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Dental Implants Review : A detailed Review
A Comprehensive Review on Dental Implants Abstract Dental implants have revolutionized modern dentistry by providing a predictable and durable solution for the replacement of missing teeth. This review aims to provide an in-depth overview of dental implants, covering their history, classifications, biomaterials, surface modifications, surgical and prosthetic protocols, complications, and success rates. It also emphasizes clinical considerations and future innovations that are shaping implantology. Introduction Tooth loss is one of the most common oral health problems, caused by trauma, caries, periodontal disease, or congenital absence. Replacement of missing teeth is crucial not only for mastication and phonetics but also for aesthetics, psychological well-being, and overall quality of life. Traditionally, removable dentures and fixed partial dentures (bridges) were the mainstay of treatment. However, these methods often caused bone resorption, compromised adjacent teeth, or failed to provide adequate stability. Dental implants emerged as a superior alternative, offering a more functional, aesthetic, and biologically favorable solution. A dental implant is defined as an artificial fixture, usually made of titanium or other biocompatible materials, surgically placed into the alveolar bone to serve as a root analogue and provide support for prosthetic restorations. The predictability of osseointegration has made dental implants a cornerstone of modern prosthodontics and oral rehabilitation. Historical Background The concept of replacing missing teeth dates back thousands of years. Archaeological evidence suggests that ancient civilizations, including the Mayans and Egyptians, attempted to use shell, ivory, or carved stones as tooth substitutes. 1940s–50s: Vitallium implants were introduced but showed limited success. 1952: Per-Ingvar Brånemark discovered the principle of osseointegration while studying bone healing around titanium chambers. This laid the foundation of modern implantology. 1965: The first titanium dental implant was successfully placed in a human. 1980s onwards: Commercial dental implant systems became widely available, leading to their global adoption. Today, implantology has evolved into a highly predictable discipline, with long-term success rates exceeding 90–95% in most clinical situations. Biomaterials in Dental Implants The choice of material plays a vital role in implant success. The most widely used materials include: Titanium and Titanium Alloys Gold standard due to excellent biocompatibility, corrosion resistance, and mechanical strength. Available in commercially pure titanium (grades I–IV) and titanium alloys (e.g., Ti-6Al-4V). Promotes osseointegration through the formation of a titanium oxide layer. Zirconia (Yttria-stabilized zirconium dioxide) Metal-free, highly aesthetic alternative. Biocompatible with reduced plaque accumulation. More brittle than titanium
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Dental Implants Review : A detailed Review
- 1. Dental Implants Presented By : DR.ABHISHEK ASHOK SHARMA BDS, MDS, Ph.D., MHA, FAGE, FICOI Member of Indian Society of Periodontology (ISP) Member of World Congress of Oral Implantology (WCOI) Member of International Board of Oral Implantology (IBOI) Member of Indian Society of Oral Implantologists (ISOI) Member of International Congress of Oral Implantologists (ICOI)
- 2. INTRODUCTION • A dentalimplant is a medical device, typically a titanium screw, that is surgically inserted into the jawbone to replace the root of a missing tooth. • Dental implants have been used to replace missing teeth for more than half a century. • They are considered to be an important contribution to dentistry as they have revolutionized the way by which missing teeth are replaced with a high success rate. • This success depends on the ability of the implant material to integrate with the surrounding tissue.
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- 4. Conventional Dental Implants BasalImplants Zygomatic Implants Pterygoid Dental Implants
- 5. Classification Based On: Nature of Implants • Long Implants / One-Piece • Integral Implants • Cortical Platform Implants • Cortical Implants • Ball attachment Implant • Screw-Type Implants • Only Integral Implants • Narrow Conical Implants • Conical Implants • Narrow Trapeze Implants • Trapeze Implants
- 6. BROAD CLASSIFICATION OFDENTAL IMPLANTS •Based on Position in Bone •Based on Implant Design •Based on Surface Characteristics •Based on Materials Used •Based on Surgical Technique •Based on Loading Protocol
- 7. Classification : Basedon Position in Bone 1. Endosteal Implants (within bone) 1. Screw type 2. Cylinder type 3. Blade type 2. Subperiosteal Implants (above bone, beneath periosteum) 3. Trans-osteal Implants (through the jawbone)
- 8. Classification : Basedon Implant Design • Root Form Implants • Plate Form Implants • Ramus Frame Implants • Intramucosal Inserts
- 9. Classification: Based onSurface Characteristics • Machined Surface • Roughened Surface (sandblasted, acid-etched) • Plasma-sprayed Coatings (titanium, hydroxyapatite) • Anodized Surfaces • Nano-textured Surfaces
- 10. Classification : Basedon Materials Used •Titanium and Titanium Alloys • Zirconia (Ceramic Implants) •Stainless Steel (historical) • Polymers (experimental) • Composites
- 11. Classification Based :On Nature of Implants Loading •Aggressive Implants •Semi-Aggressive Implants •Pre-Post Dental Implants •Cortical Placing Dental Implants
- 12. Classification : Basedon Surgical Technique •One-stage Implants •Two-stage Implants •Immediate Implants (post- extraction) •Delayed Implants
- 13. Classification : Basedon Loading Protocol •Immediate Loading Implants •Early Loading Implants •Delayed Loading Implants
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- 15. • For dentalimplants to succeed, intimate contact between the peri-implant bone and the implant surface should be achieved and maintained. • Therefore, an integration between the implant surface and the bone is required for the success of any implant system. • This integration is known as osseointegration, and is defined as “a direct structural and functional connection between ordered living bone and the surface of a load- carrying implant”.
