Surgery lec 3

Dr.Yanal Nusair
‫بسم الله الرحمن الرحيم‬

Till this moment 16/3/09, 1:05 am,, I have no copy of the slides  ,
so when u have them , go back and check if there is any extra info.
And try to match b/w wt I called "pic" in this lec & the slide that the
dr. was talking about… let's start the lec now,,, Nice one 

Contemporary implant dentistry

Why do we need to talk about dental implants?? Until 10 yrs ago implants
were a luxury for most ppl. who don’t even dream of having dental
implants . Nowadays it is becoming a main stream practice. Many of the
general practitioners all over the world practice implant dentistry.

As a dentist u have responsibility towards ur pts when a pt comes to u

-weather completely or partially edentulous- it's not acceptable not to tell
the pt about the option of dental implants, many ppl wouldn't choose it
bcoz of the cost factor, they are still expensive.

As a dentist u should tell ur pt that one of the methods of tooth

replacement -probably the best method- is dental implants.

We all know that fixed prosthesis are much better in many aspects than
removable ones, bcoz they are: more stable, look more like a natural tooth,
less bulky , provide better function & esthetics.

Now without dental implants, not all pts can have fixed prosthesis, for
example, apt with free end saddle with missing posterior teeth -with no
posterior abutment - , u can't provide him with a fixed prosthesis without
dental implants .

Pts who are completely edentulous, if u don’t consider dental implants then
those pts would have the only choice of removable prosthesis.

Advantages:
1- help improve retentional stability!! of removable prosthesis in
the form of overdentures (implants & over them removeable
prosthesis)
2- With implants almost all pts can have fixed prosthesis weather
completely or partially edentulous,,, and we said (almost all) not (all)

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Dr.Yanal Nusair
bcoz in some cases u don’t have enough bone to support implant or
pt general health status doesn’t permit surgical procedures,etc…
3- Implants are as close as u can get to natural teeth, u have a
fixture inside the bone (which replaces root of the tooth) & u have the
crown which (replaces the crown of natural tooth).
4- U can have separate teeth where u can insert a dental floss
between them (u can't do that if u have a bridge)u don’t have a
pontic where food can accumulate b/w it & the gingiva . so they are
similar but not the same as natural teeth .
5- More conservative ( if u want to make conventional prosthesis in
the form of bridge then u have to prepare 2 teeth , sacrifice a lot of
sound tooth structure in many cases to replace 1 missing tooth . but
with dental implants u don’t need to do that.
6- Improve esthetic, function & pt confidence (pts feel as if they
still have their natural teeth).
7- If u lose a tooth u lose the alveolus (to support teeth) or most of
it in that area. But if u insert an implant in that area, u transmit
functional stresses to the bone so u maintain it .
8- A few yrs ago they started to use dental implants to help in
anchorage in orthodontic tt. I (Dr.) don’t know what it means!!!!
Dr.: it helps u to move the correct tooth in the correct direction.

** Pic : an example of a complete lower denture which was made much

more stable & retentive with the aid of 2 implants & connecting bar b/w
them. ** Pic: to show u how implant resemble natural tooth.
** Pic: to show how esthetics can be greatly improved using dental
implant.

Disadvantages:
1- costly: on average u need 500 JD to get single tooth supported
by an important in Jordan  ( in other countries much more
expensive)
2- Technique sensitive: u can't afford to make mistakes bcoz it will
fail and that will be very costly.

Other then that I (dr) don’t think they've any disadvantages.

• We don’t worry about implants being a foreign body bcoz

they're well tolerated by the immune system.

NOW…. When u drill the hole & insert the screw, wt sort of interface do
we want to achieve b/w implant surface & surrounding bone??

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Dr.Yanal Nusair
Osseo-integration: we need some sort of integration b/w implant surface &
surrounding bone.
Previously they were looking for fibro-osseous-integration: where u have
the implant, the fibrous tissue resembling PDL, then bone.

Now we know that this is not valid, if an implant heals with fibro-
osseous-integration we consider it failure.
While Osseo-integration means direct connection b/w bone & implant
surface at light microscopic level .
U shouldn't see any sort of connective tissue b/w bone and implant .

