Ce 420

Dental Implants: A Comprehensive Review
Sanda Moldovan, DDS, MS, CNS

Continuing Education Units: 3 hours
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
According to the National Institutes of Health, there are over 100 million people missing teeth, and the need
for implant dentistry is stronger than ever. Patients often ask dental team members questions regarding
dental treatment options. Knowledge of the current procedures for implants is a must for anyone in the
dental field. By becoming knowledgeable about different implant options, dental professionals will be able
to help patients make educated decisions regarding their dental treatment.
Conflict of Interest Disclosure Statement
The author reports no conflicts of interest associated with this work.
ADA CERP
The Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed to the
provider or to ADA CERP at: http://www.ada.org/cerp
Approved PACE Program Provider
The Procter & Gamble Company is designated as an Approved PACE Program Provider by
the Academy of General Dentistry. The formal continuing education programs of this program
provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance
Credit. Approval does not imply acceptance by a state or provincial board of dentistry or
AGD endorsement. The current term of approval extends from 8/1/2009 to 7/31/2013.
Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013
Overview
According to the National Institutes of Health, there are over 100 million people missing teeth, and the
need for implant dentistry is stronger than ever. The number of implants placed in the United States
1
increased ten-fold between 1983 and 2002 and continues to increase every year. Dental implants are
considered the standard of care today to replace a missing tooth due to osseointegration and improved
oral function. It is critical for the dental team to be familiar with the implant procedures available. Patients
often ask dental team members questions regarding dental treatment options. Knowledge of the current
procedures for implants is a must for anyone in the dental field.
Any patient with one or more missing teeth is a candidate for dental implants. Both volume and quality of
bone in the recipient site are determining factors for treatment. The ability to provide patients with a third
set of teeth has changed how dentistry views missing teeth and how patients with missing teeth perceive
dentistry. By becoming knowledgeable about different implant options, dental professionals will be able to
help patients make educated decisions regarding their dental treatment.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
Understand the history of dental implants and Dr. Brnemarks breakthrough discovery of
osseointegration.
Understand the difference between subperiosteal and endosteal designs.
Distinguish between different dental implant treatment options.
Relate the value of CT scans prior to implant placement, the standard of care today.
Answer questions on informed consent.
Recite surgical protocol.
Complete surgical set ups.
Deliver pre- and post-surgical instructions to the patient.
Obtain basic information about bone grafting materials and implant advances.
Understand that implant maintenance is an important part of the treatment.
Properly sterilize and handle the implant equipment.
Course Contents

Glossary
History of Dental Implants
Pre-osseointegration
Discovery of osseointegration
Post-osseointegration
Rationale for Dental Implants
Endosseous Implants
Mini-implants
Zygomatic Implants
Prosthetic Options
Single Tooth
Partially Edentulous
Completely Edentulous
Diagnostics
CT Imaging
Treatment Planning Software
Surgical Protocol
Restorative Protocol
Sterilization and Handling
Patient Management
Informed Consent
Pre-surgical Preparation of the Patient
Post-surgical Instructions for the Patient
Implant Maintenance
Implant Complication
Conclusion
Course Test
References
About the Author
Glossary
abutment A tooth, root, or implant used for

support and retention for a fixed or removable
prosthesis.
Arnica montana A raw herb used in
the homeopathic treatment of bruises and
inflammation; also known as mountain tobacco
and wolfs bane.
2
atrophy A wasting or loss of tissue.
roundhouse bridge Fixed partial denture for an

entire arch.
blade form dental implant Type of endosseous

implant; shaped like a flat plate.
subperiosteal implant Cast-metal frame which

rests on bone, under the gingiva, to support an
overdenture; may be fixed with screws to the
bone; used for fully edentulous patients in the
mandibular arch.
endosseous implant Positioned within the jaw

bone, which gains support by osseointegration into
the bone.
homeopathy Nontraditional system for treating
patients; minute amounts of a substance that in
large amounts causes disease symptoms are given
to healthy individuals.
tachycardia Fast heart beat.

titanium Metal (chemical symbol Ti) having low
density, good strength, and corrosive resistant
properties.
hydroxyappatite (HA) Calcium phosphate

complex that is a primary mineral component of
bone; sprayed-on coating used on early dental
implants.
transosseous implant Machined implant

consisting of a lower plate fixated under the
mandible with pins projecting through the
mandible which penetrate into the oral cavity.
intrude Forceful change to tooth position, driving

further into the tooth sulcus resulting in less crown
visibility.
trephine A surgical instrument used for cutting

out circular sections.
ligature Piece of floss attached to small

components that acts as a safety feature for ease
of retrieval.
Vitalium Trademark name for a dental alloy

comprised of cobalt, chromium and molybdenum.
History of Dental Implants
muscles of mastication Four pairs of muscles

that aid in chewing; masseter, temporalis, and the
internal and external pterygoid.
Pre-osseointegration
Human skulls dating from 600 A.D. show that
man attempted to implant carved shells into the
anterior mandible. However, the first documented
dental implant did not appear until 1809, with a
poor success rate.2,3
open bite Lack of vertical overlap of the

maxillary centrals resulting in an opening of the
anterior teeth.
osseointegration Biological concept where a
direct connection exists between the living bone
and metal.
Teeth are anchored into the alveolar bone by the

periodontal ligament. This ligament is a muscle
attachment that acts as a shock-absorbing
mechanism. Researchers are spending
numerous hours and resources to artificially
developing a periodontal ligament that would
anchor dental implants into the alveolar bone, but
to date have not been successful (Figure1).4
osteotomy A hole in the alveolar bone made

by a dental surgeon using an implant drill for the
placement of a dental implant.
peri-implantitis The equivalent to periodontitis
manifesting around dental implants; bone loss
around implants due to bacterial pathogens.
Prior to the era of osseointegration, there

were various designs of dental implants and
frameworks used to support dentures and
partial dentures. Some of these functioned
well for several years, but most designs had
an unpredictable success rate. The first of
this type, the subperiosteal implant framework,
was described in 1949 by Drs. Goldberg and
pneumatize Formation of air cells or cavities

in tissue; in this case, when the sinus spaces are
increased due to bone resorption.
pontic Artificial tooth that replaces a missing tooth.
3
impression was made of the edentulous jaw

from which the framework was cast in Vitallium,
with posts projecting through the mucosa into
the oral cavity. A denture or partial denture was
then fabricated to fit the posts. There were a
few complications associated with this method.
Exfoliation of the bone connecting the screws,
and the exposure of the frame through mucosal
perforation were problems. Twenty-year studies
showed a failure rate of 34% in the mandible.6
A 10-year study reported a 60% survival rate,
and an even lower survival rate of 50% after 15
years.7 Because of these low success rates, this
implant framework is no longer used today.
Almost 25 years later in 1968, a new dental
implant concept called the transosseous implant
was introduced by Dr. Small. The name was
derived from the fact that it transversed the
mandible from the bottom to the top.8 This
implant was inserted underneath the chin. A flat
bone plate was fixed under the skin against the
inferior border of the mandible. Several threaded
posts projected into the anterior mandible
from the plate. Two to four of the posts went
completely through the mucosa and into the
oral cavity to help fixate the denture prosthesis.
Transosseous implants were machined from
titanium, or a gold alloy. There were several
disadvantages to this implant system. This
procedure was performed under general
anesthesia in a hospital setting and was quite
invasive. Another downside was frequent bone
loss around the posts with bleeding on probing.
Studies showed that this design had a success
rate of 91% after 10 to 16 years of function, but
it was not a healthy environment.9 This implant
design is no longer used today and was replaced
by the endosseous implant.
Figure 1. Bone forms a bond with dental implant.

