Dental Implant

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Dental implant
A dental implant (also known as an endosseous im- 15 year lifespans for the prosthetic teeth.[4]
plant or fixture) is a surgical component that interfaces
with the bone of the jaw or skull to support a dental
prosthesis such as a crown, bridge, denture, facial prosthesis or to act as an orthodontic anchor. The basis 1 Medical uses
for modern dental implants is a biologic process called
osseointegration where materials, such as titanium, form Common uses of dental implants
an intimate bond to bone. The implant fixture is first
placed, so that it is likely to osseointegrate, then a dental
prosthetic is added. A variable amount of healing time
is required for osseointegration before either the dental
prosthetic (a tooth, bridge or denture) is attached to the
implant or an abutment is placed which will hold a dental
Individual teeth were replaced with implants where it is
difficult to distinguish the real teeth from the prosthetic
Success or failure of implants depends on the health of the teeth.
person receiving it, drugs which impact the chances of osseointegration and the health of the tissues in the mouth.
The amount of stress that will be put on the implant and
fixture during normal function is also evaluated. Planning the position and number of implants is key to the
long-term health of the prosthetic since biomechanical
forces created during chewing can be significant. The position of implants is determined by the position and angle Movement in a lower denture can be decreased by
of adjacent teeth, lab simulations or by using computed implants with ball and socket retention.
tomography with CAD/CAM simulations and surgical
guides called stents. The prerequisites to long-term success of osseointegrated dental implants are healthy bone
and gingiva. Since both can atrophy after tooth extraction
pre-prosthetic procedures, such as sinus lifts or gingival
grafts, are sometimes required to recreate ideal bone and
The final prosthetic can be either fixed, where a person
cannot remove the denture or teeth from their mouth or
removable, where they can remove the prosthetic. In
each case an abutment is attached to the implant fixture.
Where the prosthetic is fixed, the crown, bridge or denture is fixed to the abutment with either lag screws or
dental cement. Where the prosthetic is removable, a corresponding adapter is placed in the prosthetic so that the
two pieces can be secured together.

A bridge of teeth can be supported by two or more

The primary use of dental implants are to support
dental prosthetics. Modern dental implants make use of
osseointegration, the biologic process where bone fuses
tightly to the surface of specific materials such as titanium and some ceramics. The integration of implant
The risks and complications related to implant therapy and bone can support physical loads for decades without
are divided into those that occur during surgery (such failure.
as excessive bleeding or nerve injury), those that occur For individual tooth replacement, an implant abutment
in the first six months (such as infection and failure to is first secured to the implant with an abutment screw.
osseointegrate) and those that occur long-term (such as A crown (the dental prosthesis) is then connected to the
peri-implantitis and mechanical failures). In the presence abutment with dental cement, a small screw, or fused with
of healthy tissues, a well integrated implant with appro- the abutment as one piece during fabrication.[6](pp211–232)
priate biomechanical loads can have long term success Dental implants, in the same way, can also be used to rerates of 93 to 98 percent for the fixture[1][2][3] and 10 to tain a multiple tooth dental prosthesis either in the form



of a fixed bridge or removable dentures.
An implant supported bridge (or fixed denture) is a group
of teeth secured to dental implants so the prosthetic cannot be removed by the user. Bridges typically connect to
more than one implant and may also connect to teeth as
anchor points. Typically the number of teeth will outnumber the anchor points with the teeth that are directly
over the implants referred to as abutments and those between abutments referred to as pontics. Implant supported bridges attach to implant abutments in the same
way as a single tooth implant replacement. A fixed bridge
may replace as few as two teeth (also known as a fixed partial denture) and may extend to replace an entire arch of
teeth (also known as a fixed full denture). In both cases,
the prosthesis is said to be fixed because it cannot be removed by the denture wearer.[6]


2.1 Planning
Techniques used to plan implants

To help the surgeon position the implants a guide is made
(usually out of acrylic) to show the desired position and
angulation of the implants.

A removable implant supported denture (also an implant
supported overdenture[7](p31) ) is a type of dental prosthesis which is not permanently fixed in place. The dental
prosthesis can be disconnected from the implant abutments with finger pressure by the wearer. To enable this,
the abutment is shaped as a small connector (a button, Sometimes the final position and restoration of the teeth
ball, bar or magnet) which can be connected to analogous will be simulated on plaster models to help determine
adapters in the underside of the dental prosthesis. Facial the number and position of implants needed.
prosthetics, used to correct facial deformities (e.g. from
cancer treatment or injuries) can utilise connections to
implants placed in the facial bones.[8] Depending on the
situation the implant may be used to retain either a fixed
or removable prosthetic that replaces part of the face.[9]
In orthodontics, small diameter dental implants, referred
to as Temporary Anchorage Devices (or TADs) can assist tooth movement by creating anchor points from which
forces can be generated.[10] For teeth to move, a force
must be applied to them in the direction of the desired
movement. The force stimulates cells in the periodontal
ligament to cause bone remodeling, removing bone in the
direction of travel of the tooth and adding it to the space
created. In order to generate a force on a tooth, an anchor
point (something that will not move) is needed. Since
implants do not have a periodontal ligament, and bone
remodelling will not be stimulated when tension is applied, they are ideal anchor points in orthodontics. Typically, implants designed for orthodontic movement are
small and do not fully osseointegrate, allowing easy removal following treatment.[11]



CT scans can be loaded to CAD/CAM software to create
a simulation of the desired treatment. Virtual implants
are then placed and a stent created on a 3D printer from
the data.

