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Biological aspects of implants /certified fixed orthodontic courses by Indian dental academy


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Biological aspects of implants /certified fixed orthodontic courses by Indian dental academy

  1. 1. Biological Aspects of Implants INDIAN DENTAL ACADEMY Leader in Continuing Dental Education
  2. 2. OverviewIntroductionDefinitionsHistoryClassificationImplant Materials, Surfaces, And FormsSurface modificationsResponse Of Bone To ImplantsOsseointegrationEvents After Implant PlacementFactors influencing OsseointegrationReferences
  3. 3. IntroductionOver years different clinical skills have been tried to help patients with the effects of partial or complete edentulism. Dental problems that were historically the most difficult can be solved today with assistance of dental implants
  4. 4. DefinitionA dental implant is a device of biocompatible material(s) placed within / against the mandibular / maxillary bone to provide additional / enhanced support for prosthesis / toothThe Glossary of Prosthodontic Terms (GPT) defines an implant as “a prosthetic device or alloplastic material implanted into the oral tissues beneath the mucosal and/or periosteal layer, and /or within the bone to provide retention and support for a fixed or removable prosthesis.”
  5. 5. HistoryThe Mayan civilization has been shown earliest known examples to have used endosseous implant, dating back over 1,350yrs before Per Branemark started with titaniumArcheologists found a fragment of mandible dating about 600AD. which is considered to be that of a woman in her 20s had three tooth shaped pieces of shell placed into sockets of three missing lower incisor.• The tooth-shaped shell implants and the jaw were examined radiographically and it was determined that compact bone had formed around 2 of the implants and the bone was radio graphically similar to that which forms around blade implants. This may be the earliest example of any endosseous implant.
  6. 6. ClassificationBased on relation to bone form Endosteal Subperiosteal TransosseousBased on shape Blade form Root formBased on material used Metallic Ceramic
  7. 7. Subperiosteal Implants (Eposteal implants): It is a framework specially fabricated to fit on top of supporting areas in the mandible or maxilla under the mucoperiosteum with perimucosal extension for support and attachment of a prosthesis.Indications: In cases of advanced alveolar resorption in which volume of residual bone is insufficient for insertion of endosteal implant. Used in atrophied bone and where jaw structure is limited
  8. 8. Subperiosteal Implants (Eposteal implants):Types: Interdental subperiosteal implants Total subperiosteal implants Circumferential subperiosteal implantsAdvantages: light weight individually designed metal framework fits over remaining bone
  9. 9. Subperiosteal Implants :(Eposteal implants)The subperiosteal implantis retained by periostealintegration in which theouter layer of periosteumprovides dense fibrousenvelope & anchors theimplant to bone throughsharpeys` fibers
  10. 10. Subperiosteal Implants (Eposteal implants):
  11. 11. Subperiosteal Implants (Eposteal implants):Preoperative Postoperative
  12. 12. Subperiosteal Implants (Eposteal implants): Used only in the anterior mandible in the very atrophic mandible Due to the complex nature of the surgical approach this implant is not used frequently.
  13. 13. Endosteal ImplantsThey are surgically placed within alveolar and basal bone and aresubdivided into• Root form implants include those that approximate the shape and dimensions of tooth roots (called root form implants)• Blade form those that are plates of metal (called blade implants)• Ramus form those that are metal frameworks where only a portion of the metal is implanted into bone (ramus frame implants).