Comparison between the tooth (left side) and
implant (right side) attachment into bone.
Image Courtesy of Nobel Biocare
Figure 2A. Blade implant design.
In 1966, Dr. Linkow presented the blade implant

around the same time as the transosseous
implant.10 This is now known as an endosseous
implant (Figure 2A, 2B). This implant is inserted
intraorally in the bone by making a groove in the
alveolar bone. One or more posts were attached
to the fin-shaped plate, which anchored the
restoration. The success rate for this implant
was under 50%, and is no longer used today.11,12
The problem with this type of implant was that it
became loose, infected, and had to be removed.
Figure 2B. Exposure of the implant

was a common complication.
Gershkoff.5 This framework could be used on the

maxilla or mandible. It was placed underneath a
gingival flap and in direct contact with the bone.
It was not implanted directly into the bone. An
4
Discovery of osseointegration
The concept of osseointegration was an
accidental discovery in the early 1960s by
physician and professor Per-Ingvar Brnemark.
Brnemark was working on his thesis, studying
bone regeneration in rabbits.13 He developed a
titanium chamber to study wound healing. This
device was implanted in the bone of a rabbit.
At the end of the study, when he wanted to
remove the chamber from the bone, it could
not be removed because the bone had fused
(osseointegrated) to the titanium surface. The
bond was so strong that it could not be broken
(Figure 3A).14 He conducted several other
experiments to confirm that titanium could indeed
integrate and become part of the bone. After this
discovery, dental applications were the first that
came to mind.
Figure 3A. Radiograph of the microscope

bone chamber used by Dr. Brnemark in a
rabbit fibula to study bone healing.
Brnemarks first patient, Gsta Larson (Figure

3B), was born in 1931 with severe chin and jaw
deformities. Larson had several congenitally
missing teeth and the teeth he had were
misaligned. He was not able to chew properly.
Larson was treated in 1965, with the first implant
supported bridge, in Gothenburg, Sweden. Four
implants were inserted in the mandible, which
integrated within six months, and the prosthesis
was then attached. Forty years later, that
prosthesis was still in place.14
Figure 3B. Dr. Brnemark (right) with his first

patient Gsta Larsson.
Following this first implant, Brnemark did

extensive clinical research and placed more
implants with regular recheck appointments.
In the beginning, he only worked with fully
edentulous patients. In 1977, Brnemark
presented his data to the Swedish government
for its aid.15 He received the support needed to
collect a large amount of data. The American
Dental Association gave full acceptance to his
dental implants for a variety of uses including:
single tooth replacement, partial and fully
edentulous bridges, and implant-supported
overdentures.
Figure 4. The original Brnemark implant,

machined surface, cylindrical screw.
Post-osseointegration
The Brnemark system was introduced into the
United States in 1982. These implants were
machine surfaced to be a cylindrical screw
(Figure 4). Since then, other endosseous implant
designs have been introduced. Cylindrical
implants are tapped into the osteotomy. Vented
cylinders, expansive screws, and hollow posts are

also available.
In order to improve the attachment of the bone
cells to the implant surface, some manufacturers
placed coatings on the implant surface. These
coatings consisted of hydroxyapatite (HA) with
5
a titanium plasma spray. HA was shown to

attract bone cells, especially in areas where bone
density was compromised.16,17 A main problem
with this type of implant was that the coating
could separate from the implant once inserted in
the alveolar bone. That separation caused the
implant to become loose, resulted in failure, and
required removal.18,19 HA-coated implants are no
longer manufactured.
It was discovered that one way to increase the
rate and success of osseointegration was to
increase the surface area of the implant. This
was accomplished by spraying the machined
implant surface with liquid titanium or by dipping
the implant in an acid that created microporosities
(Figure 5). Due to this discovery, the majority
of the implants available today have a porous
surface allowing the bone cells to better attach to
the implant surface (Figure 6).20
Figure 5. This picture demonstrates how bone

grows onto and into the porous structure of the
TiUnite surface of the Nobel Biocare implants.
Many implant studies were conducted in the

1980s. Since then, over 100 implant companies
have been established. In order to sell implants
in the United States, a manufacturer must submit
research and documentation, known as a 510(k),
to the Food and Drug Administration (FDA) for
approval. Clinical testing is currently not required
by the FDA for endosseous implants.
Figure 6. The new generation,

roughened surface implant.
during mastication.22 These forces are essential in

maintaining strong muscles and bone. Dentures
or partial dentures have the opposite effect on the
maxilla and mandible. Poorly fitted removable
prosthetics allow the bone to resorb because
they only regain approximately 10% of chewing
capability. This is not enough to maintain the bone
and results in a gradual loss of bone.23
The American Dental Association (ADA) has a

seal of acceptance given to products used in
dentistry, including dental implants. The ADA
seal is not a requirement to sell implants, but
companies voluntarily submit to receive the
seal. The ADA has stricter guidelines than the
FDA, requiring clinical testing for at least 5 years.
Among the implant companies with ADA Seal of
Acceptance include Astra, Nobel Biocare, and
Straumann.21
Since chewing ability is reduced with dentures,

atrophy is also noted in the muscles of mastication,
giving the patients cheeks a sunken appearance.
Implants also maintain facial muscles, aiding in
improved mastication and muscle tone. After
receiving dental implants, many patients who had
been missing teeth for a long time notice a natural
face-lift effect when the muscles of mastication are
once again used properly.
Rationale for Dental Implants
As the baby boomer generation ages, the

need for dental implants increases. Implants
offer several advantages over bridges and
dentures. People who are missing teeth have
compromised chewing ability and speech, facial
appearance, and self-confidence. When a tooth
is lost, the surrounding bone starts to atrophy
due to lack of use (Figure7). Dental implants
help maintain the bone profile and volume when
chewing, by applying direct forces on the bone
Patients who are rehabilitating their oral cavity

with dental implants gain a priceless, new,
self confidence. Replacing missing teeth with
implants is the best and closest thing to natural
teeth (Figure 8). Many patients forget that they
6
Figure 7. Bone loss is the end result of tooth loss.
shape was its wedging effect into the bone. This

allowed for better initial stability, especially in less
dense bone. However, if too much pressure was
exerted on the bone, then necrosis or death of the
cells occurred, causing severe pain and implant
loss within a month following surgery.24
Vent holes were also introduced toward the apex
of the implant which improved osseointegration
into the bone.4 This mechanical retention
occurred as new alveolar bone grew into the open
areas essentially locking the implant in place.
Figure 8. Implant restoration on tooth #11.