** Bone healing occurs in 1 of 2 mechanisms :

• Endochondral: in long bones at the epyphesial plate.

• Membranous: in primary bone healing when u have a fracture &
in the process of Osseo-integration.

** Wound healing occurs in 3 phases with overlapping b/w them ( no

clean cut lines separating them:

- Inflammatory phase: wt induces inflammatory reaction is surgical

trauma when u drill for the implant , that cozes → platelets
degranulation → produce (serotonin, PG, ADP (adenine-di-phosphate) ,
Thromboxane A2, etc… , which help attract cells to the surgical site (site
of trauma) as chemotaxis .

At 1st few days (3-4) , neutrophils – which are acute inflammatory cells –
predominate. Then macrophages start to take over as the process
becomes more chronic.

- Proliferative phase: after few days angioneogenesis (formation of

new blood vessels ) starts mediated by different chemical mediators .
cells start to differentiate into osteoblasts , chondroblasts ,etc… and
these cells start to lay down a connective tissue matrix & then a callus is
formed, which is a form of uncalcified Bone that forms b/w fractured
pieces of bone(it's the scar of bone ) before it calcifies. Then callus
starts to calcify→ woven bone forms ( immature bone that can't carry a
lot of stress).

- Maturation phase : Osteoblasts continue to proliferate → deposit

osteoid → more calcification.

- When u start to subject the area to functional stresses – when u

load the implant - woven bone starts to transform into mature
lamellar bone.

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Then according to functional demands , there will be remodeling in the
area, for example if u place a bone graft in the area , then excess which
doesn’t support functional demands will resorb & disappear .

A completely successful implant will lose about 2-3 mm of bone around

the neck of the implant in the 1st yr, later on it will still lose bone on an
avg of 0.1 mm/yr , so a successful implant should serve the pt easily 20-
30 yrs.

Pic: prepare cavity → place implant →clot formation→ granulation

tissue→ immature bone →calcified mature bone(Osseo-integration).

Can we always achieve Osseo-integration???

Most modern implant systems(550 different branches in the markets in

the world) & (70-80 branches in Jordan) are good enough to give u a
success rate of more than 95% , so if u correctly placed 100 implants, u
expect 95 to Osseo-integrate .

And this high success rates could be achieved bcoz we know the basic
necessities for Osseo-integration:

1- We need a biocompatible material (not rejected by immune

system): pure titanium (99.994%, almost 100%) has been shown to
be completely biocompatible,, sometimes ceramics are also
biocompatible & some implant are made of ceramics . SO IT'S
EITHER TITANUM ALLOY OR CERAMICS.
2- Precise adaptation of the implant to the prepared bony site.
(this isn’t a very rigid rule ): previously they emphasized that the
diameter of the cavity(u prepare)should fit exactly the diameter of
implant , now this is still valid but not very rigid , coz in immediate
insertion of implant after extraction , most of the time we insert an
implant smaller in diameter than the socket diameter and it still
Osseo-integrate .
3- Minimal tissue damage is imp, this is why in almost all implant
systems, drilling is done at low speed of 2000 rpm or less, to avoid
overheating.

We use copious amount of saline and sharp cutting instrument " it has
been shown that heating bone up to 56°c -even if only for 1 sec- then
irreversible damage of bone takes place." "If u heat bone up to 47°c, for
more than 1 min, then irreversible bone damage will take place.

** Irreversible bone damage isn’t similar to irreversible brain damage, bcoz

bone will heal but implant will fail.

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Dr.Yanal Nusair
4- Immobility of implant (u should not be able to move it more
than 100µm in any direction) during the healing phase. & this is much
more imp than precise adaptation.

Q: does ca++ level in the blood affect the Osseo-integration process??

No it doesn’t, wt u need is healthy bone regardless of calcium level, bcoz u

have mechanisms in ur body to compensate for the implant to b
successful.

Q: wt if the bone isn’t dense enough to put an implant??

1st of all u need to define wt is meant by "dense enough", bt always there

are solutions.

