Osseointegration/ orthodontic continuing education

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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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Osseointegration/ orthodontic continuing education

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2.  INTRODUCTIONINTRODUCTION  HISTORYHISTORY  PROCESS OF OSSEOINTEGRATIONPROCESS OF OSSEOINTEGRATION  TISSUE-IMPLANT INTERFACETISSUE-IMPLANT INTERFACE  TRANSMUCOSAL ATTACHMENTTRANSMUCOSAL ATTACHMENT  FACTORS INFLUENCINGFACTORS INFLUENCING OSSEOINTEGRATIONOSSEOINTEGRATION  - IMPLANT RELATED FACTORS- IMPLANT RELATED FACTORS  - HOST RELATED FACTORS- HOST RELATED FACTORS www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3.  FIBROOSSEOUS RETENSIONFIBROOSSEOUS RETENSION VSVS OSSEOINTEGRATIONOSSEOINTEGRATION  OSSEOINTEGRATIONOSSEOINTEGRATION VSVS OSSEOCOALESCENCEOSSEOCOALESCENCE  LOADING AND OSSEOINTEGRATIONLOADING AND OSSEOINTEGRATION  DEVICES TO MEASURE OSSEOINTEGRATIONDEVICES TO MEASURE OSSEOINTEGRATION  MEASURES TO ENHANCEMEASURES TO ENHANCE OSSEOINTEGRATIONOSSEOINTEGRATION  CONCLUSIONCONCLUSION  BIBLIOGRAPHYBIBLIOGRAPHY www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5.  INTRODUCTIONINTRODUCTION  Dental implant (endosteal) is an alloplastic materialDental implant (endosteal) is an alloplastic material surgically inserted into residual bony ridge primarily tosurgically inserted into residual bony ridge primarily to serve as a prosthodontic foundation.serve as a prosthodontic foundation.  Implants are used to –Implants are used to –  Replace missing teethReplace missing teeth  Rebuild the craniofacial skeletonRebuild the craniofacial skeleton  Provide anchorage during orthodontic treatmentProvide anchorage during orthodontic treatment  Help form new bone in the process of distractionHelp form new bone in the process of distraction osteogenesisosteogenesis www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6.  Osseointegration is defined as a relationship whereOsseointegration is defined as a relationship where bone is in direct contact with the implant,without anybone is in direct contact with the implant,without any intermediate connective tissue.intermediate connective tissue. (Branemark 1952)(Branemark 1952)  A revised definition describes it as structural andA revised definition describes it as structural and functional connection between ordered living bone andfunctional connection between ordered living bone and the surface of a load carrying implant.the surface of a load carrying implant. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7.  A process where by clinically asymptomatic rigidA process where by clinically asymptomatic rigid fixation of alloplastic material is achieved andfixation of alloplastic material is achieved and maintained in bone during functional loading.maintained in bone during functional loading. (Zarb & Alberktsson 1991)(Zarb & Alberktsson 1991) www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8.  HistoryHistory  In 1952 Per-Ingvar Brånemark used a titanium implantIn 1952 Per-Ingvar Brånemark used a titanium implant chamber to study blood flow in rabbit bone and notedchamber to study blood flow in rabbit bone and noted that the chambers could not be removed at the end ofthat the chambers could not be removed at the end of the experiment. He called the discoverythe experiment. He called the discovery “osseointegration.”“osseointegration.”  In the early 1960’s branemark and coworkers at theIn the early 1960’s branemark and coworkers at the university of Goteborg first developed a novel implantuniversity of Goteborg first developed a novel implant for clinical function.for clinical function. www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9.  Animal experiments performed by Branemark in 1969Animal experiments performed by Branemark in 1969 clearly demonstrated that it is possible to establish aclearly demonstrated that it is possible to establish a direct bone anchorage.direct bone anchorage.  Schroeder was the first investigator to clearlySchroeder was the first investigator to clearly demonstrate osseointegration in mid 1970’s.demonstrate osseointegration in mid 1970’s.  He used the new techniques to cut through theHe used the new techniques to cut through the decalcified bone and implant without separation ofdecalcified bone and implant without separation of anchorage.anchorage. www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10.  Alberktsson (1981)Alberktsson (1981) presented the background factorspresented the background factors needed for osseointegration-needed for osseointegration-  Bio- compatibilityBio- compatibility  DesignDesign  Surface conditions of implantSurface conditions of implant  Status of host bedStatus of host bed  Surgical techniqueSurgical technique  Loading conditionsLoading conditions www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11.  Biological basis of osseointegration-Biological basis of osseointegration-  The ability of the living(vital) bone tissue to developThe ability of the living(vital) bone tissue to develop and maintain,in physiological function, a direct interfaceand maintain,in physiological function, a direct interface and dynamic union with implants.and dynamic union with implants. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12.  