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					Bruce, Fiona (2007) Dental implant elective study. BDS Elective Report.

8th January 2008

Dental Implant Elective Study

Matriculation Number: 0308972

      Word Count: 4652


The aim of my elective was to broaden my knowledge of dental implants as a whole.

This procedure has become extremely popular over the last 10-20 years and there

have been vast advances in this time with regard to techniques and patient

acceptability etc.   I believe that having the insight in to the world of cosmetic

dentistry at this point in my education would prove beneficial in my future profession.

During my elective period, I spent several days observing various stages of the dental

implant procedure in my uncles’ surgery, Cullen and Bruce dental practice, 5 Lenzie

Road, Stepps, Glasgow, Lanarkshire, G33 6DY. I opted to carry out my elective

study in this practice due to the extent of my uncle’s knowledge and experience in the

dental implantology field. He has been involved in dental implantology for the last 11

yrs, following 5 yrs of oral and maxillofacial surgery experience. I believe his oral

surgery experience is extremely valuable in the field of dental implants, as currently,

dental practitioners can carry out dental implantology procedures having completed a

GDC dental implantology course, followed by suitable mentoring. In addition, as he

is a representative and spokesperson for Staumann, dental implant systems, I also had

the privilege of attending Straumann seminars. I found these extremely informative

as they were aimed at a wide range of people with varying degrees of dental

implantology knowledge. I believe having a limited understanding of the dental

implants as a whole; the seminars proved extremely beneficial and prepared me

sufficiently for the practical aspects of implantology treatment.


Dental implants are not a new phenomenon. The implant concept has existed since

ancient times. Records discovered by archaeologists date back to Phoenician and

Egyptian times and the idea has continued from this point. Although the idea of

implants was initiated in ancient times, the concept has remained the same throughout

the years. Yet it should be noted that the materials and techniques used, depended

entirely on the resources available. There have been several records found which

indicate the gradual change in implants throughout the years which include:

   •   The first case of implantology took place in 1594 by Ambroise Pare.

   •   It should be noted that until Listers’ work on antisepsis, the physiology of

       bone and reaction of soft tissues and body fluids to various metals could be

       understood as such implants had little chance of success regardless of

       technique or materials used.

   •   1886 Bugnot attempted the implantation of tooth buds and younger

       transplanted teeth into artificially created sockets.

   •   1887 Harris and Edmunds utilised surface roughened lead roots to allow tissue

       attachment and fixation.

   •   1889 and 1891 Edward and Znameski undertook implantation using teeth

       constructed from gutta percha, rubber or porcelain, incorporating grooves for

       improved adhesion.

These were all important steps through time in the advancement and development of

dental implants, however it is the 20th century, which has been able to offer the

implant idea, the appropriate technology and clinical understanding to allow it to

come to fruition in 1913. At this stage it was Greenfield, who published his paper in

the Dental Cosmos relating to a root shaped implant which could support a crown and

dentures, that left his mark on modern day implantology.

Different materials were tested for the use in dental implants however nothing proved

successful until 1937 when Veneble and Stuck recommended the use of vitallium.

This could be considered the turning point in the history of implants and the

beginning of modern implantology, as vitallium was the only material found to

exhibit no tissue reaction at the implant site.

A few years later in 1940’s, Formiggini introduced the first screw type implant which

was made of tantalium and stainless steel. This design involved a wire being bent

back on itself to form a series of spirals. The spirals were considered to be beneficial

in retention of the implant as bone would grow around and through the spirals.

However due to the poor fracture strength of the material during the bending of the

wire, the implant would experience weakness and fracture. However this problem

was overcome by Zepponi who introduced the cast spiral implant which had greater

chance of success due to less stresses on the wire.

Another screw type implant was introduced by Chercheve in 1962 which was

composed of cobalt chrome. This cobalt chrome screw implant was successful yet it

was weak when lateral forces were applied.

1966 saw the first blade implant, made form nickel and vanadium. This was placed

through the mucosa into bone. This implant was commonly used but bone resorption

was a problem and resulted in poor success rate.

Kawahara developed single crystalline forms after the blade. These implants have

only been used on the mandible. The interface between the implant and bone showed

some bone attachment areas and fibrous connective tissue attachment, but it could not

be used for freestanding fixed prostheses as complete osseo-integration is not


Another important leader in the field of dental implantology was Per Ingvar

Branemark, who from the early 1960’s, worked extensively in creating the reality of

Osseo integrated implantology.