  14. 14. Root FormAlvin Strock placed first successful root form implant in 1938 in the University of Harvard Placed directly into bone, like natural tooth forms Designed to resemble the shape of natural tooth Can be placed anywhere in mandible / maxilla where there is sufficient available bone
  15. 15. Root FormCylindrical in shapeCan be threaded, smooth, stepped, parallel/threaded, with /without coating, with /without grooves / vent 3 to 5mm in diameter 7 to 20mm in lengthAs a rule root forms must achieve osteointegration to succeed. So they are placed in an afunctional state during healing until they are osteointegrated
  16. 16. Root FormThe Root form Implants are two stage implantsStage I : is submersion / semi- submersion to permit a functional healing.Stage II : is attachment of an abutment / retention mechanism
  17. 17. Blade FormThe Endosteal Blade implant was introduced in 1967 by Leonard Linkow and also by Ralph & Harold RobertsShape: as the name suggests a metal / blade in cross-sectionAvailable in 1 stage / 2 stage forms 2.5mm in widthCan be placed anywhere in 8 to 15mm in depth mandible / maxilla 15 to 30mm in length
  18. 18. Blade
  19. 19. Ramus FormThe Ramus Frame implant was developed in 1970 First fabricated from stainless steel.In 1982, the fabrication process was changed to titantiumINDICATION: Total mandibular edentulism with severe alveolar ridge resoption
  20. 20. Ramus FormThey are technique- sensitiveThey have an external attachment bar that runs from ascending ramus on one side to ascending ramus on the other side.Posteriorly on each side they have endosteal extensions, inserts into available bone within ascending ramusAnteriorly it has plate / blade extension which is inserted into symphysis
  21. 21. Endodontic StabilizerDiffer from other endosteal implants in terms of functional applicationRather than providing additional abutment support for restorative dentistry , they are used to extend the functional length of an existing tooth root to improve its prognosis
  22. 22. Endodontic StabilizerShape: have parallel / tapered sides smooth / threadedIndication: atleast 5mm of bone should be available beyond apex of tooth being treated2nd premolars & molars are not good candidates in mandible as they are over inferior alveolar canal in maxilla as they are over maxillary sinus
  23. 23. Intermucosal Inserts Differ in form ,concept, function from other modalitiesThey provide support for a prosthesis but do not provide abutmentsMushroom shaped projections that are attached to the tissue surface of RPDs or CDs in maxilla & plug into prepared soft tissue receptor sites in the gingiva to provide additional retention & stabilityIndication: where endosteal & Subperiosteal implants are not practical
  24. 24. Intermucosal InsertsDo not come into contact with boneMode of intergegration is not osteointegrationReceptor sites in the tissue into which the inserts seat become lined with tough keritinised epitheliumOnly one appointment is required
  25. 25. IMPLANT COMPONENTS1. Implant body2. Sealing screw3. Healing cap4. Abutment5. Impression post6. Laboratory analogues7. Waxing sleeves8. Prosthesis retaining screw
  26. 26. IMPLANT COMPONENTS1.Implant body: Implant body is the endosteal dental implant that is placed within the bone during first stage surgery. It may be either a threaded or non threaded cylinderIt is either titanium alloy with or without hydroxyapatite coating.2.Sealing screw :• A screw is placed in the implant during the healing phase following stage –one surgery.Prevents the growth of the tissue over the edge of the implant.
  27. 27. IMPLANT COMPONENTS3.Healing cap:Healing cap is dome –shaped screw .They may range in length from 2 to 10mm and projects through the soft tissue into the oral cavity.Made up of resin such as polyoxymethyline or the titanium metals4.Abutment:Screws directly into implant support prosthesis.Primary component which provides retention to the prosthesis.
  28. 28. IMPLANT COMPONENTS5.Impression post:Facilitates transfer of intra oral location of abutment to similar position in laboratory cast.It screws directly into fixture / into abutment; once impression post is in place ,an impression is made.
  29. 29. IMPLANT COMPONENTS6.Laboratory analog:Component to represent either implant or abutment in laboratory cast.It screws onto the impression post after it has been removed from mouth & placed back into impression before pouring7. Waxing sleeve :Is attached to the abutment by the prosthesis retaining screw on a laboratory model.8. Prosthesis retaining screw :Penetrates the fixed restoration and secures to the abutment
  31. 31. Implant Materials, Surfaces, And FormsThe composition and nature of the surface of an implant are important characteristics because of their effect on the biologic development of an interfacial relationship between the bone and the implant.To be successful, an implant must meet 4 conditions:1. Be biocompatible so there is no undesirable reaction between the tissues and the implant (ie., corrosion, dissolution and/or resorption)
  32. 32. Implant Materials, Surfaces, And FormsTo be successful, an implant must meet four conditions …2. Have an interface that stabilizes postoperatively in as short a time as possible3. Be capable of carrying and transferring the occlusal stresses placed upon it4. Remain stable for a long period of time.