Mechanism of osseointegrationMechanism of osseointegration  The damage caused during the surgical procedure andThe damage caused during the surgical procedure and the press fit of the implant to the hard and soft tissuesthe press fit of the implant to the hard and soft tissues initiate the process of healing.initiate the process of healing.  This ultimately allows –This ultimately allows –  The implant to become anchylotic with boneThe implant to become anchylotic with bone  Establishment of delicate mucosal attachment orEstablishment of delicate mucosal attachment or barrier to the titanium device.barrier to the titanium device. www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14.  The wound healing at the implant site depends on the –The wound healing at the implant site depends on the –  Presence of adequate cellsPresence of adequate cells  Their adequate nutritionTheir adequate nutrition  Adequate stimulus for bone repairAdequate stimulus for bone repair www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15.  The three main phases of bone healing necessary forThe three main phases of bone healing necessary for osseointegration are –osseointegration are –  Phase 1 InflammationPhase 1 Inflammation  Phase 2 ProliferationPhase 2 Proliferation  Phase3 MaturationPhase3 Maturation www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16.  InflammationInflammation www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17.  The cytokines released at the inflammatory siteThe cytokines released at the inflammatory site regulate-regulate-  Adhesion molecule productionAdhesion molecule production  Increase vascularization rateIncrease vascularization rate  Enhance collagen synthesisEnhance collagen synthesis  Regulate bone metabolismRegulate bone metabolism  Activate osteoclastsActivate osteoclasts  Neutrophil aggregation occurs during the first 3-4 daysNeutrophil aggregation occurs during the first 3-4 days following surgeryfollowing surgery  At 5-6 days following surgery the inflammatoryAt 5-6 days following surgery the inflammatory response becomes more specific.response becomes more specific. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18.  Proliferative phase:Proliferative phase:  The growth factors released by the macrophages andThe growth factors released by the macrophages and undifferentiated mesenchymal cells stimulateundifferentiated mesenchymal cells stimulate fibroplasias through which undifferentiated connectivefibroplasias through which undifferentiated connective tissue forms at the apical trabecular regions of thetissue forms at the apical trabecular regions of the implant site and in the furcation regions of screwimplant site and in the furcation regions of screw shaped implants.shaped implants.  During this phaseDuring this phase neovascularisation,proliferation,activation of cells andneovascularisation,proliferation,activation of cells and production of immature connective tissue occurs.production of immature connective tissue occurs. www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19.  The provisional connective tissue is rich in –The provisional connective tissue is rich in –  Newly formed vesselsNewly formed vessels  FibroblastsFibroblasts  Undifferentiated mesenchymal cellsUndifferentiated mesenchymal cells  The undifferentiated mesenchymal cells differentiateThe undifferentiated mesenchymal cells differentiate into fibroblasts,osteoblasts and chondroblasts ininto fibroblasts,osteoblasts and chondroblasts in response to local hypoxia and cytokine release.response to local hypoxia and cytokine release.  The connective tissue matures into osteoid from whichThe connective tissue matures into osteoid from which woven bone forms to fill the void with bone tissue.woven bone forms to fill the void with bone tissue. www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20.  Woven bone with primary osteons seen at the base ofWoven bone with primary osteons seen at the base of the surgical site and in the furcation sitesthe surgical site and in the furcation sites www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21.  Reversal lines seen in the bone tissue next to theReversal lines seen in the bone tissue next to the implantimplant www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22.  4 weeks of wound healing4 weeks of wound healing  Shows remnants of old bone replaced by woven boneShows remnants of old bone replaced by woven bone www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23.  Phase of RemodellingPhase of Remodelling (8 weeks)(8 weeks) www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24.  At 4 months of implant placementAt 4 months of implant placement www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25.  TISSUE IMPLANT INTERFACETISSUE IMPLANT INTERFACE  Events leading to success or failure of the implant takeEvents leading to success or failure of the implant take place at the implant tissue interface.place at the implant tissue interface.  Numerous factors involved at the development of thisNumerous factors involved at the development of this interface are-interface are- (Alberktsson et al 1981)(Alberktsson et al 1981)  Implant related factorsImplant related factors  Patient variablesPatient variables www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26.  