BY

DR RUHI BAJAJ

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 Dental implants can be used to retain single
crowns, fixed partial dentures, full arch
bridgework and removable prostheses.
 The use of dental implants is well
established and high survival rates have been
reported.
 Implant dentistry now forms a significant
part of general dental practice and patient
awareness is steadily increasing.

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What is an Implant???

A prosthetic device or alloplastic material

implanted into the oral tissue beneath the
mucosal or/and periosteal layer and/ or in
the bone to provide retention and support
for the fixed and removable prosthesis.
GPT 2008

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CLASSIFICATION
I) Depending on the placement within the
tissues

• Epithelial implants
• Epiosteal / Subperiosteal implants
• Endosteal implants
• Transosteal implants

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Epithelial implants

• Implant is inserted into the oral mucosa

Disadvantages
• 1. painful healing
• 2. requirement of continual wear

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Epiosteal / Subperiosteal
Implant
• Receives primary bone
support by resting on it
• Placed directly beneath the
periosteum overliying the
bony cortex

Disadvantages :
1) Slow, predictable
rejection of the implant
2) Bone loss associated
with failure

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 Transosteal Implant

• Also called as Staple Bone

Implant, Transmandibular
Implant

• Penetrates both cortical

plate and passes through
the entire thickness of the
alveolar bone

• Use restricted to anterior

area of mandible

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 Endosteal Implants
Extends into basal bone for support
It transects into 1 cortical plate

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 Endosteal implants

Ramus frame implants

Root form implants Plate form implants

-Used over vertical -used over horizonta
column of bone Column of bone
1. Cylinder
2. Screw root form
3. Combination 9
Generic implant body terminology

Implant body
ENDOSTEAL IMPLANTS
- root form designed to use vertical column of bone , similar
to root of natural tooth

3 different categories

1. cylinder implants
2. screw design implants
3. combination

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Implant Body Regions
3 parts
1. crest module ( cervical geometry )
2. body
3. apex

crest module ( cervical geometry )

body

apex

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Implant Body Regions

Body
- designed for implant bone interface

Crest module

- designed to retain the prosthetic component

- has a platform on which abutment is seated

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II) Depending on the materials used

i) METALLIC IMPLANTS
• titanium
• cobalt chromium molybdenum
alloy- Titanium aluminum
vandium
• Cobalt chromium molybdenum
• Stainless steel
• Zirconium
• Tantalum
• Gold
• Platinum

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2. NON – METALLIC IMPLANTS
- ceramics
- carbon

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 Depending On Their Reaction With Bone

• Based on the ability of

implant to stimulate bone
formation
1. Bio active
• Hydroxyapatite
• Tri Calcium
Phosphate
• Calcium Phosphate
• 2. Bio inert
metals

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 Console,motor and handpiece
 Classical surgical setup
 Starter bur ( no 4 round bur ) ( high speed is
often necessary for the mandible in
particular)
 Pilot drill ( 1.6 mm diameter by 11 mm long )
with internal irrigation system
 Osteotomy drill 24 mm long ,each with
internal irrigation ( brasseler) .all drills over
3mm in diameter should be selected in
relation to the specific system of choice

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 Bur extender ,mandrel ( internal irrigation ) to
be used when adajacent teeth prevent access
to bone – denar ,imz and orthomatrix make
one that can be used for all systems)
 Paralleling pins( double ended ) ,small & large
 Depth guage
 Millimeter rule
 An implant system of choice with bone tapper
,countersink ,final sizing drills & try in

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 A torque driver
 Surgical template ( guide for implant
placement)

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Surgical Setup principles

 Aim to keep surgical area reasonably sterile

 Cover sterile instruments with sterile paper if
procedure is not started right away

