Clinical Guide to Oral Implantology: Step by Step Procedures Porus S Turner, Ferzin Turner Vazifdar, Ashdin P. Turner, Danesh R. Vazifdar
Page numbers followed by b refer to box and f refer to figure.
Abutment 90f
and prepared veneer 166f
connection 207
fitting within implant 37f
position, accurate transfer of 150f
Acrylic resin, self-curing 144
intralift kit 71f
sinus lift kit 76f
Adequate keratinized gingiva 205
Adjacent teeth, palatal surface of 183f
Aesthetic considerations 15
Algae-derived bone substitute 54
Allogenic bone 52, 53
human 53
irradiated 53
solvent preserved 53
Alloplastic bone
substitutes 53
synthetic 53
Alloplastic grafting materials 53
Alloplasts 53
American Dental Association 4
Amoxycillin 23
Anesthesia 71
Ankylos 71
balance sulcus 50f
c/x implant 4
implant 11f, 13f, 24, 34, 87, 98, 113, 139, 146f
in place 62f
placement of 26, 34
shoulder of 26f
site preparation 24
system 21, 115f, 140, 174, 179
template 31f
with abutment 12f
snap attachment 154
syncone concept 134
system 10, 12, 19, 31, 40, 69, 71, 207
Anodic oxidation surface 6
Antibiotic prophylaxis 23
Articulated study cast 17f
Atraumatic extraction 162f
Atrophic maxilla 95
Atrophic posterior maxilla, reconstruction of 69
Autogenous bone 53, 61, 66f, 129f
mixed 56f
Beta-tricalcium phosphate 53
Bioactive glass 53
Biphosphonate therapy 19
Block bone graft 60f
with delayed placement of implant 58
Blown down surgical stent 18f
Bluish membrane 75f
freeze dried 53
mineralized freeze-dried 53
biology 5
contouring bur 29, 29f
cruncher 64f
destruction 205
grafting 52
with bio-OSS 85f
growth in sinus cavity 100f
harvested 53, 56f, 64f, 73f, 182f
height measured 174f
materials, natural components of 53
position in 2
regeneration 52, 54, 61
substitutes 53
barrier membrane placed over 52f
layered with 61
to implant contact 6
Bony defect 55f
Bony window 85f
removal of 84f
replacing lateral 79f
Bridge, fixed 8
Buccal concavity 99f
Buccal contour, preservation of 171f
Buccal flap 191f, 193f, 196f
outer part of 189f
Buccal plate of bone 167
Buccal wall 164f, 170f
grafting of 170f
Butt joint implant abutment 13f
Calcium sulphate 53
Calibrated caliper 16f
regions 47f
upper right 148f
vertical fracture of 2f
Capability of ankylos 134
duplicate upper 141f
with gingival mask 49f
Cemented porcelain-fused-to-metal splinted crowns 93f
Ceramic crowns 63f, 67f
Ceramo-metal bridge cemented 160f
Cerasorb 53
Cervical threads 25f
Chlorhexidine 23f, 90
gluconate oral rinse 137
mouthwash 206
Cingulum for minicrown preparation 44f
Clindamycin 23, 80
Clonazepam 23
Closed mouth impression, posts placed for 143f
Collagen membrane 62f, 79f
Columnar epithelial cells 95
Complete denture
stabilization 154
supported 146f
upper 145f
Complete flap reflection 29f
Complete maxillary denture 12f
stability of 139
Complete overdenture supported by syncone abutments 9f
Condense bone 148f
Cone beam computed tomography 19, 74
Conical reamer flushed with bone crest 33f
Conical reamer
salient features of 33
use of 36f, 141f
Connective tissue graft 200, 201f
completed packing of 42f
removal of 42f
Crestal bone 13f
levels, excellent 173f
loss 108, 109
preservation of 108
Crestal incision 72f, 147, 183f
with median tissue bridge intact 136f
Crestal sinus floor elevation 95
Crown 58f
on maxillary left canine 9f
temporarily cemented, composite 165f
Dental implants, types of 2
Dentsply implants 10, 12, 19
Dentsply sirona implant 1, 4, 6, 21, 71, 87
final polished surface of 157f
in mouth in centric occlusion 152f
intaglio surface of 152f, 157f
over 8
polished surface of 152f
De-proteinized bovine bone material 169
Diclofenac 23
Die stone poured 49f
Endodontic file 17f
Endosseous implant 4, 4f
Esthetics, high end 161
Extraction sockets 108b
Facebow transfer 160f
Figure of eight suture, closing of wound with 170f
Fine needle holder 188f
and suturing 86f
dissecting partial-thickness 201f
Flapless procedure 109
Floor of sinus 70f
central incisor 116
floor of sinus 102f
of lateral incisor, horizontal 1f
of weak lateral incisor abutment 8f
root, atraumatic luxation of 117f
sinus floor 99f
Gingiva, healing of 50f
health 40
working time 41
margin, free 114f, 126f
being poured 48f
in place 48f
retraction 41
cord placed 132f
Gold caps 138f
Grafted sinus cavity, infection of 80