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- 17. As a resultof the absence of periodontal ligaments between the implant and its surrounding bone, when the implants are loaded, they move within the bone due to bone elastic deformation. Furthermore, osseointegrated implants cannot be moved orthodontically.
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- 23. SHAPE • Cylinder DentalImplant • Straight Screw Dental Implant • Conical Dental Implant 23
- 24. • Polished • Roughened •Hydroxyapatite • Rough & Polished Combination • 3D Texture Innova Implant Design 24
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- 27. Endosseous Fixture (Implant Body/ Fixture Screw) Scientific Term: Endosseous implant fixture • This is the root-form structure fabricated typically from commercially pure titanium (cpTi, Grades I–IV) or titanium alloys (Ti-6Al-4V ELI). • It is surgically anchored within the alveolar or basal bone and serves as the osseointegrated foundation for the prosthesis. • Surface Modifications may include: • Sandblasted, Large-grit, Acid-etched (SLA) surfaces • Plasma-sprayed titanium or hydroxyapatite coatings • Anodized surfaces for enhanced osseointegration 27
- 28. IMPLANT COLLAR (CERVICAL REGION/ TRANSMUCOSAL PORTION) Scientific Term : Implant collar or transmucosal zone • The superior segment of the fixture adjacent to the crestal bone and peri-implant soft tissue. • May be designed as machined-smooth or micro-threaded to minimize crestal bone loss. 28
- 29. IMPLANT–ABUTMENT CONNECTION Scientific Term:Implant–prosthetic junction • The precision interface ensuring the mechanical stability and bacterial seal between the fixture and the abutment. • Connection types include: • External Hex Connection • Internal Hex/Octagon Connection • Conical/ Morse Taper Connection 29
- 30. ABUTMENT (Prosthetic Abutment /Transmucosal Connector) Scientific Term : Prosthetic abutment • The intermediate component that emerges through the oral mucosa and supports the prosthetic crown, bridge, or overdenture. • Types of abutments : 1. Healing Abutment (Gingival Former / Healing Cap): Temporarily placed to shape peri-implant mucosa. 2. Temporary Abutment: For provisional restorations. 3. Definitive Abutment: For final prosthesis (straight, angled, or custom CAD-CAM fabricated). 4. Multi-unit Abutment (MUA): For multiple implant-supported prostheses and All-on-4/All-on-6 concepts. 30
- 31. ABUTMENT SCREW (Fixation Screw) ScientificTerm: Prosthetic fixation screw • A bio-mechanically critical titanium or titanium-alloy screw securing the abutment to the implant body. • Requires precise torque application (using a torque wrench, typically 20–35 N-cm) to maintain preload and screw joint stability. 31
- 32. PROSTHESIS (Suprastructure / Superstructure) ScientificTerm: Implant-supported prosthetic restoration • The visible, functional replacement of the tooth/teeth fabricated from ceramics, metal-ceramics, or zirconia. • Retention modalities: • Cement-retained prosthesis • Screw-retained prosthesis • Telescopic or attachment-retained prosthesis 32
- 33. COVER SCREW Scientific Term: Fixture cover screw • A flat-topped titanium disc-like screw used during the healing phase (submerged protocol) to protect the inner threads of the implant until second-stage surgery. OTHER ACCESSORY COMPONENTS • Transfer Coping (Impression Post) : Used to capture the 3D position of the implant in the impression for laboratory fabrication. • Laboratory Analog: Replica of the implant fixture used in the working cast. • Waxing Sleeve / Plastic Coping: For laboratory procedures to fabricate custom abutments or frameworks. 33
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- 36. INITIAL EVALUATION : •Medical history & systemic conditions • Radiographs, CBCT scans • Bone quality and quantity assessment SURGICAL STEPS : • Incision and flap reflection • Osteotomy preparation (drilling sequence) • Placement of implant fixture • Suturing and healing phase (osseointegration) PROSTHETIC PHASE : • Placement of healing abutment • Impression making • Crown/bridge/denture attachment 36
- 37. • The patient’stissue bio-type is classified according to how thick or thin the supporting bone and gingival soft tissues are defined. • Becker and Oschenbein classified 3 distinct types : 1. Pro-nounced Scalloped 2. Scalloped 3. Flat • A thin periodontium will be pro-nounced scalloped or scalloped. • A thick periodontium will present with flat gingival architecture, usually supported by thick buccal and lingual plates of alveolar bone. • The normal crest is defined as 2 mm from the CEJ and the low crest is present in patients with recession. • Sounding to bone is the best clinical parameter to help identify the attachment level. 37
