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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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  • Biotolerant – not necessarily rejected when implanted into living tissue, but are surrounded by a fibrous layer in the form of capsule .bioinert – allows close apposition of bone on their surface ,leading to contact osteogenisis . bioactive –allows formation of new bone which is chemically bonded. <br />

Ossntgrtn  / orthodontic straight wire technique Ossntgrtn / orthodontic straight wire technique Presentation Transcript

  • GOOD MORNING GOOD MORNING INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • OSSEOINTEGRATION www.indiandentalacademy.com
  • CONTENTS 1.Introduction 2. Historical review 3. Foreign body reaction 4. Theories of osseointegration 5. Stages of osseointegration 6. Ultrastructure 7. Factors influencing osseointegration 8. Success criteria 9. Methods of evaluation 10.Risk factors 11. Scope of osseointegration in dentistry 12. Conclusion www.indiandentalacademy.com
  • Tissue Integration at implant interface INTRODUCTION www.indiandentalacademy.com
  • www.indiandentalacademy.com
  • DEFINITION - “OS” ( Latin ) bone - “integration” (Latin ) meaning the state of being combined into a complete whole. www.indiandentalacademy.com
  • Osseointegration is defined as a direct bone anchorage to an implant body which can provide a foundation to support a prosthesis ; it has the ability to transmit occlusal forces directly to bone (Alberktsson et al.,1981;Branenmark,1983 ; Carlson ,et al.,1986) Osseointegration as defined by Branemark, denotes at least some direct contact of living bone with the surface of an implant at the light microscopic level of magnification. www.indiandentalacademy.com
  • • American Academy of Implant Dentistry defined it as “Contact established without interposition of non bone tissue between normal remodeled bone and on implant entailing a sustained transfer and distribution of load from the implant to and within bone tissue”. www.indiandentalacademy.com
  • • GPT 8 : The apparent direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening connective tissue. www.indiandentalacademy.com
  • • Rigid fixation is a clinical term that means the absence of observed clinical mobility. It is the clinical aspect of the microscopic bone contact with an implant & is the absence of mobility with 1 to 500 gms force applied in a vertical or horizontal direction. www.indiandentalacademy.com
  • • HISTORICAL REVIEW Dr. Per-Ingvar Branemark Professor at the institute for Applied Biotechnology, University of Goteborg, Sweden. www.indiandentalacademy.com
  • Initial concept of osseointegration -vital microscopic studies of microcirculation in bone repair mechanisms. -Titanium chamber was surgically inserted into the tibia of a rabbit. www.indiandentalacademy.com
  • • 1952 - Branemark implant system • 1965 - the treatment of first edentulous patient • 1973- Cameron et al. - bone may grow on the surface of a biocompatible material. This only happens if movement between the implant and adjacent bone is prevented until osteogenesis is complete. •   www.indiandentalacademy.com
  • • 1977 - first clinical report published • 1982 - Toronto meeting on osseointegration • Schroeder (Switzerland) – 1970’s - first to demonstrate osseointegration www.indiandentalacademy.com
  • • Skalak in 1983 –mere bone growth into irregularities of implant without any true functional connection is sufficient to carry load • Albrektsson et al. (1981) (1) The biocompatibility (2) Design (3) Surface conditions of the implant, (4) The status of the host bed, (5) The surgical technique at insertion, and (6) The loading conditions applied afterwards. www.indiandentalacademy.com
  • FOREIGN BODY REACTION foreign body Organization Ag-Ab rxn not with implants www.indiandentalacademy.com
  • THEORIES OF OSSEOINTEGRATION LINKOW (1970) BRANEMARK JAMES (1975) WEISS (1986) FIBRO- OSSEOUS OSSEO- INTEGRATION www.indiandentalacademy.com
  • 1. FIBRO-OSSEOUS INTEGRATION “tissue to implant contact- with healthy dense collagenous tissue between the implant and the bone” The fibers … www.indiandentalacademy.com
