Anatomical Basis for Implant

Selection & Positioning

Ahmed Adel
Dina Ahmed
Mahmoud Omran
Mohamed Sherif
ILOs
• Dimensions between anatomical landmarks of
maxillary and mandibular jaws
• Functional Implant zones
• Implant size recommendation related to tooth
anatomy
• Principles of implant positioning
• Number of implants and key implant positions
 Floor of the
Maxillary Sinus
Nasal Cavity

Mental
Inferior Border Inferior
Foramen
of the mandible Alveolar canal
Functional Implant zones of the Jaws

IZ 2 IZ 1 IZ 2

IZ 4 IZ 3 IZ 4
 Functional Implant Zone 1
(Traumatic Zone)

. Most commonly associated with Trauma

*Anatomical structures:
. Nasal Cavity
. Naso-palatine canal

Implant zones of the jaw: Implant location and related

success rate.. Tolstunov.. Journal of implantology 2007
Problems:
1) Distally Inclined root of the maxillary canine,
so, implant is placed Parallel to the long axis
of the canine

2) Labial Concavity ,
so, Implants are placed parallel to the
labial plate on the expense of
the palatal plate of bone.

Implant zones of the jaw: Implant location

and related success rate.. Tolstunov..
Journal of implantology 2007
3) Ridge resorption:
.Due to Trauma or Tooth loss ( caries or Pdl dx.)

. Post extraction bone resorption:

Decrease in ridge width Decrease in height
5-7 mm (50%) in the first year 1 mm within 6 month
2/3 of which occur in the first 3 month

Implant zones of the jaw: Implant location and related success rate.. Tolstunov.. Journal
of implantology 2007
 Functional Implant zone 2
(Sinus Zone)

*Anatomical structures:
. Maxillary sinus
. Posterior superior alveolar A.

Implant zones of the jaw: Implant location

and related success rate.. Tolstunov..
Journal of implantology 2007
1) Maxillary sinus:
Increased incidence of Post extraction sinus
pneumatization with:
. Teeth surrounded by a superiorly curved sinus floor
. Teeth with protruded roots into the sinus cavity (In CT scans)
. Second molar extractions
. Extraction of several adjacent posterior teeth

Maxillary sinus pneumatization following extractions: a

radiographic study..Sharan.. International journal of oral
and maxillofacial implantology
2) Posterior superior alveolar A. :
. The Intra-osseous artery is visible in CT scans in 52 %
of the cases

. It’s average height from the

crest of the ridge is 16 mm

. Because of its location it can cause

Complications in 20% of normally positioned lateral
window osteotomies
Practical Application of Anatomy for the dental implant surgeon.. Greenstein..
Journal of Perodontology 2008
 Functional Implant Zone 3
( Inter-foraminal zone )
. Narrow ridge B-lg.
so, standard or narrow implant is used

* Anatomical structures:
.Mental foramen
.Submental and sub lingual arteries
.Mentalis muscle

Implant zones of the jaw: Implant location

and related success rate.. Tolstunov..
Journal of implantology 2007
1) Mental Foramen:
. The anterior loop of the mental foramen is identifiable
in 7-27 % of panoramic radiographs and extends 3-5 mm
. Dissected cadavers showed incidence of anterior loops of
37-88 %
So, a safety margin of 4 mm
is recommended to avoid injury..

The Mental Foramen and Nerve: Clinical

and Anatomical Factors Related to Dental
Implant Placement: A Literature Review
Greenstein.. Journal of periodontology
2006
Implant zones of the jaw: Implant location
and related success rate.. Tolstunov..
Journal of implantology 2007
2) Sublingual & submental arteries:
May course anteriorly along the lingual plate and enter through
accessory foramina in the lingual cortex
Lingual plate perforation may Result in sublingual or submental
hematoma that may compromise the air way

3) Mentalis Muscle:
Should not be released during Symphyseal
Monocortical block graft harvest ,
Otherwise it may not reattach
and result in a double chin
Implant zones of the jaw: Implant location
and related success rate.. Tolstunov..
Journal of implantology 2007
 Functional Implant zone 4
( Ischemic zone )
Blood supply:
. Main: Inferior alveolar artery
. Auxiliary: Musculo-periosteal and SSM

With tooth loss, age & systemic disease

Decreased Blood supply to rely on centripetal

Leading to ISCHEMIC BONE ATROPHY

Implant zones of the jaw: Implant location

and related success rate.. Tolstunov..
Journal of implantology 2007
1) Inferior alveolar canal:
High: 2mm Intermediate: 3-5mm Low: Near border