“Osseo integration is defined as a direct structural and functional connection

between ordered, living bone and the surface of a load carrying implant. Creation

and maintenance of Osseo integration, therefore, depends on the understanding of the

tissue’s healing, repair, and remodelling capacities.”

Branemarks research initially involved the placement of titanium implants in dogs,

where results showed that is was possible for the titanium to be “functionally

ankylosed” or “Osseo integrated”.      Branemark, then broadened his research and

carried out an experiment out on humans using their upper arms for placement of

titanium to ensure there could be no biological actions taken by the body. His

experiment was successful and results proved that titanium implants could be placed

successfully. This resulted in the Branemark system being tested clinically and the

first edentulous patient was treated in July 1965.


Today, we live in a world which has become captivated by the world of cosmetic

dentistry. It does not seem so long ago, that cosmetic dentistry was focused almost

entirely on our A list celebrities and confined to the world of Hollywood. However,

times have changed and cosmetic dentistry is progressively becoming more and more

popular within the general public. This ever increasing interest and demand for

cosmetic work, I believe, is a result of extensive media exposure in coincidence with

increased disposable income and increased availability of such procedures. Another

major factor is the aging post war baby boomers who attempt to delay the appearance

caused by the aging process.

Nowadays, we are constantly bombarded with makeover programmes such as “10

years younger” and “extreme makeover”. These have opened up the eyes of the

general public and broadened the acceptance of cosmetic surgery as a whole in our

society. People are more willing than ever to dabble in the cosmetic business, as it is

generally more accepted and there is a greater number of the general public

advertising the unbelievable results. The majority of the public are now far more

appearance orientated than previous years and are especially more concerned about

the appearance of their teeth.    Many people live life with the attitude of, “first

impressions mean everything, and having a beautiful smile is a tremendous advantage

both at work and play.” Despite the popularity of dental implants, there are however,

areas of controversy surrounding some aspects of the general field of dental

implantology.    Procedures have become more widely available in the United

Kingdom due to the increased number of general dental practitioners, worryingly

lacking oral surgery experience, offering the procedure to their patients. Furthermore,

patients also have greater access to treatment due to the emergence of dental tourism

where they can seek treatment in other areas of the world.           However, several

questions must be considered, are the patients receiving the best treatment possible?

Is the patient’s safety and well-being the fundamental issue or has the financial aspect

become the most important factor for both patient and dentist?

                             What Is A Dental Implant?

A dental implant is a small screw made of titanium that is well tolerated by the body

and replaces the function of the tooth root. The dental implant is inserted directly into

the jaw bone, which is subsequently anchored firmly due to the process of Osseo

integration (when the bone attaches securely to the surface of the implant). The

healing process lasts 6 to 12 weeks depending on the initial situation. After this

period, the tooth replacement in the form of a bridge, crown or denture is secured to

the implant. The replacement tooth can look, feel and perform like a natural tooth.

                        The Advantages of Dental Implants

Implants have several advantages over fixed bridgework or partial dentures in patients

with gaps in their dentition. Unlike dentures, implant-stabilised teeth are integrated

into the patient’s natural bone, meaning that there is no slipping or movement. This

can greatly improve confidence and function.

   •   Dental implants come closest to nature. The titanium screw replaces the tooth

       root and its function.

   •   They form a stable foundation for tooth replacement.

   •   Implant-secured teeth can also prevent further bone loss around edentulous

       areas and prevent excess forces being applied to abutment teeth.

   •   Implants can also be inserted to stabilise and anchor full dentures.

   •   Conventional dental treatments, such as crowns and bridges require the

       removal of intact enamel. However the dental implant replaces the lost tooth

       root, acts as a post for the implant crown and the removal of intact healthy

       hard tissue is not required.     Thus there is maintenance of healthy tooth


      Indications To Treatment with Osseo integrated Implantology

1. Severe morphological compromise of denture- supporting area that

   significantly undermine denture retention.

2. Poor oral muscular co-ordination.

3. Low tolerance of mucosal tissues

4. Para functional habits leading to recurrent soreness and instability of


5. Unrealistic prosthodontic expectations

6. Psychological inability to wear a removable prosthesis even in adequate

   denture retention or stability is present.