Courtesy of Dr. Dell Goodrick
The thread design of implants also varies

between systems. One design is self-tapping,
meaning that the threads are sharp and able
to cut their way through the bone (i.e. Nobel
Biocare). Another design has non-cutting threads
(i.e. Straumann). A self-tapping thread has an
advantage: the osteotomy can be perfected as
the implant is being placed resulting in a close fit
between the implant and the bone.
have implants since they feel so natural due to

the osseointegration. Recipients are able to
smile with confidence, without worry of denture
displacement or showing gaps when smiling.
Dental implants can last a lifetime. The crown
work cemented to the exposed tip of the implant
may need to be replaced for esthetic reasons, but
the osseointegrated implant becomes a part of the
patients body.
The implant platform can also have different

shapes. It can have an internal or external
platform with the abutment. The original
Brnemark system had an external connection.
The internal connection platform is the most
preferred method utilized now in dental practices
(Figure 9A, 9B, 9C).
Endosseous Implants
There are several designs of root-form implants.

The original Brnemark implant was designed
as a cylindrical implant. In the 1980s, a tapered
implant became available. The advantage of this
7
Figure 9A. Internal connection implant system

implant placed post-extraction.
Figure 10. Six implants placed in the lower arch with 2

mini-implants to help keep denture stable.
Mini-implants
Mini-implants were introduced in dentistry as a

temporary implant. These were placed to support
a denture or temporary prosthesis during the
healing time following implant surgery (Figure
10).25,26 Several manufacturers now produce miniimplants for permanent restoration of missing
teeth. The cost of a mini-implant is approximately
the cost of a regular implant making it more
affordable for the patient. However, the postoperative studies to date only show a success rate
of 60-70% after five years.
Figure 9B. Prefabricated zirconia abutment fitting

the internal connection in Figure 9A.
In 1983, Creekmore and Eklund started working

with small-sized bone screws used as anchors for
elastics in orthodontics.27 These are mini-implants,
known in orthodontics as temporary anchorage
devices (TADs), and are gaining more attention
in this field. They are usually inserted and remain
in place for six to nine months, after which they
are easily removed.28 TADs have a diameter of
1.2-2 mm and are especially useful to intrude and
distalize molars and to close open bites.29
Figure 9C. Zirconia abutment torque onto implant.
Zygomatic Implants
Certain patients no longer have an adequate

amount of bone remaining in the maxilla. This
happens if the patient has worn dentures for an
extended time, or has severely atrophied bone or
bone reductions due to cancer. When posterior
teeth are missing for an extended period of time,
the sinus can pneumatize or drop down, and only
a shell of bone remains between the sinus and
oral cavity. Brnemark wanted to find a treatment
solution for these patients. If the patient proved to
Dental professionals may be easily overwhelmed

by the variety of implants available on the market.
The dentist should choose a dental implant
system based on evidence based research.
First, the system should prove reliability and a
high clinical success rate of at least 5 years.
Secondly, the implant manufacturer must be
reputable, offering a versatile implant system that
is easy to use.4
have sufficient, quality bone in the zygomatic arch

behind the maxillary sinus, a zygoma implant was
placed. The zygomatic bones are situated lateral
to the nose and also form part of the orbital bone
and prominence of the cheek. The initial 10-year
implant study conducted by Brnemark and
colleagues found a success rate of 94%.30
A bridge involves replacing the tooth with a pontic

which is suspended by one or more abutments.
This technique involves the removal of healthy,
adjacent tooth structure to create the abutment
support. It is difficult to clean underneath a bridge
which makes them more prone to caries and
periodontal disease. Also, the adjacent teeth take
on a heavier load, which increases the risk of
fracture. If a problem develops with an abutment
tooth, the entire bridge fails and must be removed.
Studies show up to 50% failure rates from 10 to
15 years in function.32
The length of a zygoma implant is 30 to 52.5

mm, which is 2 to 5 times the length of a regular
implant. By using zygomatic implants, the cost
and need for bone grafting can be decreased. A
multicenter study completed in 1997, showed a
success rate of 96.3%.30
A dental implant most closely replicates natural

tooth structure. Once it is osseointegrated, many
patients cannot differentiate an implant from a
natural tooth. Furthermore, dental implants do not
decay or need root canal therapy. Even though
the cost is slightly more than a bridge, it is an
investment for the future, as implants usually last
longer than a bridge. A 10-year report on posterior
single implants shows a success rate of 97%.33
Once an implant is placed, the osseointegration
and tissue healing time of approximately four
months is necessary before a final crown is
placed. A temporary crown can be placed the
same day the implant is placed, but this is only for
esthetics, not for function (Figure 11 A-E).
Prosthetic Options
Single Tooth
Most adults (70%) are missing at least one tooth.31
Developing a diagnosis and final treatment plan
for tooth replacement is the dentists responsibility.
However, all dental team members should be
familiar with the different options, risks and
benefits of replacing a single missing tooth.
There are 3 options to replace a single missing
tooth:
1. a removable partial denture,
2. a 2 3 unit fixed bridge, or
3. an implant finished with a permanent crown.
Young patients, those under 16-17 years of age

and still in their growing years, cannot receive
dental implants. A hand-wrist radiograph is
prescribed to determine if growth is complete
(Figure 12). If the patient is still growing, a resinbonded fixed bridge can be used as an option
until they are a viable implant recipient. Another
temporary option is a denture, also known as a
flipper or stayplate. This option is intended for
esthetics only until a permanent solution is chosen.
Dentists must agree to the American Dental

Associations Code of Ethics as a condition of
membership. This code upholds the principles
to do good and do no harm to dental patients.
The standard of care that advocates these
principles is to recommend the placement of a
dental implant. It is the most conservative option
and preserves the integrity of the adjacent teeth
and surrounding bone structure.
Partially Edentulous
When patients are missing multiple consecutive
teeth, the best replacement options are dental
implants. A bridge is not a preferred choice due
to the long span of edentulism, causing excessive
stress on the abutment teeth. A removable partial
denture is the least expensive, non-surgical
option. However, the anchor teeth supporting this
prosthesis are also subject to excessive forces.
Studies report that up to 44% of anchor teeth for
RPDs are lost early.34
A removable partial denture (RPD) is the least

expensive alternative, is reversible, and can be
altered. Many patients, however, do not like a
removable prosthetic and have trouble getting
used to it. The RPD needs to be removed at night
to let the tissues and teeth it sits on rest, it is not
as stable during chewing (10% of original chewing
capability 23) or speaking, and must be replaced
when the jaw changes shape due to bone and
tissue resorption.
Figure 11D. Immediate placement of temporary