A safety margin of 2 mm is recommended to avoid injury to the

canal contents

Anatomy of Mandibular Vital Structures. Part I: Mandibular Canal and Inferior Alveolar Neurovascular Bundle in
Relation with Dental Implantology.. J Oral Maxillofac Res 2010
2) Lingual nerve:
Located 3 mm apical to the crest and
2mm Medial to the
lingual cortical plate

. Avoid vertical releasing incisions on the lingual side,

. Incisions distal to the 2nd molar are performed bucally only as
the nerve may lie on the retromolar pad area

Implant zones of the jaw: Implant location

and related success rate.. Tolstunov..
Journal of implantology 2007
 Principles of implant positioning
• Proper implant position
• Four positional parameters:
1. Apicocoronal position in the bone(vertical).
2. Buccolingual position.
3. Mesiodistalposition.
4. Angulation of the implant
 Biological width
• The hemidesmosome of the natural tooth has
a lamina lucida and a lamina densa.
• The hemidesmosome next to animplant has a
lumina lucia, lamina densa, and
sublaminalucida (which is less adherent).
• crestal bone is reestablished
1.5 mm apical to the
implant-abutment interface.
 1. Apicocoronal position in the bone(vertical).

The wider the implant, the less distance is needed to form a gradual
emergence profile
The crestal bone is reestablished 1.5 mm apical to the implant -abutment
interface.
The sink depth of the implant shoulder should be 1 to 2 mm for a one-stage
implant or 2 to 3 mm for a two-stage implant apically to the imaginary line
connecting mid-buccal of CEJs of the adjacent teeth without gingival recession.
• Using the attachment mechanisms of the
teeth is recommended as a guide to
establishing proper vertical level of implant
• such a guide indicate to place implant
platform 3 mm below ginigival margin.
• It is recommended that the location of the
implant head be related to a line connecting
the gingival zenith of the adjacent remaining
natural dentition rather than to a line
connecting the CEJ or the crest of the ridge.
 2)Buccolingual position

• The labial aspect of the implant platform just touches an

imaginary line that touches the incisal edges of the adjacent
teeth
• implant in slight labio-version, Occlusal considerations
occasionally necessitate such placement, particularly in cases
involving excessive vertical overlap.
 3 )Mesiodistal Position

• The implant should be positioned midway in

the center of the available mesiodistal space

• improper mesiodistal positioning of the

implant
• The interproximal bone level is expected to be
more apical to the implant shoulder and
therefore exhibit a reduced or absent papilla
and also implant loosenes.
 Implant proper position
o Gingival recession and biotypes:
• A thin gingival biotype dictates placement of
the implant in a slightly more palatal position
• implant should be placed somewhat more
apically to achieve a proper emergence profile
how to know gingival bio type

• subepithelial connective tissue graft

 The presence of diastemas

1. Single implant
precise surgical templates ensure optimal
implant positioning to determine the exact
position of the missing tooth

2. Multiple implant
fabrication of a wax-up and careful presurgical
planning.
 Implant to implant distance
• Minimum distance:
R1 (Radius of implant number 1) + R2 (Radius o
implant number 2) + 2mm (Minimum
distance formula)
 Implant to implant distance
• Ideal distance:

• If contra-lateral tooth is present

measurements is done on it
• It can use for full arch reconstruction
implant placed adjacent to natural
tooth
 4 Angulations
• The implant should be perpendicular to the
plane of occlusion
• the bone of the maxilla and the mandible is not always
perpendicular to the plane of occlusion especially in
mandibular posterior and maxillary anterior

• The strain gauge measurements showed

higher, threefold and 4.4-fold, compressive
Strain concentration in the coronal zone
of the implant when 15-degree and
25-degree angulated abutments
were used, respectively

(J Prosthet Dent 1998;79:328-34

 Key implant position
• Implant positions were primarily controlled by
the teeth being replaced.
• implant positions are more critical regarding to
force reduction to the implant system
• Four guidelines for key implant position :
1. No cantilevers
2. No three adjacent pontics
3. Canine-molar rule
4. Arch dynamics
 No cantilevers

Ideal key implant positions include the terminal abutment positions when adjacent teeth
are missing. Without a terminal abutment, a cantilever exists on the restoration, which
increases complications. This is particularly important when a lateral load or heavy
bite force is applied to the cantilever.
Contemporary Implant Dentistry 3rd edition
 No cantilevers
• Cantilevers are force magnifiers to the
implants, abutment screws, cement or
prosthesis screws, and implant-bone interface
• especially noted with parafunction or reduced
crown height spaces
• The length of the cantilever is directly related
to the amount of the additional force placed
on the abutments of the prosthesis
25 lb 20 10 50 lb

75 lb

Contemporary Implant Dentistry 3rd edition

Carl E Misch-Dental implant prosthetics
Carl E Misch-Dental implant prosthetics
 Key implant position
1. one or two adjacent teeth are missing
indicate one implant per tooth
2. 3 to 14 adjacent teeth are missing, the key
implant positions include the two terminal
abutments, one on each end of the
prosthesis.

