OSSEOINTEGRATION -- DENTAL IMPLANTS

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy....
CONTENTS:
•
•
•
•
•
•
•
•
•
•
•

INTRODUCTION.
DEFINITION.
HISTORICAL REVIEW.
NORMAL BONE STRUCTURE AND PHYSIOLOGY.
BIOLOG...
INTRODUCTION
•

The ideal goal of modern dentistry is to restore the normal function,
form, and esthetics of oral structur...
DEFINITION
•

“Direct

structural and functional connection between

ordered, living bone and surface of a load carrying
i...
HISTORICAL REVIEW

•

Dr. Per-Ingvar Branemark- 1956

•

Professor at the institute for Applied Biotechnology, University ...
•

Initial concept of osseointegration stemmed from vital
microscopic studies of microcirculation in bone repair
mechanism...
EXPERIMENTS ON DOGS TIBIA

Dog tibia with titanium stabilizer

Reconstructed tibia 3 years latter

www.indiandentalacademy...
EXPERIMENTS ON DOGS MANDIBLE

Segmental defect of dog mandible
reconstructed with titanium plate

Reconstructed area 6 mon...
Formation of bone around implants

Indentation of implant on bone

Scanning electron micrograph after 9 months.
www.indian...
BONE PHYSIOLOGY AND STRUCTURE

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Bone is Continuously Remodeling

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BIOLOGICAL PROCESS OFOSSEOINTEGRATION

• OSTEOPHYLIC PHASE.
• OSTEOCONDUCTIVE PHASE.
• OSTEOADAPTIVE PHASE.

www.indianden...
OSTEOPHYLIC PHASE:
•
•
•
•
•

Blood clot formation.
Inflammatory cells infiltration.
Neovascularisation – 3rd day.
Ossific...
OSTEOCONDUCTIVE PHASE:
• Woven bone – foot plate.
• Lamellar bone formation.
• Lasts for 4 months.

osteoblasts

Neovascul...
OSTEO ADAPTIVEPHASE:
• A balanced remodeling
occurred.
Remodeling bone
• The foot plate/ woven
bone thickened in
response ...
www.indiandentalacademy.com
BONE FORMATION AROUND IMPLANT:
• OSTEOGENESIS: Formation of new bone from
osteocompetent cells.
• OSTEOCONDUCTION: Formati...
BIOLOGICAL ATTACHMENT OSSEOINTEGRATION
GINGIVA-TITANIUM OXIDE CONTACT ZONE.

Hemidesmosome like structures anchoring the e...
SUBGINGIVAL CONNECTIVE TISSUE – TITANIUM CONTACT ZONE.
fibroblast

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INTERFACE BETWEEN CORTICAL BONE AND TITANIUM.
Osteocyte

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INTERFACE BETWEEN CANCELLOUS BONE AND IMPLANT

Osteoblastic processes
Fibroblastic processes

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THEORIES OF OSSEOINTEGRATION
• BIOMECHANICAL BOND
• Branemark, Zarb, Albrektsson, 1985.

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VAN DER WALLS BONDING

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HYDROGEN BONDING

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CHEMICAL BOND

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CHEMICAL PROCESSES THAT CAN TAKE PLACE AT THE INTERFACE AT A MOLECULAR SCALE
www.indiandentalacademy.com
CHEMICAL BOND-BIOINTEGRATION
• Sul etal – 2002.
• Electrostatic ion bonding of calcium ions with
polyanioinic molecules of...
The neuromuscular system as it relates to
the
osseointegrated implant
•

A fixture site does not have periodontal ligament...
FACTORS INFLUENCING THE
OSSEOINTEGRATION
•
•
•
•
•
•
•
•
•

BIOCOMPATIBILITY
BIOMECHANICS.
IMPLANT DESIGN.
SURFACE ROUGHNE...
BIOCOMPATIBILITY
•

Biocompatibility has been defined as the
capacity of a material to exist in harmony
with the surroundi...
BIOMECHANICS IN IMPLANTS
•

Compressive forces attempt to
push masses towards each other.