2.2 General considerations
Planning for dental implants focuses on the general health
condition of the patient, the local health condition of the
mucous membranes and the jaws and the shape, size, and
position of the bones of the jaws, adjacent and opposing teeth. There are few health conditions that absolutely
preclude placing implants although there are certain conditions that can increase the risk of failure. Those with
poor oral hygiene, heavy smokers and diabetics are all
at greater risk for a variant of gum disease that affects
implants called peri-implantitis, increasing the chance of
long-term failures. Long-term steroid use, osteoporosis
and other diseases that affect the bones can increase the
risk of early failure of implants.[6](p199)



Main surgical procedures

Bisphosphonate drugs

stent) prior to surgery which guides optimal positioning of
the implant. Increasingly, dentists opt to get a CT scan of
the jaws and any existing dentures, then plan the surgery
on CAD/CAM software. The stent can then be made
using stereolithography following computerized planning
of a case from the CT scan. The use of CT scanning in
complex cases also helps the surgeon identify and avoid
vital structures such as the inferior alveolar nerve and the

The use of bone building drugs, like bisphosphonates and
anti-RANKL drugs require special consideration with
implants, because they have been associated with a disorder called Bisphosphonate-associated osteonecrosis of
the jaw (BRONJ). The drugs change bone turnover,
which is thought to put people at risk for death of bone
when having minor oral surgery. At routine doses (for
example, those used to treat routine osteoporosis) the effects of the drugs linger for months or years but the risk
appears to be very low. Because of this duality, uncer- 2.5 Main surgical procedures
tainty exists in the dental community about how to best
manage the risk of BRONJ when placing implants. A
Basic implant surgical procedure
2009 position paper by the American Association of Oral
and Maxillofacial Surgeons, discussed that the risk of
BRONJ from low dose oral therapy (or slow release injectable) as between 0.01 and 0.06 percent for any procedure done on the jaws (implant, extraction, etc.). The
risk is higher with intravenous therapy, procedures on
the lower jaw, people with other medical issues, those
on steroids, those on more potent bisphosphonates and An area with a single missing tooth
people who have taken the drug for more than three
years. The position paper recommends against placing
implants in people who are taking high dose or high frequency intravenous therapy for cancer care. Otherwise,
implants can generally be placed[12] and the use of bisphosphonates does not appear to have an impact on implant survival.[13]
An incision is made across the gingiva, and the flap of
tissue is reflected to show the bone of the jaw.


Biomechanical considerations

The long-term success of implants is determined, in part,
by the forces they have to support. As implants have no
periodontal ligament, there is no sensation of pressure
when biting so the forces created are higher. To offset this, the location of implants must distribute forces
evenly across the prosthetics they support.[14](pp15–39)
Concentrated forces can result in fracture of the bridgework, implant components, or loss of bone adjacent the
implant.[15] The ultimate location of implants is based
on both biologic (bone type, vital structures, health) and
mechanical factors. Implants placed in thicker, stronger
bone like that found in the front part of the bottom jaw
have lower failure rates than implants placed in lower density bone, such as the back part of the upper jaw. People
who grind their teeth also increase the force on implants
and increase the likelihood of failures.[6](p201–208)

Once the bone is exposed, a series of drills create and
gradually enlarge a site (called an osteotomy) for the
implant to be placed.

The implant fixture is turned into the osteotomy. Ideally,
it is completely covered by bone and has no movement
The design of implants, has to account for a lifetime within the bone.
of real-world use in a person’s mouth. Regulators and
the dental implant industry have created a series of tests
to determine the long-term mechanical reliability of implants in a person’s mouth where the implant is struck
repeatedly with increasing forces (similar in magnitude
to biting) until it fails.[16]
When a more exacting plan is needed beyond clinical A healing abutment is attached to the implant fixture, and
judgment, the dentist will make an acrylic guide (called a the flap of gingiva is sutured around the healing abutment.