crown over the abutment; laser crown lengthening
was performed on the adjacent teeth to improve
gingival symmetry.
Figure 11A. Extraction of anterior tooth (#8)

without detaching the gingiva.
Figure 11E. Four months post surgery with

temporary implant at #8.
Figure 11B. Extracted tooth with the root canal

material (gutta percha) extending from the apex.
Figure 12. Hand-wrist radiograph verifies complete

growth.
Figure 11C. A zircon (white) abutment was
attached immediately following the extraction and
implant placement.
10
There are two options when planning implant

treatment for partially edentulous patients. One is
to replace every missing tooth with an individual
implant and crown. The second option is to attach
a fixed bridge onto several implants.
properly, also leading to malnutrition, due to

eating only softer, more processed foods.
Atrophy of the alveolar arches occurs due to lack
of adequate pressure on the bone. This atrophy
results in resorption of the tissues leading to
mouth sores and tissue irritation. When the
denture is allowed to irritate the mental foramen,
the patient can experience pain and numbness
of the lower lip. A positive solution for a
denture patient is to have two to four implants
inserted into the alveolar bone. The denture
is then connected to the implants via snap-on
attachments or a bar resulting in stabilization
(Figure 13 A-C). According to the 2002 McGill
Consensus Statement on overdentures,
mandibular two-implant overdentures are
superior to conventional dentures in all clinical
trials, even up to nine years following insertion.36
Replacing every missing tooth with an implant

and crown may not be possible in every case.
However, some patients want to recreate individual
teeth. The hard task of replacing individual teeth
in the esthetic zone (anterior) is maintaining or
creating the soft tissue architecture (interdental
papillae). The best results occur when inserting
implants immediately following extraction, thus
preserving the gingival tissue. In the posterior
zone, where the forces of mastication are highest,
individual implants are recommended.
Implant-supported bridges are a predictable and
efficient way of replacing several missing teeth.
As with a tooth-supported bridge, oral hygiene
requires patient instruction in flossing underneath
the bridge and around implants. If the patient
fails to maintain healthy tissues under bridges
and around implants, bone loss, known as periimplantitis, can occur.
Since the maxillary arch is wider than the

mandibular arch, and the cancellous bone is
more porous, four to six implants are utilized
for a maxillary overdenture. An advantage
of having an implant-supported overdenture
in the maxilla is that the palatal area remains
uncovered to the soft palate. Having the palate
open to the taste buds allows for an enhanced
sense of taste. Another advantage is relief from
triggering the gag reflex. A properly inserted
overdenture can be inserted without adhesives
and easily removed allowing for consistent and
thorough cleaning. Finally, it produces better lip
support for patients who have experienced bone
loss in the anterior area.
Completely Edentulous
Many fearful dental patients avoid dental
treatment, resulting in the loss of teeth due to
periodontal disease or extensive decay. With the
advancements in dental implant technology, the
dentist can insert implants immediately following
extraction and fix a temporary, full-arch prosthesis
35
to the implants. Many patients are unaware
of the option of not going even one day with a
removable denture. It is the responsibility of the
dental team to remain current on dental technology
and to educate patients about their implant options.
Correctly completing a treatment plan for the

edentulous patient is very important. Some
edentulous patients may not be candidates for
fixed overdentures due to the lack of existing
alveolar bone. To restore the lip support,
a flange is often necessary or an extensive
amount of bone grafting must be completed. A
flange cannot be attached onto a fixed bridge
because the patient will not be able to clean
under it (Figure 14).
After approximately four months of healing, the

final denture can be fabricated. This can be
made of acrylic or porcelain. Both achieve great
esthetic results, but porcelain is three to four times
more expensive. Recent studies show that it is
beneficial to splint implants together with a fixed
temporary denture versus a removable transitional
denture because it decreases the risk of failure.23
Diagnostics
A few records are necessary to determine the

treatment options for the patient and placement
of the implant(s). When considering potential
implant treatment, the standard of care today
is for the patient to receive a Computed
As stated earlier, dentures replace approximately

10% of chewing function. This causes digestive
problems due to an inability to chew the food
11
Figure 13A. Mandibular, two-implants with O-rings to

support the overdenture.
Figure 14. Overdenture with flange to restore lip

support.
Figure 13B. Maxillary bar that attaches the

overdenture.
Figure 15. Radiographic guide for the mandible.
mounted impressions need to be obtained to

determine the correct bite and location of the
teeth to be replaced with implants. The guide is
prescribed and made in a dental laboratory.
CT Imaging
CT scans have been used in medicine since 1973
and in dentistry since 1987. The CT scan allows
the dentist to visualize the bone anatomy and
nerve locations in 3-dimension (Figure 16). The
latest technology in CT scans is called a cone
beam CBCT scan. These scans are digital and
require less radiation than a full mouth series of
dental radiographs. Medical CT scans use 40
to 60 times more radiation than CBCT scans in
dentistry.23 Most dental offices do not currently
own a CBCT scanner so patients are referred to a
local imaging center that has the dental software.
However, as the CBCT scanners become more
affordable, it is expected that more dental offices
will be purchasing them (Figure 17).
Figure 13C. Fully edentulous patient restored with

maxillary and mandibular implant supported implants.
Tomography scan, or CT-scan. A radiographic

guide should be worn by the patient during the
scanning procedure. This radiographic guide is
a great communication tool to help the surgeon
visualize implant placement (Figure 15). To make
the radiographic guide, maxillary and mandibular
12
Figure 16. CT scan cross-section of the patients

posterior maxilla and mandible; note the gutta percha
shows up as a white vertical cylinder between the arches.
Figure 18. Proper sterile treatment room set-up for
implant surgery.
procedure in laymans terms in order for the dentist

to obtain an informed consent and keep their trust.
Pre-packaged, sterile implant kits can be
purchased from implant manufacturers. The kits
can be customized for dental operatories. It is very
important to maintain a sterile field during implant
surgery. This minimizes the number of infections
post-surgically and the risk of implant failure
(Figure 18). While setting up for implant surgery,
it is recommended to have a roving, second
dental assistant who can retrieve the supplies
while an assistant wearing sterile gloves prepares
the treatment area. A proper surgical set up
requires approximately 30 minutes. This stringent
technique to maintain sterile field may be a
challenge to implement but is absolutely necessary.
Several training DVDs on proper treatment room
preparation are available and highly recommended,
especially as the team is just beginning to add
implant placement to their treatment list and for
training new dental team members.
Figure 17. Cone beam CT scan.
Treatment Planning Software