Events on the implant side:Events on the implant side:  Electrochemical events take place on the surface of theElectrochemical events take place on the surface of the implants and cause the oxide layer to double or triple inimplants and cause the oxide layer to double or triple in thickness. (Lekovic et al)thickness. (Lekovic et al)  Electrochemical reactions also lead to incorporation ofElectrochemical reactions also lead to incorporation of biological ions such as calcium,phosphorous,sulfur.biological ions such as calcium,phosphorous,sulfur.  Analysis of tissues around dental implants showedAnalysis of tissues around dental implants showed titanium at levels upto tens of ppm immediatelytitanium at levels upto tens of ppm immediately adjacent to device.adjacent to device. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27.  On biological side:On biological side:  Water molecules and hydrated ions associate withWater molecules and hydrated ions associate with implant surface within nano second.implant surface within nano second.  Implant surface acts as a substrate and alters theImplant surface acts as a substrate and alters the organization of water molecules.organization of water molecules.  Smaller affinity molecules are replaced by larger andSmaller affinity molecules are replaced by larger and greater affinity molecules for the biomaterial.greater affinity molecules for the biomaterial.  With time the cells encounter an implant surface that isWith time the cells encounter an implant surface that is preconditioned with a variety of biomolecules.preconditioned with a variety of biomolecules. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28.  Phenomena of bone formation:Phenomena of bone formation:  Distance osteogenesis:Distance osteogenesis:  Osteogenesis occurs from the bone towards theOsteogenesis occurs from the bone towards the implant.implant.  The bone surface provides a layer of osteogenic cellsThe bone surface provides a layer of osteogenic cells that deposit a new matrix which approaches thethat deposit a new matrix which approaches the implant.implant. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29.  Contact osteogenesis:Contact osteogenesis:  Osteogenesis occurs in a direction away from theOsteogenesis occurs in a direction away from the implant as the osteogenic cells are recruited onto theimplant as the osteogenic cells are recruited onto the implant surface and begin secreting bone matrix.implant surface and begin secreting bone matrix.  The relative significance of the two processes dependsThe relative significance of the two processes depends on the type of implant and its surface characteristics.on the type of implant and its surface characteristics. www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30.  TRANSMUCOSAL ATTACHMENT:TRANSMUCOSAL ATTACHMENT:  Berglundh et al 1991Berglundh et al 1991 in a study evaluated the healthyin a study evaluated the healthy gingiva and periiplant mucosa and found manygingiva and periiplant mucosa and found many similarities between the two.similarities between the two.  The radiographs of the implant site showed marginalThe radiographs of the implant site showed marginal bone termination at the implant fixture interface.bone termination at the implant fixture interface.  The barrier epithelium was seen terminating aboutThe barrier epithelium was seen terminating about 2mm from the soft tissue margin.2mm from the soft tissue margin.  Connective tissue is 1-1.5mm thick and is in directConnective tissue is 1-1.5mm thick and is in direct contact with the TiO2 layer of implant.contact with the TiO2 layer of implant. www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32.  Identical transmucosal attachments were seen withIdentical transmucosal attachments were seen with different implant systems(shapes) and it wasdifferent implant systems(shapes) and it was independent of whether the implant is submerged orindependent of whether the implant is submerged or not.not.  The profile of implant was recorded on the adjacentThe profile of implant was recorded on the adjacent tissues.tissues.  The material used in the abutment part of the implantThe material used in the abutment part of the implant was of decisive importance for the quality ofwas of decisive importance for the quality of attachment that occurredattachment that occurred.(Abrahamsson et al 1996).(Abrahamsson et al 1996)  When the mucosal thickness prior to implantWhen the mucosal thickness prior to implant connection was <2mm a consistent marginal boneconnection was <2mm a consistent marginal bone resorption was seen as a result C.T attachment in suchresorption was seen as a result C.T attachment in such cases occurred at the fixture level.cases occurred at the fixture level. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34.  Composition of connective tissue :Composition of connective tissue :  The collagen fiber bundles are oriented parallel to theThe collagen fiber bundles are oriented parallel to the implant surface.implant surface. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35.  The connective tissue at the attachment zone containsThe connective tissue at the attachment zone contains more collagen,fewer fibroblasts and blood vessels thanmore collagen,fewer fibroblasts and blood vessels than corresponding location at teeth.corresponding location at teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36.  