implantology biologic and clinical aspects / academy of fixed orthodontics

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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implantology biologic and clinical aspects / academy of fixed orthodontics

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3. Dental implants are becoming an increasingly important part of everyday dental practice. Over the last ten years, implants have evolved from an elective procedure to a routine treatment. Large clinical trials have documented the high success rates of dental implants. www.indiandentalacademy.com
  4. 4. At the same time, implants have become simpler to place and restore, allowing for implant treatment to be easily incorporated into the daily life of general practices. Implants are becoming standard of care in many clinical situations. www.indiandentalacademy.com
  5. 5. www.indiandentalacademy.com
  6. 6. www.indiandentalacademy.com
  7. 7. Clinical And Biological Aspects Of Dental Implants www.indiandentalacademy.com
  8. 8. DEFINITIONS /KEY TERMS HISTORY CLASSIFICATION INDICATIONS CONTRAINDICATIONS COMPONENTS OF IMPLANTS www.indiandentalacademy.com
  9. 9. OSSEOINTEGRATION VARIOUS SYSTEMS HOW TO SELECT AN IMPLANT SYSTEM GATHERING INFORMATION PROSPECTIVE SYSTEM Original Branemark Protocol Surgical considerations Protocol for implant placement CHOICE OF AN IMPLANT  LENGTH  DIAMETER  POSITION www.indiandentalacademy.com
  10. 10. STAGES IN IMPLANT PLACEMENT STAGE I SURGERY STAGE II SURGERY CONCLUSION REFERENCES www.indiandentalacademy.com
  11. 11. www.indiandentalacademy.com
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  13. 13. Any object or material, such as an alloplastic substance or other tissue, which is partially or completely inserted or grafted into the body for therapeutic, diagnostic, prosthetic, or experimental purposes GPT 8 www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. A prosthetic device made of alloplastic material(s) implanted into the oral tissues beneath the mucosal or/and/ periosteal layer, and on/or within the bone to provide retention and support for an fixed or removable dental prosthesis. A substance that is placed into or /and upon the jaw bone to support a fixed or removable dental prosthesis. GPT 8 www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com
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  18. 18. Implant No Cementum and PDL Blood supply is mainly from periosteum TOOTH Has cementum and PDL Blood supply is periodontium and periosteum www.indiandentalacademy.com
  19. 19. Unlike teeth, implants lack healing capacities. Implants do not have periodontal ligament. The barrier to the oral cavity is rather different around implants, principally because of a missing connective tissue. Natural tooth Vs implantsNatural tooth Vs implants www.indiandentalacademy.com
  20. 20. www.indiandentalacademy.com
  21. 21. HISTORICAL REVIEWHISTORICAL REVIEW www.indiandentalacademy.com
  22. 22. 500 BC – Etruscan population www.indiandentalacademy.com
  23. 23. 600 AD – Mayan population “First evidence of use of implants” www.indiandentalacademy.com
  24. 24. 1700 – John hunter → “Transplantation” Transmission of various diseases www.indiandentalacademy.com
  25. 25. 1809-Maggiolo Gold roots 1939-Strock Vitallium screw www.indiandentalacademy.com
  26. 26. 1943 - Dahl 1948 - Goldberg and Gershkoff Subperiosteal implant www.indiandentalacademy.com
  27. 27. 1960 – Linkow Blade vent implant www.indiandentalacademy.com
  28. 28. • Inflammatory reaction • Gradual bone loss • Fibrous encapsulation www.indiandentalacademy.com
  29. 29. “CONCEPT OF OSSEOINTEGRATION” Dr. Per-Ingvar Branemark Orthopaedic surgeon Professor University of Goteburg, Sweden. Threaded implant design made up of pure titanium. www.indiandentalacademy.com
  30. 30. Basic research 1952 to 1965 → 13-15 year extensive research 1965 → First clinical evidence of implant insertion “Edentulous human patient for resorbed edentulous ridge” www.indiandentalacademy.com
  31. 31. Classification of Implants : 1) Sub - periosteal implant 2) Transosteal implant 3) Endosseous implant 4) Endodontic or Diodontic implant 5) Intramucosal implant www.indiandentalacademy.com