- 38. BONE SOUNDING • "Bonesounding" is a technique where a periodontal probe is gently pressed through the gum tissue to the level of the bone. • This procedure helps a Periodontologist to assess the location of the underlying bone, identify any discrepancies with the gingival lining, and evaluate the health of the gingival tissues. • It is a pre-operative assessment to ensure there's sufficient bone height for an implant and can also be used to check for proper anesthesia during extractions or to ensure adequate space for a pontic in a bridge.38
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- 41. SURGICAL STEPS • Theoriginal Brånemark protocol required a vestibular flap with a two-stage approach. • The implant was placed and buried under the soft tissue and after an adequate period of healing (three months mandible, six months maxilla), a second stage surgery was performed with crestal incisions to expose the fixtures and connect a trans- epithelial abutment. • Using the one stage technique requires a crestal incision or even a flapless approach, drilling directly through the soft tissues. 41
- 42. • Langer introducedthe sub-epithelial connective tissue graft as a predictable technique for augmenting thin tissue and it is especially useful when minor ridge resorption is present. • The most common donor site is the palatal tissue mesial to the first molar. • Another popular donor site is the tuberosity tissue. This area is especially desirable when a thicker graft is needed for ridge augmentation procedures (inlay or pouch technique) in the anterior aesthetic zone. 42
- 43. POSITION & ANGULATIONOF IMPLANT • The initial drilling (round bur) starting point can be moved and the angulation of the implant tipped to avoid bone dehiscence or fenestration. • The more palatal the movement, the deeper sub-gingivally the implant platform must be positioned to accommodate for the emergence of the restorative components through the soft tissue. • Dense bone (Type D-1 & D-2) requires careful attention to drilling with adequate irrigation in order not to overheat the bone. • Placing the implant into too tight a site can lead to failure due to pressure necrosis. The shape of the implant, parallel walled vs. tapered will also greatly affect the tightness (primary stability). 43
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- 45. • Type 3and 4 bone requires modification of the drilling protocol. • Tapered implants have an advantage in softer bone due to the wedging effect at the time of placement. • The tapered implant is more challenging at the time of placement, because the depth of the prepared site needs to be exactly at the level of where the desired final position of the implant needs to be placed. • As opposed to a parallel wall implant that can be placed deeper if desired, due to the ability to sink the implant into the prepared site. 45
- 46. TIMING OPTIONS • Extractand wait several months prior to implant placement. • Orthodontic forced eruption to move the gingival complex and crestal bone into a more favorable position prior to extraction. • Extract and bone graft the socket to help preserve soft tissue contours and minimize collapse of the ridge, if the buccal plate is thin or has a slight dehiscence. • Extract and place implant immediately into socket (single rooted teeth and buccal plate is thick and intact). • Two stage buried. • One stage with healing abutment or customised healing abutment. • Immediate load implant with provisional restoration. 46
- 47. TIMING OPTIONS • Extractand wait several months prior to implant placement. • Orthodontic forced eruption to move the gingival complex and crestal bone into a more favorable position prior to extraction. • Extract and bone graft the socket to help preserve soft tissue contours and minimize collapse of the ridge, if the buccal plate is thin or has a slight dehiscence. • Extract and place implant immediately into socket (single rooted teeth and buccal plate is thick and intact). • Two stage buried. • One stage with healing abutment or customised healing abutment. • Immediate load implant with provisional restoration. 47
- 48. • Extract andwait two to three months, then bone graft (Intra-oral block or GBR). • After five to six months healing, place the implant. • Single anterior teeth are best for immediate loading as compared posterior teeth where the occlusal forces are far greater. • In the fully edentulous cases, immediate loading with a rigid splinted interim prosthesis is advised. 48
- 49. SOCKET SHIELDING TECHNIQUE •In the socket-shield technique (SST) the root is bisected, and the buccal two-third of the root is preserved in the socket so that the periodontium along with the bundle bone and the buccal bone remains intact. • The SST provides a promising treatment modality to manage these risks and preserve the post-extraction tissues in esthetically challenging cases. The principle is to prepare the root of a tooth, which is indicated for extraction, in such a manner that the buccal/facial root section remains in place. 49