There was no difference in the composition of theThere was no difference in the composition of the connective tissue when implant abutments withconnective tissue when implant abutments with different surface roughness were used. (Abrahamssondifferent surface roughness were used. (Abrahamsson et al)et al)  Vascular supply:Vascular supply:  supra periosteal blood vessels (Berglundh et al)supra periosteal blood vessels (Berglundh et al) www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37.  Initial implant stabilization:Initial implant stabilization:  It is achieved primarily by friction acting at implant-It is achieved primarily by friction acting at implant- bone interface.bone interface.  In order to achieve adequate initial stability by frictionIn order to achieve adequate initial stability by friction significant torsional and axial forces have to be imposedsignificant torsional and axial forces have to be imposed during implant placement.during implant placement.  F fr = µf x FnF fr = µf x Fn  During the initial phases of healing the resoprtion ofDuring the initial phases of healing the resoprtion of the necrotic bone causes a decrease of frictionalthe necrotic bone causes a decrease of frictional resistance, this forms the critical basis for limited orresistance, this forms the critical basis for limited or ideally no loading during the healing phase.ideally no loading during the healing phase. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38.  The initial stability is independent of the implant toThe initial stability is independent of the implant to bone contact and so not dependent on the length andbone contact and so not dependent on the length and diameter of implant.diameter of implant.  Increasing the implant to bone contact –Increasing the implant to bone contact –  Helps to maintain stabilityHelps to maintain stability  To resist significant transverse forces acting on implantTo resist significant transverse forces acting on implant www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39.  Factors influencing osseointegration:Factors influencing osseointegration:  Implant related factors:Implant related factors:  Implant materialImplant material  Implant designImplant design  Surface topographySurface topography www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40.  Host related factors-Host related factors-  Systemic conditions and medicationsSystemic conditions and medications  Hosts ability to healHosts ability to heal  Ability to adapt to loading conditionsAbility to adapt to loading conditions  Possibility to respond to peri-implant infection.Possibility to respond to peri-implant infection.  Surgical techniqueSurgical technique  Time of loadingTime of loading www.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41.  Implant material:Implant material:  Titanium and titanium alloysTitanium and titanium alloys  Cobalt –chromium –molybdenum alloysCobalt –chromium –molybdenum alloys  Stainless steelStainless steel  ZirconiumZirconium  TantalumTantalum  GoldGold  Ceramics and carbonCeramics and carbon www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42.  Advantages of titanium –Advantages of titanium –  Passivates upon contact with air and normal tissuePassivates upon contact with air and normal tissue fluids,this aids in osseointegration.fluids,this aids in osseointegration.  Titanium is more ductile and helps in blending theTitanium is more ductile and helps in blending the implant to receive straight abutmentsimplant to receive straight abutments  Better resistance to corrosionBetter resistance to corrosion  The modulus of elasticity is 5 times greater thanThe modulus of elasticity is 5 times greater than bone ,which emphasizes the importance of design inbone ,which emphasizes the importance of design in proper distribution of stress transfer.proper distribution of stress transfer.  High bio-compatibilityHigh bio-compatibility www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43.  SURFACE TOPOGRAPHY:SURFACE TOPOGRAPHY:  The surface topography describes –The surface topography describes –  1. The degree of roughness that the surface exhibits1. The degree of roughness that the surface exhibits measured in perpendicular and parallelmeasured in perpendicular and parallel directionsdirections  2. Orientation of the irregularities on the surface2. Orientation of the irregularities on the surface Isotropic and AnisotropicIsotropic and Anisotropic Devices used –Devices used – Confocal laser scanning ProfilometerConfocal laser scanning Profilometer InterferometersInterferometers www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Wennenberg indicated that for threaded implants 9 measurements are sufficient for proper characterization 3D measurements are more reliable www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45.  Topography of a surface is defined in terms of –Topography of a surface is defined in terms of –  FormForm  WavinessWaviness  RoughnessRoughness www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46.  Surface roughness is further described in terms of –Surface roughness is further described in terms of –  Sa-Sa- amplitudeamplitude – vertical height of irregularities– vertical height of irregularities  Scx –Scx – spacingspacing – space between irregularities– space between irregularities  Sdr –Sdr – hybridhybrid – (spacing and amplitude)– (spacing and amplitude)  For proper characterization atleast one parameter fromFor proper characterization atleast one parameter from each 3 groups must be included in the topographiceach 3 groups must be included in the topographic evaluation of top,flank and valley.evaluation of top,flank and valley. (Wennenberg &(Wennenberg & Alberktsson)Alberktsson) www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47.  