advances
in Implant Design

23. 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: 1.8mm to 2.9mm (less than 3mm)
◉Various lengths: 10, 13, 15 & 18 mm’s

24. ◉The MDI are available with either an O-ball head for use with
removable or fixed dentures, or a square head for fixed prostheses or
retrofitting a poorly adapted partial denture
◉The body connects the tip with the prosthetic head and can be a
parallel sided cylinder or a progressively tapered cone
◉A small pilot bit is used to create the opening for the implant to be
threaded into the bone.
◉The definitive implant supported crowns are usually delivered
within 2 weeks of surgery

25. Advantages
◉Immediate loading,
◉Can be inserted in minimal tissues without relying on grafting
techniques
◉Minimally invasive procedure
◉One-stage denture stabilization
◉Does not require osteotomy
◉Cost-effective
◉Can be placed with a simple technique in patients with ridge too
narrow for conventional implants
◉.

26. Narrow-diameter implants: Are they a predictable
treatment option? A literature review
José-Luis Sierra-Sánchez Med Oral Patol Oral Cir Bucal. 2014
Jan 1;19 (1):e74-81.
◉The review included
◉Four randomized clinical trials
◉Ten prospective studies
◉Seven retrospective studies
◉The follow-up periods -12 months to 12 years.
◉Total of 1607 patients
◉The patient age - 13 to 87 years
◉2980 implants

27. ◉The recorded implant survival rates were above 90% in all the
studies. Six studies published a survival rate of 100% at the end of
the follow-up period
◉The lowest survival rate (90.9%) corresponded to the study
published by Barter et al.
◉58 failures (implant loss) were recorded out of a total of 2980
implants
◉A larger number of failures were recorded with implants measuring
≤ 13 mm in length
◉Nineteen studies measured changes in peri-implant bone height
after implant loading :0.065 mm the first year to 1.74 mm after a
follow-up period of 10 years

28. ◉Araujo published a retrospective study on 3.3 mm implants placed
in posterior areas and rehabilitated following an immediate loading
protocol.
Implant survival rate was 95.5% after 9 years of follow-up.
◉That same year, Degidi et al. published a study comparing delayed
and immediate loading in narrow-diameter implants placed in both
anterior and posterior zones.
Survival rate was 99.4% after a mean follow-up of 20 months.

29. 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
◉They should be placed at least 1.5 mm from adjacent teeth and
the distance between any transitional implant and a definitive
implant must be at least 1.5-2 mm

30. ◉The abutment head generally has a 5 degree taper, which makes it
optimal for retention of cement retained prostheses.
◉Only one drill, a 1.5 mm or 2 mm twist drill is required for
placement of the implants.
Advantages :
Provisionalisation of fully and partially edentulous jaws
Undisturbed healing of bone grafts
Effective way to generate aesthetic transitional appliances
Allows evaluation of phonetics and function.
Cost effective.

31. One – Piece Implants
◉The implant is machined from a piece of titanium that
incorporates both the implant body and an integral fixed abutment
in a single component.
◉3 diameters -3.5, 4.3, and 5 mm
◉ 4 lengths -10, 13, 15 and 16 mm

32. Clinical and radiographic evaluation of one-piece implants
used for immediate function
Jack a. Hahn, journal of oral implantology vol. 33(3)2007
◉The aim of the present research was to evaluate the radiographic
outcome of a 1-piece implant when used for immediate function in
an ordinary patient pool
◉Forty-seven NobelDirect and NobelPerfect 1-piece implants
(Nobel Biocare, Go¨teborg, Sweden) were placed in maxillae and
mandibles.

33. ◉In this study 1 of the 47 implants had to be removed, resulting in a
cumulative implant survival rate of 97.9% throughout the follow-up
period
◉The mean marginal bone level relative to the reference point after
1 year of loading (0.78 - 1.60 mm), as well as after 2 and 3 years of
loading, was located above the first implant thread
◉In this study, a bone level 2 mm apical to the reference point after
1 year of loading was observed at 2 implants (6%).

