|Year : 2013 | Volume
| Issue : 3 | Page : 135-142
Implant dentistry: Surgical, radiological, and mechanical factors in a multidisciplinary approach
Latha S Davda1, Sanjay V Davda2
1 University of Portsmouth Dental Academy, Portsmouth, PO1 2QG, United Kingdom
2 Department of Oral Surgery, King's College London Dental Institute, Denmark Hill, United Kingdom
|Date of Web Publication||21-Apr-2014|
Latha S Davda
University of Portsmouth Dental Academy, Portsmouth, PO1 2QG
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The long-term success of any dental implant treatment is influenced by several factors, including patient factors, preventative measures used by the patient, esthetics, surgical factors, mechanical factors of the implant system, periodontal factors, and restorative factors. The patient factors, esthetic factors and prevention influencing the treatment planning of a dental implant patient were discussed in the previous paper. This article will discuss the surgical, radiological, and mechanical factors involved in dental implant treatment with a relevant case study. The periodontal and restorative factors will be discussed in the final article.
Clinical Relevance to Interdisciplinary Dentistry
- Long term implant success in dependant on several factors, some of which are discussed in this article. Knowledge of surgical dentistry, radiology and mechanical factors are discussed to demonstrate application of interdisciplinary dentistry.
Keywords: Dental implant, long term success, mechanical factors, multidisciplinary, radiological, surgical
|How to cite this article:|
Davda LS, Davda SV. Implant dentistry: Surgical, radiological, and mechanical factors in a multidisciplinary approach. J Interdiscip Dentistry 2013;3:135-42
|How to cite this URL:|
Davda LS, Davda SV. Implant dentistry: Surgical, radiological, and mechanical factors in a multidisciplinary approach. J Interdiscip Dentistry [serial online] 2013 [cited 2019 Aug 22];3:135-42. Available from: http://www.jidonline.com/text.asp?2013/3/3/135/131194
| Introduction|| |
Dental implant placement and restoration was mainly carried out by specialists who either worked in a team or individually. Now with more general dental practitioners placing implants or restoring implants it is important that they have a good knowledge base of all the disciplines of dentistry, which are required for successful implant treatment. A multidisciplinary approach would include a sound knowledge of applied anatomy, diagnosis and imaging, preventative dentistry, periodontology, orthodontics, surgical dentistry, and restorative dentistry. Aspects of all these specialties and their role in successful implant treatment are discussed.
The long-term success of any dental implant treatment is influenced by several factors listed in [Table 1]. ,, Patient factors, implementation of prevention and certain aspects of esthetics were discussed in previous article.  In this article, the surgical factors, radiological factors, and mechanical factors influencing long-term implant success are discussed followed by a case report.
| Surgical Factors|| |
Surgical aspects of dental implant treatment include assessment of the quality and quantity of bone, the soft tissue flap design, timing of implant placement, techniques used in bone preparation and bone augmentation, preoperative and the postoperative care.
Misch  classified the bone density based on macroscopic cortical and trabecular bone characteristics. D1 is the dense cortical bone mostly found in anterior part of mandible. D2 is dense-to-thick porous cortical bone on the crest, coarse trabecular bone, and mostly found in the mandible. D3 consists of thin porous cortical bone and fine trabecular bone within typically found in the anterior maxilla and sometimes in the posterior mandible. D4 consists of fine trabecular bone with no cortex and usually found in the posterior maxilla. However, the only sure way of knowing the bone density is how it feels when it is drilled during surgery.
Imaging of the area where implants need to be placed should be based on the patient's needs. Appropriate radiographs mainly orthopantomograph and periapical films provide the basic information regarding the amount of bone present and proximity to the vital structures. Digital orthopantomographs provide information on the vertical bone height and the trabecular pattern. They aid in identifying the proximity to vital structures and presence of any bone or tooth pathologies.
In the maxilla, our main concern is the proximity to maxillary sinus, the nasal cavity and the nasopalatine foramen. The incisive canal can be very large in some patients contributing to poor bone in the anterior region. There are reported cases of obliterating the foramen with graft material before placing implants.  Occasionally, the bone forming the nasal floor is cortical in nature and can be engaged with the implant to improve implant stability.  In the posterior maxilla, the maxillary sinus is often pneumatized and descends into the alveolus reducing the amount of bone available for implant placement.