3. Late implantation (three months or more after tooth

Placing the implant

There are also various options for when to attach teeth to
Most implant systems have five basic steps for placement dental implants, classified into:
of each implant:[6](pp214–221)
1. Immediate loading procedure.
1. Soft tissue reflection: An incision is made over the
2. Early loading (one week to twelve weeks).
crest of bone, splitting the thicker attached gingiva
roughly in half so that the final implant will have a
3. Delayed loading (over three months)
thick band of tissue around it. The edges of tissue,
each referred to as a flap are pushed back to expose
the bone. Flapless surgery is an alternate technique, 2.5.3 Healing time
where a small punch of tissue (the diameter of the
implant) is removed for implant placement rather For an implant to become permanently stable, the
than raising flaps.
body must grow bone to the surface of the implant
2. Drilling at high speed: After reflecting the soft tis- (osseointegration). Based on this biologic process, it was
sue, and using a surgical guide or stent as neces- thought that loading an implant during the osseointegrasary, pilot holes are placed with precision drills at tion period would result in movement that would prevent
highly regulated speed to prevent burning or pres- osseointegration, and thus increase implant failure rates.
As a result, three to six months of integrating time (desure necrosis of the bone.
pending on various factors) was allowed before placing
3. Drilling at low speed: The pilot hole is expanded by the teeth on implants (restoring them).[6]
using progressively wider drills (typically between However, later research suggests that the initial stability
three and seven successive drilling steps, depend- of the implant in bone is a more important determinant of
ing on implant width and length). Care is taken success of implant integration, rather than a certain penot to damage the osteoblast or bone cells by over- riod of healing time. As a result, the time allowed to heal
heating. A cooling saline or water spray keeps the is typically based on the density of bone the implant is
temperature low.
placed in and the number of implants splinted together,
4. Placement of the implant: The implant screw is
placed and can be self-tapping,[18](pp100–102) otherwise the prepared site is tapped with an implant
analog. It is then screwed into place with a torque
controlled wrench[19] at a precise torque so as not
to overload the surrounding bone (overloaded bone
can die, a condition called osteonecrosis, which may
lead to failure of the implant to fully integrate or
bond with the jawbone).

rather than a uniform amount of time. When implants
can withstand high torque (35 Ncm) and are splinted to
other implants, there are no meaningful differences in
long-term implant survival or bone loss between implants
loaded immediately, at three months, or at six months.[21]
The corollary is that single implants, even in solid bone,
require a period of no-load to minimize the risk of initial

5. Tissue adaptation: The gingiva is adapted around
the entire implant to provide a thick band of healthy
tissue around the healing abutment. In contrast, an
implant can be “buried”, where the top of the implant is sealed with a cover screw and the tissue is
closed to completely cover it. A second procedure
would then be required to uncover the implant at a
later date.

2.5.4 One-stage, two-stage surgery


Timing of implants after extraction of teeth

After an implant is placed, the internal components are
covered with either a healing abutment, or a cover screw.
A healing abutment passes through the mucosa, and the
surrounding mucosa is adapted around it. A cover screw
is flush with the surface of the dental implant, and is designed to be completely covered by mucosa. After an
integration period, a second surgery is required to reflect
the mucosa and place a healing abutment.[23](pp190–1)

In the early stages of implant development (1970−1990),
There are different approaches to placement dental im- implant systems used a two-stage approach, believing that
it improved the odds of initial implant survival. Subseplants after tooth extraction.[20] The approaches are:
quent research suggests that no difference in implant survival existed between one-stage and two-stage surgeries,
1. Immediate post-extraction implant placement.
and the choice of whether or not to “bury” the implant in
2. Delayed immediate post-extraction implant place- the first stage of surgery became a concern of soft tissue
ment (two weeks to three months after extraction). (gingiva) management[24]


Additional surgical procedures

When tissue is deficient or mutilated by the loss of teeth,
implants are placed and allowed to osseointegrate, then
the gingiva is surgically moved around the healing abutments. The down-side of a two-stage technique is the
need for additional surgery and compromise of circulation to the tissue due to repeated surgeries.[25](pp9–12) The
choice of one or two-stages, now centers around how best
to reconstruct the soft tissues around lost teeth.


height of bone.
For an implant to osseointegrate, it needs to be surrounded by a healthy quantity of bone. In order for it
to survive long-term, it needs to have a thick healthy soft
tissue (gingiva) envelope around it. It is common for either the bone or soft tissue to be so deficient that the surgeon needs to reconstruct it either before or during implant placement.[18](p1084)

Immediate placement

An increasingly common strategy to preserve bone and
reduce treatment times includes the placement of a dental implant into a recent extraction site. On the one
hand, it shortens treatment time and can improve esthetics because the soft tissue envelope is preserved. On the
other hand, implants may have a slightly higher rate of
initial failure. Conclusions on this topic are difficult to
draw, however, because few studies have compared immediate and delayed implants in a scientifically rigorous



Additional surgical procedures

Hard tissue reconstruction

2.6.1 Hard tissue (bone) reconstruction
Main articles: Sinus lift and Bone grafting
Bone grafting is necessary when there is a lack of bone.
While there are always new implant types, such as short
implants, and techniques to allow compromise, a general
treatment goal is to have a minimum of 10 mm in bone
height, and 6 mm in width. Alternatively, bone defects
are graded from A to D (A=10+ mm of bone, B=7–9
mm, C=4–6 mm and D=0–3 mm) where an implant’s
likelihood of osseointegrating is related to the grade of
To achieve an adequate width and height of bone, various
bone grafting techniques have been developed. The most
frequently used is called guided bone graft augmentation
where a defect is filled with either natural (harvested or
autograft) bone or allograft (donor bone or synthetic bone
substitute), covered with a semi-permeable membrane
and allowed to heal. During the healing phase, natural
bone replaces the graft forming a new bony base for the