  33. 33. Implant Materials, Surfaces, And FormsTwo basic types of materials are used in implant dentistry: Metals Ceramics (either in a pure form or a hybrid type )Titanium Implants• Titanium’s biocompatibility, corrosion resistance, relatively light weight, low density, low modulus and high tensile strength make titanium based materials attractive for use in dentistry.• There are six different types of titanium based materials used to fabricate dental implants. These materials include Four types of commercially pure titanium (cpTi) Two titanium alloys
  34. 34. Implant Materials, Surfaces, And FormsCP titanium is available in 4 grades. Titanium Alloys Cp grade I Ti Ti-6Al-4V Cp grade II Ti Ti-6Al-4V Cp grade III Ti Cp grade IV Ti.The main difference between the 4 grades of titanium and the two alloys is the increasing ultimate tensile strength either in a pure form or a hybrid type
  35. 35. Measuring Surface TopographyThe surface topography describes (1) the degree of roughness that the surface exhibits and (2) the orientation of the irregularities on the surface.Surface roughness occurs in two principal planes: one perpendicularto the surface and one in the plane of thesurface (Thomas 1999)Currently 3 groups of instruments are available that mayprovide such information:1. Mechanical contact stylus instruments2. Optical instruments3. Scanning probe microscopes (SPM).
  36. 36. Surface modificationsTitanium implant surface characteristics may be modified by Plasma spraying & ion sputter coating• Additive methods (eg.Titanium Plasma Spray [TPS], Hydroxyapatite [HA]-coated)• Subtractive methods (eg.acid etched, particle blasted and combinations)
  37. 37. Surface modificationsPlasma sprayingInvolves heating the HA by a plasma flame at a temperature of approximately 15,000° C to 20,000°C.The HA is then propelled onto the implant body in an inert environment like argon, to a thickness of 50 to 100 μm.Ion-sputter coating• Process by which a thin, dense layer of HA can be coated onto an implant substrate.• Machined implants had a roughness of 5 micrometers while hydroxyapatite coated implants had a roughness of 30 to 50 micrometers
  38. 38. Implant Surface ModificationsBlasted Surface Blasted & Etched Etched Hydroxyapatite Coated
  39. 39. Advantages of increased surface roughness of Cp Ti implant• Increased surface area of the implant adjacent to bone.• Improved cell attachment to the implant surface.• Increased bone present at the implant surface.• Increased biomechanical interactions of the implant with bone.• Bone formation and maturation occurs at a faster rate in the initial phases on HA coated implants than on non-coated implants
  40. 40. Disadvantages of Surface Coatings• Flaking, cracking, or scaling upon insertion• Increased plaque retention when placed above the bone.• Increased bacterial adhesion and acts as a nidus for infection• Complications of treating the failing implants• Increased cost
  42. 42. Branemark (1952) Described the relationship between titanium and bone for which they coined the term osseointegration and defined it “as a direct structural and functional connection between ordered, living bone and the surface of a load- carrying implant.”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.
  43. 43. The Glossary of Prosthodontic Terms(GPT) refers to the term “osseous integration”which is defined as “the apparent direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening connective tissue.”
  44. 44. Bone to Implant InterfaceTwo basic theories 1.Fibro-osseous integration by Linkow, James & Weis 2 Osseointegration by Branemark Meffert divided osseointegration Adaptive osseointegration Biointegration American Academy of implant dentistry defined fibrous integration as tissue to implant contact with healthy dense collagenous tissue between the implant and bone.
  45. 45.
  46. 46. Mechanism of Osseointegration Blood clot (between fixture & bone) Clot transformed by phagocytic cell (1st to 3rd day) Procallus formation (containing fibroblasts & phagocytes) Procallus becomes dense connective tissue (Differentiation of osteoblasts & fibroblasts) Callus (Osteoblasts on the fixture) Fibro cartilagenous callus (between fixture & bone) Bone callus (Penetrates & matures)Prosthesis attached to the fixtures stimulating bone remodeling
  47. 47. EVENTS AFTER IMPLANT PLACEMENTBone Necrosis• About 1 mm of cortical bone adjacent to the osseous wound (osteotomy site) undergoes post surgical necrosis in spite of careful surgical technique. Three phases have been described in the development of the bone-implant interface1.stabilization phase• Subendosteal and subperiosteal calluses form and adhere to the implant surface.• The bone is relatively low in density at this time (woven bone)
  48. 48. 2.The Strength Phase• The implant is stabilized• The process of resorption begins• Stronger, weight bearing bone is formed (lamellar bone)• Osteoclasts resorb nonvital bone and restore it with new lamellar bone3. The Durability Phase• Extensive remodeling occur and additional strength is developed.• With remodeling and proper prosthodontic function, the interface bone will tend to show very mature lamellated bone
  49. 49. • The fibers are arranged irregularly, parallel to the implantbody, when forces are applied they are not transmittedthrough the fibers. So no bone remodeling is expected in fibro-integration.• A direct bone implant interface occurs when an implant is allowed to heal in bone undisturbed.• Main factors affecting osseointegration include – Implant oxide layer contamination. – Poor temperature control during drilling.