  • 2. OSSEO-INTEGRATION direct connection b/w living bone & implant at light microscopic level Meffert, et all. 1987 Adaptive Biointegration osseointegration www.indiandentalacademy.com
  • Adaptive osseointegration – has osseous tissue approximating the surface of the implant without apparent soft tissue interface at the light microscope level Biointegration is a direct biochemical bone surface attachment confirmed at the electron microscopic level www.indiandentalacademy.com
  • Contact osteogenesis vs distance osteogenesis : Osborn and Newesley (1980) Distance osteogenesis Osteogenic cells line the old bone surface. The blood supply to these cells is between the cells and the implant. Hence the bone is laid down on the old bone surface itself. www.indiandentalacademy.com
  • • Osteogenic cells are first recruited to the implant surface. The blood supply is between the cells and old bone, hence new (de novo) bone is laid down. Contact osteogenesis www.indiandentalacademy.com
  • REQUIREMENTS FOR OSSEOINTEGRATION • 1. Adequate cells www.indiandentalacademy.com
  • • 2. Adequate stimulus i) dying cells chemical signals undiff. mesenchymal cells ii) Matrix molecules( injured bone) + u m c www.indiandentalacademy.com
  • • iii) peizoelectric signals – movt. of fracture ends www.indiandentalacademy.com
  • STAGES OF OSSEOINTEGRATION www.indiandentalacademy.com
  • 11. Osteophytic phase ( 1 month) www.indiandentalacademy.com
  • • Granulation tissue www.indiandentalacademy.com
  • • Procallus www.indiandentalacademy.com
  • • 2. Osteoconductive phase Woven bone www.indiandentalacademy.com
  • Lamellar bone www.indiandentalacademy.com
  • Woven Lamellarcellularity rate of formation mineral content Collagen fibres strength Resistance functional load implant www.indiandentalacademy.com
  • 3. Osteoadaptive phase remodelling www.indiandentalacademy.com
  • • CREEPING SUBSTITUTION ( cortical bone repair) vessels penetrate the necrotic border osteoclasts resorb necrotic b.(bone multicellular units) osteoblasts form new bone around vessel www.indiandentalacademy.com
  • ULTRASTRUCTURALULTRASTRUCTURAL LEVELLEVEL soft tissue cortical bone cancellous boneu www.indiandentalacademy.com
  • Electron microscopically 20-200nm www.indiandentalacademy.com
  • • Intermolecular forces • Bio-mechanical bond • Interactions are electrostatic • Oxide layer is highly polar and negatively charged thus, it provides a strongly attractive alternative to water for the charged bodies ( Ca++ & PO4-) www.indiandentalacademy.com
  • Factors influencing osseointegration Loading conditio n ALBREKTSON www.indiandentalacademy.com
  • WORTHINGTON www.indiandentalacademy.com
  • I. PRE- OPERATIVE HOST FACTORS www.indiandentalacademy.com
  • I. GENERAL HOST FACTORS Sex of pt. Bone metabolic diseases Tobacco smoking Malabsorption syndromes Hormonal diseases Coagulation disorders www.indiandentalacademy.com
  • II . LOCAL HOST TISSUE CONDITIONS 1.Local bone quality and quantity –Initial stability 2.Local anatomy – max. tuberosity – not fav. canine,zygomatic , pterygoid areas anterior mandible- fav. 3.Degree of resorption 4. Congenital defects 5. irradiation bone- healing depressed www.indiandentalacademy.com
  • BONE QUALITY - bone density, anatomy and volume • Bone volume does not by itself influence osseointegration, but is an important determinant of implant placement www.indiandentalacademy.com
  • LIKHOM AND ZARB CLASSIFICATION 1985 Class I : Jaw consist almost exclusively of homogeneous compact bone Class II : Thick compact bone surrounds highly trabecular core Class III : Thin cortical bone surrounds highly trabecular core Class IV : Thin cortical bone surrounds loose, spongy core Bone density www.indiandentalacademy.com
  • • MISCH CLASSIFICATION 1988 D1 D2 D3 D4 www.indiandentalacademy.com
  • Bone anatomy Branemark system (5 year documentation) Mandible – 95% success Maxilla – 85-90% success Aden et al (1981) – 10% greater success rate in anterior mandible compared to anterior maxilla. Schnitman et al (1988) – lower success rate in posterior compared to anterior mandible - posterior maxilla higher failure rates.www.indiandentalacademy.com
  • According to Branemark and Misch D1 and D2 bone → initial stability / better osseointegration D3 and D4 → poor prognosis Selection of implant D1 and D2 – conventional threaded implants D3 and D4 – HA coated or Titanium plasma coated implants www.indiandentalacademy.com