34. ◉The 1-piece implant design enables undisturbed healing
of the peri-implant soft tissue and avoids disruption of the
soft tissue seal when placing the definitive prosthetic
restoration.
◉Annibali, et al reported a series of patients treated
consecutively for first molar replacement according to :
◉ Immediate = group 1,
◉ Early = group 2
◉ Late = Group 3
The implant survival rate:
91.7% for early implants
95.0% for immediate post-extraction
implants
100% for implants placed in healed
sites.

35. Short Dental Implants
◉A dental implant with length of 7 mm or less. (Friberg et al. 2000)
◉Any implant under 10 mm in length referred to as a ‘‘short’’
implant (Griffin TJ, Cheung WS. 2004)
◉A device with an intra-bony length of 8 mm or less. (Renouard
and Nisand 2006)
Indication :
Atropic Jaw
Proximity to vital structure
Single crowns
Overdentures

36. Advantages:
1. Bone grafting for height often unnecessary
2. Less money, pain, and time prior to restoration of the implant.
3. Simplified bone surgery.
4. Implant insertion easier.

37. ◉Goodacre, et al in 2003 reviewed ,
2,754 implants - <10 mm
3,015 implants - >10 mm in length.
◉The failure rate of implants 10 mm or less was 10%, compared
to a 3% failure rate of implants longer than 10 mm.
◉Ivanoff, et al in 1999 found an 8-mm-long, 5-mm-diameter
implant failed 25% of the time in the maxilla and 33% of the
time in the mandible. On the other hand, the 10-mm and 12-
mm implants that were 5 mm in diameter reported no
mandibular failure and a 10% failure in the maxilla.
Misch CE Short Dental Implants: A Literature Review and Rationale for Use Dent Today. 2005 Aug;24(8):64-6, 68

38. ◉On the other hand, a retrospective report by Misch, et al was compiled
from 2 private offices using a square thread implant body design
(BioHorizons) rather than a v-shaped thread as primarily reported in the
previous literature.
◉During a 3-year period, 126 patients received implants less than 10 mm
long
◉Of the 437 implants there were 3 implant failures in the posterior
mandible and 1 failure in the posterior maxilla (99% survival)
◉All these failures were implants 9 mm long and 4 mm in diameter.

39. Advances in Implant materials

41. ◉Previously implants had macro-irregularities like macroscopic
threads, fenestrations, pores, grooves, steps, threads, or other
surface irregularities that were visible.
◉However, difficulty in achieving initial stability, post implantation
relative motion, adverse interfacial bone remodelling all lead to
search for improvement of the surface quality of a titanium dental
implant

42. BLASTING
◉Blasting -aluminium oxide, titanium oxide and calcium phosphate
with particle size ranging from small, medium to large (150- 350
µm)
◉Blasting a smooth Ti surface with Al2 O3 particles of 25 µm, 75 µm,
or 250 µm produces surfaces with roughness values of 1.16 to 1.20,
1.43, and 1.94 to 2.20, respectively.
◉A series of investigations have demonstrated a firmer bone
fixation of the implant with an average surface roughness (sa) of 1-
1.5µm than those of smoother implants with an average surface
roughness of 0.6µm

43. Blasting and Acid Etching
◉Acid etching can be done by using an HCL/ H2 SO4 mixture or by
pickling in 2% HF/10%HNO3 . These processes leave pits and craters.
◉Alumina or TiO2 for blasting the surface:
◉Small - 25μm
◉large grit -0.25-0.5mm
◉medium grit - 250-500μm
◉Sand blasted and acid etched surfaces have a hydrophobic surface.

44. ◉The etching leads to the formation of Titanium hydrides and the
replacement of hydride by oxygen results in the slow transformation of
the implant surface, resulting in nanometre sized particles of titanium on
the surface, which helps in protein adhesion on implant surface
◉Dual acid etching with HCl and H2SO4 heated above 100ᴼC has
produced surface topography able to attach to fibrin scaffold and
promote adhesion of osteogenic cells.
◉Sand blasting and etching can increase the rate and amount of the
bone formation

45. Flouride Surface Treatments
◉This treatment enhances osseointegration and osteoblastic
differentitation with increased expression of Cbfa1, osterix and
bone sialoprotein
◉Fluoridated rough implants also withstood greater push-out
forces and showed a significantly higher removal torque than
control implants
◉However, detrimental effect of F on the corrosion resistance of
titanium and titanium alloys has been extensively reported