Granulation tissue, formation of 80
Green-stick fracture 148f
Gutta-percha 136f
Hard and soft tissues, maintenance of 153f
Healing after 3 weeks 145f
Hemostat 188f
Hydrodynamic piezoelectric internal sinus floor elevation 95
Hydroxyl apatite 24
Implant 142f
aesthetics 121
subepithelial connective tissue grafting for 199
after placement, two 177f
analogs 49f
attachment to 143f
angulations 136f
before prosthetic rehabilitation 9f
coronal part of 65f
delayed loading of 146
direct impression recording position of 160f
exposure of 184f
final placement of 114f
grafting and placement of 104f
healing 5
in grafted bone, placement of 57f
in place immediately after grafting 100f
in upper and lower jaw, placement of 145f
level impression technique 49f
maintenance of 205, 207
motorized insertion of 36f
number 19
osteotomies, position of 136f
part of 65f
placement 13f, 54, 55f, 62f, 88f, 89f, 108, 170f, 174
advantages of immediate 108b
complications after 179
grafting and 100f
size 19
spacing 19
subcrestal placement of 137f
submerged 35
subperiosteal 3, 3f
supported fixed bridge 8f
supported prosthesis
fixed 14f
impression making for 40, 45
surgery, basic 21
three-dimensional placement of 126f
tissue interphase 5
to bone contact 87
transferring orientation of 49f
treatment 205
uncovering of 38f, 171f
width of 60f
with forceps, removal of 181f
with placement heads exhibiting 142f
immediate 167
prerequisites for immediate 110b
Implantology 1
fixed bridges 8
overdentures 10
making, repositioning technique of 50f
accurate 40
after removal 181f
syringing of 41
removal of 47f
technique 41
Incision 83f
line opening 80
up to adjacent teeth 27f
Incisors, central 47f
Initial osteotomy, positioning of 168f
Instrumentation, quality of 4
Interdental papilla, spontaneous regeneration of 58
Interrupted suture technique 189
modified 191
Intralift kit 96f, 99f
occlusal view 92f
of failed implant 183f
of fractured tooth 111f
view, preoperative 82f, 140f, 167f
Intrasulcular incisions 109
Jaw relation recorded 151f
Keratinized tissue, thin band of 200f
Knot tied on buccal
side 190f
surface 192f, 194f
Lindemann drill 30f, 35, 69
sequential use of 162f
Lingual flap 190f, 191f, 193f
mobilization of 28f
Lithium disilicate crowns after cementation 67f
Luxated root, removal of 117f
Luxator, use of 112f, 168f
Mandibular nerve, anterior loop of 174
Mattress suture technique
horizontal 191, 193
vertical 191, 195
Maxilla, anterior 108
overdentures 10
sinus, grafting of 69
Mayo tray 23f
after removal of bony window 77f
elevation 84f
on right side 86f
platelet rich fibrin 105
Mental foramen
coronal to inferior alveolar canal 176f
identification of 175f
Mesial and distal surface 112f
Microsurgical blades, periotomes 121
Midcrestal incision 27f
Monofilament nylon 186
Mucogingival junction, level of 195f
Mucoperiosteal flaps, reflection of 26
Mucositis 205
Mucositis-like gingivitis 205
Nasal opine with chisel 182f
Nasal spine 56, 129f
Nicotine 207
Noble biocare implants 6
Noble implant system 4
Non-eugenol temporary cement 115f, 120f
Non-salvageable upper right central incisor 116f
Open tray
impression posts in place 149f
technique 46f
Optimal bone quality 121
Oral anxiolytic agents 23
Oral hygiene
in implant patients 205
contents of 207f
for implant patients 206f
Orthopantomogram, preoperative 111f
Orthopantomography 7
Osseointegration 2, 6
loss of 205
Osteoblast deposition 26f
Osteophylic phase 5
Osteotome 70f
to condense bone 141f
use of 36f, 141f
Osteotome-mediated sinus floor elevation 95
Osteotomy 69, 71, 109, 126
and drill in posterior, anterior 31f
and implant placement 5
in compromised bone 35
initial 30f
preparation of 29, 118f
site 184
with conical reamer 32f
Palatal alveolar bone 64f
Palatal cortical bone 118f
Palatal crest 169f
Palatine artery, posterior superior 199
Panoramic radiograph, postoperative 139f
elevator reflecting marginal tissues 28f
elevator, discoid-shaped semi-sharp 28f
lack of 132f
missing 200f
regeneration of 203f
spontaneous regeneration of 59f
Paracetamol 23
Partial denture
fixed 59f, 61, 156f
with provisional removable 16f
without provisional removable 15f
Partial thickness flaps, preparation of 201f
Particulate mineral bovine bone 123f
Peri-implant tissues 203f
healthy 58