  • II. PERI-OPERATIVE FACTORS www.indiandentalacademy.com
  • 1. Implant biocompatability ZONES Ti HA Ti6Al4V Al2O3 Cu Ag www.indiandentalacademy.com
  • MetalsMetals CeramicsCeramics PolymersPolymers BiotolerantBiotolerant GoldGold PolyethylenePolyethylene Cobalt-Cobalt- chromiumchromium alloysalloys PolyamidePolyamide Stainless steelStainless steel PolymethylmethaPolymethylmetha crylatecrylate ZirconiumZirconium PolytetrafluoroetPolytetrafluoroet hylenehylene NiobiumNiobium PolyurethanePolyurethane TantalumTantalum BioinertBioinert CommerciallyCommercially pure titaniumpure titanium AluminumAluminum oxideoxide Titanium alloyTitanium alloy (Ti-6Al-4V)(Ti-6Al-4V) ZirconiumZirconium oxideoxide BioactiveBioactive HydroxyapatiteHydroxyapatite TricalciumTricalcium phosphatephosphate CalciumCalcium pyrophosphatepyrophosphate www.indiandentalacademy.com
  • METALS Commercially pure titanium (CPTi) : 99.75% Most biocompatible material Adherent, self passivating titanium dioxide (TiO2/ TiO) layer. (50-100A) (10A0 within seconds, 100A0 within a minute.) Steinman (1988) referred this layer as Biologically inert www.indiandentalacademy.com
  • Reason for bioinertness of Ti - surface oxide - corrosion - allergy www.indiandentalacademy.com
  • CERAMICS (Calciumphosphate hydroxyapatite, Al2O3, Tricalcium phosphate) • Develop a chemical bond of a cohesive nature • Applied in the form of coating onto the metallic core. Hydroxyapatite coated implant Adv: rapid bone response Disadv: coat loosening • Hahn J (1997) HA coated implant – 97.8%(6 yrs) clinical success. www.indiandentalacademy.com
  • POLYMERS Not used •Inferior mechanical properties •Lack of adhesion to living tissues •Adverse immunological reaction www.indiandentalacademy.com
  • Non threaded •Tendency for slippage •Bonding is required •No slippage tendency •No bonding is required Threaded 2. Implant design www.indiandentalacademy.com
  • Implant Design characteristic : 3 D structure of the implant. Form, shape, configuration, geometry, surface macro structure, macro irregularities. Cylindrical Screw shaped implants. Threaded Non threaded. www.indiandentalacademy.com
  • Threaded implants : Alteration in the design, size and pitch of the threads can influence the long term osseointegration. www.indiandentalacademy.com
  • • Cylindrical implants www.indiandentalacademy.com
  • Topographic properties Implant surface texture & roughness Physical properties Surface energy and charge Physiochemical properties Implant surface chemistry 3.Implant surface characteristics www.indiandentalacademy.com
  • 1) Turned surface/ machined surface 2) Acid etch surface - HCl and H2SO4 3) Blasted surface – TiO2 / Al2O3 particles 4) Blasted + Acidetch surface - Al2O3 particles & HCl and H2SO4 - Tricalcium phosphate & HF & NO3 1. Surface topography www.indiandentalacademy.com
  • 5) Hydroxyapatite coated surface (HA) 6) Titanium plasma sprayed surface (TPS) 7) Oxidized surface 8) Doped surface 9) Nanosized hydroxyapatite coated surfaceswww.indiandentalacademy.com
  • Roughness parameter (Sa) 0.04 –0.4 µm - smooth 0.5 – 1.0 µm – minimally rough 1.0 –2.0 µm – moderately rough > 2.0 µm – rough • Wennerberg (1996) – stated that moderately rough implants developed the best bone fixation. Smooth surface < 0.2 µm – soft tissue →no bone cell adhesion → clinical failure. Moderately rough surface more bone in contact with implant → better osseointegration.www.indiandentalacademy.com
  • Advantages of moderately rough surface : Faster osseointegration, retention of the fibrin clot, osteoconductive scaffold Increase rate and extent of bone accumulation → contact osteogenesis Increased surface area renders greater osteoblastic proliferation, differentiation of surface adherent cells. Increased cell attachment growth and differentiation. Increased rough surfaces : Increased risk of peri-implantitis Increased risk of ionic leakage / corrosion www.indiandentalacademy.com
  • Additive surface treatment : Titanium plasma spraying (TPS) hydroxyapatite (HA) coating Substractive surface treatment : Blasting with titanium oxide / aluminum oxide and acid etching www.indiandentalacademy.com
  • Machined / turned surface SEM x 1000 SEM x 4700 Cp Titanium www.indiandentalacademy.com
