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  1. 1. Dr. Nitika Jain
  2. 2.  Implant introduction  Implant classification  Implant geometry ( Macro design) ◦ Endosseous implants ◦ Subperiosteal implants ◦ Transmandibular implants  Implant surface characteristics ( micro design) ◦ Additive processes ◦ Subtractive processes  Hard tissue interface ◦ Stages of bone healing and ossointegration  Soft tissue interface
  3. 3. Implant :- 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. Dental implant :- A prosthetic device of alloplastic material Implanted into the oral the oral tissues beneath the mucosa, periosteal layer and or within the bone to provide retention and support for a removal or fixed prosthesis.
  4. 4. Implantology :- The study or science of placing and restoring dental implants. Implant surgery :- The phase of implant dentistry concerning the selection, planning, and placement of the implant body and abutment. Implant prosthodontics :- The phase of prosthodontics concerning the replacement of missing teeth and/or associated structures by restorations that are attached to dental implants
  5. 5. Implant dentistry:- The selection, planning, development, placement, and maintenance of restoration(s) using dental implants. Implant abutment :- The portion of the dental implant that serves to support and or retain any prosthesis. Implant prosthesis:- Dental prosthesis such as crown and other fixed dental prostheses, removable dental prostheses as well as maxillofacial prostheses supported and retained in part or whole by dental implants.
  6. 6. 1.Based on implant design 2.Based on attachment mechanism 3.Based on macroscopic body design 4.Based on the surface of the implant 5.Based on the type of the material
  7. 7.  Endosseous implants ◦ blade like ◦ Pins ◦ Cylindrical (hollow and solid) ◦ Disklike ◦ Screw shaped ◦ Tapered and screw shaped  Subperiosteal framelike implants  Transmandibular implants
  8. 8.  Inserted into the jaw bone after mucoperiosteal flap elevation.  Tapped in place in a narrow trench made with a rotary bur.  One or more posts pierced through the mucoperiosteum after suturing of the flaps.  After a few week healing, a FPD is fabricated by a classic method and cemented on top of it.
  9. 9.  Three diverging pins were inserted either transgingivally or after reflection of mucoperiosteal flaps in holes drilled by spiral drills.  At the point of convergence, the pins were interconnected with cement to ensure the proper stability because of their divergence.
  10. 10.  Hollow and  Full cylindrical ◦ Straumann and co workers introduced hollow cylinders in mid1970s. ◦ Implant stability would benefit from the large bone to implant surfaces provided by means of the hollow geometry. ◦ Holes ( vents ) favour the ingrowth of bone to offer additional fixation.
  11. 11.  Full cylindrical implants were used by Kirsch and became available under the name of IMZ .  The long term survival rates were unacceptable, leading to the limited use of this implant type currently.
  12. 12.  They are rarely used at present.  The concept was developed by Scortecci. It is based on the lateral introduction into the jaw bone of a pin with a disk on top.  Once introduced into the bone volume, the implant has strong retention against extraction forces.
  13. 13.  The most common type of implant is the screw shaped, threaded implant.  A decrease in the interthread distance at the coronal end of the implant has been proposed to enhance the marginal bone level adaptation.
  14. 14. 1. Minimize apical bone fenestration 2. Allow for implant placement in narrow apical sites 3. Amenable to immediate placement into anterior extraction socket
  15. 15.  They are customized according to plaster model derived from an impression of the exposed jawbone, prior to the surgery planned for implant insertion.  They are designed to retain the overdenture.  They are rarely used.
  17. 17.  They were developed to retain the dentures in the edentulous lower jaw.  The implant was applied through submandibular skin incision.  “staple bone” implant developed by Small, consisted of a splint adapted to the lower border of the mandible.
  18. 18. Cylindrical Implant Threaded implants Plateau implants Perforated implants Solid implant Vented implant Hollow implant
  19. 19.  Biomechanics involved in Implantology includes The nature of the biting forces on the implants Transferring of the biting forces to the interfacial surfaces The interfacial tissue reaction
  20. 20.  A successfully osseointegrated implant provides a direct and relatively rigid connection of the implant to the bone.  A critical aspect affecting the success or failure of an implant is the manner in which mechanical stresses are transferred from the implant to bone smoothly.
  21. 21.  Surface plays an important role in biological interactions.  Surface modifications have been applied to metallic biomaterials in order to improve the ◦ Mechanical ◦ Chemical ◦ Physical  such as ◦ Wear resistance ◦ Corrosion resistance ◦ Biocompatibility and surface energy, etc.