Experimental studies investigating surface roughnessExperimental studies investigating surface roughness and osseointegration:and osseointegration:  Invivo experiments showed better bone fixation withInvivo experiments showed better bone fixation with enlarged isotropic surface when compared to turnedenlarged isotropic surface when compared to turned anisotropic surface.anisotropic surface. (Wennenberg 1996)(Wennenberg 1996)  A positive correlation was seen between the implantA positive correlation was seen between the implant roughness and the degree of implant incorporationroughness and the degree of implant incorporation (Gotfredsen et al 2000)(Gotfredsen et al 2000) www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48.  Ideal degree of osseointegration was given in implantsIdeal degree of osseointegration was given in implants with –with –  Sa value (amplitude 3D) – 1.45 µmSa value (amplitude 3D) – 1.45 µm  Scx value(spacing 3D) – 11 µmScx value(spacing 3D) – 11 µm  Sdr ratio (hybrid 3D) – 1.5Sdr ratio (hybrid 3D) – 1.5 www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50.  Modification of implant design to resist loads and forModification of implant design to resist loads and for better bone ingrowth-better bone ingrowth-  Finely threaded coronal region for bone ingrowthFinely threaded coronal region for bone ingrowth  Use of implants with surface design that allows 3DUse of implants with surface design that allows 3D interlockinginterlocking  Use of implant design that allows tensile,compressiveUse of implant design that allows tensile,compressive and shear force transfer at bone-implant interface.and shear force transfer at bone-implant interface. www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52.  Influence of surface treating on osseointegration:Influence of surface treating on osseointegration:  Surface roughness of commercially available implants-Surface roughness of commercially available implants-  1. Blasted surface:1. Blasted surface: (Tioblast)(Tioblast) Surface blasted with TiO2 particlesSurface blasted with TiO2 particles results in isotropic surfaceresults in isotropic surface Sa- 1.07µmSa- 1.07µm Scx – 10.11µmScx – 10.11µm Sdr – 29%Sdr – 29% www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53.  2. Blasted & Etched:2. Blasted & Etched: surface is blasted followed by acid etchingsurface is blasted followed by acid etching Sa – 1.42Sa – 1.42 Scx – 16.60Scx – 16.60 Sdr – 33%Sdr – 33% 3. Etched surface:3. Etched surface: (osseotite)(osseotite) Surface is etched in a two step procedureSurface is etched in a two step procedure Results in a isotophic surface with high frequencyResults in a isotophic surface with high frequency irregularitiesirregularities Sdx- 20%Sdx- 20% www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54.  Hydroxyapatite coated surfaceHydroxyapatite coated surface:( sterioss):( sterioss)  creates rough isotrophic surfacecreates rough isotrophic surface  Sa – 1.68Sa – 1.68  Scx – 13.47Scx – 13.47  Sdr – 55%Sdr – 55% www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55.  Oxidized surface:Oxidized surface: Ti UniteTi Unite Electrolytic oxidation of the surface increases theElectrolytic oxidation of the surface increases the surface thickness of oxide layersurface thickness of oxide layer Results in isotropic craterous surfaceResults in isotropic craterous surface Sa- 1.08 Scx – 10.98 Sdr – 37%Sa- 1.08 Scx – 10.98 Sdr – 37% www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56.  Titanium plasma sprayed surface: bonefit,steriossTitanium plasma sprayed surface: bonefit,sterioss  SteriossSterioss(nobel biocare) is the roughest implant surface(nobel biocare) is the roughest implant surface among all, with an increase in surface area by 134%among all, with an increase in surface area by 134% Sa – 3.86 µmSa – 3.86 µm Scx – 19.55 µmScx – 19.55 µm www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57.  Rate of development of osseointegration-Rate of development of osseointegration-  Is related to osseoconductivity of different surfacesIs related to osseoconductivity of different surfaces  Ability to resist interfacial tensile forcesAbility to resist interfacial tensile forces This is achieved by sintered porous surfaces withThis is achieved by sintered porous surfaces with interconnected pores suitable for bone ingrowth.interconnected pores suitable for bone ingrowth. (endopore)(endopore) This helps in use of shorter implants in cases withThis helps in use of shorter implants in cases with compromised bone quality and quantity.compromised bone quality and quantity. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58.  The surface modification of implants provides-The surface modification of implants provides- (Carlsson et al, Feighan et al)(Carlsson et al, Feighan et al) Better mechanical stability following installationBetter mechanical stability following installation Surface configuration that properly retains blood clotSurface configuration that properly retains blood clot Stimulates bone healing processStimulates bone healing process www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59.  