If bone width is inadequate it can be regrown using either Three common procedures are:[26](p236)
artificial or cadevaric bone pieces to act as a scaffold for
natural bone to grow around.
1. The sinus lift
2. Lateral alveolar augmentation (increase in the width
of a site)
3. Vertical alveolar augmentation (increase in the
height of a site)
When a greater amount of bone is needed, it can be taken
Other, more invasive procedures, also exist for larger
from another site (commonly the back of the bottom
bone defects including mobilization of the inferior alvejaw) and transplanted to the implant site.
olar nerve to allow placement of a fixture, onlay bone
grafting using the iliac crest or another large source of
bone and microvascular bone graft where the blood supply to the bone is transplanted with the source bone and
reconnected to the local blood supply.[14](pp5–6) The final
decision about which bone grafting technique that is best
is based on an assessment of the degree of vertical and
The maxillary sinus can limit the amount of bone height horizontal bone loss that exists, each of which is classiin the back of the upper jaw. With a “sinus lift”, bone fied into mild (2–3 mm loss), moderate (4–6 mm loss) or
can be grafted under the sinus membrane increasing the severe (greater than 6 mm loss).[27](p17)


Soft tissue (gingiva) reconstruction


3 Recovery

Main articles: Gingival graft and Subepithelial connective tissue graft
Soft tissue reconstruction

When mucosa is missing, a free gingival graft of soft
tissue can be transplanted to the area.

When the metal of an implant becomes visible a con- The steps taken to secure dental crowns on the implant fixture
nective tissue graft can be used to improve the mucosal including placement of the abutment and crown
The prosthetic phase begins once the implant is well inThe gingiva surrounding a tooth has a 2–3 mm band of tegrated (or has a reasonable assurance that it will intebright pink, very strong attached mucosa, then a darker, grate) and an abutment is in place to bring it through the
larger area of unattached mucosa that folds into the mucosa. Even in the event of early loading (less than 3
cheeks. When replacing a tooth with an implant, a band months), many practitioners will place temporary teeth
of strong, attached gingiva is needed to keep the implant until osseointegration is confirmed. The prosthetic phase
healthy in the long-term. This is especially important of restoring an implant requires an equal amount of techwith implants because the blood supply is more precar- nical expertise as the surgical because of the biomechanious in the gingiva surrounding an implant, and is theo- ical considerations, especially when multiple teeth are to
retically more susceptible to injury because of a longer at- be restored. The dentist will work to restore the vertical
tachment to the implant than on a tooth (a longer biologic dimension of occlusion, the esthetics of the smile, and
the structural integrity of the teeth to evenly distribute
the forces of the implants.[6](pp241–251)
When an adequate band of attached tissue is absent, it
can be recreated with a soft tissue graft. There are four Prosthetic procedures for single teeth, bridges and
fixed dentures
methods that can be used to transplant soft tissue. A roll
of tissue adjacent to an implant (referred to as a palatal An abutment is selected depending on the application.
roll) can be moved towards the lip (buccal), gingiva from In many single crown and fixed partial denture scenarios
the palate can be transplanted, deeper connective tissue (bridgework), custom abutments are used. An impression
from the palate can be tranplanted or, when a larger piece of the top of the implant is made with the adjacent teeth
of tissue is needed, a finger of tissue based on a blood and gingiva. A dental lab then simultaneously fabricates
vessel in the palate (called a vascularized interpositional an abutment and crown. The abutment is seated on the
periosteal-connective tissue (VIP-CT) flap) can be repo- implant, a screw passes through the abutment to secure it
sitioned to the area.[25](pp113–188)
to an internal thread on the implant (lag-screw). There are
Additionally, for an implant to look esthetic, a band of variations on this, such as when the abutment and implant
full, plump gingiva is needed to fill in the space on ei- body are one piece or when a stock (prefabricated) abutther side of implant. The most common soft tissue com- ment is used. Custom abutments can be made by hand,
or zirplication is called a black-triangle, where the papilla (the as a cast metal piece or custom milled from metal
small triangular piece of tissue between two teeth) shrinks
back and leaves a triangular void between the implant and
the adjacent teeth. Dentists can only expect 2–4 mm of
papilla height over the underlying bone. A black triangle
can be expected if the distance between where the teeth
touch and bone is any greater.[18](pp81–84)

The platform between the implant and the abutment can
be flat (buttress) or conical fit. In conical fit abutments,
the collar of the abutment sits inside the implant which
allows a stronger junction between implant and abutment
and a better seal against bacteria into the implant body.