7. Active or hyperactive gag reflexes elicited by a removable prosthesis.

8. Unfavourable number and location of potential abutment in a residual

   dentition.   Adjunctive location of optimally placed Osseo integrated root

   analogues would allow for provision of a fixed prostheses.

9. Single tooth loss to avoid involving neighbouring teeth as abutments.

             Medical Contra Indications: General or temporary


•   Acute infectious diseases

•   Systemic bone diseases e.g. osteogenesis imperfecta

•   Haematogical disease

•   Post head and neck radiation therapy

•   Pathological findings in the mandible or maxilla as well as pathological

    findings of soft tissues

•   Pregnancy

•   Unfinished cranial growth, incomplete tooth eruption

•   Alcohol/drug abuse

•   Immuno suppressed or immunocompromised

•   Heart conditions

•   Diabetes/anaemia


                           Dental Contra indications

•   Poor or inadequate oral hygiene; need of general rehabilitation

•   Ongoing periodontal problems

•   Occlusal considerations; bruxism and lack of interdental height

•   Reduced quantity and quality of alveolar bone


        The implant procedure is best divided into 6 main stages:

1. Planning and Diagnosis

2. Surgical Phase

3. Healing Phase

4. Impression taking

5. Fitting crown or bridge

6. Recall

                  What Possibilities Do Implants Offer?

1. Replacement of a single tooth, whether it be a posterior or an anterior tooth.

2. Treatment of Edentulous Areas with Implants:

3. Treatment of the edentulous jaw

Implants can be inserted to stabilise and anchor full dentures. In the conventional

complete denture method, the removable appliance is retained in the mouth by a close

relationship of the denture to the gums with a film of saliva. The film of saliva is

necessary for the “suction” of the denture to the gum to be successful and this can

present a problem in some patients. In addition, there is continued bone loss in

denture wearers due to the absence of loading. The denture, with time, gradually

becomes ill fitting and is difficult to retain. Poor or absent denture stability is a big

aesthetic problem for many patients and may result in painful pressure areas on the


Implants can in fact be used in conjunction with dentures and there appears to be

several advantages over the use of dentures alone. Implants stabilise removable

complete dentures on the jaw and also aid the preservation of the alveolar bone. The

denture can in fact be easily removed and replaced which allows cleaning of the

denture relatively straightforward. The dental implant anchorage technique spares the

troublesome side effects such as painful pressure points which are relatively common

in conventional denture wearers.



The full dental implant procedure is relatively time consuming due to the various

stages involved. A recipient site of the same size and shape as the implant is created

in the jawbone with drilling instruments. The implant is inserted into the site prepared

and usually, a healing period is required for the jaw bone to fuse with the implant.

The jawbone has different densities in different areas - the denser the bone, the shorter

the healing period. After this healing period, the prosthesis is constructed over the

implant and the treatment is completed. Normally the time scale for start to finish is

approximately 3-4 months however it can possibly take up to a year to perform more

complex dental implant treatments requiring bone grafts due to decreased bone

quantity and density. Unfortunately due to this lengthy time scale, I was unable to see

the same patient both before and after treatment. However, I did witness the various

stages involved in various different patients.

The surgery can commence after thorough examination/history taking, diagnosis and

treatment planning as well as any pre- prosthetic surgery, including sinus lifts, hip

grafts and on lay grafts have been completed. It is vital to establish whether the

patient is a smoker or not. Success rate of dental implantology is approximately 95-

98% in non smokers; however this figure is significantly reduced in smokers. It is

important to highlight at this stage that dental implants are not placed in smokers in

the USA due to the lowered success rate and complications which are likely to arise.

It is also vitally important that special investigations are also completed prior to

commencement of treatment.        These special investigations include study models

articulated with face bow, radiographs (periapical, OPT), CT scan with CT

radiographic stent in situ, ridge mapping and photographs.          It is also a legal

requirement that consent is given, both verbal and written. It is also wise to offer the

patient an implant questionnaire. A copy of the questionnaire provided to patients in

Cullen & Bruce Dental Practice is as follows:

  The following, is a description of the most common dental implant placement

  procedure in the region of upper left 1:


  •   Surgical stent is constructed pre treatment.