Several companies are providing dental software
as a solution for accurate treatment planning of
implant cases. Surgeons can simulate implant
placement prior to surgery and obtain bone
density values. Once the simulation of implant
placement is set, a precisely replicated surgical
guide can be fabricated leaving little or no chance
for error.
Surgical Protocol
Any licensed, properly trained dentist can place

dental implants. It is important to understand
the implant placement protocol of the system
used. A team approach will result in a smoother
procedure and a happier patient.
The responsibilities of a surgical assistant are:

setting up the treatment room, monitoring the
patient, instrument exchange, retraction, and
effective oral evacuation of the oral cavity and
surgical site. Ideally, a second, roving assistant
stays available to obtain any necessary supplies
outside of the sterile area.
Patients count on the dental assistant to answer

questions regarding the procedure, often when
the doctor is out of the treatment room. The
dental assistant can ease a nervous or confused
patient. It is advisable to give complete
information to the patient about the surgery
so they are confident of the procedure before
surgery. Patients must understand the whole
A challenge with the implant surgical kit is

maintaining the organization of many small parts
that are used intraorally (Figure 19). It is important
to ensure that small drills and/or screwdrivers
13
Figure 19. Implant surgical kit for Nobel Biocare

Replace Select Tapered System.
Courtesy of Sanda Moldovan, DDS, MS, CNS
are not aspirated by the patient. Screwdrivers

can be ligated at the handle with a long piece of
floss for easy retrieval if they slip and become an
aspiration risk.
Figure 20. The OseoSet electric unit for implant

placement; a saline bag is set up for irrigation while
drilling.
Every dental implant system has a unique

drilling sequence. Some designs are tapered
and some are cylindrical. The cylindrical system
kit has fewer drills. It is important to know the
correct terminology for each piece of the kit
prior to surgery. It is recommended to contact
the company representative and arrange an
education session with the entire clinical team to
learn about each particular implant system.
Restorative Protocol
A restorative temporization procedure immediately

follows implant placement surgery. Often times,
especially in the esthetic zone, immediate
abutments are placed over the implant to support
an immediate, temporary restoration.
All implant handpieces are electric and need to

be set up prior to the start of surgery. The electric
unit can be used with any implant drill system.
Dental unit water lines utilizing city water should
be suspended for implant procedures. Sterile
saline bags are connected to the unit, allowing
saline to be pumped to the handpiece at all times
during drilling of the osteotomy. Sterile saline is
used to prevent the possibility of any infection
caused by bacterial bioburden in regular water.
As a regular handpiece uses water for cooling,
the use of irrigation fluid helps to prevent overheating of the bone, which can lead to implant
failure (Figure 20).37
After four to six months of tissue healing

and osseointegration, the final restoration is
fabricated. An impression is obtained, either at
implant level or at the abutment level, to fabricate
the final crown. The implant-level impression
records the implant position and requires
precision. An impression coping is screwed onto
the implant to be transferred into the impression.
The copings are utilized for a closed- or opentray technique. The closed-tray technique is
used mostly with one implant, and the open-tray
technique is used more frequently for multiple
implants, when different implant angles exist
(Figure 21A, 21B). With either technique, the
14
Figure 21A. Closed tray impression copings.
Figure 22B. Metal-free fixed partial denture cemented

on abutments.
Figure 21B. Open tray impression copings connected

with acrylic.
Figure 22C. Final smile line.
of abutment is made according to the esthetics

desired, thickness of tissue around the implant,
and the angle of the implant. It is important to
note that every abutment is connected to the
implant using a screw.
The crown can be cemented into place or
retained by screw over the implant. For a multiple
implant bridge or bar overdenture restoration, the
framework try-in appointment is important prior to
porcelain build-up or overdenture fabrication to
ensure a passive fit. The fit must be confirmed
by a radiograph. Framework trial appointments
require a minimal set-up. No anesthetic is
required, however a screwdriver for the chosen
implant system is required.
Figure 22A. Titanium custom abutments.
impression material most often recommended

is polyether.38 Bite registration, shade selection,
and opposing models are collected in the same
manner as crown and bridge cases.
The implant prosthesis delivery appointment

is similar to that of a crown or bridge delivery
(Figure 22B-C). If the prosthesis is screw
retained, then no cement is necessary and an
occlusal filling material, such as composite, is
necessary. After the occlusal bite registration
There are different types, shapes, and sizes

of abutments that are either pre-fabricated by
the manufacturer or custom crafted by a dental
laboratory technologist (Figure 22A). The choice
15
is checked, the patient receives home care

instructions regarding restoration maintenance.
Sterilization and Handling
The instruments used in the dental implant

placement and restoration require special care. It
is important to contact a representative from the
manufacturer of the implant system for specific
recommendations of that particular system.
All instruments and reusable drills used in the
dental implant procedure should be cleaned
using an ultrasonic cleaner with an enzymatic
wash. Prior to placing them in the ultrasonic
bath, each drill, screwdriver, and torque wrench
must be cleaned manually with a small brush to
remove any blood or bone particles. The torque
wrench must be disassembled if it was used in
a surgical field, to remove any remaining blood
and debris preventing it from proper sterilization
and future use (Figure 23). Some drills have an
internal channel used for irrigation during surgery
that acts as a cooling system. This inside drill
channel is kept free of blockages by cleaning it
after every surgery with an irrigation syringe and
water. To prevent rusting, it is important to dry
the instruments before sterilization. Dry heat,
autoclave, gas, and chemiclave techniques are
all acceptable methods of sterilization. It is very
important to replace the drills in their proper
position in the surgical kit.
The contra-angle must be cleaned first under
running water. The head should be separated
from the shank and both parts carefully lubricated
and sterilized according to the manufacturers
recommendations.
Figure 23. Top: Proper cleaning of the surgical drills

by irrigating them with water to remove blockages.
Middle: Implant handpiece cleaning station.
Bottom: Cleaning of the manual torque wrench.
Patient Management
Informed Consent
The informed consent information should be
presented to the patient prior to the start of
treatment. Proper informed consent paperwork
will list the dentist performing the treatment, the
patients name, the expected procedures being
completed, alternatives to treatment, the risks
involved in performing treatment and refusing
treatment, the average times for healing and
possible healing complications, and the expected
costs to be incurred. By signing the consent
form, the patient is confirming an understanding
Courtesy of Nobel Biocare
of the treatment, the risks of treatment, and any

alternative options.
A pre-operative discussion with time for questions
and answers is completed prior to the date of
surgery. Patients may telephone with additional
concerns before the surgery date. These
questions should be asked and addressed in
person at a follow up consultation appointment.
Additional informed consent information can
16
be presented by any member of the dental

team, after the initial consultation appointment.
However, it is the doctors responsibility to review
the risks, benefits and alternatives with the
patient, prior to an implant procedure.23
Patients must follow all medication protocols as

prescribed, especially in taking the antibiotic as
directed until gone. They are advised to rest,
eat soft foods, and rinse with salt water for the
remainder of the day. The patient is given an ice
pack to minimize swelling and a pack of sterile
gauze to be used in case of minor bleeding.
They should start chlorhexidine mouth rinses
the second day post surgery. Chlorhexidine, the
active ingredient in Peridex or Periogard, has
been shown to inhibit the initial stages of blood
clot formation, therefore emphasis must be placed
on delaying these rinses until the second day post
surgery. Additional home care instructions include
not smoking, using drinking straws, exercising, or
directly brushing the surgical site for one week.
It is important to update all patient medical