HOST DETERMINANTSHOST DETERMINANTS  Age:Age:  Increased parathyroid hormone secretionIncreased parathyroid hormone secretion  Decreased calcitonin and vit-D absorption andDecreased calcitonin and vit-D absorption and activationactivation  Increased Ph in stomach which leads to decreasedIncreased Ph in stomach which leads to decreased calcium absorptioncalcium absorption  Decreased testosterone with age in menDecreased testosterone with age in men  Thinning of cortical bone and increased trabecularThinning of cortical bone and increased trabecular spacingspacing  Increase in number of dead osteocytesIncrease in number of dead osteocytes  Reduced vascular supplyReduced vascular supply www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60.  Using patients of different age groups (BranemarkUsing patients of different age groups (Branemark system) found that age as such even advanced doesnotsystem) found that age as such even advanced doesnot have an impact on osseintegration.have an impact on osseintegration. (Bass et al; Tiplett et al)(Bass et al; Tiplett et al) www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. Bone factors:Bone factors:  Quality of boneQuality of bone  Quantity of boneQuantity of bone www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. CLASSIFICATION OF BONE QUALITY(Lekholm and Zarb et al 1985) Type I: Jaw consists almost exclusively of homogenous compact bone no cancellous bone www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. Type II:Thick cortical compartment with varying sized cancellous region www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. Type III:Thin cortical bone surrounding dense cancellous portion. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65. Type IV: Thin cortical bone surrounds loose, spongy core. www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. CLASSIFICATION OF BONE QUALITY (Misch 1990) DI : Thick compact bone D2 : Thick porous compact bone D3 : Thin porous compact bone –loosely structured cancellous bone D4 : Loose, thin cancellous bone. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. Low bone density at the site implant placement (Type IV bone) has been associated with increased risk of implant failure.(Lang et al 1990, Jaffin et al 1991). They reported high number of losses of Branemark implants in bone of reduced structural quality and showed that less dense alveolar cancellous bone correlates with loss of endosseous implants. www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. DIABETES MELLITUS. Uncontrolled diabetes has been shown to be risk factor for periodontal disease.(Nelson et al 1990).  In a prospective study by Morris et al in 663 patients using 2887 implants showed that significantly more failures occurred in type II diabetics. Shernoff et al reported that the failure rate of implants in NIDDM is 7.3%. This seems to indicate that osseointegration can be obtained in diabetic patients but the medium to long term prognosis is currently guarded. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69.  Osteoporosis/osteopenia:  Studies by Friberg et al showed a survival rate of 97% during an observation period of 6 months to 14 years in patients with osteoporosis.  However it is advisable to use implants with more active surface and delay the loading. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70.  Hormone replacement(estrogen):  Post menopausal women without HRT had nearly twice the maxillary implant failure rate compared to patients under replacement therapy. Chung et al 2001.  Sjogrens syndrome:  Isidor et al presented the outcome of implant therapy in paients with sjogrens syndrome and found a overall failure rate of 16.7% which is much heigher than in healthy patients. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71.  HIV patients:  To date only one case report described successful placement of endosseous implant in immediate extraction socket for single tooth replacement followed for 18 months. Rajnay et al 1998.  Hypophosphatasia and Vit –D deficiency:  In a study by Bergendahl et al 2000 8 out of 10 implants showed failure in patients with Vit D deficiency where as none of the implants failed in hypophosphatasia group. www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72.  Platelet and coagulation disorders:  In patients with platelet and coagulation disorders such as thrombocytopenia, Von willebrands disease,hemphilia placement of dental implants is a challenge and osseointegration is rarely achieved. www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. MEDICATIONS A positive medical and medication history has been associated with an increased risk of implant loss. (Weyant et al 1994). Isolated reports have associated implant failure with the consumption of anti-osteoporotic drugs ,di- phosphonate in particular. (Stark et al 1995) Cyclosporine has a more challenging effect on osseointegrating implants namely its well documented effect of accelerating bone turnover and provoking a negative bone balance. www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74.  Chemotherapy and irradiation:  Placement of implants in irradiated patients involves the risk of inducing osteoradionecrosis as well as risk of losing implants.  Esposito et al in a meta analysis concluded that failure rate is slightly higher in irradiated bone10% than normal bone7%.  Failure was also dependent on irradiation dosage,implant failure was heigher above 55 Gy.  In such cases implant survival can by enhanced by use of hyperbaric oxygen. www.