  32. 32. Classification : Based on placement within the tissues Sub - Periosteal Implants Transosteal Implants Endosteal Implants www.indiandentalacademy.com
  33. 33. Sub Periosteal Implant : an implant that is placed beneath the periosteum of the bone. It receives it’s primary bone support by resting on it. This implant does not osseointegrate. www.indiandentalacademy.com
  34. 34. www.indiandentalacademy.com
  35. 35. Transosteal Implants : an dental implant that penetrates both cortical plates and passes through the entire thickness of the alveolar bone. www.indiandentalacademy.com
  36. 36. www.indiandentalacademy.com
  37. 37. Endosseous Implant : an implant that is present within the bone , extends into basal bone for support. Types : Screw form Cylinder form (Hollow,Solid) Blade form www.indiandentalacademy.com
  38. 38. www.indiandentalacademy.com
  39. 39. Endosseous implant 1) Blade form or Plate form 2) Root form implants Screw ( V-thread, Buttress thread, Power or square thread) Cylinder ( Hollow or Solid ) Endosseous, root form, screw type, power thread Endosseous, root form, tapered, hollow, cylindrical, www.indiandentalacademy.com
  40. 40. Depending on the materials used : a) Metallic Implants : Titanium Titanium alloy Cobalt chromium molybdenum b) Non - Metallic Implants Ceramics Carbon Depending on their reaction with bone (Meffert) a) Bioactive HA coated, CaP coated b) Bio-inert implants Metals www.indiandentalacademy.com
  41. 41. www.indiandentalacademy.com
  42. 42. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com
  44. 44. INDICATIONS : 1)Edentulous patient 2) Partially edentulous patient Conventional complete denture , removable partial denture or fixed partial denture is not totally satisfactory.www.indiandentalacademy.com
  45. 45. Orthodontic anchorage www.indiandentalacademy.com
  46. 46. Applications of Osseointegration concept in Maxillofacial prosthesis Lost his ear after oncosurgery for malignant melanoma Implants , percutaneous abutments & dental bar for retention of the prosthesis Appearance after silicone rubber prosthesis. TISSUE INTEGRATED PROSTHESIS Maxillofacial prostheses www.indiandentalacademy.com
  47. 47. Scope of osseointegrated implants 1) Prosthetic rehabilitation of missing teeth Complete edentulous maxilla and mandible rehabilitation. Removable prosthesisFixed prosthesis www.indiandentalacademy.com
  48. 48. Single tooth replacementPartial dental loss replacement www.indiandentalacademy.com
  49. 49. 2) Anchorage for the maxillofacial prosthesis Auricular Prosthesis www.indiandentalacademy.com
  50. 50. Ocular Prosthesiswww.indiandentalacademy.com
  51. 51. Nasal prosthesis www.indiandentalacademy.com
  52. 52. 3) For rehabilitation of congenital and developmental defects - Cleft palate - Ectodermal dysplasia www.indiandentalacademy.com
  53. 53. 4) Complex maxillofacial defect rehabilitation 5) Orthodontic anchorage. www.indiandentalacademy.com
  54. 54. Contraindications: Uncontrolled systemic conditions/ crippling disease. Diabetes mellitus Hypertension Steriod therapy Smoking pregnancy High dose irradiation Occlusal trauma psychiatric patients Lack of muscular co-ordination to manage oral hygiene procedureswww.indiandentalacademy.com
  55. 55. Smoking and osseointegration : • History of smoking affect the healing response in osseointegration. • Lower success rates with oral implants • Mechanism behind Vasoconstriction Reduced bone density Impaired cellular function • Mean failure rates in smoker is about twice than in non smoker.www.indiandentalacademy.com
  56. 56. Requirements: Good oral hygiene Good periodontal health Restorations done Adequate bone quality and quantity Well motivated patient www.indiandentalacademy.com
  57. 57. I ) Metals • Stainless Steel • Cobalt Chromium Molybdenum Alloys • Titanium and Its Alloys • Gold • Tantalum Biomaterials Used In Implantology: II ) Ceramics • Hydroxyapatite Coated • Bioglases • Aluminum Oxide III ) Polymers And Composites IV ) Carbons www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 59. PROSTHETIC SCREW CROWN PROSTHETIC ABUTMENT FIXTURE OR IMPLANT Generic terminology of implants Root form implants are a category of Endosseous implants that are designed to use a vertical column of bone, similar to the root of a natural tooth • Cylinder root form implants (tapered) depend on a coating to provide microscopic retention &/ or bonding to the bone • Screw root form are threaded into a bone site & have macroscopic retentive element for bone fixation www.indiandentalacademy.com