  22. 22.  Micro rough surfaces ◦ Better bone apposition ◦ Higher percentage of bone in contact with the implant ◦ Influence the mechanical properties of the interface ◦ Stress distribution ◦ Bone remodelling  Smooth surfaces ◦ Bone resorption ◦ Fibrous connective tissue layer
  23. 23. • Surface coatings • Carbon, glass, ceramic coating • Hydroxyapatite coating • Ca –P coating • Composite coating • Titanium Nitride coating • Titanium plasma spray coating • Titania film coating Additive
  24. 24. Increase the functional surface of implant-bone interface Effective stress transfer Promote bone apposition Improved osseointegration
  25. 25.  The surface of titanium has been modified by ion beam mixing a thin carbon film.  The corrosion resistance and other surface and biological properties were enhanced using carbon plasma immersion ion implantation and deposition.  Reactive plasma spray produces a feasible BAG- coating for Ti-6Al-4V dental implants.  The coating withstands, without any damage , an externally generated tensile stress of 47MPa,and was adequate for load bearing applications.
  26. 26.  Enhancement of the osteoconductivity of Ti implants is potentially beneficial to patients since it ◦ shortens the treatment time and ◦ Increases the initial stability of the implant Hydroxyapatite Tri calcium phosphate
  27. 27.  Ca-P coatings are applied to ◦ To combine the strength of the metals with the bioactivity of Ca-P. ◦ Accelerates the bone formation around the implant and effectively the osseointegration rate  Various technique ◦ Ion beam dynamic mixing technique(IBDM) ◦ Radio frequency magnetron sputter ◦ Biometric ◦ Deposition ◦ Electrochemical deposition ◦ Plasma spraying
  28. 28.  BioActive Ca-P ◦ Phosphate based glass ◦ Hydroxy apatite  TCP – tri calcium phosphate  CPP – calcium pyrophosphate  The cells on the coatings expressed higher alkaline phosphatase activity than pure Ti. ◦ Suggesting the stimulation of the osteoblastic activity on the coatings.
  29. 29.  Titanium nitride is known for its high surface hardness and mechanical strength. ◦ Increasing the corrosion resistance &surface hardness of the implant surfaces exposed  Titanium nitriding - various methods ◦ Gas nitriding ◦ Plasma nitriding by plasma diffusion treatment ◦ Plasma assisted chemical vapour deposition ◦ Pulsed DC reactive magnetron sputtering ◦ Closed field unbalanced magnetron sputtering ion plating
  30. 30.  Favour the osseointegration of the bone because of the inherent roughness of such coating
  31. 31.  An ion beam assisted sputtering deposition technique has been used to deposit thick and dense TiO2 films on titanium surfaces which are not easily breached and hence improved corrosion protection.
  32. 32. • Sand blasting • Shot peening and LASER peening • Dual acid etched technique Subtractive
  33. 33. Cleaning surface contaminants to prior to further operation Roughening surfaces to increase effective/functional surface area Producing beneficial surface compressive residual stress
  34. 34.  Alumina (Al2O3)  Silica ( SiO2)
  35. 35.  Similar to sand blasting but has more controlled peening power, intensity, and direction.  It is a cold process in which the surface of a part is bombarded with small spherical media called shot.
  36. 36.  The LASER peening technology is recently developed ◦ Non contact ◦ No media ◦ Contamination free peening method
  37. 37.  High intensity (5 -15GW/cm2)nano second (10-30ns) of LASER light beam (3-5mm width)striking the ablative layer generate a short lived plasma which causes a shock wave to travel into the implant.  The shock waves induces the compressive residual stress that penetrates beneath the surface and strengthens the implant, resulting in improvement in fatigue life and retarding the stress corrosion cracking occurrence.
  38. 38.  Dual acid etched technique ◦ To produce microtexture rather than macrotexture ◦ Enhance the osteoconductive process through the attachment of fibrin and osteogenic cells, resulting in bone formation directly on the surface of the implant. ◦ Higher adhesion and expression of platelet and extracellular genes, which help in colonization of osteoblasts at the site and promote osseointegration.
  39. 39.  Sandblasted and acid etched (SLA) method ◦ SLA given by BUSER et al, ◦ Sand blasted, large grit, acid etched. ◦ The surface is produced by large grit blasting process followed by acid etching using hydrochloric acid.
  40. 40. Vs
  41. 41. Stages of bone healing and osseointegration
  42. 42. A, Three-dimensional diagram of the tissue and titanium interrelationship showing an overall view of the intact interfacial zone around the osseointegrated implant. B, Physiologic evolution of the biology of the interface over time.
  43. 43.  The term Osseointegration was first used by Prof I-P Branemark. since then it has been used to describe the procedure of bone attachment with titanium. Though lately, the Glossary of Prosthetic Terms (Sixth Edition) lists the terms Osseointegration and osteointegration but recommends the use of the term osseous integration.
  44. 44.  Osseointegration was originally defined as, a direct structural and functional connection between ordered living bone and the surface of a load-carrying implant. ◦ Branemark in 1985  A direct on light microscopical level, contact between living bone and implant. ◦ Albrektsson in 1981  A bony attachment with resistance to shear and tensile forces. ◦ Steinemann in 1986
  45. 45.  Branemark in 1990, then gave a modified definition of his own – ◦ “A continuing structural and functional coexistence, possibly in a symbolic manner, between differentiated, adequately remodeling, biologic tissues and strictly defined and controlled synthetic components providing lasting specific clinical functions without initiating rejection mechanism.”