histories at each visit to identify any health
issues and the list of prescribed medications.
Patients who have had a recent heart attack,
complications of diabetes, mental illness,
immunosuppression, and certain blood disorders
may not receive a dental implant unless their
physician approves the treatment.
Pre-surgical Preparation of the Patient
The patient should have an oral hygiene
appointment within the month before the surgery
to minimize the amount of plaque present at the
time of surgery. A 30-second rinse immediately
before surgery with 0.12% chlorhexidine
mouthwash also aids in reducing the amount
of bacteria present in the mouth at the time
of surgery.39 Any removable appliances, such
as partial dentures and retainers are removed
from the patients mouth prior to the rinse and
surgery. Prior to implant surgery, antibiotic and
anti-inflammatory medications are administered
to the patient to reduce the chance of infection.
One gram of amoxicillin or 300 mg clindamycin
for patients allergic to penicillin, and 600 mg of
ibuprofen may be administered.
Written, post-operative instructions may also

include recommended homeopathic treatments.
The most common of these is the plant extract,
Arnica montana, which aids in decreasing
bruising, swelling, and pain. This product is
commonly used after plastic surgery or any other
trauma. It comes in gel, cream or sublingual
pellets. The sublingual pellets are preferred
for implant surgery. Only short term use is
recommended as there are potential, undesirable
side effects including tachycardia, shortness of
breath, and contact dermatitis.
Implant Maintenance
Implants attach differently to bone than teeth. The

periodontal ligament (PDL) is a fibrous attachment
that anchors teeth into the alveolus. When the
PDL is lost or diseased, the tooth becomes loose
and tender. Since implants do not rely on PDLs
for attachment, even if the majority of bone is lost
around an implant, no mobility is observed. Often
times, the patient does not have any symptoms
when peri-implantitis occurs. Therefore, it
is imperative that regular dental prophylaxis
appointments are scheduled. If bone loss is
detected early, treatment can be administered
quickly to restore health around the implants.
Most implant surgeries may be performed without

any type of patient sedation. However, if the
patient requests sedation, the risks and benefits
of oral or intravenous (I.V.) sedation procedures
should be discussed. Oral sedation is a great
option for shorter procedures lasting less than
2 hours. Patients undergoing any sedation
procedures must have transportation when
leaving the office and this must be discussed with
the patient as pre-surgical protocols. Patients
must follow protocols concerning the premedications and food intake prior to surgery.
Home care for dental implants is the same as

for natural teeth. Daily brushing and flossing are
mandatory to remove plaque build-up, which can
cause peri-implantitis. However, patients rely
on the dental team to give them instructions on
how to clean the implants. If regular floss is too
small for the interproximal spaces, then proxy-
Post-surgical Instructions for the Patient

Written and oral post-operative instructions must
be reviewed with the patient prior to the start
of surgery and again after the surgery. Having
an advocate with them to help with immediate
instructions and the return home is advised.
17
brushes should be recommended (Figure 24). It

is necessary to offer home care instructions for
every oral hygiene aid offered to a dental implant
patient.
For an older patient with poor dexterity, due
to arthritis for example, it may be difficult or
impossible to clean using dental floss. Irrigating
devices may be recommended for daily use for
patients receiving an implant. Antiseptic rinses can
be used as the irrigation in the reservoir helping to
reduce the inflammation in the tissues surrounding
the implant.40
Figure 24. Proxybrush is a great tool to clean under

the overdenture bars.
Implant Complication
Dental implants are the best option we have

today to replace missing teeth. However,
complications during treatment may arise, such
as failure to osseointegrate or bone loss while in
function (Figure 25).
Implant integration happens in 95%-99% of the
cases. Occasionally, gingival tissue infections
occur shortly after surgery due to any one of the
billions of bacteria in the oral cavity. To minimize
infections, it is important for the patient to take an
oral antibiotic, as well as use an antiseptic rinse
from post surgery days two through seven.
As mentioned earlier, dental implants require daily
brushing and flossing or peri-implantitis can occur.
This condition is the equivalent to periodontitis
due to poor oral hygiene and lack of recare/recall
visits (Figure 26). Signs of this condition include
redness, bleeding upon probing and gingival
pocketing.
Figure 25. Radiograph showing significant bone loss

around the implant, one year after placement.
Geriatric patients, patients with osteoporosis, and

those receiving treatment for certain cancers,
have a higher incidence of implant failure due
to decreased bone density. With these groups
of patients, their physician often prescribes
bisphosphonate drugs, such as Boniva and
Zometa. These drugs can interfere with
normal bone healing and prevent necessary
osseointegration. This condition is called
osteonecrosis of the jaw (ONJ). Patients taking
these types of drugs for other health conditions
should not be recommended for dental implants.41
Figure 26. Peri-implantitis note the exposed

implants, receding gingiva and plaque present on the
exposed implant surfaces.
implants due to force overload. However, the

incidence of fixture fracture has been reported
to be less of an issue than that of tooth fracture
(Figure 27A-B).13
Mechanical complications include loosening of

screws, fractured screws, and even fractured
18
Figure 28. Smile of patient with a dental implant.
Figure 27A. Radiograph of fractured posterior implant.
Many patients struggle with ill fitting removable

full and partial dentures. The resulting conditions
of periodontal bone loss, malnutrition, and overall
low self esteem can occur. Fortunately, better
options exist with todays implant technology.
As patients are counseled on dental implant
procedures, they can be assured that with
basic home care protocols, their dental implant
investment can have a high rate of success.
Furthermore, implants will not decay once
osseointegrated so crowns do not need to be
replaced due to recurrent caries (Figure 28).
Every patient must understand the importance of
having any dental treatment. Dental professionals
must comprehend all implications involved
in implant kit choices and the pre- and postoperative procedures. This knowledge enhances
the advocation for single tooth implants and
implants that allow for a well- fitting overdenture.
Patients count on dental team members to
educate them on all choices to replace missing
teeth and dental implants are recommended as
the standard of care for patients.
Figure 27B. Gingiva incised and a trephine drill used

to remove fractured implant.
Conclusion
Dentistry has advanced significantly in the area

of dental implant technology. Dental implants
offer same day tooth replacement options. After
a few months of tissue healing, osseointegration,
and final crown delivery, patients will have a
fixed restoration that enhances their oral health
function and esthetic appearance.
19
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to
www.dentalcare.com and find this course in the Continuing Education section.
1.
_______________ discovered osseointegration and brought dental implants to North

America in 1982.
a. Dr. Linkow
b. Dr. Brnemark
c. Dr. Albrektsson
d. Dr. Maggiolo
2.
Current implant research indicates success rates for individual implants in the ________
range.
a. 70 - 75%
b. 75 - 80%
c. 80 - 85%
d. 95 - 99%
3.
Self-tapping implants can cut into the bone and thus have a closer fit. The blade implant is
no longer used in dentistry.
a. Both statements are true.
b. The first statement is true. The second statement is false.
c. The first statement is false. The second statement is true.
d. Both statements are false.
4.
Pre-surgical implant protocols for the patient include _______________.