•

Tensile forces pull objects ...
IMPLANT DESIGN
•

A smooth cylinder implant body
results in essentially a shear type
of force at the implant-to-bone
inter...
Threaded implants:
•
•
•

•

More surface area.
Maximum initial bone contact.
Facilitate dissipation of
stresses at bone -...
THREAD PITCH:
• The number of threads per
unit length.
• The finer the pitch, the
more threads on implant
body for a given...
THREAD SHAPE:
• The shear force on a Vthread face is about 10
times greater than the
shear force on a square
thread.

www....
THREAD DEPTH:
• Is the distance between the
minor diameter and major
diameter of implant.
• The deeper the thread
depth, f...
IMPLANT TAPER:
• A smooth sided tapered implant allows for a component of
compressive load to be delivered to the bone-to-...
APICAL DESIGN OF IMPLANT:
•

Round cross cross sections at
apex of implant do not resist
torsional or shear forces when
ab...
IMPLANT WIDTH:
• Most implants falls with in the range of 3.5 to 6 mm.
• Increased implant width adequately increases the ...
LENGTH OF IMPLANT:
• Most common lengths are
between 8 to 15 mm.
• As the length of implant
increases, the total surface
a...
CREST MODULE DESIGN:
• A smooth parallel, sided crest module
will result in shear stresses.
• An angled crest module of mo...
SURFACE ROUGHNESS OF IMPLANT
•

Moderately rough implants
developed the best bone fixation –
Wennerberg, 1996.

www.indian...
IMPLANT SURFACE MODIFICATION
NEED FOR SURFACE MODIFICATION:
• To increase surface area.
• To remove surface contaminants.
...
TECHNIQUES OF SURFACE MODICATION OF TITANIUM:
GRIT BLASTING:
• 250 µm diameter Al₂O₃ particles for 6 seconds at o.8
Mpa pr...
ANODIC OXIDATION:
• An electrochemical method of treatment.
• The sample is placed in an electrolyte bath, and a
potential...
PLASMA OXIDATION:
• An oxygen plasma is used instead of liquid
electrolyte.
• Plasma oxidation is a cleaner method than an...
HYDROXYAPETITE COATING:
Advantages:
• Faster healing bone interface.
• Enhances gap healing.
• Stronger interface.
• Less ...
CONTAMINATION:

www.indiandentalacademy.com
HEAT PRODUCTION DURING
OSTEOTOMY:
•

Heating of bone to a temperature in
excess of 47°C during implant surgery
can result ...
LOADING
• Minimum integration time:
Region of implant
time

Minimum

Anterior mandible

–

3 months

Posterior mandible

–...
PATIENT FACTORS:
•
•
•
•
•
•
•
•
•
•
•
•

Age.
Compromised oral hygiene.
Heavy smoking.
Anemia.
Vitamin-c deficiency.
Unco...
BONE DENSITY:
CLASSIFICATION: Misch in 1988.
• D1 bone is primarily dense cortical bone.
• D2 dense to thick cortical bone...
• Increased bone density – provides mechanical
immobilization of implant and also permits
distribution and transmission of...
REVIEW OF LITERATURE

www.indiandentalacademy.com
IJOMI 2007;22:533-551.
•T-CAM, Tetra cell adhesion molecules enhanced the
differentiation of osteoblast like cells.
•T-CAM...
•Phosphated titanium has the potential to accelerate implant
osseointegration by increased TGF-b1 production.
•EMD did not...
• Three different surfaces were evaluated. A machined
surface (Ti-M), was consider as control.
• The second surface was ac...
FUTURE CONCEPTS OF OSSEOINTEGRATION

www.indiandentalacademy.com
Combining the concept of biomimetics and dental implants may change the world
of implant dentistry as we know it today.
BM...
Research and development in this field will require attention to three main
aspects.
1.Selecting the appropriate surface t...
INTEGRINS
– Receptor proteins
which permit
cells to bind &
respond to the
extracellular
matrix.

www.indiandentalacademy.c...
BENEFITS
• Same-Day Teeth.
• Eliminates discomfort during a long
healing period.
• Fixtures are inserted in the
morning an...
OSSEOPERCEPTION :
The interaction between the osseointegrated
fixture bone tissue, receptor systems and
nervous system has...
CONCLUSION:

# THOROUGH UNDERSTANDING AND APPLICATION OF
FACTORS AFFECTING THE OSSEOINTEGRATION AND
BIOLOGICAL PROCESS OF ...
REFERENCES
• Dental implants in Prosthodontics
– Carl E.Misch.
• Textbook of Dental Implants
– Weiss.
• Textbook of Period...
ACKNOWLEDGEMENT
•
•
•
•
•
•
•
•

Dr. L. Krishna Prasad – Professor & Head.
Dr. P. Srinivas chakravarthy
Dr. K. Naga Neelim...
THANK U
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
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Osseointegration - dental implants training by Indian dental academy /certified fixed orthodontic courses by Indian dental academy

  1. 1. OSSEOINTEGRATION -- DENTAL IMPLANTS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. CONTENTS: • • • • • • • • • • • INTRODUCTION. DEFINITION. HISTORICAL REVIEW. NORMAL BONE STRUCTURE AND PHYSIOLOGY. BIOLOGICAL PROCESS OF OSSEOINTEGRATION. BIOLOGICAL ATTACHMENT OF OSSEOINTEGRATION. THERIES OF OSSEOINTEGRATION. FACTORS INFLUENCING OSSEOINTEGRATION. REVIEW OF LITERATURE. FUTURE CONCEPTS OF OSSEOINTEGRATION. CONCLUSION. www.indiandentalacademy.com
  3. 3. INTRODUCTION • The ideal goal of modern dentistry is to restore the normal function, form, and esthetics of oral structures. • Implant dentistry is unique because of its ability to achieve this goal. • The word osseointegration consists of “OS” the Latin word for bone and “integration” derived from Latin word meaning the state of being combined into a complete whole. www.indiandentalacademy.com
  4. 4. DEFINITION • “Direct structural and functional connection between ordered, living bone and surface of a load carrying implant”. -- Brane mark 1956. • A time dependent healing process whereby clinically asymptomatic rigid fixation of alloplastic materials is achieved, and maintained, in bone during functional www.indiandentalacademy.com loading.-- Zarb 1991.
  5. 5. HISTORICAL REVIEW • Dr. Per-Ingvar Branemark- 1956 • Professor at the institute for Applied Biotechnology, University of Goteborg. www.indiandentalacademy.com
  6. 6. • Initial concept of osseointegration stemmed from vital microscopic studies of microcirculation in bone repair mechanisms. Titanium chamber surgically inserted into tibia of rabbit www.indiandentalacademy.com
  7. 7. EXPERIMENTS ON DOGS TIBIA Dog tibia with titanium stabilizer Reconstructed tibia 3 years latter www.indiandentalacademy.com Integrated titanium screws
  8. 8. EXPERIMENTS ON DOGS MANDIBLE Segmental defect of dog mandible reconstructed with titanium plate Reconstructed area 6 months later www.indiandentalacademy.com
  9. 9. Formation of bone around implants Indentation of implant on bone Scanning electron micrograph after 9 months. www.indiandentalacademy.com
  10. 10. BONE PHYSIOLOGY AND STRUCTURE www.indiandentalacademy.com
  11. 11. Bone is Continuously Remodeling www.indiandentalacademy.com
  12. 12. BIOLOGICAL PROCESS OFOSSEOINTEGRATION • OSTEOPHYLIC PHASE. • OSTEOCONDUCTIVE PHASE. • OSTEOADAPTIVE PHASE. www.indiandentalacademy.com
  13. 13. OSTEOPHYLIC PHASE: • • • • • Blood clot formation. Inflammatory cells infiltration. Neovascularisation – 3rd day. Ossification begins during first week. This phase lasts about one month. www.indiandentalacademy.com
  14. 14. OSTEOCONDUCTIVE PHASE: • Woven bone – foot plate. • Lamellar bone formation. • Lasts for 4 months. osteoblasts Neovascularization Callus www.indiandentalacademy.com
  15. 15. OSTEO ADAPTIVEPHASE: • A balanced remodeling occurred. Remodeling bone • The foot plate/ woven bone thickened in response to the load transmitted through the implant. • Some reorientation of vascular pattern may be seen. www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com
  17. 17. BONE FORMATION AROUND IMPLANT: • OSTEOGENESIS: Formation of new bone from osteocompetent cells. • OSTEOCONDUCTION: Formation of bone along scaffold from hosts osteocompetent cells. • OSTEOINDUCTION: Formation of new bone from the differentiation and stimulation of mesenchymal cells by bone inductive proteins. www.indiandentalacademy.com