46. Anodized Surface Implants
◉Anodized surface implants are implants which are placed as anodes
in galvanic cells, with phosphoric acid as the electrolyte and current is
passed through them – also c/a “Tiunite surface”
◉The surface oxides grow from the native state of 5nm to
approximately 10,000nm
◉The sa of TiUnite is reported to be 1.1µm and its sdr 37%
◉Anodic oxidation results in the growth of a native titanium oxide
layer and a porous topography, with the bone formation occurring
directly on the moderately rough oxidized surface

47. Clinical and Radiographic Evaluation of Brånemark Implants with an
Anodized Surface following Seven-to-Eight Years of Functional Loading
David Gelb , Bradley McaAllister et al Int J Dent. 2013; 2013: 583567
◉The aim of this study was to evaluate the clinical and
radiographic long-term outcomes of dental implants with an
anodized TiUnite surface, placed in routine clinical practice.
38 single
prosthesis
22 FPDs
80
implants
in maxilla
27 in
mandible
Mean marginal bone level change-
1.49 ± 1.03 mm
90.7% of cases- no visible plaque
9.3% -visible plaque
No prosthetic complication

48. ◉Calandriello evaluated immediately placed anodized
implants in 33 patients and found a mean marginal bone
loss of 1.17 mm after 5 years
◉Friberg and Jemt compared 280 TiUnite implants to 110
machined implants in 111 patients and found marginal
bone loss after 5 years to be 0.75 and 0.6 mm, respectively,
with no significant difference between the two types of
implants.

49. Laser etching and Micro Arc Oxidation
◉After the implants are ultrasonically cleaned, they are laser etched
by using an Nd:YAG laser at a power of 50kw, frequency of 7.5khz
and 16.4A current.
◉They are then processed in an electrolyte solution with 3.5%
glyceroposphate disodium salt pentahydrate and 1.2% calcium
acetate monohydrate by microarc oxidation (voltage 350v,
frequency 800hz) for 15 seconds
◉Microarc oxidation produces a titania film with a porous structure
and micropores of 1-5µm
◉The mechanism of osseointegration of the oxidized implants has
been shown to be mechanical interlocking and biochemical
bonding

50. Surface coating :Ti Plasma Spray
◉Porous / rough Ti surface have been fabricated by plasma
spraying a Ti powder form of molten droplets at high temperature
at temperature in order of 15000C, at 600m/s
◉ The Ti plasma spray after solidification often provides 0.04 – 0.05
mm thickness.
◉Ti A spray has been reported to increase the surface area of bone
to implant interface (as much as 600%) and stimulate adhesion
osteogenesis

51. ◉Advantages:
Enhance attachment by increasing ionic interactions
Increased load bearing capability by 25%-30%
Increased tensile strength through ingrowth of bony tissues into 3D feature
◉Disadvantages
 Cracking and scaling of coating because of stresses produced by elevated
temprature processing
Risk of accumulation of abraded material in the interface zone during
implantation of TPS

52. Hydroxyapatite coatings
◉Hydroxyapatite [Ca10(PO4)6OH]2 coating was brought to the
dental profession by DeGroot
◉HA forms a strong chemical bond with bone due to the presence
of free calcium and phosphate compounds at the implant surface
◉The HA coating consists of amorphous and crystalline forms with
a large density of cracks.
◉The top 1-2 µm of the HA layer being amorphous, while the rest
of the crystalline layer is hexagonally packed

53. ◉Indicated: Fresh extraction sites.
Newly grafted sites.
Advantages :
1. Protection of surrounding bone against metal ion release from the
substrate.
2. Reported chemical bonding between HA and living bone-intimate
contact-biointegration
3. Partial dissolution of HA makes surrounding fluid rich in calcium
and phosphate ions which trigger cellular differentiation and bone
formation

54. Disadvantages:
◉ Induction of impurities due to thermal decomposition during
processing- affecting long term clinical fixation
◉ Dissolution of HA at lower pH
HA coating on the implant surface (50-70µm) by various methods
1. Plasma spraying
2. The vacuum deposition technique(ion beam sputtering, radiofrequency
sputtering)
3. The sol gel and dip coating method
4. Electrolytic process