Q: osteoporosis: it's a relative contraindication of implants (it's one of the

.(metabolic disorders of bone

Now, wt about soft tissue-implant interface? And that's the interface as

the implant exits through the gingiva ??

We need a sort of good seal, some unbroken per mucosal seal, u want
something to seal oral fluids & saliva from the bone surrounding the
implant. For this we depend totally on epithelium, hemidesmosomes
that form b/w titanium surface & the epithelium around the implant ,
which is similar to wt u have in the junctional epithelium with a natural
tooth, but the main difference is that in natural teeth beneath junctional
epithelium we have connective tissue , but in implant u have epithelium
then bone ( no CT) , that's why soft tissue seal around an implant is
significantly less resistant to inflammation & infection compared to
natural teeth.

Plus , if u insert an implant it may succeed and osseo-integrate , but for

it to last for along time , a high standard oral hygiene should be
maintained .

If gingival inflammation takes the natural tooth 10 yrs to become

mobile, then it may take less than 1 yr to do the same if happened
around an implant . and these figures are just to clarify the pic " don’t
catch them " …dr said

Biomechanical factors :

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Dr.Yanal Nusair
Keep in mind that implants don’t have a PDL with proprioceptors to tell
u that u're biting too heavy , so excessive load cozes bone resorption &
if bone resorbed around an implant , it can't be compensated , so don’t
overload the implant .

Now in case of an implant, lateral forces are much more damaging , coz
implants can tolerate forces directed along their access very well , but
they can't resist lateral forces. This is why connecting implant to natural
tooth isn’t preferable ( it's not contraindicated , or wrong , but it's not
ideal ).
Suppose we have missing 6&7 , & u have 2,3,4,5 in place – sound and
good- one of the options for tt is to replace the missing 6&7 , is to place
an implant with crown in the area of 6, and another implant and crown
in the area of 7 (2 implants supporting 2 separate crowns) . however ,
the less expensive option is to place an implant in the area of 7 ,
prepare the 5 , & make a 3 unit bridge connecting the 5 to the implant
and replacing the 6 as a pontic .

This is something we don’t like , and implants don’t like , why ? bcoz if u
connect :

2 implant together ,,, it's fine,they are similar.

2 natural teeth together by a bridge ,,, it's fine

BUT
Implant with a natural tooth isn’t good , coz implant is very stable in
bone (doesn’t move ), while natural teeth have some degree of
movement which is less than 1mm in any direction .

Now if u connect implant to a natural tooth, every time the pt bites on

the bridge & the 5 for example sinks deeper in socket, the bridge works
as a lever exerting lateral forces on implant on the long term this may
coz either frequent unbonding in the bridge which is simple & u can
always recement it. Or can coz bone resorption in the mesial aspect of
implant & this can't be compensated.

Now :
* number of implants is important ,,, ideally each missing tooth should
be replaced with an implant , but this is very expensive .

If u want to use bridge , then u can use on Avg one implant for 2
crowns. So replacing 12 teeth from 6 to 6 then u need 6 implant (6-8 is

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Dr.Yanal Nusair
ideal) & a lesser number of implants means overloading the implant u
have and shortening its expected life.

* angulation of implant: we are humans & our hand could move & shake
during preparing the implant site, sometimes the direction of bone
forces us to place the implant in an angle, so we don’t perforate the
buccal or lingual plates.

So ,
* if u place the implant a absolutely perpendicular to the occlusal plane →
that's the ideal .

* If u place it at an angle & compensate for that with an angled

abutment,then off access more than 25 ° means failure . The amount of tilt
in ur implant from the vertical access shouldn't be more than 25°.

- Cantilevers: they are not preferable. Unless u make them under very light
occlusion , just to fill the gap not to participate in function .

Wt limits implant placement , is usually quantity & quality of bone. so for

an implant to succeed, u need a minimum of 1mm of bone around the
implants in all directions if the area has been edentulous for a few yrs then
u expect some sort of resorption & in many cases the amount of available
bone isn’t enough to support an implant then u need grafting and
expansion technique to create the amount of bone that u need.

* pts general health status : like any surgical procedure this is something
should be taken into consideration.

* cost : full mouth rehabilitation with implant may cost 15000 JD's .