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Surgical Setup - Operatory

 Drape surgical tables with sterile towel /

paper
◦ Instrument tray table
◦ Supply tray table
◦ Implant motor table

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Surgical Setup - Operatory

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Surgical Setup– Instrument Tray
 Mirror (A)
 Periosteal elevator, i.e
Molt-9 (B)
 Periodontal probe (C)
 Cotton forceps (D)
 Instrument for removing
tissue tags, i.e. Scaler (E)
 Castroviejo calipers (F)
 Needle holder, i.e.
Castroviejo type(G)
 Suture scissors (H)
 Tissue forceps (I)
 Hemostat (K)
 Implant torque wrench(L)
 3 4x4 gauze (M)
 5 2x2 gauze (N)
 Topical anesthetic (O)
 Anesthetic cartridges (P)
 Anesthetic Needle (Q
 Anesthetic syringe (R)
 Round scalpel w/ 15c
blade (S)
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Surgical Setup– Instrument Tray
R Q P O N M

S L
K

A B C D E F G H I 23
 Surgical Setup –
Instrument Tray

Water/air syringe & Biohazard bag Surgical suction

Surgical handpiece 24
Surgical Setup – Supply tray
 Cotton forceps (A)
 Rinn kit & 2 X-ray sensors (B)
 Mirror kit (C)
 Suture (4-0, reverse cutting needle) (D)
 2 alcohol wipes (E)
 Surgical lube & cotton tip applicator (F)
 Protective glasses for patient (G)
 Cup with ½ oz of saline (H)
 Cup with ½ oz of Chlorhexidine gluconate
mouthrinse (I)

 Photo camera wrapped with barrier membrane

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Surgical Setup – Supply Tray
I H G

F D

A B C 26
IMPLANT MOTOR TABLE (
IMPLANT KIT)
 Follow manufacturers’ guide – Usually includes
◦ Large round bur to flatten site
◦ Small round bur to mark implant site
◦ Lindeman bur for decortication ( in case of zimmer
implant system)
◦ At least 2 osteotomy drills:
 Pilot drill
 Larger sizes depending on bone density and implant
diameter
◦ Implant driver for handpiece + Torque wrench with
implant driver
◦ Hex tool
◦ Bone tap

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 Contains a bur to create a hole in the cortex
 Osteotomy drills that create a bone
preparation similar to the shape of the
implant
 Bone taps that shape the cortical part of the
bone preparation to match the implant shape

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 Some type of implant driver that delivers and
inserts the implant into the bone preparation
◦ Shape differs by implant system. For Zimmer
implants, they are hex tools
 A wrench that is used to torque the implant
into its final position (and a certain torque in
some implant systems)

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 Most systems are now color coded to
highlight instruments used for different
implant diameters
 Most systems feature sequential use of
increasing osteotomy drills

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 Sequential use of drills with increasing
diameters allow precise gradual widening of
osteotomy.

 This is important as the osteotomy must be

slightly narrower than the implant, so that the
implant can engage just enough bone for
stability, but not too much bone that would
prevent insertion of the implant at a normal
force.

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 All of the electrical circuitry ,controls for
speed ,irrigant, hand piece selection ,readout
in rotation per minute ( rpm) and power are
located on the console
 Even the foot controlled rheostat plugs into
and is powered by the console .

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NSK Implant Motor Console

Coolant flow Gear ratio

(Level 3-5) (20:1) Direction

Torque (Ncm) Speed

Speed (rpm)

Torque

Coolant Forward/
Flow Reverse

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NSK Implant Motor Foot Pedal

( Program )
Coolant Forward /
Flow Reverse

Speed

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 The motor housing cords plugs into the front
of the console and utilizes its voltage supply
 The tiny motors inside the housing are
commonly referred to as micromotor and
they are designed to run at different speed.
 The most commonly used motors for root
form implants turn at 20000 ,30000 and
40000 rpm.

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NSK Surgic XT Implant motor

Saline flow block

Console

Staging
Block

Handpiece

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Surgical Setup – Implant Motor
 Assemble handpiece & connect to implant motor
console
 Assemble saline supply & make sure tubing is
mounted correctly in peristaltic pump
 Close tube lock to prevent spilling of saline while
motor is not used
 Mount pilot drill
 Turn on unit to verify function
 IMPORTANT:
 Some systems have disposable tubing, others don’t –
Please find out before you dispose tubing

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HANDPIECES

 Handpiece is any apparatus attached to an

electrical or an air- or nitrogen-powered
motor that accepts a bur.
 There are two types of handpieces:
 contra-angle and straight ; these enable the
practitioner to increase or maintain a motor’s
speed reliably.