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75.  Microbiological state:  There is no evidence that presence of previous periodontal disease or periodontal pathogens is a serious risk for osseontegration except immediate implants. Rosequist et al  However long term success of osseointegrated implants can get effected due to increased number of P.gingivalis and P. intermedia. www.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76.  Smoking: Smoking has a negative influence on peripheral microcirculation and wound healing. Bain and Moy suggested that smoking influences bone quality which inturn may lead to higher failure rate. When potential confounding variables were assesed in bivariate and multivariate survival analysis overall implant failure was noted to be 7.72% Smokers at the time of implant placement had failure rate of 23.08%(early implant failure) Late implant failure is associated with a positive history of smoking more than 25 cigarette years. Habsha et al 2000 www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. Fibro-osseous Retention vsFibro-osseous Retention vs OsseointegrationOsseointegration  Fibroosseous retention is defined as interposition of healthy,dense collagenous tissue between the implant and bone.  Weiss defends the presence of collagen fibers between the implant and bone and interprets it as peri-implant membrane with osteogenic potential.  The piezoelectric effect created by the fibers has osteogenic potential.  The premise that peri-implant ligament is osteogenic and exerts and piezoelectric effect is only a hypothesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. Is there a fibrous tissue interface between implant and bone?  It must be realized that there is never a 100% bone to implant interface.  Johansson & Alberktsson reported a fibrous tissue interface at 1 month following implantation,  50% bone –implant contact at 3 months  65% bone –implant contact at 6 months  85% bone-implant contact at 1 year  Using screw type implants in rabbits. www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80.  Weiss hypothesis-  Implant should be placed in hypofunctional mode from the day of insertion and full function within 1-2 months  Branemark hypothesis-(later proven in animal experiments)  Implant should be completely protected and afunctional during a period of 0-12 months.  Remodelling phase 3-18 months when exposed to masticatory forces  Steady state – after 18 months. www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. What may be the cause for connectiveWhat may be the cause for connective tissue interface?tissue interface?  Premature loading of implant system earlier than 3-6Premature loading of implant system earlier than 3-6 monthsmonths  Apical migration of junctional epithelium into theApical migration of junctional epithelium into the interface followed by connective tissue elementsinterface followed by connective tissue elements  Placing the implant with too much of pressurePlacing the implant with too much of pressure  Linkow & WertmanLinkow & Wertman  Overheating the bone during site preparation (>116 F)Overheating the bone during site preparation (>116 F)  Implant not fitting the site exactlyImplant not fitting the site exactly Carlsson et alCarlsson et al www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. Osseointegration vs OsseocoalescenceOsseointegration vs Osseocoalescence  Osseointegration refers to pure mechanical interlockingOsseointegration refers to pure mechanical interlocking between the implant and bonebetween the implant and bone  This mechanical interlocking will not withstand tensileThis mechanical interlocking will not withstand tensile forcesforces  Osseocoalescence refers to chemical integration ofOsseocoalescence refers to chemical integration of implants in the bone.implants in the bone.  This is achieved by bio active materials such asThis is achieved by bio active materials such as hydroxyapatite and bio active glasshydroxyapatite and bio active glass  Physicochemical interaction between the bone and HAPhysicochemical interaction between the bone and HA layer causes direct deposition of bone on the implantlayer causes direct deposition of bone on the implant surfacesurface www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83.  Devices to measure implant stability andDevices to measure implant stability and osseointegration:osseointegration:  1.1. PeriotestPeriotest Schulte & Lukas 1993Schulte & Lukas 1993  Uses metal probe accelerated by an electromagnetUses metal probe accelerated by an electromagnet  Contact time related to implant mobilityContact time related to implant mobility www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84.  2.2. Resonance frequency analysisResonance frequency analysis:: MeredithMeredith  A frequency rise was seen from 7473 Hz at the time ofA frequency rise was seen from 7473 Hz at the time of implant placement to 7915 Hz 8 months later.implant placement to 7915 Hz 8 months later.  The amplitude signals are used to caliculate implantThe amplitude signals are used to caliculate implant stability ratio within a scale of 0-100.stability ratio within a scale of 0-100.  www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. LOADING AND OSSEOINTEGRATIONLOADING AND OSSEOINTEGRATION  Time of loading of an endosteal implant depends on-Time of loading of an endosteal implant depends on-  Type of boneType of bone  Characteristics of implant surfaceCharacteristics of implant surface  Amount of bone to implant contactAmount of bone to implant contact www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86.  