Peri-implantitis 180f, 182f, 205
Periodontal fibers 112f
severe 111
Periosteal blood, fresh 74f
Periosteum 109, 202f
Piezosurgery 59
Piezotome 96f
Pilot drill 30
Plasma spraying 24
Platelet-derived growth factors 104
Plus clavulanic acid 23
Polyglactin 186
Polyglycolic acid 187
Porcelain fused-to-metal crowns splinted 91f, 92f
Porcelain laminate veneer 165f
Post-surgical palatal stent 202f
cemented in patient's mouth, fixed 49f
replacing, fixed 98
Prosthodontics, quality of 4
Provisional restoration 127f, 108b, 132f
Reamer with nentwig instrument 164f
Resorbable collagen membrane 66f, 78f
Restoration, fixed 158
Retraction cord 58f
Root forcep, rotational movements of 117f
Root fracture, vertical 55f
Scalpel blade, aid of microsurgical 201f
Schneiderian membrane 76
Scissors 187
Sculpt tissues 172f
Silicone sleeve
covering lamella 155f
removal of 157f
Simple interrupted suture technique 189
Simultaneous impression technique 51f
Single tooth restorations 8, 12
access window to 74
grafting 79f
lateral wall of 73f
curette 77f
floor 70f
grafting 69, 78, 95
membrane 76, 77f
elevation curettes 77f
elevation of 76
management of perforation of 76
tenting 70f
with osteotomes, lifting 69
kit 75
patients, maintenance of 90
Sling sutures 202f
Snap attachment
abutments 154
region of 156f
grafting before flap reflection 130f
palatal wall of 164f
Soft denture liner during interim period 150f
Soft tissue
around implant 203f
infiltration, prevent 62f
management 121
recession 184f
Stabilized collagen membrane 56f
Stay suture in place 73f
Stent with radiographic markers 18f
Sticky bone 105f
preparation of 105f
Straumann implant system 4
formers in place 156f
removal of 50f
Supragingival plaque, removal of 205
Surgeon's knot 195
Surgical knots 194
Surgical procedure 35, 81, 135
Surgical protocol 21
Surgical stent, step in preparation of 14f
Surgical suction unit 21f
Surgical technique 69, 71, 97
Surgical torque control motor 22f
Suture scissor 189f
Suturing instruments 187
Suturing techniques 189
Suturing, principles of 186
Syncone abutments 11f, 137f
dentsply implants 10
paralleled 144f
Syncone caps 11f, 138f, 145f
in place on abutments 144f
with cast metal framework 12f
Syncone gold caps cemented to metal framework 151f
Syncone treatment concept 139
Tacking pins 56f
Tapping thread 34
Temporary crown 115f
cemented 115f
placed 177f
Thicken mucosa around implants 200
Tissue forceps 187
Tissue-holding forcep, delicate 188f
Tobacco habits, cessation of 207
Toxic areosols 207
Trabecular bone 25f
Transgingival healing 34
with aid of sulcus former 35f
with gingival formers 106f
Transosseous implant 3, 3f
Tray technique, combination of open and closed 46f
Treatment plan 7, 135, 140
Trephine burs 64f
Tricalcium phosphates 53
Tunnel technique 201f
modified 200f
Ustomed kit 59
Valsalva's maneuver 97
Versatility 4
Vertical double-crossed sutures 200
Wel-documented cell occlusive 65
Window outline, drilling of 83f
Wound healing
excellent 171
hemostasis and primary 202f
surgical 5
Xenogenic bone 52, 53
chemically treated 54
thermally treated 54
abutment 165f
all ceramic crowns 178f
crown 58
implants 4
Chapter Notes

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Introduction to ImplantologyChapter 1

The goal of implant therapy is to restore an individual to normal anatomy, function, aesthetics, comfort and speech regardless of the loss of bone due to disease or injury to the stomatognathic system. Based on the concepts of osseointegration described by Branemark more than 50 years ago implant dentistry has evolved extensively and has become an integral part in dental rehabilitation.1 Though it was developed primarily to rehabilitate fully edentulous patients, and it has gradually shifted to partially edentulous patients. Today single tooth replacement by implant has become the number one indication rather than fixed prosthodontics (bridge) because of increased risk of pulpal damage, secondary caries, factures of abutment teeth and periodontal disease (Figs. 1.1A and B). Today implants are no longer placed only in areas where adequate width and height of bone are available but due to the significant advances in bone augmentation procedures implants are placed wherever prosthesis are required.