To improve the gingival seal around the abutment collar,
a narrowed collar on the abutment is used, referred to as
platform switching. The combination of conical fits and
platform switching gives marginally better long term periodontal conditions compared to flat-top abutments.[29]
Regardless of the abutment material or technique, an impression of the abutment is then taken and a crown secured to the abutment with dental cement. Another variation on abutment/crown model is when the crown and
abutment are one piece and the lag-screw traverses both
to secure the one-piece structure to the internal thread
on the implant. There does not appear to be any benefit, in terms of success, for cement versus screw-retained
prosthetics, although the latter is believed to be easier to
maintain (and change when the prosthetic fractures) and
the former offers high esthetic performance.[18](p1233)


Alternatively, stock abutments are used to retain dentures
using a male-adapter attached to the implant and a female
adapter in the denture. Two common types of adapters
are the ball-and-socket style retainer and the button-style
adapter. These types of stock abutments allow movement
of the denture, but enough retention to improve the quality of life for denture wearers, compared to conventional
dentures.[31] Regardless of the type of adapter, the female
portion of the adapter that is housed in the denture will
require periodic replacement, however the number and
adapter type does not seem to impact patient satisfaction
with the prosthetic for various removable alternatives.[32]

3.2 Maintenance
After placement, implants need to be cleaned (similar

Prosthetic procedures for removable to natural teeth) with a Teflon instrument to remove any
plaque. Because of the more precarious blood supply to

the gingiva, care should be taken with dental floss. Implants will lose bone at a rate similar to natural teeth in
the mouth (e.g. if someone suffers from periodontal disease, an implant can be affected by a similar disorder)
but will otherwise last. The porcelain on crowns should
be expected to discolour, fracture or require repair approximately every ten years, although there is significant
variation in the service life of dental crowns based on the
A cast bar of metal is secured to the implants. The com- position in the mouth, the forces being applied from opplete denture then attaches to the bar with semiprecision posing teeth and the restoration material. Where implants
are used to retain a complete denture, depending on the
attachments allowing no movement of the denture.
type of attachment, connections need to be changed or
refreshed every one to two years.[14](p76) A powered irrigator may also be useful for cleaning around implants.[33]

Ball and socket type attachments can be placed on
implants and dentures to prevent most movement.

4 Risks and complications

When a removable denture is worn, retainers to hold the
denture in place can be either custom made or “off-theshelf” (stock) abutments. When custom retainers are
used, four or more implant fixtures are placed and an impression of the implants is taken and a dental lab creates a custom metal bar with attachments to hold the
denture in place. Significant retention can be created
with multiple attachments and the use of semi-precision
attachments (such as a small diameter pin that pushes
through the denture and into the bar) which allows for
little or no movement in the denture, but it remains
removable.[7](pp33–34) However, the same four implants
angled in such a way to distribute occlusal forces may be
able to safely hold a fixed denture in place with comparable costs and number of procedures giving the denture
wearer a fixed solution.[30]

4.1 During surgery
Placement of dental implants is a surgical procedure and
carries the normal risks of surgery including infection, excessive bleeding and necrosis of the flap of tissue around
the implant. Nearby anatomic structures, such as the
inferior alveolar nerve, the maxillary sinus and blood vessels, can also be injured when the osteotomy is created or
the implant placed.[34] Even when the lining of the maxillary sinus is perforated by an implant, long term sinusitis
is rare.[35] An inability to place the implant in bone to
provide stability of the implant (referred to as primary
stability of the implant) increases the risk of failure to
Implant complications


Bone loss (peri-implantitis) on implants over 7 years in a
heavy smoker


Dental cement under the gingiva causes peri-implantitis
and implant failure.

4.2 First six months
4.2.1 primary implant stability
Primary implant stability refers to the stability of a dental
implant immediately after implantation. Its value is deRecession of the gingiva leads to exposure of the metal rived from a mechanical engraving of the titanium screw
abutment under a dental crown.
implant in the patient’s bone tissue. High initial stabilization may be an indication for immediate loading with
prosthetic reconstruction.
The value of primary implant stabilization decreases
gradually with reconstruction of bone tissue around the
implant in the first weeks after surgery, ceding to secBlack triangles caused by bone loss between implants ondary stability. Its character is quite different from the
and natural teeth
initial stabilization, because it results from the ongoing
process of osseointegration. When the healing process is
complete, the initial mechanical stability is fully replaced
by biological stability. The most dangerous moment for
implantation success is the moment of the lowest initial
stabilization, pending sufficient bone reconstruction supporting long-term maintenance of the implant. Usually
this occurs during the 3–4 weeks after implantation. If
primary stability was not high enough following implantation, the implant’s mobility is high and can cause failure.
Fracture of an implant and abutment screw is a catastrophic failure and the fixture cannot be salvaged.
4.2.2 Immediate post-operative risks
1. Infection (pre-op antibiotics reduce the risk of implant failure by 33 percent but have no impact on the
risk of infection)[36]
2. Excessive bleeding[14](p68)
Fracture of an abutment (all-zirconia) requires replacement of the abutment and crown.