55. Nanotitania coatings
◉Nanotitania coatings were prepared by using the sol-gel
technique
◉Nanotitania implants had an increased feature density and a large
feature coverage area as compared to the nano-HA implants.
◉This could present more binding sites for the protein cell
attachment and for increased bone contact
◉he Nanotitania implants exhibited an ordered arrangement,
forming a homogenous layer on underlying topography

56. Biologically active drugs incorporated dental
implants
◉Bisphosphonates :Bisphosphate-loaded implant surfaces have
been reported to improve implant osseointegration.
◉Simvastatin:
◉Simvastatin, could induce the expression of bone morphogenetic
protein (BMP) , mRNA that might promote bone formation and
increase bone mineral density
◉Gentamycin along with the layer of HA can be coated onto the
implant surface which may act as a local prophylactic agent along
with the systemic antibiotics in dental implant surgery

57. Biochemical Methods
of the Surface
Modifications

58. Biochemical Methods of the Surface
Modifications
◉Their goal is to immobilize proteins, enzymes or peptides on
biomaterials for the purpose of inducing specific cell and tissue
responses,
1. One approach uses cell-adhesion molecules like fibronectin,
vitronectin, Type I collagen, osteogenin and bone sialoprotein
2. The second approach uses biomolecules with osteotropic
effects which range from mitogenicity (interleukin growth
factor-I, FGF-2, platelet derived growth factor –BB) to the
increasing activity of the bone cells, which enhances the
collagen synthesis for osteoinduction

59. Zirconia implants
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.

60. Advantages of Zirconia Dental Implants
◉No dark colour of the metal showing through the gums
◉No corrosion of the zirconia as with titanium
◉No piezo-electric currents between dissimilar metal in
the mouth
◉It is thermally non-conductive
◉Greater BIC (Bone – Implant Contact)
◉20% more bone apposition than titanium implants
Zeynep O¨ zkurt ,Zirconia Dental Implants: A Literature Review Journal of Oral Implantology Vol. 37(3)2011

61. ◉RTQ (removal torque testing): Gahlert et al evaluated the RTQ values of
machined zirconia implants, sandblasted zirconia implants, and SLA titanium
implants. The mean RTQ for machined zirconia implants was 25.9 N/cm, the
mean RTQ for zirconia rough implants was 40.5 N/cm, and the mean RTQ for
SLA titanium implants was 105.2 N/cm
◉Fracture strength : within clinically acceptable limits
◉Stress analysis: . Kohal et al observed the stress distribution patterns of
zirconia implants (ReImplant), which were found to have low, well distributed,
and similar stress distribution compared with titanium implants

62. PEEK implants (poly etheretherketone)
◉These implants are available in three fundamentally different
designs;
◉TAU : Diameter -4..8 mm ; lengths :10 , 12.5 ,15 mm
immediate loading possible
Low density bone
◉THETA : Similar to TAU but D1 bone
◉IOTA : It is a 3mm diameter implant (10 and 12 mm)
used in narrow ridges

63. Advantages:
◉Good strength,fracture resistance and bioinertness
◉Promotes human oseteoblast cell growth
Disadvantages:
◉Faintly radiopaque –difficult for post-op evaluation
◉Lengths and diameters range is restricted

64. Advances in
commercially
available implant
systems

66. 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.

67. 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.
◉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% .

68. NobelReplace™ Tapered Groovy implant
◉NobelReplace™ Tapered Groovy implant is shaped to resemble a
tooth root.
◉New and unique grooved threads
◉ 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.