Guided-bone regeneration with or without membranes and sinus floor elevation have become standards of care to correct bone deficiencies in other parts of the oral cavity. Improved osteophylic microstructured titanium implant surfaces such as the Plus Surface (Dentsply Sirona Implants) significantly reduce treatment time because of accelerated growth of bone.2
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Fig. 1.1A: Horizontal fracture of lateral incisor.
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Fig. 1.1B: Radiographic view of vertical fracture of canine.
These advances in implant therapy have made implants more predictable and attractive to patients. This has also led to more dentists placing implants in daily practice then ever before.
Osseointegration refers to incorporation of an inanimate metallic component into living bone. A successful osseointegrated implant is one in which there is a direct connection between ordered living bone and titanium. This attachment must be able to endure conditions of loading. There is no fibrous tissue intervening between the implant and bone, hence the osseointegrated implant is more akin to an ankylosed tooth root. The success of osseointegration has been proven beyond all doubts, however successful achievement of osseointegration depends on careful planning, meticulous surgical technique and skilful prosthetic management. It demands an appreciation of bone biology and wound healing in particular.
The prepared implant site is treated correctly as a wound in which tissue damage has to be minimized. The special characteristics of titanium particularly its resistance to corrosion and its biocompatibility are important. When these above criteria are met living bone recognizes titanium as its own and not as a foreign object.
Types of Dental Implants
Implants may be classified according to their position in the bone, constituent material, and their morphologic design.
Position in the bone
Implants may be subperiosteal, transosseous, or endosseous.3
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Fig. 1.2: Subperiosteal Implant.
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Fig. 1.3: Transosseous Implant.
Subperiosteal Implant
Subperiosteal implant is a non-osseointegrated implant which rests on the surface of the bone below the mucoperiosteum (Fig. 1.2). Some of these implants may have served the patients well for several years but even the best of case reports have not shown success rates over 10 years. Problems have included infection, exposure of framework by down growth of epithelium and damage to the bone. Removal of these implants are also often difficult.
Transosseous Implants
The most common example of a transosseous implant is the mandibular staple implant. It has a plate which fits on to the lower border of the mandible at the symphysis and has posts arising from it (Fig. 1.3). Some of these posts pass 4into the jaws and others pass transosseously into the mouth where they serve to stabilize a denture. They are used only in the mandible. Bone loss around the post has been a common problem.
Endosseous Implants
Endosseous implants are placed into the maxilla or mandible from intraoral incisions after raising the mucoperiosteum and drilling into the bone. The shapes and construction materials vary, however the most common today is a tapered microtextured screw implant (Fig. 1.4). They may be used to replace single teeth, partially edentulous jaws or totally edentulous jaws. Most claim to be osseointegrated.
The most frequently used material for dental implants today is pure titanium or a titanium alloy. However, Zirconia implants are also available commercially.
There are numerous implant designs in the market, however the most prevalent today is the solid screw, which confirms to the shape of the tooth root and has a microtextured rough surface. An example of a good design is the Ankylos C/X Implant, Xive (Dentsply Sirona Implants), Noble Implant System and Straumann Implant System. In a survey of practicing dentists, Worthington listed the following features as important in making a right choice for an implant system:
  • Demonstration of reliability (over at least 5 years)
  • American Dental Association Approval
  • Quality of instrumentation
  • Quality of Prosthodontics
  • Versatility
  • Reputation of the manufacturing company
    zoom view
    Fig. 1.4: Endosseous Implant.
  • Ease of use
  • Training and after sales services
  • Cost to the patient
  • Start up cost.