  60. 60. Components of Implants : IMPLANT BODY Implant body has 3 parts : 1) Apex region 2) Body 3) Crest module (Smooth area) Hex (external) Crest module Body of the implant Apex region Implant collar www.indiandentalacademy.com
  61. 61. Attachment mechanism : External hex : It resides on the platform Internal hex : It will extend to within the implant body www.indiandentalacademy.com
  62. 62. Functions of hex: 1) Hex basically acts as a retentive mechanism between implant body and abutment. 2) It also serves as an effective antirotation element.  Hex area is the weakest area in the entire implant body abutment connection  Screw loosenings, fracture of implant components have been noted with traditional external hex than the internal hex www.indiandentalacademy.com
  63. 63. Cover screw At the time of insertion of implant body or stage I surgery, a first stage cover is placed into the top of the implant to prevent bone , soft tissue or debris from invading the abutment connection area during healing. If it is screwed into place its termed COVER SCREW. Cover screw Healing screw First stage cover www.indiandentalacademy.com
  64. 64. Permucosal extension A trans epithelial portion known as PERMUCOSAL EXTENSION is attached as it extends the implant above the soft tissue & result in the development of permucosal seal around the implant Permucosal extension Healing abutment www.indiandentalacademy.com
  65. 65. Abutment : The abutment is the portion of the implant that supports and / or retains a prosthesis or implant superstructure. 3 main types depending on how the prosthesis or superstructure is retained to the abutment 1) Abutment for screw retention : uses screw to retain the prosthesis 2) Abutment for cement retention : uses dental cement to retain the prosthesis 3) Abutment for attachment : uses an attachment device to retain a removable prosthesis Abutments can also be  Straight  Angled www.indiandentalacademy.com
  66. 66. “The apparent direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening connective tissue”. - GPT 8 Structurally oriented definition : “Direct structural and functional connection between the ordered, living bone and the surface of a load carrying implants”. - Branemark and associates (1977) www.indiandentalacademy.com
  67. 67. Histologically : Direct anchorage of an implant by the formation of bone directly on the surface of an implant without any intervening layer of fibrous tissue. - Albrektson and Johnson (2001) www.indiandentalacademy.com
  68. 68. Clinically : Ankylosis of the implant bone interface. -Schroeder and colleagues 1976 “functional ankylosis” “It is a process where by clinically asymptomatic rigid fixation of alloplastic material is achieved and maintained in bone during functional loading” - Zarb and T Albrektson 1991 www.indiandentalacademy.com
  69. 69. Biomechanically oriented definition : “Attachment resistant to shear as well as tensile forces” - Steinmann et al (1986). www.indiandentalacademy.com
  70. 70. Endosseous osseointegrated dental implantwww.indiandentalacademy.com
  71. 71.  “ Fibrous integration as tissue to implant contact with interposition of healthy dense collagenous tissue between the implant and bone”.  “Direct bone to implant interface without any intervening layer of fibrous tissue”. FIBROINTEGRATION Vs Concept of Bony Anchorage Branemark (1969) Concept of soft tissue anchorage Linkow (1970), James (1975), Weiss (1986). OSSEOINTEGRATION www.indiandentalacademy.com
  72. 72. Fibrosseousintegration Osseointegration www.indiandentalacademy.com
  73. 73. ULTRASTRUCTURE OF OSSEOINTEGRATION Soft tissue interface Cortical bone Spongy bone www.indiandentalacademy.com
  74. 74. ITI Foundation (International Team for Oral Implantology) Big Names Best Systems • Deportter Endopore Highest Studies • Carl Misch Maestro Highest Research • Willi Schulte Friadent Highest Follow-up Latest in Hardware and Software Latest Innovations • Branemark System & ITI System www.indiandentalacademy.com