In the mandible the proximity to the inferior dental canal and the mental foramen are vital to implant placement. The vertical depth and the width of the bone available can be calculated by using a metal ball bearing of known dimension in a splint when the jaw is radiographed and calculating the magnification of the radiograph. The inferior alveolar nerve makes an anterior loop before exiting from the mental foramen as mental nerve to supply the lower lip and anterior mucosa and is of importance when planning implants in the lower premolar area. , The anterior loop of the nerve runs from 0.5 to 3 mm anterior to the radiographic mental foramen. A safe guideline of 4 mm, from the anterior point of the mental foramen, was recommended when planning implants in this area by Kuzmanovic et al.  Misch and Crawford  suggests that on routine panoramic radiograph, if the nerve approaches the foramen from below then it usually proceeds anterior to the foramen for about 1-3 mm. The disadvantages of panoramic image is that it is two dimensional and the geometric distortion of the anatomical structures.  They also do not allow assessment of buccolingual dimensions.  The concavities present in the buccal bone surfaces in the maxillary anterior region and in the mandibular lingual areas cannot be assessed with radiographs.
The computed tomography (CT) scans provide a three-dimensional image of the surgical site. The exposure to radiation is significant and therefore needs to be justified before subjecting the patient to radiation. The cone beam computed tomography (CBCT) involves less radiation to the patient than conventional CT scans, can be limited to the area of interest and has been shown to accurately reflect the anatomical measurements.  CBCT can be used to plan the implant size and angulation. The use of radiographic surgical stents with CBCT can help to provide important information about bone position and therefore placement of implants and final restorations.  The International Congress on Oral Implantologists have produced a consensus report on the use of CBCT in implant dentistry.  They recommend that CBCT scans must be justified on individual basis and performed when no other method of imaging can give the true regional three dimensional anatomical picture. They suggest that the literature supports the use of CBCT in diagnosis of the surgical site, evaluating the proximity to vital structures and in the fabrication of surgical guides. There is a lack of evidence in the usefulness of the CBCT in judging the density of bone, aiding surgical placement and in postimplant evaluation.
Surgical splints can be constructed on the study casts with or without the CT scans. They can be mucosa supported or bone supported. The accuracy of both has been debated in several papers. Thorough knowledge of the surgical anatomy and the restorative aspects of implants are more important than relying primarily on the surgical guides.
Implants placed immediately in the extraction sockets have marginally lower success and survival rates compared with those placed after the soft tissue healing has occurred, but before the bone has formed completely.  In case of multi-rooted tooth replacement, it is best to wait for soft tissue healing to occur before implant is placed. This gives better soft tissue coverage and the extraction socket is filled with new bone making it easier to place a wide diameter implant. After raising an adequate soft tissue flap, the bone is drilled following the system protocol in terms of the speed and torque of the drill and use of internal or external sterile normal saline irrigation. The bone should be treated with care so that it is not crushed or burnt, while drilling as this will lead to necrosis and failure of implant to integrate. It is essential to get primary stability for long term success of the implants.
During implant placement, the deficiency in the alveolar ridge bone can be corrected by techniques of bone manipulation and bone augmentation.  Bone manipulation involves expansion of cortical plates with osteotomes and bone dilators used in increasing diameters, which will gradually increase the buccolingual width of the bone and condense the trabecular bone. Misch and Dietsh  describes recipient site bony defects ranging from five walled defects (e.g. extraction socket) to one-walled defects. The choice of graft material used depends on the defect and also the function of the future bone.
Bone can be augmented by autogenous grafts, allogenous graft or allografts. ,, Bone grafting materials act through three different mechanisms, which are osteogenesis, osteoinduction, and osteoconduction.  Osteogenesis refers to a material capable of forming bone directly from osteoblasts. Osteoinductive material induces the transformation of undifferentiated mesenchymal cells into osteoblasts, which in turn lay down bone. Osteoconductive materials (often inorganic) permits bone apposition from existing bone and require the presence of bone or differentiated mesenchymal cells.
In a general practice set up where it may not be possible to harvest autogeneous bone graft, it is best to use alloplastic materials. Currently, the improved implant surface characteristics and the availability of short implants have decreased the need for bone grafting. The bone released while preparing the implant bed can be collected using a bone collector making sure there is a separate salivary suction during the surgical procedure. The advantage of using host bone is that the body readily accepts it and there is less chance of rejection.
Alloplastic materials are synthetic or deorganified biocompatible materials, which are used in broad range of clinical situations for bone growth or soft tissue support.
They are mostly ceramics in different shape, size or texture. They can be macroporous, microporous, dense, amorphous or crystalline. Calcitite, Osteograf, Interpore are example of some commercially available hydroxyapatite. 
Tricalcium phosphate has calcium to phosphorous ratio of 3:2. It is intended to provide a scaffold for initial bony proliferation. It has been reported to act as a short term biologic filler which is resorbed over time by osteoclasts and substituted by living bone cells which grow directly in contact to the material without any encapsulation.  Calciresorb, Synthograf, and Augmen are commercially available Technical Consumer Products. Bovine bone is available as Bio-Oss (Geistlich) in larger defects it may be necessary to use guided tissue regeneration using membranes like Gore-Tex (W.L Gore and Associates) or Bio-Gide (Geistlich) to protect the graft. 