69. Indications
◉For immediate placement after extraction.
◉Whenever immediate or early loading is applied.
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

70. 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

71. ◉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
◉It provides the possibility to increase torque and place the
implant further down without repeating the drilling procedure

72. 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

73. NobelSpeedy™ Groovy
◉Same benefits as NobelSpeedy™ Replace.
In addition:
◉External Abutment Connection
◉Including Shorty implant
NobelSpeedy™ Shorty (7mm)

74. NobelActive™ Implant
◉NobelActive™ implants do not 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

75. ◉This is useful where sites are close to vital anatomical
structures: the mandibular nerve canal or the maxillary
sinus, and nose cavity.
◉Immediate placement in the esthetic region, even when
buccal bone plate is very thin
◉Excellent stabilization in wide sockets

76. NobelPerfect™
◉NobelPerfect™ is a unique, anatomically designed implant for
esthetically demanding areas from premolar to premolar.
◉The interproximal bone may be preserved in situations where the
three-dimensional ridge topography results in a height discrepancy
between the facial and interproximal aspect of the osteotomy.
◉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

77. 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™.
◉With this design, the soft tissue is supported entirely by the
implant body, irrespective of the shape of the osseous ridge.

78. 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.

79. 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.

80. MicroThread™
◉The neck of Astra Tech implants are designed with MicroThread
that has minute threads that offer optimal load distribution and
lower stress values.

81. ◉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

82. 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
few days after contact with the new surface.
◉This surface reduced the average healing time from 12
weeks (TPS surface) to only 6-8 weeks.

83. 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.

84. Software Simplifying
Treatment Planning

85. SimPlant software
◉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.

86. ◉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.

87. 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.

88. 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.
◉It combines a patient's detailed clinical information with 3D
radiographic data into a sophisticated virtual environment.

89. 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.

90. CAD/
CAM
system
Provider Implant
restoration type
Restoration
material
Procera Nobel
Biocare
Abutments
Fixed partial
denture
frameworks
Milled bars
Titanium
Alumina
Zirconia
Atlantis Astra
Tech
Abutments Titanium
Titanium with gold
coating
Zirconia
Encode Biomet 3i Abutments Titanium
Titanium with gold
coating

91. CAM
StructSURE
Biomet 3i Milled bars Titanium
CARES Straumann Abutments Titanium
Zirconia
Etkon Straumann Frameworks
Abutments
Zirconia
Titanium
BioCad BioCad
Medical
Abutments
Milled bars
Titanium

92. Recent advances in
Implant Abutments

93. Angled abutments
◉Used to improve the path of insertion of prosthesis or final
esthetic result
◉Fabricated in 2 pieces - so weaker in design
◉Implant placed at an angle requires angled abutment
◉Inclination range from 10-350
◉Has 12 facets & 12 positions of angulation in a 3600 circle
◉Has non rotating interface with implant

94. UCLA ABUTMENT
◉Designed by JohnBeumer, Wynn Hornburg, and Peter E. Staubli
◉It fits directly on top of either the implant fixtures intraorally or
the laboratory implant fixture analogues
◉It is a plastic castable sleeve.
◉Made to simplify the complicated prosthetic rehabilitation of
Nobel Biocare implant.
◉This abutment is available for all implant systems

95. Advantages
◉Subgingival placement of the restoration
◉Helps with interocclusal distance limitations
◉Improved esthetics
◉More apical position only allows the emergence profile through
the soft tissue and natural in appearance
◉Can be in porcelain instead of the usual titanium
cylinder

96. Ceramic abutments
◉Densely sintered high-purity alumina (al2o3) ceramic
◉Yttria (Y2O3) -stabilized tetragonal zirconia polycrystal
ceramics
Alumina abutments :
◉Flexural strength of 400 mpa
◉ A fracture toughness value between 5 and 6 mpa ⁄ m0.5
◉ Modulus of elasticity of 350 GPa

97. Advantages
◉Easier to prepare intraorally
◉Less whitish than zirconia abutments
The problems
◉Radioopalescence at the time of radiographic examination
◉Weak resistance to fracture
Zirconia abutments
◉Twice the flexural strength of alumina ceramic -900–1400 mpa
◉ A fracture toughness of up to 10 mpa ⁄ m0.5,
◉Modulus of elasticity value -210 gpa

98. Advantages :
◉Perfect aesthetics and stability
◉ Outstanding anatomical design
◉ Dual concept: titanium base / ZrO2 abutment
◉ Highest precision of fit
Indications:
◉Fixed restorations, single crowns and bridgework.