3. Flap breakdown (less-than 5 percent)[14](p68)
4.2.3 Failure to integrate

An implant is tested between 8 and 24 weeks to determine if it is integrated. There is significant variation in
the criteria used to determine implant success, the most
commonly cited criteria at the implant level are the abFracture of abutment screws (arrow) in 3 implants sence of pain, mobility, infection, gingival bleeding, rarequired removal of the remainder of the screw and diographic lucency or peri-implant bone loss greater than
1.5 mm.[37]
Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the


Long term


patient’s oral hygiene, but the most important factor is
primary implant stability.[38] While there is significant
variation in the rate that implants fail to integrate (due
to individual risk factors), the approximate values are 1
to 6 percent[14](p68)[21]

in cement-retained crowns compared to screw-retained
crowns overall.[40] In compound implants (two stage implants), between the actual implant and the superstructure (abutment) are gaps and cavities into which germs
can penetrate from the oral cavity. Later these germs will
Integration failure is rare in most cases, particularly if a return into the adjacent tissue and can cause periimplanthese implant interior spaces should
dentist’s or oral surgeon’s instructions are followed closely titis. As prophylaxis
by the patient. Immediate loading implants may have a
higher rate of failure, potentially due to being loaded im- Criteria for the success of the implant supported dental
mediately after trauma or extraction, but the difference prosthetic varies from study to study, but can be broadly
with proper care and maintenance is well within statistical classified into failures due to the implant, soft tissues or
variance for this type of procedure. More often, osseoin- prosthetic components or a lack of satisfaction on the
tegration failure occurs when a patient is either too un- part of the patient. The most commonly cited criteria
healthy to receive the implant or engages in behavior that for success are function of at least five years in the abcontraindicates proper dental hygiene including smoking sence of pain, mobility, radiographic lucency and perior drug use.
implant bone loss of greater than 1.5 mm on the implant,
the lack of suppuration or bleeding in the soft tissues and
occurrence of technical complications/prosthetic mainte4.3 Long term
nance, adequate function, and esthetics in the prosthetic.
In addition, the patient should ideally be free of pain,
The long-term complications that result from restoring paraesthesia, able to chew and taste and be pleased with
teeth with implants relate, directly, to the risk factors of the esthetics.[37]
the patient and the technology. There are the risks associated with esthetics including a high smile line, poor The rates of complications vary by implant use and prosgingival quality and missing papillae, difficulty in match- thetic type and are listed below:
ing the form of natural teeth that may have unequal points
of contact or uncommon shapes, bone that is missing, at- 4.3.1 Single crown implants (5-year)
rophied or otherwise shaped in an unsuitable manner, unrealistic expectations of the patient or poor oral hygiene.
1. Implant survival: 96.8 percent[42]
The risks can be related to biomechanical factors, where
2. Crown fracture: a) metal-ceramic: 95.4 percent, allthe geometry of the implants does not support the teeth
ceramic; 95.4 percent (cumulative rate of ceramic or
in the same way the natural teeth did such as when there
veneer fracture: 4.5 percent)[42]
are cantilevered extensions, fewer implants than roots or
teeth that are longer than the implants that support them
3. Peri-implantitis: 9.7 percent[42]
(a poor crown-to-root ratio). Similarly, grinding of the
teeth, lack of bone or low diameter implants increase the
4. Implant fracture: 0.14 percent[42]
biomechanical risk. Finally there are technological risks,
where the implants themselves can fail due to fracture
5. Screw or abutment loosening: 12.7 percent[42]
or a loss of retention to the teeth they are intended to
6. Abutment screw fracture: 0.35 percent[42]
From these theoretical risks, derive the real world complications. Long-term failures are due to either loss of bone 4.3.2 Fixed complete dentures
around the tooth and/or gingiva due to peri-implantitis or
1. Progressive vertical bone loss but still in function
a mechanical failure of the implant. Because there is no
(Peri-implantitis): 8.5 percent[3]
dental enamel on an implant, it does not fail due to cavities
like natural teeth. While large-scale, long-term studies
2. Failure after the first year 5 percent at five years, 7
are scarce, several systematic reviews estimate the longpercent at ten years [3]
term (five to ten years) survival of dental implants at 93–
98 percent depending on their clinical use.[1][2][3] During
3. Incidence of veneer fracture at:
initial development of implant retained teeth, all crowns
13.5[3] to 30.6
were attached to the teeth with screws, but more recent
advancements have allowed placement of crowns on the
10-year: 51.9 percent (32.3 to
abutments with dental cement (akin to placing a crown
75.5 percent with a confidence
on a tooth). This has created the potential for cement,
interval at 95 percent)[4]
that escapes from under the crown during cementation
15-year: 66.6 percent (44.3 to
to get caught in the gingiva and create a peri-implantitis
86.4 percent with a confidence
(see picture below). While the complication can occur,
interval at 95 percent)[4]
there does not appear to be any additional peri-implantitis




4. 10-year incidence of framework fracture: 6 percent
(2.6 to 9.3 percent with a confidence interval at 95
5. 10-year incidence of esthetic deficiency: 6.1 percent
(2.4 to 9.7 percent with a confidence interval at 95
6. prosthetic screw loosening: 5 percent over five
years[3] to 15 percent over ten years[4]
The most common complication being fracture or wear of
the tooth structure, especially beyond ten years[3][4] with
fixed dental prostheses made of metal-ceramic having significantly higher ten-year survival compared those made
of gold-acrylic.[3]

While studying bone cells in a rabbit tibia using a titanium chamber, Branemark was unable to remove it from bone. His realization that bone would adhere to titanium led to the concept of
osseointegration and the development of modern dental implants.
The original x-ray film of the chamber embedded in the rabbit
tibia is shown (made available by Branemark).