  75. 75. IJP 2004 Quality of dental implants :As of October 2003 80 companies ; 220 implant brands. Code A or Grade A: Extensive clinical documentation i.e. more than 4 prospective and /or retrospective trails. Osseotite,3i implant innovations Astra tech , Friadent, Endopore Straumann, ITI, Nobel Biocare Zimmer Code B or Grade B: With limited clinical documentation i.e. less than 4 trails, but of good methodological quality. Biohorizons, Maestro, IMTEC, Bicon, Sargonwww.indiandentalacademy.com
  76. 76. Code C or Grade C : less than 4 retrospective or prospective clinical trails, but they are of poor methodological quality. Code D or Grade D : No studies. 80 systems/companies : 10 Grade A 10 Grade B 60 Grade C & Dwww.indiandentalacademy.com
  77. 77. www.indiandentalacademy.com
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  83. 83. www.indiandentalacademy.com
  84. 84. Selecting an Implant system Gathering information Investigating a prospective systemwww.indiandentalacademy.com
  85. 85. Branemark’s Original Protocol : Tooth Extraction 6months Stage I Surgery or Implant Placement 4-6 Months Osseointegration Period Stage II Surgery or Prosthesis Placement www.indiandentalacademy.com
  86. 86. Drawbacks of Branemark’s Original Protocol • Long drawn out affair • Extremely expensive • Selection Criteria was very strict, so benefit could be passed on to very few Osseointegration Was Accepted As a Clinically Achievable,Osseointegration Was Accepted As a Clinically Achievable, Reproducible Phenomenon.Reproducible Phenomenon. Nobody Questioned the Concept of Osseointegration, but theNobody Questioned the Concept of Osseointegration, but the Protocol to Achieve the Same Was Questioned…….Protocol to Achieve the Same Was Questioned……. Implantology Moved Ahead With These Path breaking StudiesImplantology Moved Ahead With These Path breaking Studies www.indiandentalacademy.com
  87. 87. Challenges to the Branemark, Albrektsson protocol Osseointegration histological level Immobility Clinically Branemark Protocol Immediate Loading “Clean” Atmosphere Clinicians could violate the original protocol, but still achieve Osseointegration www.indiandentalacademy.com
  88. 88. Two types of design options 1) Submerged 2) Nonsubmerged protocol Submerged Protocol : A closed healing environment underneath the mucoperiosteal cover is an absolute prerequisite for osseointegration. Non- submerged Protocol : Trans gingival implants penetrating the mucosa from the time of placement Transgingival regions of all these are highly polished.www.indiandentalacademy.com
  89. 89. Changing your clinical setup into an implantlogyChanging your clinical setup into an implantlogy unitunitwww.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. www.indiandentalacademy.com
  92. 92. www.indiandentalacademy.com
  93. 93. Protocol for implant placement Meticulous initial evaluation of a potential implant patient is critical to successful treatment. Diagnosis includes : Systemic Dental evaluation. Diagnosis : www.indiandentalacademy.com
  94. 94. Preimplant medical evaluation is similar to any periodontal or oral surgery procedures. The most common systemic conditions and implications for dental implants therapy are: Smoking Diabetes Osteoporosis Age Head and neck radiotherapy Immunocompromised patients Psychological conditions. Systemic Evaluation www.indiandentalacademy.com
  95. 95. Dental Evaluation As in any other procedure, a thorough oral diagnosis must precede the dental evaluation. General Considerations: Traditional radiographic surveys such as panoramic and full mouth series are often needed. Periodontal charting and caries detection are part of the early evaluation. www.indiandentalacademy.com
  96. 96. The treatment plan should address control of diseases prior to considering implant placement. Home oral hygiene must be exquisite, and no implant treatment should be considered without full patient cooperation. www.indiandentalacademy.com