  • Titanium plasma sprayed coating (TPS) Coated with titanium powder particles in the form of titanium hydride Plasma flame spraying technique  6-10 times increase surface area. Steinemann 1988, Tetsch 1991 www.indiandentalacademy.com
  • Hydroxyapatite coatings HA coated implant bioactive surface structure – more rapid osseous healing comparison with smooth surface implant. ↓ Increased initial stability Can be Indicated - Type IV bone - Fresh extraction sites - Newly grafted sites SEM 100X www.indiandentalacademy.com
  • 2. Physical characteristic : • •Surface energy and charge. Hypothesis : A surface with high energy →high affinity for adsorption → show stronger osseointegration. Baier RE (1986) – Glow discharge (plasma cleaning) results in high surface energy as well as the implant sterilization, www.indiandentalacademy.com
  • 3. Implant surface chemistry : • Chemical alteration → increases bioactivity → increase implant bone anchorage. Chemical surfaces : • Ceramic coated – hydroxyapatite (HA), Calcium phosphate • Oxidized/anodized surfaces with electrolytes containing phosphorous, sulfur, calcium, magnesium and flouride. • Doped surfaces with the BONE stimulating factors / growth factors. www.indiandentalacademy.com
  • Anchorage Mechanism or Bonding Mechanism in Osseointegrated implants : Biomechanical bonding In growth of bone into small surface irregularities of implant surface → three dimensional stabilization Seen in : • Machined / turned screw implant • Blasted /Acid etch surface → moderately rough implant surface. www.indiandentalacademy.com
  • Biochemical bonding Seen with certain bioactive implant surfaces like : • Calcium phosphate coated implant surfaces • HA coated implant surfaces • Oxidized/ anodized surfaces Biointegration : •“Strong chemical bond may develop between the host bone and bioactive implant surfaces and such implants are said to be biointegrated”. www.indiandentalacademy.com
  • Doped surfaces that contain various types of bone growth factors or other bone-stimulating agents may prove advantageous in compromised bone beds. *BMP = Bone morphogenetic protein. Doped surfaces www.indiandentalacademy.com
  • 4. Fixture site position • Bicortical initial stablization • min. Width of the bone • min. distance between fixtures • min distance from adjacent teeth • Min. distance from anantomic structures www.indiandentalacademy.com
  • 5. Number of fixture sites In mandible – 1st molar area to other not recommended 1 fixture – 1 crown 2 fixtures – bridge 4 fixtures- full arch bridge www.indiandentalacademy.com
  • 6.Trauma to host tissues Objective: Controlled surgical technique  Surgical skill / technical excellence Parameters : 1. Profuse irrigation for cooling 2. Use of well sharpened drills and use of graded series of drills www.indiandentalacademy.com
  • 3. Slow drill speeds 4. Proper drill geometry 5. Intermitent drilling Eriksson R.A : • Drill speed < 2000 rpm, tapping at 15 rpm. • Cooling during tapping and insertion of screw Violent surgical technique • Frictional heat / overheating → increased temperature rise in bone → wide zone of necrosis → fibrous tissue, primary failure of osseointegration. www.indiandentalacademy.com
  • • Critical temp. – 47 C • Maintain vitailty – 43 C ( alk. Phosphatase) • Ideal – 39 C www.indiandentalacademy.com
  • III.POST- OPERATIVE CONSIDERATIONS www.indiandentalacademy.com
  • • Healing time 3 months – dense bone 6 months – cancellous bone www.indiandentalacademy.com
  • • Loading condition “ No loading while healing” • Delayed loading: an implant prosthesis with an occlusal load afer more than 3 months after implant insertion. • Early loading:an implant supported restoration in in occlusion between 2 weeks and 3 months • Immediate / Direct loading:implant supported prosthesis in occlusal contact within 2 weeks of implant insertionwww.indiandentalacademy.com
  • • Fibrous tissue formation (Albrektson) • Direct loading- 40%- 90% contact (Adell) www.indiandentalacademy.com
  • • Medication • Calcium carbonate , antibiotics www.indiandentalacademy.com