Now … What is the implant made of????????

Titanium, is very biocompatible, coz the 1st second u expose it to air , it
becomes covered by a very dense & strong layer of titanium oxide . and
this layer shields it from the immune system , so it cant be recognized as
foreign body.

- To improve mechanical properties of Ti , we mix it with some

Aluminum & Vanadium . ( Ti – 6Al – V )
- it has been shown that smooth surfaces don’t actually Osseo-
integrate , so we need a rough surface of the implant , & this can be
created by either :

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Dr.Yanal Nusair
• Plasma spray technology: where they spray droplets of molten
Ti on the surface to make it rough.
• Sand plasting .
• Acid etching.

- some companies coat the implant surface with a 50-70 µm of

hydoxyapetite , this has been shown to speed up the process of
osseo-integration & reduce the healing time ( time b/w insertion &
loading of implant ) as it increases the strength of anchorage b/w
implant & bone .

however, strength of bonding b/w hydroxyapetite & implant is weak ,

and some implants fail bcoz hydroxyapetite under functional stress
chips off from the surface of implant .

Absolute contraindications of implants:

1- any acute illness : as long as the tt is elective (as implant
placement)
2- any uncontrolled metabolic disease: most common is diabetes.
3- Pregnancy : to avoid antibiotics & pain killers unnecessarily .

Relative contraindications:
1- Abnormal bone metabolism: like osteoporosis, if u placed
implant, then healing time would be longer & chances of success
would be less, but still u can place implants.
2- Poor oral hygiene: if the pt can't keep his natural teeth &
change his attitude , then he would be unlikely to preserve the
implant.(coz implants are much damaging , needs highly motivated
pt)
3- Previous radiation to the implant site : this depends on dose of
radiation & duration since the last dose of radiation. Coz we worry
about osseo-radio-necrosis .
4- Unrealistic expectations: if pt expectation is unrealistic, then no
matter what u do, u won't be able to please him, he will always come
back complaining.

So tell the pt that implants are very similar to natural teeth, but they
aren’t the same .

5- Lack of operator experience.

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Dr.Yanal Nusair
Phases of treatment :
Surgical phase:

The 1st thing to evaluate after pt general medical status is the implant
site.
* Any lesion in the area.
* Any remaining root.
* Any acute infection.
*Soft tissue: r they healthy? Do I have enough keratinized gingiva in the
area? Is the width & height of the ridge sufficient to support the
implant?
* Anatomic limitations:
- in mandible: how much bone do I have above the inferior alveolar
canal? if u have 5-6 mm then that is not enough to support an implant
and if u placed an implant there, u would damage the ID nerve & cause
ur pt lip numbness .

- In maxilla : u worry about proximity to the maxillary sinus, or

floor of the nose in the ant. region.

* informed consent is a must , it's not legally required yet but sooner or
later it will be . it means that the pt should know the expected results,
alternatives and possible complications (like pain, swelling ,3-4 % chance
of implant failure, etc………)

If u have a completely edentulous pt & u can get ur prostho-dontist to

help u by creating a surgical guide template ( something like an acrylic
plate u place it over the edentulous ridge & it has holes to help u know
where to place ur implant ), that will greatly facilitate ur job .

** Pic : this pt has bone resorption in this area, the width of the ridge
was insufficient, so we took some bone from the ramus, carted it to this
area, screw it → 2 months later we exposed the area, removed the
screw, place 1 implant here & 2 implants there.
This line demarcates the upper border of the ID canal , & the mental
foramen .
In order to estimate the length of ur implant , u measure the distance
from here to the crest of the ridge & keep in mind that in panorama
radiograph there is 20-30 % magnification.

So if this area is 12mm then u can place an implant of 9mm . length

safely (u reduce 30 % which is the amount of magnification.
So :

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Dr.Yanal Nusair
This is the area →Anesthesia → crestal incision → flap is reflected ( to
inspect the area, if there is any undercut buccally or lingually) →
prepare implant site following the instructions of the manufacturer
company. (There is a user manual which tells u the sequence of burs to
use, at wt speed, etc…………)

Usually we select the height of the implant (9mm for ex. )→ start with
initial perforator, which perforate cortical bone and then a sequence of
drills with different diameters starting with the smaller one, ending with
larger one & each time going to the full depth ( length of implant) .