Animal studies have shown that bone morphogenetic proteins and growth factors used with grafts around implants increased the rate of bone formation. There was even an increase in bone density around the implants.  Platelet-rich plasma when coated onto implant and mixed with the graft has been reported to produce better osseointegration and soft tissue healing around the implants. 
Preoperative care involves making sure that the bacterial load in the mouth is minimum. Using 0.1% chlorhexidine mouth wash is shown to reduce the bacterial load in the mouth.  Evidence also suggests that use of 2-3 g of amoxicillin orally as a single dose 1 h before placement significantly reduces failure of dental implants placed in ordinary conditions. 
| Mechanical Factors|| |
The mechanical factors that may influence the implant success are listed in [Table 2].
Implant success is described by Kohn  as a function of biomaterials and biomechanical factors, in addition to patient's overall medical and dental status, the surgical techniques used and patient's tissue-healing properties. The three dimensional structure of the implant with all the elements and characteristics that compose it is referred to as implant design. 
The design of an "optimal" implant requires the integration of material, physical, chemical, mechanical, biological, and economic factors.  Factors such as material biocompatibility, implant design, surface, surgical technique, host bed, and loading conditions all are shown to influence the implant osteointegration.  A given design can often incorporate a few factors and compromise on the other factors.
All implant systems use titanium or its alloy. However, surface modifications can alter the strength and characteristics of the implant.  All implants now have root form and taper with threads. Geometric analysis and torque resistance of the dental implants have shown a threaded architecture to be more favorable design for ideal stress distribution, when compared with nonthreaded implants and rough surfaced implants resisted torque better than smooth surfaced implants. 
The thread design of implants can vary from V-thread, buttress thread and square thread.  Threads help to dissipate shearing stress.  A stress diversion design of the threads may lead to better distribution of the load applied to the implant.  In cancellous bone, increasing the implant surface are by using implants with smaller pitch might be beneficial. 
One of the criteria of judging implant success is radiographic evaluation of the crestal bone level. The physiologic response of crestal bone levels surrounding an implant is associated with three phases  of primary site preparation, uncovering the implant and prosthetic loading and function phase. Jung et al.  have reported rapid bone loss occurred in the first 3 months for all four implant systems he used. The amount of bone stabilized at the first thread and at 12 months showed correlation with the length of polished neck. In another study with Branemark implants used for single tooth restorations bone loss was found along the entire length of the polished divergent collar.  A prospective study of Astra single tooth implants with microthreads showed mean bone level of 0.46-0.48 mm apical to the top of the implant with no statistically significant changes at 2 years.  It appears through these studies that a microthread or roughened neck retains marginal bone integrity better than smooth collars.
The roughened surfaces can improve the clinical properties of implants by achieving a higher percentage of bone to implant contact and higher removal torque values in mechanical testing. Surface treatments can roughen the surfaces to a varying degree. Some of the surface treatments are sandblasted and acid etched, grit blasted and acid etched (Friadent), dual acid etched (Osseotite), anodized Ti Unite surface (Nobel Biocare), Fluoride treated TiO surface (osseospeed Astra). Friadent (Dentsply), dual acid etched (Osseotite), Anodized Ti Unite surface. , An in vitro study  found the hydrophilic sand-blasted and acid etched surface showed better bone-implant contact and significantly higher shear strength after 3 and 6 weeks compared with oxidized surface. In a review article by Albrektsson and Wennerberg,  TiO blast surface was the only surface with 10 years follow-up. Due to the advances in technology most of the implants available now have good osteointegration.
Abutment implant interface can influence their long-term stability. Traditionally, an implant was connected to the abutment with external hex. High incidence of abutment loosening, screw loosening and fractures resulted in design change. New designs are available with increase in the height of the external hex, internal hex, internal octagon, spline connection, internal hex with taper, friction fit and locking taper were introduced. ,
The incidence of screw loosening is a function of implant and prosthetic component design. Implant abutment connections with an unstable mating interface place undue stress of the screw that connects the implant to the abutment.  The abutment-implant interface is the weakest point of the implant and most failures occurred in this area.  It can be improved by improving various design features. Dixon et al.  described the causes of screw joint stability as adequate preload by accurate tightening of the screw, precision of the fit of matching components diameter, internal, external hex, friction grip, conical taper, basic anti-rotational characteristics hex and the abutment material and design. An incidence of 0.5-8% abutment screw fractures have been reported. 
Internal hex design and mating taper provided increase in lateral stability and antirotational resistance.  In a study where various implant connections and diameters were subject to static and fatigue tests and scanning electron microscopy evaluation it was found that in wider diameter implants the fatigue strength of the abutment screw was higher. 