In evaluating an implant system, the clinician must inquire:
  • Were animal experiments conducted before the implant system was marketed?
  • Were progressive clinical trials undertaken?
  • Are the results of at least 5 years long trials published in reputed journals?
  • Have there been multicenter replication studies?
The clinician should realize that it is not valid to extrapolate results from one product to another merely on the basis of some superficial morphologic resemblance. The composition of the material, its purity, its surface characteristic and its preparation are of vital importance.
Surgical Wound Healing after Osteotomy and Implant Placement
Osteophylic Phase
When an implant is first placed into bone a blood clot forms around the implant. Titanium is a light weight non-noble metal that is corrosion resistant as the result of the formation of surface oxides. The biologic inertness of this oxide leads to the implants being so biocompatible. The body does not react to the oxides on titanium as a foreign object but recognize it immunologically as self.
It is important to inflict the least damage to the bone and soft tissues while drilling and placing implants. Sharp drills and proper saline coolants are necessary to keep the temperature in the bone below 47°C for one minute.2,3 After the blood clot has formed, there is generalized inflammation due to the surgical insult. However while the inflammatory phase is still on, a more mature vascular network forms around the implant during the first 3 weeks. In addition ossification also begins during the first week by the migration of osteoblasts from the periosteum and endosteal osteoblast from the walls of the osteotomy. The trauma of placing the implant also results in necrosis of a thin layer (0.5 mm to 1 mm) of peri-implant bone. There is a critical period at around 2 weeks when bone resorption exceeds bone formation resulting in lower degree of primary stability than that achieved at the time of placement. The inflammatory or osteophylic phase lasts for one month and results in the formation of weak cell rich woven bone which chemically bonds to the oxides of the titanium implant. Following the formation of woven bone, the remodeling phase starts at the end of 4 weeks.
Remodeling Phase
Osteoclasts and osteoblasts interact in a coordinated way to replace the weak woven bone into a more load bearing lamellar bone. The remodeling phase lasts 6for about 3 months. It is influenced by micro-movement (not more than 100 μ) between the bone and implant, and good vascular supply.4 Under electron microscope, it is shown that there is an intimate contact between the bone and the implant surface oxides due to certain bone matrix proteins which act as binders.
Primary Stability
Primary stability or the initial rigid fixation of the implant to the bone is of prime importance for secondary osseointegration. An implant which is mobile at the time of placement will never achieve secondary osseointegration. By mobile we mean which moves inside the osteotomy and is not in close contact to the bone. It is different from an implant which is in close contact to the bone but only turns when you torque it (spinner). A spinner implant which has a moderately rough surface, e.g. Dentsply Sirona Implants Plus surface and Noble Biocare Implants—Anodic oxidation surface, can get subsequently osseointegrated. Most implant systems today use screw threads to gain primary stability. The presence of screw threads also help by transferring compressive forces to the surrounding cortical and cancellous bone which is favorable and leads to increased bone density.
Osseointegration is the replacement of initial bone fixation of the implant with mature load bearing lamellar bone. The surface roughness of the implant especially the grit blasted and thermally acid etched (Dentsply Sirona Implants—Plus surface) are of immense benefit for faster and stronger laying of load bearing bone due to their osteoconductive surface.5 The rough surface also leads to increased surface area on implant which helps in obtaining greater bone to implant contact (BIC). An additional advantage of the thermal acid etching is that in addition to increasing the surface roughness of the grit-blasted surface, it also cleans and removes foreign matter from the implant surface.
  1. Branemark PI, Adell R, Breine U, et al. Intra-osseous anchorage of dental prostheses. I: Experimental studies. Scand J Plast Reconstr Surg. 1969;3:81–100.
  1. Eriksson AR, Albrektsson T. Temperature threshold levels for heat induced bone tissue injury: a vital-microscopic study in the rabbit. J Prosthet Den. 1983;50:101–7.
  1. Eriksson AR, Albrektsson T. The effect of heat on bone regeneration: an experimental study in rabbits using the bone growth chamber. J Oral Maxillofac Surg. 1984;42:705–11.
  1. Szmukler-Moncler S, Piattelli A, Favero GA, Dubruille JH. Considerations preliminary to the application of early and immediate loading protocols in dental implantology. Clin Oral Implants Res. 2000;11:12–25.
  1. Neugebauer J, Weinlander M, Lekovic V, et al. Mechanical stability of immediately loaded implants with various surfaces and designs: a pilot study in dogs. Int J Oral Maxillofac Implants. 2009;24(6):1083–92.