  46. 46.  Defined as direct bone deposition on the implant surface.  Characterized by structural and functional connection between ordered, living bone and the surface of a load-bearing implant.  Compared to as direct fracture healing, in which the fragment ends become united by bone, without intermediate fibrous tissue or fibrocartilage formation.
  47. 47. Material and surface properties Primary stability and adequate load
  48. 48.  Material and surface properties ◦ Bio inert materials  Titanium ◦ Rough surfaces  Improve adhesive strength  Favors bone deposition  Degree of mechanical interlock  Primary stability and adequate load ◦ Requires perfect stability ◦ Exact adaptation and compression of the fragments
  49. 49. incorporation by woven bone formation; •4 to 6 weeks adaptation of bone mass to load (lamellar and parallel-fibered bone deposition); and Second month adaptation of bone structure to load (bone remodeling). Third month
  50. 50.  The first bone tissue formed is woven bone.  characterized by a random, felt-like orientation of its collagen fibrils, numerous, irregularly shaped osteocytes and, at the beginning, a relatively low mineral density.  it grows by forming a scaffold of rods and plates and thus is able to spread out into the surrounding tissue at a relatively rapid rate
  51. 51.  (deposition of parallel-fibered and lamellar bone)  lamellar bone, or towards an equally important but less known modification called parallel- fibered bone ◦ Three surfaces qualified for deposition of fibered and lamellar bone  Woven bone formed in the first period of OG  Pre-existing or pristine bone surface  The implant surface
  52. 52.  Woven bone ◦ Deposition of more mature bone on the initially formed scaffold results in reinforcement and often concentrates on the areas where major forces are transferred from the implant to the surrounding original bone.  Pre – existing or pristine bone ◦ The trabeculae become necrotic due to the temporary interruption of the blood supply at surgery. Reinforcement by a coating with new, viable bone compensates for the loss in bone quality (fatigue), and again may reflect the preferential strain pattern resulting from functional load.
  53. 53.  The implant surface ◦ Bone deposition in this site increases the bone- impIant interface and thus enlarges the load- transmitting surface. Extension of the bone- implant interface and reinforcement of pre- existing and initially formed bone compartments are considered to represent an adaptation of the bone mass to load.
  54. 54.  (bone remodeling and modeling)  Last stage of OG  It starts around the third month and, after several weeks of increasingly high activity, slows down again, but continues for the rest of life.  Remodeling starts with osteoclastic resorption, followed by lamellar bone deposition. Resorption and formation are coupled in space and time.
  55. 55.  The cutting cone advances with a speed of about 50 pm per day, and is followed by a vascular loop, accompanied by perivascular osteoprogenitor cells.  Remodeling in the third stage of osseointegration contributes; to an adaptation of bone structure to load in two ways: ◦ It improves bone quality by replacing pre-existing, necrotic bone and/or initially formed, more primitive woven bone with mature, viable lamellar bone. ◦ It leads to a functional adaptation of the bone structure to load by changing the dimension and orientation of the supporting elements.
  56. 56. six key factors for successful osseointegration: ◦ implant material; ◦ implant design; ◦ surface quality; ◦ prosthetic load; ◦ surgical technique; ◦ bone health.
  57. 57.  The healthy soft, keratinized tissues facing teeth and implants frequently have a pink color and a firm consistency. The two tissues have several microscopic features in common. The gingiva as well as the keratinized, peri-implant mucosa is lined by a well-keratinized oral epithelium that is continuous with a junctional epithelium that is about 2 mm long.
  58. 58.  The interface between epithelial cells and the titanium surface is characterized by the presence of hemi desmosomes and a basal lamina.  Capillary loops in the C/T under the junctional and sulcular epithelium around implant appear normal  The thickness of the epithelium is 0.5mm
  59. 59.  The average direction of the collagen fiber bundles of the gingiva is parallel with the implant.  Even if perpendicular then they are never embedded as in the case of dentogingival and dentoperiosteal fibers around the teeth.  The fiber bundles also have cuff like orientation – soft tissue seal around the implant.
  60. 60.  The vascular supply of the peri implant gingival or oral alveolar mucosa is more limited than that around natural teeth.
  61. 61. Schematic illustration of the blood supply in the connective tissue cuff surrounding the implant/abutment is scarcer than in the gingival complex around teeth because none originates from a periodontal ligament.
  62. 62.  Newman, Takei, Klokkevold, Carranza. Carranza’s Clinical Periodontology, 10th Edition and 11th Edition  Lindhe, Lang, Karring. Clinical Periodontology & Implant Dentistry, 5th Edition.  Carle E. Misch. Contemporary Implant Dentistry. 3rd edition.  PHILLIP’S – SCIENCE OF DENTAL MATERIALS – Kenneth J. Anusavice , Phd ,DMD  Robert K, Schenk & Daniel Buser. Osseointegration: A reality. Perio 2000. Vol 17, 1998, 22-35.
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