Contemporary Implant Dentistry 3rd edition

 completely edentulous mandibles
• edentulous mandible, available bone in the
posterior regions may be insufficient for root
form implant placement, without advanced
procedures (e.g., nerve repositioning, iliac crest
bone grafts).
• When the implants are in one plane, the
cantilever should rarely extend farther than the
A-P distance
• The distance from end of cantilever is resistance
arm , and the distance between implants is
anteroposterior distance ( A-P) spread
 The anteroposterior distance (A-P spread) of
five implants in the mandible is measured from
the distal of the last two
implants to the mid position of the most
anterior implant. Because these splinted
implants form an arch, the cantilever may
extend up to 2.5 times the A-P distance (when
patient force factors are low and bone density
is good).

Arch shape affects the A-P distance.

The ovoid arch
form (A) often has an A-P distance of 6 to 8
mm.
A square arch form (B) often has an A-P
dimension of 2 to 5 mm.
A tapered arch form (C) has the greatest A-P
distance, larger than 8 mm

Contemporary Implant Dentistry 3rd edition

http://www.dentaltown.com/dentaltown/Article.aspx?aid=5318
 No Three Adjacent Pontics
• subjected to considerable additional force
especially in the posterior regions of the mouth
• all pontic spans between abutments flex under
load.
• A one pontic span exhibits little flexure 8 mm or
less with precious metal under a 25-lb load.
• A two-pontic span flexes eight times more than a
one pontic span, all other variables being equal
• A three pontic span flexes 27 times more than a
one-pontic span
• The flexure of materials in a long span is more
of a problem for implants than natural teeth.
Because an implant is more rigid than a tooth
• The span of the pontics in the ideal treatment
plan should be limited to the size of two
premolars, which is 13.5 to 16 mm.
Carl E Misch-Dental implant prosthetics
• When a molar is one of the teeth missing
between existing teeth, the missing molar
space may be 10- to 14-mm long. Therefore
when the span is greater than 14 it considered
as two premolars depend on number of roots
in lower molar or buccal roots of maxillary
molars

Contemporary Implant Dentistry 3rd edition

• edentulous arch missing 14 natural teeth we
rarely replace lower second molar
• key implant positions are located in the
terminal abutments and additional pier or
intermediary abutments are indicated to limit
the pontic spans to 2 premolar sized pontics
or less
Canine and First Molar Sites

Contemporary Implant Dentistry 3rd edition

Contemporary Implant Dentistry 3rd edition
Contemporary Implant Dentistry 3rd edition
Contemporary Implant Dentistry 3rd edition
Carl E Misch-Dental implant prosthetics
http://www.slockimplant.com/board/forum.aspx?recordidx=20140602154113386&boardname=guide
 4-Key Arch Positions
• arch may be divided into five segments
• two central and two lateral incisors are one
segment
• the canines are independent segments
• the premolars and molars on each side form a
segment.
• when two or more segments of an arch are
connected, the tripod effect is greater, and as
a benefit an A-P distance is created from the
most distal terminal abutments to the most
anterior pier abutment.
• one implant in each
edentulous segment of
the arch.

Contemporary Implant Dentistry 3rd edition

 IMPLANT NUMBER
• In the past, the number of implants most
often was determined in function of the
amount of available bone in the mesiodistal
dimension
• So the four guidlines are not applicable by us
in four implant to support full arch prothesis
• The decision on the number of implants in the
treatment plan begins with the implants in the
ideal key positions.
• number of implants between adjacent teeth can
be calculated
• 1.5 mm from an adjacent natural tooth and 3 mm
from an adjacent implant
• So take crest module of an implant (e.g., 4.0 mm)
and adding these dimensions
• This results with dividing the length of the span
by 7 mm for the maximum number of implants
• Increasing the number of implants is the most
efficient method to increase surface area and
reduce over all stress.
• after the key implant positions are selected,
additional implants are indicated to reduce
the risks of overload from patient force factors
or implant sites with reduced bone density