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- 52. SURGICAL COMPLICATIONS • In orderto minimize post-surgical complications, careful planning of the flap design, and gentle soft tissue manipulation is required. • Control of bleeding, along with releasing incisions that allow for flap advancement and closure without tension are mandatory. • Failure to maintain flap coverage due to sloughing or opening of the incision line will lead to delayed healing with compromised results. • Smoking affects both hard and soft tissue healing and has been shown to be the greatest risk factor. 52
- 53. •The medically compromisedpatient (e.g. Diabetes Mellitus, Autoimmune disease, patients on long term steroids, radiation treatment etc.) needs special attention, but is not contra-indicated to receiving treatment. •Logical and ethical decisions need to be made with the patient and their physicians. 53
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- 56. 1. Age factor 2.Mesial Drift of teeth in Maxilla & Mandible 3. Oral Hygiene & Maintenance 4. Bruxism 5. Smoking 6. Peri-Implantitis 7. Bleeding Disorder 8. Osteoporotic Patients 9. Cardiovascular Disorders 56
- 57. AGE • Older patientsare more prone to altered systemic health conditions, have poor local bone conditions and potentially longer healing times. • Patients older than 60 years have/had less implant survival than usual. • Implant submersion continues throughout adult life, and its rate varies with age during the second and third decades of life when compared with the fourth and fifth. 57
- 58. MESIAL DRIFT OFTEETH IN THE MAXILLA AND MANDIBLE • The spontaneous mesial drift of teeth in the step dentition phase is well understood. • There is about 5 mm mesial movement/drifting of teeth in the lateral segment of jaw (canine to the first molar) between 10 and 21 years of age. • There is 2.5 mm buccal movement of incisors which may result in a loss of space in arch leading to crowd. • Dental implant does not take part in this mesial drift of teeth. 58
- 59. ORAL HYGIENE &MAINTENANCE • The accumulation of bacterial plaque leads to gingivitis, periodontitis, and peri-implantitis. • Furthermore, the presence of any symptoms of infection, radiographic evidence of peri-implant bone loss, and/or neuropathies reduced vascularity concomitant with parallel-oriented collagen fibers may be indicative of an ailing or failing implant. • This can be managed by the use of interproximal brushes penetrate 3 mm into the gingival sulcus or pocket. • It also requires maintenance visit for the evaluation of prosthetic component for plaque and calculus, stability of the implant-abutment, peri-implant tissue margin, implant body, and radiographs after every 12–18 months. 59
- 60. BRUXISM • Glauser etal. 2001, evaluated 41 patients who received 127 immediately loaded implants. Their results showed that implants in patients with bruxism were lost more frequently than those placed in patients with no parafunction (41% vs. 12%). • The higher failure rate among the bruxers is due to uncontrolled functional loading of the implant, which leads to micro-motions above the critical limit, resulting in fibrous encapsulation of the implant instead of osseointegration. • It was suggested that early or immediate loading is not detrimental for osseointegration unless excessive micro-motions occur at the bone-implant interface during the healing phase. 60
- 61. SMOKING • Smoking reducesleukocyte activity and causes reduced chemotactic migration rate and low phagocytic activity leading to low infection resistance and delayed wound healing. • Smoking affects osseointegration process by lowering blood flow rate due to increased peripheral resistance and platelet aggregation. Smoking residues are carbon monoxide and cyanide, which delay wound healing capacity and along with nicotine, inhibit cell proliferation rate. 61
- 62. PERI-IMPLANTITIS • Peri-implantitis isa progressive inflammatory condition which affects the tissues surrounding an osseointegrated implant, leading to the loss of the supporting bone and implant failure. • It is characterized by bleeding, suppuration, increased pocket probing depth, mobility of implant, and radiographical bone loss. • This inflammatory process is more intense and, goes deeper and faster around the dental implant as compared to the inflammation around the adjacent natural tooth. 62
- 63. BLEEDING DISORDER •Bleeding disordersUncontrolled hemorrhage can be caused by platelet disorders, coagulant factors deficiency, and using anticoagulant drugs such as aspirin and warfarin. •It is due to platelet deficiency. •The most life-threatening adverse effect of dental implant placement in these patients is upper airway obstruction. 63
- 64. CARDIOVASCULAR DISEASE • Cardiovasculardiseases interfere with healing and osseointegration process, resulting in reduced fibroblast activity, impaired macrophage function, and decreased collagen synthesis. •Cardiovascular disease does not have a significant influence on the long-term success rate of dental implant treatment. 64
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