Removable dentures (overdentures)

1. Loosening of removable denture retention:


2. Dentures needing to be relined or having a retentive
clip fracture: 16 to 19 percent[43]



Panoramic radiograph of historic dental implants, taken 1978

of a young Mayan woman, with three missing incisors replaced by pieces of shell, shaped to resemble teeth. Bone
growth around two of the implants, and the formation of
calculus, indicates that they were functional as well as esthetic. The fragment is currently part of the Osteological
Collection of the Peabody Museum of Archaeology and
Ethnology at Harvard University.[5][44]

Greenfield’s basket: one of the earliest examples of a successful
endosseous implant was Greenfield’s 1913 implant system

There is archeological evidence that humans have attempted to replace missing teeth with root form implants
for thousands of years. Remains from ancient China (dating 4000 years ago) have carved bamboo pegs, tapped
into the bone, to replace lost teeth, and 2000-year-old
remains from ancient Egypt have similarly shaped pegs
made of precious metals. Some Egyptian mummies were
found to have transplanted human teeth, and in other instances, teeth made of ivory.[5](p26)[44][45]
Wilson Popenoe and his wife in 1931, at a site in Honduras dating back to 600 AD, found the lower mandible

The early part of the 20th century saw a number of implants made of a variety of materials. One of the earliest
successful implants was the Greenfield implant system of
1913 (also known as the Greenfield crib or basket).[46]
Greenfield’s implant, an iridioplatinum implant attached
to a gold crown, showed evidence of osseointegration and
lasted for a number of years.[46] The first use of titanium as an implantable material was by Bothe, Beaton
and Davenport in 1940, who observed how close the bone
grew to titanium screws, and the difficulty they had in extracting them.[47] Bothe et al. were the first researchers
to describe what would later be called osseointegration
(a name that would be marketed later on by Per-Ingvar
Brånemark). In 1951, Gottlieb Leventhal implanted titanium rods in rabbits.[48] Leventhal’s positive results led
him to believe that titanium represented the ideal metal
for surgery.[48]

In the 1950s research was being conducted at Cambridge
University in England on blood flow in living organisms. These workers devised a method of constructing a
chamber of titanium which was then embedded into the
soft tissue of the ears of rabbits. In 1952 the Swedish
orthopaedic surgeon, Per-Ingvar Brånemark, was interested in studying bone healing and regeneration. During
his research time at Lund University he adopted the Cambridge designed “rabbit ear chamber” for use in the rabbit femur. Following the study, he attempted to retrieve
these expensive chambers from the rabbits and found that
he was unable to remove them. Brånemark observed that
bone had grown into such close proximity with the titanium that it effectively adhered to the metal. Brånemark
carried out further studies into this phenomenon, using
both animal and human subjects, which all confirmed
this unique property of titanium. Leonard Linkow, in the
1950s, was one of the first to inserted titanium and other
metal implants into the bones of the jaw. Artificial teeth
were then attached to these pieces of metal.[49] In 1965
Brånemark placed his first titanium dental implant into a
human volunteer. He began working in the mouth as it
was more accessible for continued observations and there
was a high rate of missing teeth in the general population
offered more subjects for widespread study. He termed
the clinically observed adherence of bone with titanium
as “osseointegration”.[28](p626)
Common types of implants

A standard 13 mm root form dental implant with pen
beside it for size comparison

A zygomatic implant is longer than standard implants
and used in people without adequate bone in the maxilla.
It secures to the cheek bone.

A small diameter implant is a single piece implant (no
abutment) that requires less bone.

Ultrashort Plateau Root Form (PRF) or “finned” dental
implants used in regions that would otherwise require a
sinus lift or bone graft.