  18. 18. BIOLOGICAL ATTACHMENT OSSEOINTEGRATION GINGIVA-TITANIUM OXIDE CONTACT ZONE. Hemidesmosome like structures anchoring the epithelial cells to the implant surface www.indiandentalacademy.com
  19. 19. SUBGINGIVAL CONNECTIVE TISSUE – TITANIUM CONTACT ZONE. fibroblast www.indiandentalacademy.com
  20. 20. INTERFACE BETWEEN CORTICAL BONE AND TITANIUM. Osteocyte www.indiandentalacademy.com
  21. 21. INTERFACE BETWEEN CANCELLOUS BONE AND IMPLANT Osteoblastic processes Fibroblastic processes www.indiandentalacademy.com
  22. 22. THEORIES OF OSSEOINTEGRATION • BIOMECHANICAL BOND • Branemark, Zarb, Albrektsson, 1985. www.indiandentalacademy.com
  23. 23. VAN DER WALLS BONDING www.indiandentalacademy.com
  24. 24. HYDROGEN BONDING www.indiandentalacademy.com
  25. 25. CHEMICAL BOND www.indiandentalacademy.com
  26. 26. CHEMICAL PROCESSES THAT CAN TAKE PLACE AT THE INTERFACE AT A MOLECULAR SCALE www.indiandentalacademy.com
  27. 27. CHEMICAL BOND-BIOINTEGRATION • Sul etal – 2002. • Electrostatic ion bonding of calcium ions with polyanioinic molecules of bone matrix proteins will occur. • The calcium cations will stimulate particular surface receptors and trigger further recruitment of osteoprogenitor cells and osteoblasts through calcium signaling pathway. www.indiandentalacademy.com
  28. 28. The neuromuscular system as it relates to the osseointegrated implant • A fixture site does not have periodontal ligament but has nerve endings located near the fixture, sensing pain and temperature. • As the periodontal ligament is lost the fixture remains with reduce amount of receptors. • Impulses from the fixture sites are transmitted through nucleus of trigeminal nerve. www.indiandentalacademy.com
  29. 29. FACTORS INFLUENCING THE OSSEOINTEGRATION • • • • • • • • • BIOCOMPATIBILITY BIOMECHANICS. IMPLANT DESIGN. SURFACE ROUGHNESS OF IMPLANT. SURFACE MODIFICATION OF IMPLANT. HEAT PRODUCTION DURING OSTEOTOMY. CONTAMINATION. PRIMARY STABILITY OR INITIAL STABILITY LOADING www.indiandentalacademy.com
  30. 30. BIOCOMPATIBILITY • Biocompatibility has been defined as the capacity of a material to exist in harmony with the surrounding biologic environment; not having toxic or injurious effects on biologic functions. • Key factors that influence the benefits and maintenance of biocompatibility: • Corrosion resistance. • Cytotoxicity of corrosion products. • Metal contamination. www.indiandentalacademy.com
  31. 31. BIOMECHANICS IN IMPLANTS • Compressive forces attempt to push masses towards each other. • Tensile forces pull objects apart. • Shear forces on implants cause sliding. www.indiandentalacademy.com
  32. 32. IMPLANT DESIGN • A smooth cylinder implant body results in essentially a shear type of force at the implant-to-bone interface. www.indiandentalacademy.com
  33. 33. Threaded implants: • • • • More surface area. Maximum initial bone contact. Facilitate dissipation of stresses at bone -implant interface. Rigidly fixed initially to limit micro movement during healing. www.indiandentalacademy.com
  34. 34. THREAD PITCH: • The number of threads per unit length. • The finer the pitch, the more threads on implant body for a given unit length. • The greater the number of threads, the greater the functional surface area. www.indiandentalacademy.com
  35. 35. THREAD SHAPE: • The shear force on a Vthread face is about 10 times greater than the shear force on a square thread. www.indiandentalacademy.com
  36. 36. THREAD DEPTH: • Is the distance between the minor diameter and major diameter of implant. • The deeper the thread depth, functional surface of the implant body. www.indiandentalacademy.com
  37. 37. IMPLANT TAPER: • A smooth sided tapered implant allows for a component of compressive load to be delivered to the bone-to-implant interface, depending on degree of taper. • The larger the taper, the greater the component of compressive load delivered to the interface. • The amount of taper cannot be greater than 30°. • Tapering of threaded implant has no advantage. www.indiandentalacademy.com