  •   Chlorohexidine mouthwash for 1 min

  •   Betadine face wash to minimise infection

  •   Surgical cap, safety glasses and drapes to be worn by patient

  •   Gloves, drapes and masks to be worn by dentist and nurse

  •   2 suctions: 1) saliva 2) bone trap for osteotomy

  •   Local anaesthetic

  •   Create flap


  •   Raise flap

•   Place surgical guide

•   Mark site for implant placement

•   Remove stent and evaluate position

•   Use pilot drill – pilot drill is 2.2mm in diameter. Should drill to a depth of


•   Check angulations and proclination with depth gage. This is vital as the

    implant cannot be more than 20degrees from the vertical

•   Once anglination and proclination are correct the pilot drill is used to drill to

    the required depth e.g. 12mm. Again angulation and proclination should be

    rechecked using depth gage.

   •   2.8mm diameter drill should now be selected and should be used to drill to the

       same depth and angulation as the pilot drill.

   •   The profile drill should then be used to open up the osteotomy – in essence

       create a flare.

   •   3.5mm diameter drill then used.

Implant placement:

   •   The implant used in the upper left 1 region is a 4.1mm by 12mm SL Active

       implant. The surface is hydrophilic. These implants are manufactured in a

       nitrogen atmosphere by machines.        This allows for no contamination by

       hydrocarbons from the environment, resulting in reduced healing time from 8

       to 4 weeks. The implant must however be placed within 15 minutes of

       removal from container.

•   The implant is transported and placed in the pre constructed implant space.

•   The implant is fitted into place by the use of a torque wrench. The Straumann

    implant shoulder should lie 1mm below the ACJ of adjacent teeth (do not want

    implant too deep or too shallow).

   •   It is important to check flap elasticity at this point to ensure that there is

       adequate elasticity for closure. If the flap appears as if it will not close,

       periosteal release may be required.

   •   Next, bone is required to be place on the surface of the implant. There are

       different schools of thought regarding the reuse of the patients own bone,

       removed during the osteotomy, being used at this stage, or whether the

       alternative bone material such as bio-oss should be used individually.

   •   A membrane can also be placed. This prevents soft tissue ingress into the

       bone graft. Thus, preventing implant failure.

   •   The flap must now undergo primary closure.

Post – Op:

   •   The healing time is variable however is normally 4 weeks without bone graft

       or 8 weeks with bone graft.

   •   The patient should be supplied with post-op implant instructions to ensure

       they are aware of the “do’s and don’ts. An example of a post op instruction

       sheet supplied by Cullen & Bruce dental practice is as follows:

•   After a 2 week period, impressions are taken. Impression coping is screwed

    into the implant and the impression taken with coping in situ. Once set, the

    coping plus impression tray are removed as one.

•   The agreed restorative procedure can now be completed, whether it is a crown,

    cemented or screw retained, or a bridge.

                                   Dental Tourism

Nowadays, dental tourism is a big business. Patients are travelling worldwide to

receive more affordable dental procedures. Companies, however, are aware that

dental implants and further cosmetic procedures are becoming more widely available

in the UK and they must offer their potential patients much more than simply “cheap”

dental treatment in order for them to board the plane. The question that must be

considered is, the treatment may be cheaper abroad but could the patient’s health end

up paying the price?

The following is an example of an advertising technique used by one company to

entice their potential patients,

“With its glorious climate, spectacular scenery and fine beaches, Spain has long been

one of Britain's favourite holiday destinations. This makes it the perfect location to

combine a relaxing break with high quality dentistry whilst still making a huge saving

on UK prices.

Our modern Dental Surgery is located just a few minutes walk from the beautiful

Puerto Banus – with its array of first class restaurants and bars, designer boutiques

and stunning beaches.

A first-class service, state of the art facilities, in chair DVD/CD entertainment and

our gentle and friendly approach ensure an enjoyable and efficient transition to an

attractive smile and healthy mouth.

Furthermore, our guarantee and aftercare program ensures your new smile will look

good now and for many years to come.”