  97. 97. Arch shapes and sizes Maximum intercuspation, centric relation, occlusal interferences Anterior guidance General wear facets and other signs of Parafunctional habits Interarch relationships Adjacent teeth Esthetic evaluation Diagnostic casts and diagnostic wax-up Dental examination particularly relevant to implant therapy www.indiandentalacademy.com
  98. 98. Clinical Evaluation The clinical examination includes evaluation of tissue health, attached gingiva, and ridges. Ridge mapping A clinical procedure in which soft tissue is measured at several locations of an edentulous ridge. Measurements can be reported on a drawing or a model to estimate the width of underlying bone architecture. www.indiandentalacademy.com
  99. 99. Radiographic Diagnosis Radiographic measurements are usually initiated with traditional two-dimensional methods such as periapical or panoramic films. However, these methods do not allow for buccolingual visualization or evaluation of bone density, and further techniques may be necessary. www.indiandentalacademy.com
  100. 100. A radiographic method used to obtain cross sectional images in which the radiographic sources and film rotate around the plane of interest. Cross-sectional images of any portion of the maxilla and mandible can be obtained using linear tomography. Linear tomography www.indiandentalacademy.com
  101. 101. (CT scanning) a software assisted radiographic technique that produces an exact cross- sectional view of the mandible or maxilla. The most advanced radiographic methodology for dental implant diagnosis is computed tomography. Computed tomography www.indiandentalacademy.com
  102. 102. CT images are inherently three dimensional digital images. Typically of 512 x 512 pixels with a thickness described by the slice spacing of the imaging technique. The individual element of the CT image is called a Voxel, which has a value referred to in Hounsfield units, that describes the density of the CT image at that point. www.indiandentalacademy.com
  103. 103. CT Number or Hounsfield Units - 1000 for Air + 1000 for Dense bone + 3000 for Enamel 0 for Water www.indiandentalacademy.com
  104. 104. A CT-Scanner showing dough shaped gantry , computerized couch, microprocessor and TV monitor www.indiandentalacademy.com
  105. 105. X-ray tube Patient Detector array Both the x-ray tube and detector revolve around the patient www.indiandentalacademy.com
  106. 106. Only the X-ray tube rotates, more than 1000 detectors are fixed X-ray tube Patient Fixed detectors www.indiandentalacademy.com
  107. 107. Standard Imaging Planes Used in CT -Scanning. Axial scan would be perpendicular to the long axis of the body. Coronal section would be parallel to the long axis of the body. www.indiandentalacademy.com
  108. 108. CBVT – Cone Beam Volumetric Tomography www.indiandentalacademy.com
  109. 109. Classification of bone quality and quantity Bone volume classifications www.indiandentalacademy.com
  110. 110. www.indiandentalacademy.com
  111. 111. IMPLANT LENGTH:  Implant length is selected according to bone availability.  Measurement from the crest to a vital structure will give an approximation of bone height.  For mandibular posterior areas, it is recommended to maintain the osteotomy at least 2 mm from the nerve. CHOICE OF IMPLANT LENGTH, DIAMETER, AND POSITION www.indiandentalacademy.com
  112. 112. IMPLANT DIAMETER: Estimate the buccolingual ridge dimension prior to selecting a diameter, remembering that at least 1 mm of bone buccal and 1 mm of bone lingual of the implant must remain. For example, a 6 mm wide ridge is necessary to place a 4 mm implant. www.indiandentalacademy.com
  113. 113. IMPLANT POSITION: For posterior teeth, implant angulation should allow the implant's long axis to emerge from the center of the occlusal surface. For anterior teeth, the angulation should allow the long axis to emerge through cinguli. Implant placement should not be compromised by lack of bone width. Bone grafting prior to placement is preferable to poor placement. www.indiandentalacademy.com
  114. 114. The implant should not touch adjacent roots. Multiple implants should ideally be placed at least 3 mm apart. Multiple adjacent implants should be parallel whenever possible. www.indiandentalacademy.com
  115. 115. www.indiandentalacademy.com