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Surgical Setup – Surgical
Handpiece
 Assemble surgical handpiece
 Mount no. 4 round bur
 Run handpiece for at least one
minute over plastic cup to
eliminate excess oil from
handpiece

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 If any of the following are noted while the motor is
in use, action must be taken:
 • The practitioner feels a loss of speed with
vibration of the handpiece head. (This can cause
gear stripping and handpiece failure.)
 • The bur wobbles or chatters during cutting. (This
causes friction to the handpiece and can burn and
injure the bone.)

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 • The sound of the motor changes, or the
motor begins to growl or buzz. (This may
indicate a drop in speed and power as a
result of an internal problem in the gear
housing.)
 • The motor and handpiece begin to feel
warm and get progressively hotter over
time. (This may indicate a worn gear
assembly.)

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 In such instances, the rheostat should be
used to increase motor speed, because this
may help reduce the difficulties. To prevent
these problems, the practitioner should:
 1. Make smaller increases in drill diameters
 2. Use new, sharp burs and drills at
appropriate velocities and change them often
 3. Stay within the proper handpiece power
zones

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Round Bur

 Sometimes used to prepare

implant site before creating
osteotomy
 Used to create flat ridge prior to
osteotomy creation so that implant
platform is level with surrounding
bone

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Pilot drill

 First rotary instrument

 Cuts bone at tip and at sides
 Used to mark osteotomy site
 Used to cut through cortex at osteotomy
 Also used to correct osteotomy location or
direction by removing bone from side of
ostetomy
 Zimmer Lindeman Bur is gold-colored

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Osteotomy drills
 Creates osteotomy shaped like implant
 Mostly cuts at tip.
 Depth marks indicate implant lengths
 Drill-tip (called “Y-point”) is 0.5 mm long in addition
to indicated length (i.e. 11.5 mm = 12 mm actual
length)

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Paralleling Tool ( Direction
indicator)
 Used after creating first, narrow
osteotomy.
 Shows direction of osteotomy
clinically and radiographically
 Often features hole to tie floss
through it so it is less likely to be
aspirated
 Sometimes features markings
 Simply a metal pin of the same size
than the first osteotomy drill. Think of
it as “dummy implant” to show where
implant would be

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Implant Driver
 Used to deliver implant into
osteotomy site
 Two varieties with different
attachments
◦ One for use in Implant handpiece (Top)
◦ Other for use in Implant wrench
(Bottom)
 Different size of hex for different
implant platforms
◦ One for 3.7, 4.1 and 4.5 mm diameter
implants
◦ Other for 6 mm implants

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Implant wrench ( zimmer)

Can be used both sides:

Arrow facing you: Inserts implant
Arrow facing tissue: Backs out implant
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Surgical Guide

 Place surgical guide in 70% ethanol for at

least 15 minutes prior to surgery and wash
with sterile water/saline before use

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 To effectively carry out any procedure, it is
crucial to familiarise oneself with the
components involved
 The first step is to determine the implant
system used (eg Nobel Replace, Nobel
Brånemark System, AstraTech Osseospeed,
Straumann SLActive, alfa bio etc) , as this will
dictate the type of impression components
used.

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Each implant system has its own set of
impression components that are designed to
fit accurately onto the fixture head of the
implant, which is machined to specific
geometry.
Irrespective of the implant system used, the
impression components and techniques are
broadly very similar.

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Nobel Replace fixture heads

Brånemark fixture head

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 An implant screwdriver is a critical piece of
equipment used to screw and unscrew
various components onto the fixture head.
 Depending on the implant system,
screwdrivers heads can be slotted, hexagonal,
star shaped, etc .
Screwdrivers (from left to right) with a
hexagonal head (AstraTech) and star
shaped heads (Straumann and Nobel
Biocare)

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Screwdrivers are often designed to fit into a
manual or motor driven torque device, which
can be used to tighten components to a
predetermined torque .

Manual torque device

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 The fixture head is usually at the level of the
alveolar bone crest, therefore, in order to
provide access to the fixture head, a
removable transmucosal component known
as a healing abutment/cap is screwed onto
the fixture head by the surgeon, either at the
time of implant placement or as a second
surgical procedure.