  • Success criteria of implants : Schuitman and Schulman criteria (1979) 1) The mobility of the implant must be less than 1mm when tested clinically. 2) There must be no evidence of radiolucency 3) Bone loss should be less than 1/3rd of the height of the implant 4) There should be an absence of infection, damage to structure or violation of body cavity, inflammation present must be amneable to treatment. 5) The success rate must be 75% or more after 5 years of functional service. www.indiandentalacademy.com
  • Albrektson and Zarb G (1980) 1) The individual unattached implant should be immobile when tested clinically 2) The radiographic evaluation should not show any peri-implant radiolucency 3) Vertical bone loss around the fixtures should be less than 0.2mm annually after first year of implant loading. 4) The implant should not show any sign and symptom of pain, infection, neuropathies, parasthesia, violation of mandibular canal and sinus drainage. www.indiandentalacademy.com
  • Smith and Zarb (1989) 6) Implant design allow the restoration satisfactory to patient and dentist. 5) Success rate of 85% at the end of 5 year observation period and 80% at the end of 10 year service. www.indiandentalacademy.com
  • Methods of evaluation ofosseointegration Invasive method •Histological section •TEM (transmission electron microscopy) •Pullout test www.indiandentalacademy.com
  • Non-invasive methods : •Radiographs - OPG, CT Scan, Dentascan •Periotest •Reverse torque www.indiandentalacademy.com
  • •Resonance frequency analysis www.indiandentalacademy.com
  • • Risk factors for osseointegration SUBJECT IMPLANT IMPLANT SITE www.indiandentalacademy.com
  • 1. subject risk 1. - nicotine - v.c – blood supply reduced - impaired wound healing - 1996 heavy smoking – absolute C/I - Bain & Moy implant failure rate- 11.3% 2. - decrease bone density - contradictory results www.indiandentalacademy.com
  • 3. - relative C/I - hypergycemia& angiopathies – dec. immune response , dec. healing reduced bone remodelling 4. - antiosteoporosis drugs, diphosphonates www.indiandentalacademy.com
  • 5. - rapid progressive periodontal dis. higher risk of peri- implant dis. 6. - inc. peri- implantitis - inc. marginal bone loss www.indiandentalacademy.com
  • 2. Implant risk • 1. - diff. I/O sites- diff. implant survival rates - bone density - state of host bed • 2. - threaded implants - shorter implants prone to overload - HA coated – higher failure www.indiandentalacademy.com
  • 3. Site- specific risk 1. - absence of bleeding on probing - F applied – 0.2N . - higher probing F – attachment 2. - decreased – inc. peri-implant dis. - non- ker. Mucosa – succeptible to progression of peri-implantitis www.indiandentalacademy.com
  • Scope of osseointegration in dentistry 1) Prosthetic rehabilitation of missing teeth Complete edentulous maxilla and mandible rehabilitation. Single tooth replacementPartial dental loss replacementwww.indiandentalacademy.com
  • 2) Anchorage for the maxillofacial prosthesis Auricular Prosthesis Ocular Prosthesis www.indiandentalacademy.com
  • 3) For rehabilitation of congenital and developmental defects - Cleft palate - Ectodermal dysplasia 4) Complex maxillofacial defect rehabilitation www.indiandentalacademy.com
  • 5) Orthodontic anchorage. www.indiandentalacademy.com
  • Conclusion Osseointegration has been a breakthrough in oral implantology previously regarded as non lege artis. The success of osseointegration has been proven beyond doubt, but achieving successful osseointegration depends on careful planning , meticulous surgical technique & skilled prosthetic management www.indiandentalacademy.com
  • • References 1. Contemporary implant dentistry 3rd edn. , Carl .E. Misch 2. Fundamentals of implant dentistry, Weiss& Weiss 3. Dental implants- art & science , Babbush 4. Tissue integrated prosthesis-osseointegration in clinical dentistry , Branemark/ Zarb 5. Implant & restorative dentistry – Scortecci 6. Clinical periodontology and implant dentistry, Lindhe,Karring, Lang 7. Theory & practice of osseointegration, S. Hobo 8. Advanced osseoinegration surgery- Worthington 9. Color atlas of dental & maxillo-facial implants , Hobkirk www.indiandentalacademy.com
  • 10. Atlas of implant dentistry, Cranin 11. DCNA 1989; 33(4) : 537 12. DCNA 1986;30(1) :151 13. JPD 1987;57(5):599 14. JPD1983;50(1):108 15. JPD 1983;50(1):101 16. JPD1983;50(3):399 17. JPD1983;49(6):838 www.indiandentalacademy.com
  • THANK YOU For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com