However, dental tourism remains an issue of great controversy. Falling ill on holiday

is a travelling nightmare, yet for a great number of patients seeking dental treatment,

the lure of combining affordable dental care with attentive room service is a chief

draw for packing the suitcase and boarding a plane. Patients do have the free will to

choose where they seek their dental treatment from, whether it is here in the United

Kingdom or in another area of the world. Many opt for treatment abroad due to the

financial benefits. However, it must be emphasised that operations or treatments

abroad, regardless of how small, do still present with the same risks as any surgical

procedure, and patients should ensure they have researched thoroughly and are aware

of the risks of receiving treatment abroad. In addition it is also wise to research the

operating dentist and history of experience. Having researched this topic extensively

I do not believe that patients should be mixing “business with pleasure”. Especially,

when they are unaware of the quality of the treatment they will be receiving and

health and safety procedures in place.

                                  Further Education

Initially, implants were placed by oral surgeons and restored by prosthodontists in a

team effort. Recently however, with the simplification of implant hardware and

surgical techniques, general dental practitioners have become increasingly interested

in providing implant treatment. It has become routine for general dental practitioners

to offer dental implants as an everyday procedure to their patients having completed a

dental implantology course. Not all dental practitioners have undergone the dental

implantology course however the number of dentists seeking this additional education

is progressively growing. This recent surge in dental practitioners offering the dental

implants in general practice is due to the increasing demand from patients. However

it has to be queried whether a general dentist is apt to handle this as well as an oral


As it stands, dental practitioners can attend dental implant training courses which

provide both academic and practical teaching techniques.           There are several

companies which offer training courses and depending on which company and dental

implant system selected, the type of courses may vary. I had the advantage of

attending an ITI Gateway seminar led by experienced practitioners who offered an

insight into how implantology can be successfully incorporated into practice. During

these events, I had the opportunity to gain an understanding of the Straumann Dental

Implant System as well as the ITI training programme and the various courses which

they offer to their candidates.

There were several training courses available. These ranged in topic, format, length

of training and price and were available to dental practitioners as well as hygienists

and nurses. ITI Gateway offers a wide range of education whether it was the simplest

of courses consisting of single lectures for increasing practitioner knowledge or

whether it was a complete implantology year course. This year course is a continuing

professional education programme which is divided into 10 modules extending over a

period of one year, in accordance with the GDC “good practice” guide. Throughout

the year, candidates are provided with long-term support and learning and are

educated on all aspects of dental implantology, from diagnosis, bone grafting to

immediate implant placement.

The programme is as follows:

   •   Day 1- Introduction

Introduction to the history of dental implants and the Straumann Dental Implant


   •   Day 2 – Treatment Planning

Learn and practice how to develop a logical, team approach to treatment planning

sequence and diagnosis

   •   Day 3 – Surgical Implantology

Practical learning of surgical principles and procedures

   •   Day 4 – Restorative Implantology

Gain a complete understanding of component choice through case discussion and

hands on training

   •   Day 5 – Soft Tissue Management

A theoretical and practical day using pigs’ jaws to practice techniques for achieving

aesthetic results through soft tissue management

   •   Day 6 – Bone Grafting

Lecture based day providing a comprehensive introduction to the techniques needed

to gain the ideal implant placement

   •   Day 7 – Periodontal Regeneration

A one day theoretical course discussing the development of the biological principles

for tissue regeneration and their clinical applicability

   •   Day 8 – Fixed Removable Options

Specifically addressing the provision of implant-retained over dentures and their

association considerations and techniques

   •   Day 9 – Immediate Implantology

Immediate implant placement and immediate restoration or loading

   •   Day 10 – ITI Annual Lecture

Anatomical aspects of implant dentistry

Therefore, it is clear from this extended course, that all aspects of dental implants are

covered, however, are all dental practitioners opting for this year course or are they

simply attending shorter, more intense courses lasting perhaps a few days? Is this

really sufficient training for a general dental practitioner to be offering dental implant

treatment to their patients in practice? They may well have been supplied with

sufficient education and training however does experience not play a vital role in the

success and quality of the dental implant placed?