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56
 Healing abutments/caps vary in height, width
and profile.
 An appropriate healing abutment is selected
to mould the peri-implant tissues during
healing and prevent tissue overgrowth.

healing abutments

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 The impression coping is the component that
fits onto the implant fixture head or an
implant abutment while making an
impression.
 There are two types of impression copings:
. one that is used with a closed tray and
retained in the mouth after the impression is
removed
. the second, used with an open custom tray,
in which the impression is removed with the
coping in situ within the impression

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 Once cast, the impression copings transfer
the position of the implant fixture
head/abutment onto the working model.

closed tray impression coping open tray fixture level impression

coping

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IMPLANT LEVEL IMPRESSION
TECHNIQUES
 CLOSED TRAY IMPRESSION TECHNIQUE

Transfer copings connected to implants

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Impression Made
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Impression removed leaving copings behind

Coping-Implant analogue assembly

Impression poured
inserted into impression 62
Pick Up/Open Tray

Transfer copings and guide pin

assembly attached to implant

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Syringe material injected around
Tray filled with Impression material
transfer copings
and impression made

Impression material allowed to polymerize

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Coping-pin-implant analogue Impression poured
assembly inserted to impression 65
Prosthetic Attachment
Abutment
portion of the implant that supports or retains a prosthesis
or implant superstructure

Superstructure
metal framework that attaches to the implant abutment
and provides either retention for removable prosthesis
or framework for fixed prosthesis

prosthesis
superstructure

abutment

Implant body
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 Categories of implant abutment
based on method by which prosthesis or
superstructure is retained to the
abutment

1. Screw retention

2. cement retention

3. for attachment
• attachment device to retain a
removable prosthesis 67
 Prefabricated stock abutments are off-the-
shelf components produced in a variety of
collar heights, widths and angulations

 . These are available in titanium, gold and

ceramic and can be screwed (or press fitted
with some systems) directly to the fixture
head before impression making.

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 Some standard abutments come with
individual impression copings (eg Easy
Abutment, Snappy Abutment, etc, Nobel
Biocare)

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 Prefabricated abutments are relatively cheap
and they simplify impression making by
moving the restoration margin coronally
DISADVANTAGE
 . However, they come in a relatively limited
number of shapes and sizes and are
inappropriate in all circumstances, especially
when the fixture head is deeply subgingival.

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 For implant retained overdentures,
prefabricated abutments with a variety of
attachment mechanisms (eg ball, magnets,
LOCATOR, etc) are available in a series of
different heights and widths, with its own
specifically designed impression coping

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 Custom abutments, individualised for each
restoration, can be used where prefabricated
abutments are inadequate.
 They are often made using CAD/CAM
techniques and are available in a variety of
metals and ceramics .

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 Custom abutments are generally more
expensive than prefabricated abutments.

 However, they can be designed so that the

abutment-crown junction is hidden to ensure
superior aesthetics.

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 Depending upon retention
 Abutment for screw retention
 Abutment for cement retention
 Abutment for attachment

Depending upon angulation

• Straight abutment
• Angled abutment

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– Steri oss abutment
– Paragon abutment
– Ceraone abutment
– Ceradapt abutment
– UCLA abutment
– Noble bio care abutment
– Estheticone abutment
– Mirus cone abutment
– Noble pharma single tooth abutment
– Branemark system angulated abutment
– Astra abutment

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 One-piece implants incorporate an integral
abutment.
 This abutment is usually prepared using
special burs designed to cut titanium. Care
must, however, be taken to ensure that the
implant is not overheated and the abutment
is not excessively reduced.