  38. 38. APICAL DESIGN OF IMPLANT: • Round cross cross sections at apex of implant do not resist torsional or shear forces when abutment screws tightened. • As a result, an anti rotational features are incorporated, usually in the apical region of implant body, with a hole or vent being the most common design. • Another antirotational features are flat sides or grooves at apical region. www.indiandentalacademy.com
  39. 39. IMPLANT WIDTH: • Most implants falls with in the range of 3.5 to 6 mm. • Increased implant width adequately increases the area over which occlusal forces may be dissipated. www.indiandentalacademy.com
  40. 40. LENGTH OF IMPLANT: • Most common lengths are between 8 to 15 mm. • As the length of implant increases, the total surface area increases. • Within anatomical limitation it is good practice to use the longest implant. www.indiandentalacademy.com
  41. 41. CREST MODULE DESIGN: • A smooth parallel, sided crest module will result in shear stresses. • An angled crest module of more than 20° will impose beneficial compressive component. • Crest module of an implant should be slightly larger than the outer thread diameter. • Thus the crest module seats fully over the implant body osteotomy, providing a deterrent for ingress of bacteria. www.indiandentalacademy.com
  42. 42. SURFACE ROUGHNESS OF IMPLANT • Moderately rough implants developed the best bone fixation – Wennerberg, 1996. www.indiandentalacademy.com
  43. 43. IMPLANT SURFACE MODIFICATION NEED FOR SURFACE MODIFICATION: • To increase surface area. • To remove surface contaminants. • To bring better bonding. • To increase surface roughness of metal. • To increase corrosion resistance of metal. • To make the metal more passive. www.indiandentalacademy.com
  44. 44. TECHNIQUES OF SURFACE MODICATION OF TITANIUM: GRIT BLASTING: • 250 µm diameter Al₂O₃ particles for 6 seconds at o.8 Mpa pressure. • It provides a defined roughness. • Micro-retentive surface pores are formed ACID ITCHING: • Done in a solution of Hcl at 40⁰c. • The resulting surface textures, ranging in dimension from 1µm to 50µm micro retentive pits. www.indiandentalacademy.com
  45. 45. ANODIC OXIDATION: • An electrochemical method of treatment. • The sample is placed in an electrolyte bath, and a potential is applied, a current will flow through the electrolyte due to ion transport. • The transport of oxygen ions through the electrolyte builds up a passivating oxide layer on the surface of sample. www.indiandentalacademy.com
  46. 46. PLASMA OXIDATION: • An oxygen plasma is used instead of liquid electrolyte. • Plasma oxidation is a cleaner method than anodic oxidation. • Increased surface cleanliness usually results in an increase in surface energy. • Increases surface area of bone-to-implant interface. • Stimulate osteogenesis. • Resist shear forces and improve load transfer. www.indiandentalacademy.com
  47. 47. HYDROXYAPETITE COATING: Advantages: • Faster healing bone interface. • Enhances gap healing. • Stronger interface. • Less corrosion of metal. Disadvantages: • Flaking, cracking on insertion. • Increased plaque retention when above bone. • Increased bacteria and nidus for infection. • Increased cost. www.indiandentalacademy.com
  48. 48. CONTAMINATION: www.indiandentalacademy.com
  49. 49. HEAT PRODUCTION DURING OSTEOTOMY: • Heating of bone to a temperature in excess of 47°C during implant surgery can result in cell death and denaturation of collagen. • As a result, osseointegration may not occur, instead the implant becomes surrounded by a fibrous capsule. www.indiandentalacademy.com
  50. 50. LOADING • Minimum integration time: Region of implant time Minimum Anterior mandible – 3 months Posterior mandible – 4 months Anterior maxilla – 6 months Posterior maxillary – 6 months Bone graft – 6-9 mon www.indiandentalacademy.com