99. CERADAPT ABUTMENT
◉All ceramic alternative to metal abutments
◉Pre machined precision milled abutment made to fit the implant
hex - made up of densely sintered 99.8% pure aluminium oxide
◉It is a non metallic , non corrosive , bio compatible
◉Soft tissue response is excellent
◉Tooth coloured and light diffusion property
◉Used for implant supported single and multiple tooth restoration
in the anterior canine and premolar regions
◉The CerAdapt abutment is a cylinder of 12 mm high and 6 mm in
diameter

100. ◉Indications
1. An implant placed too superficially,resulting in exposed Ti at
the buccal aspect
2. An implant with excessively buccal placement & thin peri-
implant mucosa -"shining-through" effect of the Ti abutment
3. A slight disangulation of the implant, resulting in a need to
correct the direction of the implant pillar to create a
harmonious embrasure & anatomy of the crown restoration

101. Multi-Unit abutment
◉Serve as a one-piece abutment.
◉Available in 7 lengths for each platform, from a 1-to 9-mm collar
◉Total height of multi-unit abutment, including the gold cylinder
& the unigrip prosthetic screw is 5.05 mm.
◉Allows for a disangulation of as much as 40 degrees between the
long axis of the implants.
◉In situations with greater disangulation, the angulated abutment
is used

102. Implant –Abutment
Interface

103. External Hex Internal Hex Morse Taper
•External hex-0.7mm standard
hexagon
•Interchangeable in regular
size platform
•Screw loosening
•Mechanical failure
•Rotational misfit
•1.7-mm-deep hex below a 0.5-
mm– wide, 45° bevel
•Distribute intraoral forces deeper
within the implant to protect the
retention screw from excess
loading,
•Reduce the potential of
microleakage
•Superior strength
•Tapered
abutment post is
inserted into the
nonthreaded shaft
of a dental
implant with the
same taper

104. Osseotite Certain, 3i Implant Innovations,
◉The internal connection implant design incorporates an audible
and tactile “click” when the components are properly seated.
◉Reduces the need for radiographs
◉This internal connection design incorporates a 6-point hex
and a 12-point, double-hex internal design.
 The 6-point internal hex -straight abutments.
The 12-point, double-hex -machined preangled abutments to
correct the off-axis emergence of the implant
Israel M. Finger et al The evolution of external and internal implant/abutment connections; Pract Proced
Aesthet Dent 2003;15(8):625-632

105. Platform switching
◉The platform switching concept is based on the use of an
abutment smaller than the implant neck
◉This type of connection moves the perimeter of IAJ to the center
of implant axis.
◉It is likely that moving the IAJ inward brings out bacteria more
internally and, therefore, away from the bone crest this would
explain the limitation in bone resorption

106. ◉Atieh et al. (2010) conducted a systematic review on the clinical
relevance of platform switching and preservation of peri-implant
crest bone levels. Ten clinical studies reported a statistically
significant influence of the platform switching on the maintenance
of marginal bone levels.
◉Annibali et al. (2012) conducted a similar systematic review en
randomized controlled trials were selected for review dated from
2007 to 2011. Six of the ten clinical studies noted a significant
difference of reduced marginal bone loss around platform
switching implant-abutment group versus a traditional design.
José Paulo Macedo et al Morse taper dental implants and platform switching: The new paradigm in oral
implantology Eur J Dent. 2016 JanMar; 10(1): 148–154.

107. New concepts in
Implants

108. All on Four
◉Four implants in edentulous jaws,: two straight ;two tilted
providing a secure and optimal support for a prosthetic fixed
bridge (even with minimum bone volume)
◉Maximizes the use of available bone by tilting the posterior
implants by up to a maximum of 45º
◉Benefits of Angled posterior implants:
• Help avoid relevant anatomical structures and can be anchored in
better quality anterior bone
• Offer improved support of the prosthesis by reducing cantilevers
• Reduce the need for bone grafting by maximizing the use of
available bone

109. ◉Final restoration:
• Full-arch restoration with only 4 implants
• Fixed and removable final prosthetic solutions
• Flexible solutions
◉Efficient Treatment Flow:
• Immediately loaded for shorter treatment times and improved patient
satisfaction
◉Implant Placement Accuracy
• All-on-4 Guide assists with accurate placement of implants
• Can be combined with computer-aided diagnostics and treatment concept
NobelGuide

110. Zygoma Implants
◉Branemark developed a specific implant called the zygomaticus
fixture to provide fixed solutions even when the conditions for
implant insertion were poor in the posterior maxilla.
◉zygomatic implants as self-tapping screws in commercially pure
titanium with a well-defined machined surface.
◉8 different lengths, ranging from 30 to 52.5 mm.
◉45 angulated head to compensate for the angulation between the
zygoma and the maxilla.