a. a 30-second chlorhexidine rinse to reduce oral bacteria
b. a prophylaxis within 30 days of surgery
c. taking antibiotics to reduce possibility of infection
d. All of the above.
5.
The term osseointegration refers to _______________.

a. bone fusing to another bone
b. a metal implant fusing with the bone
c. two bones fusing together at a joint
d. a healed bone fracture
6.
_______________ is used in water lines during implant surgery.

a. Regular water
b. Soft water
c. Sterile saline
d. A water and chlorhexidine mix
7.
The advantage(s) of dental implants is/are they _______________.

a. preserve the bone around it
b. do not require cutting into adjacent teeth
c. do not develop cavities
d. have high, long-term success rate(s)
e. All of the above.
20
8.
The advantage(s) of a removable partial denture is/are that _______________.

a. no surgical treatment is involved
b. it is easy to get used to
c. it does not affect the teeth it rests on
d. it is cost-effective
e. Both A and D.
9.
The disadvantage(s) of dentures is/are _______________.

a. they replace only 10% of the chewing function
b. nutrition is impaired because food is not chewed properly
c. bone resorption progresses
d. soft tissue irritation is common
e. All of the above.
10. An abutment is _______________.

a. connected to the implant with a screw
b. connected directly to the bone
c. part of the implant crown
d. completely submerged under the gingiva
11. _______________ can surgically place dental implants.
a. Only oral surgeons
b. Only periodontists and oral surgeons
c. Any licensed, trained dentist
d. Only endodontists
12. The roughed, porous surface of the dental implant has been recommended to generate a
stronger bond to bone because of increased surface area. Hydroxyapatite-coated implants
are preferred in dentistry today.
13. In dentistry, TAD stands for _______________.
a. transfer abutment device
b. temporary anchorage device
c. titanium alloy dip
d. Both A and C.
14. A falsehood regarding zygomatic implants is that they _______________.
a. are placed in the zygomatic bone
b. have a 94% success rate, in a 10-year study
c. are used for patients with severely atrophied maxillae
d. are used for patients with severely atrophied mandibles
15. Approximately ________ month(s) time is required for an implant to integrate before a final
crown restoration can be placed.
a. four
b. three
c. two
d. one
21
16. _______________ is/are the responsibility(ies) of a sterile surgical assistant during implant
surgery.
a. Monitoring the patient
b. Effective oral evacuation and retraction
c. Instrument transfer
17. The _______________ should NOT be included on the informed consent.
a. patients name
b. procedure being performed
c. patients address and emergency contact information
d. alternative treatments
e. possible risk factors
18. _______________ is/are a contraindication(s) for dental implants.
a. An edentulous patient
b. A patient who has had cancer treatment with I.V. bisphosphonates
c. An 80-year-old woman
d. Both B and C.
19. CBCT scans are less desirable in treatment planning as they require more radiation to the
patient than a full mouth series of radiographs. A patient may have a dental implant placed
after bone development ends.
20. Specialized implant instruments require special care including _______________.
a. drill channel irrigation
b. manual scrub and/or ultrasonic cleaning in an enzyme wash
c. sterilization by autoclave, gas, chemiclave, or dry heat
22
References
1. Millenium Research Group Report: US Markets for Dental Implants, 2006.

2. Ring ME, Dentistry: An Illustrated History. 1985: C.V. Mosby.
3. Ring ME. A thousand years of dental implants: a definitive history--part 1. Compend Contin Educ
Dent. 1995 Oct;16(10):1060, 1062, 1064 passim.
4. Worthington Philip LBR, LaVelle WE, Osseointegration in Dentistry. An Introduction1994:
Quintessence.
5. Goldberg NI, Gershkoff A. The implant lower denture. Dent Dig. 1949 Nov;55(11):490-494.
6. Bodine RL, Yanase RT, Bodine A. Forty years of experience with subperiosteal implant dentures in
41 edentulous patients. J Prosthet Dent. 1996 Jan;75(1):33-44.
7. James RA, Lozada JL, Truitt PH, Foust BE, Jovanovic SA. Subperiosteal implants. CDA J. 1988
Jan;16(1):10-14.
8. Small IA. The mandibular staple bone plate. Its use and advantages in reconstructive surgery. Dent
Clin North Am. 1986 Apr;30(2):175-187.
9. Small IA, Misiek D. A sixteen-year evaluation of the mandibular staple bone plate. J Oral Maxillofac
Surg. 1986 Jan;44(1):60-66.
10. Linkow LI, Mahler MS. Validating the endosteal blade-vent implant. Oral Health. 1975 Nov;65(11):
16-23.
11. Kapur KK, Veterans Administration Cooperative Dental Implant Study--comparisons between
fixed partial dentures supported by blade-vent implants and removable partial dentures. Part I:
Methodology and comparisons between treatment groups at baseline. J Prosthet Dent. 1987 Oct;
58(4):499-512.
12. Kapur KK. Veterans Administration Cooperative Dental Implant Study--comparisons between
fixed partial dentures supported by blade-vent implants and removable partial dentures. Part II:
Comparisons of success rates and periodontal health between two treatment modalities. J Prosthet
Dent. 1989 Dec;62(6):685-703.
13. Branemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses: osseointegration in clinical
dentistry. 1985, Chicago: Quintessence.
14. Biocare N. The Story about an invention that makes people smile. 2005, Sweden: Nobel Biocare.
15. Brnemark PI, Hansson BO, Adell R, Breine U, et al. Osseointegrated implants in the treatment of
the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;
16:1-132.
16. Kay JF. Calcium phosphate coatings: understanding the chemistry and biology and their effective
use. Compend Suppl. 1993;(15):S520-525.
17. Gottlander M, Albrektsson T. Histomorphometric studies of hydroxylapatite-coated and uncoated CP
titanium threaded implants in bone. Int J Oral Maxillofac Implants. 1991 Winter;6(4):399-404.
18. Albrektsson T, Sennerby L. Direct bone anchorage of oral implants: clinical and experimental
considerations of the concept of osseointegration. Int J Prosthodont. 1990 Jan-Feb;3(1):30-41.
19. Lewandowski JA, Johnson CM. Structural failure of osseointegrated implants at the time of
restoration. A clinical report. J Prosthet Dent. 1989 Aug;62(2):127-129.
20. Tufekci E, Brantley WA, Mitchell JC, McGlumphy EA. Microstructures of plasma-sprayed
hydroxyapatite-coated Ti-6Al-4V dental implants. Int J Oral Maxillofac Implants. 1997 Jan-Feb;
12(1):25-31.
21. ADA Council on Scientific Affairs. Dental endosseous implants: an update. J Am Dent Assoc. 2004
Jan;135(1):92-97.
22. von Wowern N, Gotfredsen K. Implant-supported overdentures, a prevention of bone loss in
edentulous mandibles? A 5-year follow-up study. Clin Oral Implants Res. 2001 Feb;12(1):19-25.
23. Misch CE. Contemporary Implant Dentistry, 3rd ed. 2008: Mosby Elsevier. 1101.
24. Palma-Carri C, Maestre-Ferrn L, Pearrocha-Oltra D, et al. Risk factors associated with early
failure of dental implants. A literature review. Med Oral Patol Oral Cir Bucal. 2011 Jul 1;16(4):e514-7.
25. Minsk L. Interim implants for immediate loading of temporary restorations. Compend Contin Educ
Dent. 2001 Mar;22(3):186-90, 192, 194, passim.
23
26. Mazor Z. Using transitional implants for immediate fixed temporary prostheses. [Interview]. Dent
Implantol Update. 2000 Apr;11(4):29-31.
27. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod. 1983 Apr;17(4):
266-269.
28. Singh K, Kumar D, Jaiswal RK, Bansal A. Temporary anchorage devices - Mini-implants. Natl J
Maxillofac Surg. 2010 Jan;1(1):30-34.
29. Jae-Hyun Sung H, Seong-Min Bae, Hyo-Sang Park, Oh-Wn Kwon, James A. McNamara Jr.,
Microimplants in Orthodontics. 2006, Daegu, Korea: Dentos.
30. Sevetz EB Jr. Treatment of the severely atrophic fully edentulous maxilla: the zygoma implant option.
Atlas Oral Maxillofac Surg Clin North Am. 2006 Mar;14(1):121-136.
31. Meskin L, Brown J. Prevalence and patterns of tooth loss in U.S. adult and senior populations. Int J
Oral Implantol. 1988;5(1):59-60.
32. Scurria MS, Bader JD, Shugars DA. Meta-analysis of fixed partial denture survival: prostheses and
abutments. J Prosthet Dent. 1998 Apr;79(4):459-464.
33. Priest GF. Failure rates of restorations for single-tooth replacement. Int J Prosthodont. 1996 JanFeb;9(1):38-45.
34. Aquilino SA, Shugars DA, Bader JD, White BA. Ten-year survival rates of teeth adjacent to treated
and untreated posterior bounded edentulous spaces. J Prosthet Dent. 2001 May;85(5):455-460.
35. Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in
edentulous arches: ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac
Implants. 1997 May-Jun;12(3):319-324.
36. Feine JS, Carlsson GE, Awad MA, Chehade A, et al. The McGill consensus statement on
overdentures. Mandibular two-implant overdentures as first choice standard of care for
edentulous patients. Montreal, Quebec, May 24-25, 2002. Int J Oral Maxillofac Implants. 2002 JulAug;17(4):601-602.
37. Piattelli A, Piattelli M, Mangano C, Scarano A. A histologic evaluation of eight cases of failed dental
implants: is bone overheating the most probable cause? Biomaterials. 1998 Apr-May;19(7-9):683-690.
38. Assif D, Fenton A, Zarb G, Schmitt A. Comparative accuracy of implant impression procedures. Int J
Periodontics Restorative Dent. 1992;12(2):112-121.
39. Veksler AE, Kayrouz GA, Newman MG. Reduction of salivary bacteria by pre-procedural rinses with
chlorhexidine 0.12%. J Periodontol. 1991 Nov;62(11):649-651.
40. Levin RP. Waterpik dental water jet: creating value for your patients. Compend Contin Educ Dent.
2009 Mar;30 Spec No 1:20-21.
41. Etminan M, Aminzadeh K. Bisphosphonates and ONJ. J Am Dent Assoc. 2008 May;139(5):535-536.
About the Author