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 Implant surgery
Implant system broadly are of 2
types
2. two piece implant system
1. one piece implant system implant system
implant body + prosthodontic abutment
prosthodontic abutment

immediate One stage Two stage

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Implant surgery…
Two stage surgery
1st surgery
- implant body placed below the soft tissue

after initial bone healing has occurred

2nd surgery
-soft tissue are reflected
- permucosal element or abutment is
attached
One stage surgery
1st surgery
- implant and permucosal element placed
after initial bone healing has occurred
-abutment replaces the permucosal element
without reflection of flap

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 Prosthesis screw

coping

Analog
A)implant body
B) abutment
Transfer coping
A) direct
B) indirect
Hygiene screw

Abutment
A) for screw retentin
B) for cement retention
C) for attachment
Second stage permucosal extension
or healing abutment

First stage cover screw

Implant body 79
 Alpha-Bio Tec specializes in developing
and producing advanced dental solutions, focusing
on the field of implants and prosthetics.
 The unique and simple system makes the
dentist's work extremely convenient and
accomplishes several major advantages:
• Wide range of products with proven clinical
biocompatibility.
• Fast and easy insertion.
• High primary stability.
• High predictability.
• High success rates, in immediate loading.

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Surgical drills – internal irrigations
 The surgical drills are available in sequential
diameters and in two lengths .
 The drills are made of surgical titanium and
are to be used with internal irrigation .
 All drills are color and groove coded for easy
identification during surgery .
 Drills are groove marked for lengths

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2 mm 2.8 mm 4.3 mm 5.2 mm
3.2 mm 3.65 mm

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 Surgical drills –external irrigation
 The surgical drills are available in sequential
diameters and in two lengths .
 The drills are made of stainless steel and are
to be used with external irrigation .

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2 mm 2.8 mm 3.2 mm 3.65 mm 4.3 mm 5.2 mm

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 Straight drills are intended for close sinus lift
and for drilling close to anatomic structures .

Stopper

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To prevent over drilling. Use HTD 1.25 for fixation

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 DRILL EXTENSION - Extends drill by 17.5
mm.

 INSERTION TOOLS 2.5 mmd(ITD) ( stainless

steel )
 Used for placing threaded implants with
internal hex 2.5mm .
 Hexagonal 6.35mm or square head 4mm

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6.35mm 2.5 mm

4 mm

contraangle –motor mount insertion tool ( IT 1.25

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 HEX DRIVER ( 1.25 mm) HTD ( Stainless steel)
 For all types of cover screws, healing
abutment and prosthetic pieces .
 Hexagonal 6.35mm or square head 4mm

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 6.35mm 2.5mm
14.5mm

4mm
11.5 mm

contraangle –motor mount hex driver ( HT (1.25 m)

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 RATCHET WRENCH ( stainless steel)
for 6.35 hexagonal head

UNIVERSAL TORQUE / RATCHET ( stainless steel)

Allows the clinicians to accurately apply the recommended preload
torque for surgery and prosthetics

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Parallel / depth pin ( titanium )
For accurate measurement of x ray distortion . Each step
is 1 mm.

1 mm
3mm 1.9 mm
10mm

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Parallel guide
Used for precise spacing and parallel placement of implant

2.3 mm

7 mm

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 IDG IMPLANT DEPTH PROBE ( STAINLESS STEEL)

Its gently rounded apex simplifies depth measurements and

provides easy tactile examination of bone preparation and
sinus membrane

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13
11.5
10
8mm

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Sinus lift instruments

Subantral membrane elevator

•New innovation for hydraulic sinus lift .

•reduces risks of membrane tears
•Single use , supplied sterile

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OSTEOTOMES

Use for implant placement ,sinus elevation , ridge expansion and

Site preparation .

STRAIGHT OSTEOTOME

ANGLED OSTEOTOME

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STOPPERS FOR DRILLS OR OSTEOTOME

•To prevent overdrilling

•Use HTD 1.25 for fixation

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BIBLIOGRAPHY

Carl E Misch: Contemporary Implant Dentistry

Charles M Weiss : Principles And Practice Of Implant Dentistry
Steven ,Friedrickson and Geiss: Implant Prosthodontics-Clinical and Laboratory
Procedure
Maurice J Fagan :Implant prosthodontics:
Block Kant : Endosseous Implant For Maxillofacial Reconstruction
Norman Cranin :Atlas of Oral Implantology
Michael Norton :Dental Implants- Guide for General Practitioner
 British Dental Journal Vol 201;77

 Journal Of Prosthetic Dentistry Vol 89;611

 Alfabio tech manual

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Thank You
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