The diameter is color coded :

Red: 4mm, yellow: 3.75mm, green: 3.25mm, blue: 4.9mm

Implant comes sealed & sterilized, take it out with out touching the implant
surface.→ insert it in the site u prepared → screw it slowly with special
screw driver . some implants are screwed until become flush with the crest
& others are seated sub crestally . (Depending on the system u use) .

There is an internal hex, just like a well in the implant which has a
hexagonal shape to support the abutment later on . u need to protect
the internal hex from tissue may grow there so we have something
called healing screw or cover screw to cover it→ then u suture the flap.

- Time for integration varies; previously they were talking about

4-6 months healing time. ( 4 in mandible & 6 in maxilla (coz bone is
less dense )
- New implant surfaces, rough surfaces (hydroxyapetite coated)
we talk about healing period of 2-4 months (2 in mandible & 3
months in maxilla) are sufficient for healing.
- If Implant is inserted in an area which is not load bearing, like
ant. Area of maxilla→ 3 weeks may be enough.
- Nowadays there is a lot of talk about immediate loading, where
u insert the implant & load it in the same day, but there is a lot of
debate about that(they call it immediate, but in fact they place a
crown on the implant in the same day, but they keep it completely
out of occlusion. keep the pt on soft diet for 2-3 weeks then soft diet
for another 2-3 weeks.( I (Dr.) would call it progressive loading rather
than immediate loading).
But any way they use it especially in ant. region for cosmetic
reasons.

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Dr.Yanal Nusair
Now , stage 2 surgery : after the implant has Osseo-integrated , u need
to expose it either by creating a punch in tissues on the crest of the
ridge , OR by creating a crestal incision & elevate the gingiva buccally &
lingually, OR creating apically repositioned flap.

In this stage u have to make sure that the implant has Osseo-
integrated : either:

-Radiographically : no radiolucency b/w bone & implant.

-clinically: no detectable movement.

** Pic: an example of an implant that radigraphically looks Osseo-

integrated; there is no radilucency b/w bone & implant.
** Pic: clinical case showing stage 2 surgery.
** Pic : a pt for whom I(Dr.) placed an implant in area of upper lateral
incisor → 3 months later implant looks Osseo-integrated radiographically
.

Now I gave anesthesia →reflected a flap (u can see enough bone in all
directions , & the implant was stable)→removed cover screw with a special
screw driver→ placed wt we call healing abutment or a gingival former →
screwed it→ sutured the gingiva around it → give it 10 days – 2 weeks →
gingiva heals around it → remove the stitches .

By now , If u un screw the healing abutment , u see an epithelialized

cavity leading u to implant → do rest of the procedure without
anesthesia.

And then the prosthetic part comes → which we will not be covering in
this case.

Complications :
in stage 1 surgery:
like any surgical procedure : pain, swelling, bleeding, etc….
now ailing or failing implant:

An implant can fail before osseo-integration or after it.

After: either bcoz of increase biomechanical overload , peri-
implantitis(infection of soft tissues around implant) which lead to bone
resorption → loss of implant.

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Dr.Yanal Nusair
Before : overheating , growth contamination , placement in an area which
doesn’t have enough bone to support it , etc….
** Key reasons for failure ( ma b3rf lesh 3adhom !!!!!)
-Off-angled positioning of more than 25° .
-Overheating during placement.
-Poor bone quality & quantity.
–Infection.
-Lack of keratinized gingiva around the implant.

Notes by the Dr. :

- No change in the syllabus, just they swabbed lecs , so Dr. Yanal
gave us this lec , & when Dr. Ma'moun comes back he will
compensate for today's lec.
- The 2 lecs that we took after the mid-term in the 1st semester,
will b included in this semester mid-term.

AND NOW, I CAN'T BELIEVE IT'S THE End

Any mistake ,,, plz let me know 

BEST WISHES for all …….

Maram Bataiha

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Dr.Yanal Nusair

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