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Basic Surgical Techniques for Endosseous Implant Placement. Division of Oral and Maxillofacial Surgery University of Minnesota. WHAT IS A DENTAL IMPLANT?. Dental implant is an artificial titanium fixture which is placed surgically into the jaw bone to

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basic surgical techniques for endosseous implant placement
Basic Surgical Techniques for Endosseous Implant Placement

Division of Oral and Maxillofacial Surgery

University of Minnesota

what is a dental implant
  • Dental implant is an artificial titanium fixture

which is placed surgically into the jaw bone to

substitute for a missing tooth and its root(s).

history of dental implants
History of Dental Implants

In 1952, Professor Per-Ingvar Branemark,

a Swedish surgeon, while conducting research

into the healing patterns of bone tissue, accidentally discovered that when pure titanium comes into direct contact with the living bone tissue, the two literally grow together to form a permanent biological adhesion. He named this phenomenon "osseointegration".

first implant design by branemark
First Implant Design by Branemark

All current implant designs are modifications of this initial design

surgical procedure
Surgical Procedure





fibro osseous integration
Fibro-osseous integration

• Fibroosseous integration

– “tissue to implant contact with dense collagenous tissue between the implant and bone”

• Seen in earlier implant systems.

• Initially good success rates but extremely poor long term success.

• Considered a “failure” by todays standards

  • Success Rates >90%
  • Histologic definition
    • “direct connection between living bone and load-bearing endosseous implants at the light microscopic level.”
  • 4 factors that influence:

Biocompatible material

Implant adapted to prepared site

Atraumatic surgery

Undisturbed healing phase

soft tissue to implant interface
Soft-tissue to implant interface
  • Successful implants have an
    • Unbroken, perimucosal seal between the soft tissue and the implant abutment surface.
  • Connect similarly to natural teeth-some differences.
    • Epithelium attaches to surface of titanium much like a natural tooth through a basal lamina and the formation of hemidesmosomes.
soft tissue to implant interface10
Soft-tissue to implant interface
  • Connection differs at the connective tissue level.
    • Natural tooth Sharpies fibers extent from the bundle bone of the lamina dura and insert into the cementum of the tooth root surface
    • Implant: No Cementum or Fiber insertion.

Hence the Epithelial surface attachment is IMPORTANT

the parts
The “Parts”
  • Implant body-fixture
  • Abutment (gingival/temporary healing vs. final)
  • Prosthetics
team approach
Team Approach
  • A surgical – prosthodontic consultation is done prior to implant placement to address:
    • soft-tissue management
    • surgical sequence
    • healing time
    • need for ridge and soft-tissue augmentation
clinical assessment
Clinical Assessment
  • Assess the CC and Expectations
  • Review all restorative options:
    • Risks and Benefits
  • Select option that meets functional and esthetic requirements
patient evaluation
Patient Evaluation
  • Medical history
    • vascular disease
    • immunodeficiency
    • diabetes mellitus
    • tobacco use
    • bisphosphonate use
history of implant site
History of Implant Site
  • Factors regarding loss of tooth being replaced
    • When?
    • How?
    • Why?
  • Factors that may affect hard and soft tissues:
    • Traumatic injuries
    • Failed endodontic procedures
    • Periodontal disease
  • Clinical exam may identify ridge deficiencies
surgical phase treatment planning
Surgical Phase- Treatment Planning
  • Evaluation of Implant Site
  • Radiographic Evaluation
  • Bone Height, Bone Width and Anatomic considerations
basic principles
Basic Principles
  • Soft/ hard tissue graft bed
  • Existing occlusion/ dentition
  • Simultaneous vs. delayed reconstruction
smile line
Smile Line
  • One of the most influencing factors of any prosthodontic restoration
  • If no gingival shows then the soft tissue quality, quantity and contours are less important
  • Patient counseling on treatment expectations is critical
anatomic considerations
Anatomic Considerations
  • Ridge relationship
  • Attached tissue
  • Interarch clearance
  • Inferior alveolar nerve
  • Maxillary sinus
  • Floor of nose
radiological imaging studies
Radiological/Imaging Studies
  • Periapical radiographs
  • Panoramic radiograph
  • Site specific tomograms
  • CAT scan (Denta-scan, cone beam CT)
width of space and diameter of implant
Width of Space and Diameter of Implant

Attention must be paid to both the coronal and interradicular spaces

a case against routine ct
A case against routine CT
  • Expense
  • Time consuming process
  • Use of radiographic template/proper fit requires DDS present
  • Contemporary panoramic units have tomographic capabilities
  • Usually adds no additional data over standard database
dental implant surgery phase i
Dental Implant Surgery Phase I
  • Aseptic technique
  • Minimal heat generation
    • slow sharp drills
    • internal irrigation?
    • external cooling
dental implant surgery phase i38
Dental Implant Surgery Phase I
  • Adequate time for integration
  • Adequate recipient site
    • soft tissue
    • bone
  • Kind & Gentle technique


1. Chlorhexidine

2. Analgesics

+/- antibiotics

limitations to implant placement in the maxilla
Limitations to Implant placement in the Maxilla
  • Ridge width
  • Ridge height
  • Bone quality
Summers, RB. A New concept in Maxillary Implant Surgery: The Osteotome technique. Compendium. 15(2): 152, 154-6
  • Ridge expansion technique
    • 3-4 mm of crestal alveolar width required
  • Sinus floor elevation technique
    • 8-9 mm of alveolar bone height required in order to place a 13 mm implant

(4-5 mm sinus floor elevation)

introduction ridge expansion technique
IntroductionRidge expansion technique
  • 1.6 mm pilot hole
  • Summers osteotome # 1-4
    • sequenced tapered osteotomes.
    • ridge expansion (displacement) versus bone removal.
  • Final drill coincident with the final implant size (sometimes not necessary)
introduction sinus floor elevation technique
IntroductionSinus floor elevation technique
  • 1.6 mm pilot hole
  • Summers osteotome # 1-4
    • Sinus floor microfractured superiorly
    • Sinus floor can be elevated 4-5 mm
    • May backfill with bone allograft/alloplast
  • Final drill coincident with final implant size

A. Rake, K. Andreasen, S. Rake, J. SwiftA Retrospective Analysis of Osteointegration in the Maxilla Utilizing an Osteotome Technique versus a Sequential Drilling Technique, 1999 AAOMS Abstract

  • 155 maxillary implants in 84 patients restored for at least 6 months
    • 57 were placed utilizing the osteotome technique
    • 98 were placed utilizing the drilling technique
  • One implant failed of the 98 in the drill group
  • None of the implants had failed of the 57 in the osteotome group
stage ii surgery preoperative considerations68
Stage II Surgery Preoperative Considerations
  • Done under local anesthesia
  • Pre-op medications
    • Chlorhexidine rinse


  • The failing implant is very difficult to treat
  • Traumatic surgical manipulation with initial instability of implant increases risk of failure
  • Implant success is only as good as the prosthodontic reconstruction