  50. 50. Factors influencing Osseointegration – Biomaterial for dental implant – Surface composition and structure – Implant design – Heat during osteotomy – Contamination – Primary stability or initial stability – Bone quality – Epithelial down growth – Loading• A minimum of 3 month healing in mandible and 6 months in maxilla is necessary before load is applied
  51. 51. Bone resorption can be caused by 12 months following fixture insertion vertical bone loss is observed due to traumatic surgical procedure. – Vertical bone loss approximately 1 to 1.5 mm in first year – Marginal bone loss of 0.05 to 0.1 mm in first year – These measurements can be used a reference and in a bone loss condition should be evaluated to minimize failure.
  52. 52. The main contributing factor to bone resorption are1. Local inflammation from plaqueDirect action of plaque products induces formation ofosteoclasts, destroys bone through a non cellularmechanism2.Trauma from occlusionStimulate gingival cells, which release mediators forosteoclast formation.
  53. 53. 3. Heat• 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• The implant becomes surrounded by a fibrous capsule• The shear strength of the implant-host interface is significantly reduced.
  54. 54. 4. Primary stability or Initial stability – where an implant fits tightly into its osteotomy site then osseointegration is more likely to occur. – This is often referred to as primary stability, and when this happens failure is less probable. – This property is related to the quality of fit of the implant, its shape, and bone morphology and density.
  55. 55. 7.BONE QUALITY & QUANTITY• Areas of jaws – More cortical bone (anterior mandible) Anchor implant successfully cancellous bone- Maxilla Difficulty to achieve initial stability for implant osteointegration requires a longer healing period.•
  56. 56. • Vertical dimension of bone - Minimal for endosteal implant is 8mm. It is important to leave at least 2mm of bone between the apical end of the implant and inf..alveolar canal .• Bone width – implants should be a minimum of 1mm of bone on the buccal and lingual aspects of dental implant. Ex -for a 4mm diameter implant 6mm of available bone width is necessary• ;
  57. 57. • Vertical dimension of bone - Minimal for endosteal implant is 8mm. It is important to leave at least 2mm of bone between the apical end of the implant and inferior alveolar canal .• Bone width – implants should have a minimum of 1mm of bone on the buccal and lingual aspects of dental implant. Ex -for a 4mm diameter implant 6mm of available bone width is necessary.
  58. 58. Bone Density Classification (Misch)
  59. 59. 6. Contamination – Contamination of the implant site by organic and inorganic debris can prejudice the achievement of osseointegration. – Material such as necrotic tissue, bacteria, chemical reagents and debris from drills can all be harmful in this respect.
  60. 60. 7. Loading schemesDelayed loading: The prosthesis is attached at the second procedure after a conventional healing period of 3 to 6 monthsEarly loading: The prosthesis is attached during a second procedure, earlier than the conventional healing period of 3 to 6 months. Time of loading should be stated in days to weeksImmediate / Direct loading: The prosthesis is attached to the implants the same day the implants are placed.
  61. 61. Biomechanical Overload BIOMECHANICAL OVER LOAD Biomechanical Over Load Bone Loss At Coronal Aspect Micro Fracture At Coronal Aspect Of Implant- Bone Interface Loss Of Ossteointegration Apicalgrowth Of Epitelium & C.TThe speed and degree of loss of implant-bone contact depends upon thefrequency and magnitude of the occlusal loading as well as superimposedbactrerial invasion
  62. 62. Revised criteria for implant success– Individual unattached implant is immobile when tested clinically.– No evidence of peri implant radiolucency is present as assessed on an undistorted radiograph.– Mean vertical bone loss is less than 0.2 mm after 1st year of service.– No persistent pain, discomfort or infection.– A success rate of 85% at the end of a 5-year observation period and 80% at the end of a 10-year period are minimum levels of success.
  63. 63. References1. Caranza’s Clinical Periodontology 10th Edition2. Jan Lindhe Clinical Periodontology and Implant Dentistry 4th edition3. Weiss Principles and Practice of Implants4. Carl Misch Contemporary Implant Dentistry
  64. 64. Thank