Implants are available in different lengths and diameters. If the overall surface area is increased, then osseointegration is increased. Keeping this in mind, one should attempt to place an implant that matches the anatomy of the tooth it is replacing. Short implants with wide diameter to replace posterior teeth avoid the need for bone augmentation and potential damage to the vital structures, thereby reducing morbidity in the patients.
Conventionally implants are loaded after 8-12 weeks to establish osseointegration. Immediate loading is when the implants are restored with interim abutments within a week and early loading is when they are loaded between 1 week and 8 weeks. There was no evidence to suggest prosthesis failure, implant failure or bone loss associated with different loading times of implants.  The final restoration could be screw retained or cement retained. In the posterior teeth, screw retained prosthesis works better, as these crews can be accessed easily for maintenance. In the anterior sites, due to the angulation of the implant and aesthetics cement retained prosthesis may be necessary. The material of the final prosthesis is based on the esthetics and occlusion. Porcelain is esthetically more pleasing and good for single crowns and small bridges. In full arch bridges using porcelain may lead to fracture of the porcelain superstructure due to wear. If it is opposing natural dentition, it may lead to wear in the natural teeth. In these situations, high strength composite is a good alternative. It can be easily altered and repaired chairside and is kinder on the natural teeth.
| Case Report|| |
A 23-year-old male patient presented with an edentulous space caused by loss of upper left central and lateral incisor to trauma [Figure 1]. The left lateral incisor was congenitally missing. The central incisor was damaged as a result of injury with a lacrosse stick and was extracted a year ago. He was wearing an ill-fitting single tooth denture and wanted to have implants as he was dissatisfied with his appearance. His medical history was clear. His smile line was low and gingival margins were not visible when he smiled [Figure 2].
|Figure 1: Patient presenting with missing maxillary left central and lateral incisor and loss of buccal alveolar bone|
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Intraorally, the patient was wearing a very ill-fitting denture. He had calculus deposits and mild gingivitis. The upper right central incisor had a composite restoration and was nonvital. The edentulous space formed by loss of two teeth was reduced due to migration of neighboring teeth. The midline was shifted by 2 mm. There was marked concavity on the buccal alveolus in the central incisor region caused by resorption of the buccal bone. Periapical radiograph of the region showed a periapical area on the upper right central incisor and sufficient bone in the alveolus to place one implant [Figure 3]. The bone looked less dense and the naso palatine foramen could be clearly seen. Study casts were articulated and a wax-up done to plan the number of teeth that could be restored in the space [Figure 4]. Once the patient was satisfied with the wax-up, it was decided to place one implant in the missing upper left central incisor region and to cantilever the pontic of upper left lateral incisor. The upper right central incisor was root canal treated and planned for porcelain bonded to metal crown.
|Figure 3: Periapical radiograph showing the quantity of bone in the maxillary left alveolus where teeth are missing and radiolucency on right central incisor|
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A chair side silicone guide was fabricated on the wax-up to guide the implant positioning [Figure 5]. A full thickness mucoperiosteal flap was raised with the horizontal incision of the flap placed palatal to the crest. The implant position was marked with the pilot drill. The alveolus was thinned out due to the resorption of the buccal bone and a pronounced concavity was present. The implant site was prepared by expanding the bone using bone expanders in increasing diameters. The bone was D2 in nature. The implant bed was prepared using the Megagen system protocol. Drills of increasing diameter were used with external saline irrigation. The bed was tapped and a 5 mm diameter implant of 15 mm length was placed [Figure 6]. There was good primary stability, but the buccal wall had a dehiscence. Bio-Oss bone graft was placed [Figure 7] and covered with Bio-Gide membrane. Primary closure was done and an interim removable denture placed [Figure 8].The implant was exposed after 12 weeks. Radiograph showed good bone formation around the implant [Figure 9]. Upper right central was prepared for a crown and intermediate restorations were cemented to allow the gingiva to heal around the implant. After 12 weeks, once the gingiva has stabilized around the anteriors, final impressions were taken for permanent restorations [Figure 10]. The final prosthesis had an esthetic gingival contour [Figure 11].
|Figure 6: Megagen implant in central incisor region showing dehiscence of buccal bone|
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|Figure 9: Periapical radiograph taken at 12 weeks after implant placement|
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|Figure 10: Crown preparation of right central incisor and implant impression coping for final open tray impression technique|
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An esthetic and functional result was achieved [Figure 12] in this case using routine radiographs, articulated wax-up and chairside silicone guide. A thorough knowledge of the surgical anatomy and meticulous adherence to surgical principles ensures that the implant is successful. Mechanical factors influenced the choice of the implant system and lack of space indicated use of a single implant of sufficient length and width to be able to support a cantilever bridge.
| Conclusion|| |
Long-term success of dental implant treatment is dependent on several factors. The surgical, radiological, and mechanical factors influencing implant success are discussed.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]