There have been studies carried out and some show that placement of a single tooth

implant can be performed by a general dental practitioner who has received adequate

training. However in another study, a group of general dental practitioners with no

previous experience in implant surgery underwent an intensive training course in

implant treatment for a single tooth. Using a system of simplified instrumentation

with strict adherence to protocol, the group in the study installed and restored single

tooth implants in a wide range of clinical situations. The success rate of treatment

compared favorably with the results from centers where a specialist team provided


Many believe that dental implantology is a procedure which can be mastered after

attending a single course lasting approximately a couple of days.            However I

personally believe as many others do, that practitioners have a feeling of false

confidence after attending a few courses. They feel they have the necessary tools and

knowledge to offer the procedure to patients in practice, however I very much

disagree. I personally believe there is no such thing as a “simple” implant. Dental

implantology may in fact be a minor operation however all surgical procedures have

risks and complications and are not uncommon with respect to the placement of

dental implants. As seen in medicine, the doctor is required to be well educated and

experienced in the management of not only procedures when they go well, but when

complications arise. Furthermore, GP’s do not carryout all procedures and treatments

single handily for their patients. There are doctors who specialise in certain fields and

the GP’s refer patients accordingly. I believe the treatment of dental patients should

be carried out in a similar way. The surgical procedures such as dental implants

should be left to those with the sufficient education, knowledge and experience to

place them, whereas, the restorative aspect should be the role of the experienced

restorative dentist. Thus, this team approach works well in medicine and the same

approach should also be taken in dentistry.


In conclusion, I feel my time spent with Dr K Bruce during my elective period was

extremely beneficial and broadened my knowledge and understanding of the dental

implantology procedure. I was given the opportunity to spend time with general

practitioners eager to further their profession by learning new and ever changing

popular procedures, which are currently of high demand, during the Straumann and

ITI Gateway seminars. These seminars provided me with substantial knowledge, of

dental implantology as a whole as well as the implantology courses which are

available to general practitioners in this day in age. I was provided with presentations

which gave detailed information and proved vital for my observation of the practical

aspect of the procedure.     Furthermore, my days spent in the surgery were both

interesting and educationally beneficial.

Finally, in view of the increased clinical acceptance and patient demand for dental

implants, there is an associated need to provide further education in this field for both

general dental practitioners and undergraduate and postgraduate dental students. I

personally believe we are entering a new era of dentistry. Cosmetic dentistry is

booming and will continue to advance with time. We as dentists should strive to keep

up with the modernising techniques and procedures available, as the demand for

cosmetic dentistry, from out patients, are rapidly increasing.         Yet, it must be

highlighted that dental implantology does and can have complications. I believe that

dental implantology is a procedure which should only be carried out by persons with

the adequate knowledge, qualifications and experience to do so. As stated previously,

I believe the team approach is the favourable option. Adding experienced specialists

to the team will undoubtedly favor the delivery of optimal dental care.


   •   Straumann and ITI Gateway Seminar information pack

   •   International Team for Implantology (ITI) Uk & Ireland Continuing Education

       Programme 2007

   •   Straumann patient information “A new Quality of life with dental implants”

   •   Cullen & Bruce Post-Op instruction

   •   Cullen & Bruce Implant- Patient questionnaire


   •   Straumann- Marketing your Practice – Why do Patients want implants?

   •   Straumann – Implant Contra indications, Anatomy, Medical and Dental

       Contra indications



   •   Norman Cranin “History of Dental Implants” – Journal of Oral Implantology



   •   Andersson B, Odman P, Lindvall AM, Branemark PI. Surgical and
       prosthodontic training of general practitioners for single tooth implants: a
       study of treatments performed at four general practitioners’ offices and at a
       specialist clinic after 2 years. J Oral Rehabil 1995;22:543-8.

   •   Andersson B, Odman P, Lindvall AM, Branemark PI. Five-year prospective
       study of prosthodontic and surgical single-tooth implants treatment in general
       practices and at a specialist clinic. Int J Prosthodont 1998;11:351-5.

   •   McMillan AS, Allen PF, Bin Ismail I. A retrospective multicenter evaluation
       of single tooth implant experience at three centers in the United Kingdom. J
       Prosthet Dent 1998;79:410-4.

•   18. Henry PJ, Rosenberg IR, Bills IG, et al. Osseo integrated implants for
    single tooth replacement in general practice: a 1-year report from a multicentre
    prospective study. Aust Dent J 1995;40:173-81.


I would like to offer my thanks to Mr D Gordon who encouraged and supported

this elective study. Also, Dr K Bruce for allowing my observation of the dental

implant procedure and for his general assistance and guidance, which has proven