  51. 51. PATIENT FACTORS: • • • • • • • • • • • • Age. Compromised oral hygiene. Heavy smoking. Anemia. Vitamin-c deficiency. Uncontrolled periodontal disease. Psychological problem. Uncontrolled diabetes. Radiation treatment. Chemotherapy. Bone density. Available bone www.indiandentalacademy.com
  52. 52. BONE DENSITY: CLASSIFICATION: Misch in 1988. • D1 bone is primarily dense cortical bone. • D2 dense to thick cortical bone on the crest and coarse trabecular bone underneath. • D3 bone has thinner porous cortical crest and fine trabecular bone within. • D4 bone has almost no crestal cortical bone. www.indiandentalacademy.com
  53. 53. • Increased bone density – provides mechanical immobilization of implant and also permits distribution and transmission of stresses. www.indiandentalacademy.com
  54. 54. REVIEW OF LITERATURE www.indiandentalacademy.com
  55. 55. IJOMI 2007;22:533-551. •T-CAM, Tetra cell adhesion molecules enhanced the differentiation of osteoblast like cells. •T-CAM coating significantly enhanced the peri implant bone formation in rabbit femur. www.indiandentalacademy.com
  56. 56. •Phosphated titanium has the potential to accelerate implant osseointegration by increased TGF-b1 production. •EMD did not accelerate osteoblast function www.indiandentalacademy.com
  57. 57. • Three different surfaces were evaluated. A machined surface (Ti-M), was consider as control. • The second surface was acid itched Ti-AE. • Third surface was prepared by exposing Ti-AE to NaOH solution. • Third surface exhibited greater efficiency for enhancing cell differentiation, and in turn, may speed up the process of osseointegration www.indiandentalacademy.com
  58. 58. FUTURE CONCEPTS OF OSSEOINTEGRATION www.indiandentalacademy.com
  59. 59. Combining the concept of biomimetics and dental implants may change the world of implant dentistry as we know it today. BMP’s may act as growth and differentiation factors and as chemotactic agents. They stimulate angiogenesis, migration, proliferation and differentiation of stem cells from the surrounding mesenchymal tissues into bone forming cells in an area of injury. Coating implants with BMP’s may also accelerate initial healing time during integration of the dental implant, thereby reducing overall treatment times and improving overall success rate. www.indiandentalacademy.com
  60. 60. Research and development in this field will require attention to three main aspects. 1.Selecting the appropriate surface texture. 2.Developing efficient carrier vehicles or surface precoating agents for initial retention of the biomimetic substances and their controlled release. 3. Identifying appropriate biomimetic agents. www.indiandentalacademy.com
  61. 61. INTEGRINS – Receptor proteins which permit cells to bind & respond to the extracellular matrix. www.indiandentalacademy.com
  62. 62. BENEFITS • Same-Day Teeth. • Eliminates discomfort during a long healing period. • Fixtures are inserted in the morning and the final prosthesis is anchored in the afternoon. • No rejection www.indiandentalacademy.com
  63. 63. OSSEOPERCEPTION : The interaction between the osseointegrated fixture bone tissue, receptor systems and nervous system has to be studied. www.indiandentalacademy.com
  64. 64. CONCLUSION: # THOROUGH UNDERSTANDING AND APPLICATION OF FACTORS AFFECTING THE OSSEOINTEGRATION AND BIOLOGICAL PROCESS OF OSSEOINTEGRATION IN CLINICAL PRACTICE IS THE KEY FACTOR FOR SUCCESS.# www.indiandentalacademy.com
  65. 65. REFERENCES • Dental implants in Prosthodontics – Carl E.Misch. • Textbook of Dental Implants – Weiss. • Textbook of Periodontology – Langden. • Textbook of implantology -- Branemark. www.indiandentalacademy.com
  66. 66. ACKNOWLEDGEMENT • • • • • • • • Dr. L. Krishna Prasad – Professor & Head. Dr. P. Srinivas chakravarthy Dr. K. Naga Neelima Devi Dr. M. Sridhar Dr. Suprakash Dr. Ram Kumar. Dr. Sumanth Krishna. Dr. Raja Satish. www.indiandentalacademy.com
  67. 67. THANK U Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

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