Sanda Moldovan, DDS, MS, CNS
Sanda Moldovan, DDS, M.S., CNS, specializes in dental implants, periodontics
and integrative nutrition. She graduated from the School of Dentistry of Ohio State
University in Columbus, Ohio in 2001. She continued her studies in the Department
of Postgraduate Periodontics at UCLA, concurrent with a Master of Science in Oral
Biology. After she completed her postgraduate program in 2004, Dr. Moldovan
accepted a lecturer position at UCLA School of Dentistry. Today, she is in private
practice and provides dental implant lectures in the Continuing Education Department
of the UCLA School of Dentistry. She is a regular on the Doctors TV show on CBS
and has appeared on several other TV networks.
Dr. Moldovan is a Diplomate of the American Academy of Periodontology. She continues to stay involved
and up-to-date with the latest research and technology available in her field, including laser techniques
and stem cell bone grafting techniques.
24

Ce 420

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Ce 420

Enviado por

Direitos autorais:

Formatos disponíveis

Dental Implants: A Comprehensive Review

Sanda Moldovan, DDS, MS, CNS

Conflict of Interest Disclosure Statement

The author reports no conflicts of interest associated with this work.

The Procter & Gamble Company is an ADA CERP Recognized Provider.

Approved PACE Program Provider

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

abutment A tooth, root, or implant used for

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

atrophy A wasting or loss of tissue.

roundhouse bridge Fixed partial denture for an

blade form dental implant Type of endosseous

subperiosteal implant Cast-metal frame which

endosseous implant Positioned within the jaw

tachycardia Fast heart beat.

hydroxyappatite (HA) Calcium phosphate

transosseous implant Machined implant

intrude Forceful change to tooth position, driving

trephine A surgical instrument used for cutting

ligature Piece of floss attached to small

Vitalium Trademark name for a dental alloy

History of Dental Implants

muscles of mastication Four pairs of muscles

open bite Lack of vertical overlap of the

Teeth are anchored into the alveolar bone by the

osteotomy A hole in the alveolar bone made

Prior to the era of osseointegration, there

pneumatize Formation of air cells or cavities

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

impression was made of the edentulous jaw

Figure 1. Bone forms a bond with dental implant.

Figure 2A. Blade implant design.

In 1966, Dr. Linkow presented the blade implant

Figure 2B. Exposure of the implant

Gershkoff.5 This framework could be used on the

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

Figure 3A. Radiograph of the microscope

Brnemarks first patient, Gsta Larson (Figure

Figure 3B. Dr. Brnemark (right) with his first

Following this first implant, Brnemark did

Figure 4. The original Brnemark implant,

cylinders, expansive screws, and hollow posts are

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

a titanium plasma spray. HA was shown to

Figure 5. This picture demonstrates how bone

Many implant studies were conducted in the

Figure 6. The new generation,

during mastication.22 These forces are essential in

The American Dental Association (ADA) has a

Since chewing ability is reduced with dentures,

Rationale for Dental Implants

As the baby boomer generation ages, the

Patients who are rehabilitating their oral cavity

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

Figure 7. Bone loss is the end result of tooth loss.

shape was its wedging effect into the bone. This

Figure 8. Implant restoration on tooth #11.

The thread design of implants also varies

have implants since they feel so natural due to

The implant platform can also have different

There are several designs of root-form implants.

Crest Oral-B at dentalcare.com Continuing Education Course, February 11, 2013

Figure 9A. Internal connection implant system