111. ◉The portion that engages the zygoma, the apical two thirds, has a
diameter of 4.0 mm and the portion that engages the residual
maxillary alveolar process, alveolar one third, has a diameter of 4.5
mm to 5 mm.
◉Provide immediate or early loading with immediate function
◉Less morbidity,
Indications
◉Severe resorption of maxilla.
◉Free-end situations in maxilla with insufficient bone height
◉Total edentulism together with reduced bone height
◉Pneumatization of maxillary sinus.

112. The most common complication was maxillary sinusitis,
Other less frequent complications –
◉ Minor sinus membrane perforation
◉Gingival infections
◉Fistula
◉Lip laceration
◉Paresthesia
◉ Implant
◉Fractures of prosthesis
◉The weighted average success is 97.05%, and maxillary
sinusitis was the most common complication, ranging from
1.5% to 18.42%

113. Conclusion
•With the advancements in bioengineering and biomaterials fields
continued effort of dedicated dental faculties, several innovation have made
implant dental treatment a highly successful option for patient.
•The incorporation of new tech. and by methods has improved the specific
areas of conventional treatment procedures.
•Continued research will determine if specific implant modification will
diminish complication and improve implant serviceability additionally,
future deviation in material and tech will surely improve their efficacy

114. References
◉Carl e misch contemporary implant dentistry 3 rd edition
◉Israel m. Fingerthe evolution of external and internal implant/abutment
connections ; pract proced aesthet dent 2003;15(8):625-632
◉ Eugenia candel-martı rehabilitation of atrophic posterior maxilla with
zygomatic implants: review journal of oral implantology vol. Xxxviii/no. Five/2012
◉Suraksha shrestha current concepts in biomaterials in dental implant science
research. Vol. 2, no. 1, 2014, pp. 7-12.
◉ Hemlata garg et al ; implant surface modification : a review ;journal of clinical
and diagnostic research. 2012 april, vol-6(2): 319-324
◉S.Anil et al dental implant surface enhancement and osseointegration implant
dentistry ;a rapidly evolving practice
◉William c. Scarfe clinical applications of cone-beam computed
◉Tomography in dental practice jcda february 2006, vol. 72, no. 1

115. ◉David gelb; clinical and radiographic evaluation of brånemark
implants with an anodized surface following seventoeight years of
functional loading int j dent. 2013; 2013: 583567
◉Dental implant surface treatments using laserlok microchannels |
biohorizons
◉Aishwarya nagarajan et al diagnostic imaging for dental implant
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◉Jack a. Hahn clinical and radiographic evaluation of one-piece
implants used for immediate function journal of oral implantology;
vol. Xxxiii/no. Three/2007
◉Ralf-j. Kohal ceramic abutments and ceramic
◉Oral implants. An update periodontology 2000, vol. 47, 2008, 224–
243

116. ◉ Reham b. Osman a critical review of dental implant materials with
an emphasis on titanium versus zirconia materials 2015, 8, 932-958
◉ Puneet chopra mini dental implants-the same day implants;ijcd
;june ,2011 (3)
◉José paulo macedo et al morse taper dental implants and platform
switching: the new paradigm in oral implantology eur j dent. 2016
janmar; 10(1): 148–154.
◉Mohit g kheur transitional implants: an asset to implantologyj
interdiscip dentistry year : 2011 | volume : 1 | issue : 1 | page : 49
◉Zeynep o¨ zkurt zirconia dental implants: a literature review ; journal
of oral implantology vol. Xxxvii/no. Three/2011
◉Ashu sharma; zygomatic implants/fixture: a systematic review journal
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117. Thank you!