An orthodontic implant is placed beside teeth to act as
an anchor point to which braces can be secured.
Since then implants have evolved into three basic types:
1. Root form implants; the most common type of implant indicated for all uses. Within the root form
type of implant, there are roughly 18 variants, all
made of titanium but with different shapes and surface textures. There is limited evidence showing
that implants with relatively smooth surfaces are less
prone to peri-implantitis than implants with rougher
surfaces and no evidence showing that any particular type of dental implant has superior long-term
2. Zygomatic implants; a long implant that can anchor
to the cheek bone by passing through the maxillary
sinus to retain a complete upper denture when bone
is absent. While zygomatic implants offer a novel
approach to severe bone loss in the upper jaw, it has
not been shown to offer any advantage over bone
grafting functionally although it may offer a less invasive option, depending on the size of the reconstruction required.[51]
3. Small diameter implants are implants of low diameter with one piece construction (implant and abutment) that are sometimes used for denture retention
or orthodontic anchorage.[10]
A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface.
The majority of dental implants are made out of commercially pure titanium, which is available in four grades
depending upon the amount of carbon, nitrogen, oxygen
and iron contained.[52] Cold work hardened CP4 (maximum impurity limits of N .05 percent, C .10 percent, H
.015 percent, Fe .50 percent, and O .40 percent) is the




most commonly used titanium for implants. Grade 5 ti- [9] Arcuri MR (Apr 1995). “Titanium implants in maxillofacial reconstruction”. Otolaryngol Clin North Am 28 (2):
tanium, Titanium 6AL-4V, (signifying the titanium alloy
351–63. PMID 7596615.
containing 6 percent aluminium and 4 percent vanadium
alloy) is slightly harder than CP4 and used in the industry
mostly for abutment screws and abutments.[53](pp284–285) [10] Chen, Y.; Kyung, H. M.; Zhao, W. T.; Yu, W. J. (2009).
“Critical factors for the success of orthodontic miniMost modern dental implants also have a textured surimplants: A systematic review”. American Journal of Orface (through etching, anodic oxidation or various-media
thodontics and Dentofacial Orthopedics 135 (3): 284–291.
blasting) to increase the surface area and osseointegration
doi:10.1016/j.ajodo.2007.08.017. PMID 19268825.
potential of the implant.[54](p55)
If C.P. titanium or a titanium alloy has more than [11] Lee, SL (2007). Applications of orthodontic mini implants.
Hanover Park, IL: Quintessence Publishing Co, Inc. pp.
85% titanium content it will form a titanium biocom1–11. ISBN 9780867154658.
patable titanium oxide surface layer or veneer that encloses the other metals preventing them from contacting [12] Ruggiero, S. L.; Dodson, T. B.; Assael, L. A.; Landesberg,
the bone.[55]
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• c Branemark, Per-Ingvar; Zarb, George (1989).
Tissue-integrated prostheses (in English). Berlin,
German: Quintessence Books. ISBN 0867151293.
• Branemark, Per-Ingvar Worthington, Philip, ed
(1992). Advanced osseointegration surgery: applications in the maxillofacial region (in english).
Carol Stream, Illinois: Quintessence Books. ISBN
• Laskin, Daniel (2007). Decision making in oral and
maxillofacial surgery. Chicago, IL: Quintessence
Pub. Co. ISBN 9780867154634.
• Lee, SL (2007). Applications of orthodontic mini
implants. Hanover Park, IL: Quintessence Publishing Co, Inc. pp. 1–11. ISBN 9780867154658.

• Sclar, Anthony (2003). Soft tissue and esthetic
considerations in implant dentistry (in english).
Carol Stream, IL: Quintessence Books. ISBN
• Buser, Daniel; Schenk, Robert K (1994). Guided
bone regeneration in implant dentistry (in english). Hong Kong: Quintessence Books. ISBN
• Pallaci, Patrick (1995). Optimal implant positioning and soft tissue management for the Branemark
system (in english). Germany: Quintessence Books.
ISBN 0867153083.
• Renouard, Frank (1999). Risk Factors in Implant Dentistry: Simplified Clinical Analysis for Predictable Treatment. Paris, France: Quintessence International. ISBN 0867153555.
• Lindhe, Jan; Lang, Niklaus P; Karring, Thorkild,
eds. (2008). Clinical Periodontology and Implant
Dentistry 5th edition (in English). Oxford, UK:
Blackwell Munksgaard. ISBN 9781405160995.
• Newman, Michael; Takei, Henry; Klokkevold,
Perry, eds. (2012). Carranza’s Clinical Periodontology (in English). St. Louis, Missouri: Elsevier
Saunders. ISBN 9781437704167.



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• File:Basicimplant_preop_ridge.jpg Source: License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]
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• File:Connective_tissue_graft_to_implant.gif Source:
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• File:Dental-implant.gif Source: License: CC BY-SA 3.0 Contributors: Own work Original artist: Coronation Dental Specialty Group[1]



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• File:Gingival_recession_on_an_implant.jpg Source:
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• File:Greenfield_implant.jpg Source: License: Public
domain Contributors: Implantation of artificial crown and bridge abutments Original artist: E.J. Greenfield
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• File:Implant_orthodontic_anchor_model.jpg Source:
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• File:Implant_overdenture_model.jpg Source:
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• File:Implant_retained_bridge_model.jpg Source:
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• File:Mini_Dental_Implant_3M.jpg Source: License: CC BY-SA 3.0 Contributors: Own work Original artist: Roderick Dailey
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• File:Periimplantitis_due_to_dental_cement.gif Source:
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• File:Zygomatic-implant.gif Source: License: CC BY-SA
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