  116. 116. Perforation made in the stent Palatal view of surgical template on diagnostic cast with perforation over the planned implant sites Clinical view of the surgical template in place www.indiandentalacademy.com
  117. 117. Three upper incisors are missing Removable plastic template in place to serve as a surgical template Stent was coined after an English dentist Charles R. Stent Also known as • Collumellar stent • Periodontal stent • Skin graft stent An appliance which is used to apply pressure to the soft tissues to facilitate healing and prevent cicatrisation and collapse. Surgical stent :A surgical stent is a prosthetic appliance, which helps to orient & position the implantswww.indiandentalacademy.com
  118. 118. www.indiandentalacademy.com
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  120. 120. www.indiandentalacademy.com
  121. 121. www.indiandentalacademy.com
  122. 122. www.indiandentalacademy.com
  123. 123. www.indiandentalacademy.com
  124. 124. www.indiandentalacademy.com
  125. 125. Steps involved in implant placementSteps involved in implant placement FIRST STAGE SURGERYFIRST STAGE SURGERY 1 2 3 4 www.indiandentalacademy.com
  126. 126. 5 6 7 8www.indiandentalacademy.com
  127. 127. 9 10 11 12www.indiandentalacademy.com
  128. 128. 13 14 15 16www.indiandentalacademy.com
  129. 129. 17 18 19 20www.indiandentalacademy.com
  130. 130. 21 22 23 24www.indiandentalacademy.com
  131. 131. 25 26 27 www.indiandentalacademy.com
  132. 132. 28 29 30www.indiandentalacademy.com
  133. 133. SECOND STAGE SURGERY www.indiandentalacademy.com
  134. 134. 1 2 3 4www.indiandentalacademy.com
  135. 135. 5 6 7 8www.indiandentalacademy.com
  136. 136. 9 10 11 12www.indiandentalacademy.com
  137. 137. 13 14 15 16www.indiandentalacademy.com
  138. 138. 17 18 19 20www.indiandentalacademy.com
  139. 139. 21 22 23www.indiandentalacademy.com
  140. 140. IMPLANT MAINTENANCE www.indiandentalacademy.com
  141. 141. www.indiandentalacademy.com
  142. 142. www.indiandentalacademy.com
  143. 143. 1.Osseointegration in clinical dentistry – Branemark, Zarb, Albrektsson 2.Osseointegration and occlusal rehabilitation – Sumiya Hobo 3.Contemporary Implant Dentistry – Carl E.Misch 4.Endosseous implants for Maxillofacial reconstruction – Block and Kent 5.Implants in Dentistry –Block and Kent 6.Dental and Maxillofacial Implantology – John. A. Hobkrik, Roger Watson www.indiandentalacademy.com
  144. 144. 7.Endosseous Implant : Scientific and Clinical Aspects – George Watzak 8.Optimal Implant Positioning and Soft Tissue management – Patrik Pallaci 9.Osseointegration in craniofacial reconstruction- T. Albrektssson. 10.Osseointegration in dentistry : an introduction : Philip Worthington, Brein. R. Lang, W.E. Lavelle. www.indiandentalacademy.com
  145. 145. Schroeder et al.,(1981).The reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. Journal of Maxillofacial Surgery 9,15-25. Adell et al.,(1981). A 15 year study of osseointegrated implants in the treatment of edentulous jaw. International journal of Oral Surgery 6,387-399. Zarb & Symington (1983).Osseointegrated dental implants: preliminary report on a replication study. Journal of prosthetic dentistry 50,271-279. Albrektsson et al.,(1986).The long-term efficacy of currently used dental implants: a review and proposed criteria for success. International journal of Oral and Maxillofacial Implants 1,11-25. www.indiandentalacademy.com
  146. 146. Johansson & Albrektsson. (1987) Integration of screw implants in the rabbit. A 1- year follow-up of removal of titanium implants. International journal of 0ral and Maxillofacial Implants 2,69-75. Zarb & Albrektsson.(1991).Osseointegration –A-requiem for the periodontal ligament ? Editorial. International Journal of Periodontology and Restorative Dentistry 11,88-91. Albrektsson & Sennerby.(1991) State of the art in Oral implants. Journal of clinical periodontology 18,474-481. Wennerberg & Albrektsson.(1993) Design and Surface Characteristics of 13 commercially available oral implant systems. International Journal of Oral and Maxillofacial Implants 8,622-23 www.indiandentalacademy.com
  147. 147. For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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