Immediately following placement – bone –implant contact  D1 – 80%  D2 - 70%  D3 – 50%  D4 – 25%  Ideal bone for bone to implant prosthesis is lamellar bone, it heals 50% faster than the cortical bone and is highly organized. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. Bone density Initial healing Reconst ruction Gap b/w appointm ents Total time D-1D-1 55 66 11 6.56.5 D-2D-2 44 1010 22 6.56.5 D-3D-3 66 1414 33 9.59.5 D-4 8 18 4 12.5 www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88.  Pilliar et al poposed a value for critical relative displacements =30µm to prevent bone ingrowth.  However with surface modifications such as titanium plasma spraying and hydroxyapatite coating on the implants the relative displacement of the implants has increased to 50-75µm without any interference with osseointegration.  But immediate loading when done in patients with compromised bone quality will result in crestal bone loss and fibrous encapsulation of implant and subsequently implant failure. www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89.  Adel et al 1981  -Boneloss of 1-1.5mm occurs during the first year of implant placement as a result of surgical trauma  Marginal bone loss of 0.05-0.1mm occurs annually.  Any overloading during the phase of remodelling results in excessive crestal bone loss  The use of a period of graduated loading is recommended to avoid overloading failure of newly formed bone.  This graduated loading period should correlate with one or more remodeling units to occur. www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90.  Immediate loading and OsseointegrationImmediate loading and Osseointegration  In a histologic study conducted in 5 patients using 9In a histologic study conducted in 5 patients using 9 implants 2 loaded immediately and 5 following 2implants 2 loaded immediately and 5 following 2 months of healing,retrieved after 5-9 months ofmonths of healing,retrieved after 5-9 months of function showed bone –implant contact of 92% andfunction showed bone –implant contact of 92% and 81% respectively. (Antonio et al)81% respectively. (Antonio et al) www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91.  In a 3 year retrospective study using 97 branemarkIn a 3 year retrospective study using 97 branemark implants placed in 46 patients followed for 34 monthsimplants placed in 46 patients followed for 34 months showed a cumulative survival rate of 91%showed a cumulative survival rate of 91%  Nine implants in 8 patients failed during the first 8Nine implants in 8 patients failed during the first 8 weeks of loading and the remaining implants showedweeks of loading and the remaining implants showed good long term prognosis.good long term prognosis. www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92.  Measures to enhance osseointegration::Measures to enhance osseointegration::  Maintain the periosteal supply as much possible at theMaintain the periosteal supply as much possible at the implant siteimplant site  Use implants with isotrophic surface with more porousUse implants with isotrophic surface with more porous configurationconfiguration  Use implants of large surface areaUse implants of large surface area  Graduated loading of implantsGraduated loading of implants  Using implants with mesenchymal stem cellsUsing implants with mesenchymal stem cells incorporated with BMP’s on the surfaceincorporated with BMP’s on the surface  Low level laser treatment –biostimulatory effect causesLow level laser treatment –biostimulatory effect causes an increase in the number of viable osteoblasts.an increase in the number of viable osteoblasts. www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. CONCLUSIONCONCLUSION www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94.  BIBLIOGRAPHYBIBLIOGRAPHY 1.1. Clinical Periodontology and Implant Dentistry Jan Lindhe 4th edition. 2.2. Implant therapy-Clinical approaches and Evidence of success Vol II –Nevins and Mellonig 3. Contemporary Implant Dentistry Carl Misch 3rd edition. 4. Ageing, Osteoporosis and Dental Implants  Lekholm & Zarb 5. Dental Implants DCNA: (50);2006 www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95. 6.6. Use of oral Implants in compromised patients Periodontology 2000; vol 33. 7.7. Risk Factors in implant dentistry Franck Renouard and Bo Rangert 8. Osseointegration in oral implantology consensus development conference statement 1988 9. The long term efficacy of currently used dental implants : A Review and proposed criteria of success T.Alberktsson,P.Worthington,A.R.Eriksson J Oral Maxillofac Implants 1986 vol 1 (11-25) www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. 10.10. Histology of retrieved immediately and early loaded oxidized implants: Light microscopic observations after 5-9 months of loading in the posterior mandible Clinical Implant Dentistry 2003(5);88-97. 11. Immediate loading in the maxilla using flapless surgery,implants placed in predetermined positions and prefabricated restorations: A retrospective 3 year clinical study. Clinical Implant Dentistry 2003(5);29-36.. www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. www.indiandentalacademy.comwww.indiandentalacademy.com

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