PERIO

1. 7th.
RAPID REVIEW AND REVISION COURSE
IN
PERIODONTOLOGY AND IMPLANTOLOGY
23-26 Jan,2015
at
Dept. of Periodontics, Faculty of Dental Sciences,
Sri Ramchandra University
Chennai

2. IMPLANT BASIS & OSSEOINTEGRATION
T.K.Pal
MDS(L.U.), Ph.D.(J.U.), Post doc.Implant (N.Y.Uni., New York)
Prof. & Head,
Department of Periodontics,
Guru Nanak Institute of Dental Sciences & Research,
Kolkata.-700 114.

3. IMPLANT BASIS & OSSEOINTEGRATION
T.K.Pal
MDS(L.U.), Ph.D.(J.U.), Post doc.Implant (N.Y.Uni., New York)
Prof. & Head,
Department of Periodontics,
Guru Nanak Institute of Dental Sciences & Research,
Kolkata.-700 114.
BASIS= foundation
BASICS=fundamental

4. Way back in 1967

5. Father of Modern Dental Implantology
BRANEMARK, P.I.
1967

6. Father of Modern Dental Implantology
BRANEMARK, P.I.
1967

7. Father of Modern Dental Implantology
BRANEMARK, P.I.
1967

8. The Historical Experiment of Branemark started in 1952 on Dogs

10. Unscrewing was not possible…….

12. Father of Modern Dental Implantology
BRANEMARK, P.I.
1952 1967
16 years of research
on one single problem

13. Father of Modern Dental Implantology
Visited India during
World Prosthodontics
Conference (1996)
at New Delhi
BRANEMARK, P.I.

14. Unscrewing was not possible…….

15. –Titanium
• Lightweight(At. Number 22, At.wt.48)
• biocompatible
• corrosion resistance (dynamic inert oxide layer)
• Strong

16. [ Pal et al,1992 ]
Atmospheric Oxygen
Highly Reactive Ti to O
Passivated through
TiO ,TiO ,TiOӡ
With oxygen
²

17. [ Pal et al,1992 ]
Atmospheric Oxygen
Highly Reactive Ti to O
Passivated through
TiO ,TiO ,TiOӡ
With oxygen
²

18. Oxygen
Metal ion
{
Thickness increases
Color changes
TITANIUM

19. [Pal et al,1992 ]
Experimental Titanium Screw:ASTM 1986 Profile
Designed for Rabbit Transcortical Femoral Model:Dr.T.K.Pal
Within 1 millisecond after fresh cut (machining) ………

20. Ti TiO Bone
Titanium can not touch the bone………..
It is the oxide layer which comes in contact with BONE
X

21. BONE
Ti
TiO of 10 nanometre
Ceramic

22. Osteotomy done as per the implant dimention

23. Implant in drill-osteotomised
bone-hole

24. Ti
Potential space
Potential space

25. TiO
Ti
Bio-
Liquid
(Blood)
Bone
PETENTIAL SPACE FILLED IN WITH BIO-LIQUIDS

26. Small biomolecules,
Water, Ions
Large molecules,
Tissue fragments
UDM Cells of
Bone marrow/
Blood cells
Surface Free Energy
(wettability)
Highest amongst all
tested biomaterials
30 kcal/mol
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

27. Macrophage
Osteoclast
Pellicle Layer of 10 nm thickness
The pellicle layer dictates
subsequent adherence of
other formative cells on it
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

28. Pellicle layer
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

29. Too much roughness
on implant surface
invites unnecessary
accumulation of
macrophages
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

30. Macrophage clears up
macromolecules and other
cell debris
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

31. Bone resorption:
50-100µ per day
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE
Micromovement allowed
upto 150µ

32. Newly formed
osteoblasts
Oxidation-reduction potential : Vascular Supply & Oxygen Tension
UDM Pre-osteoblast
Otherwise, Fibroblasts will be generated leading to failure
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

33. Osteoid
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE
GAGs:
Proteoglycans
Glycoproteins
Structured Fibres:
Enzymes:
Mineral ions:

34. INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

35. Woven bone is formed
at a pace upto 100µm/day
Osteoblasts will not enter
into less than 100µ porosities; ONLY
GROUND SUBSTANCE IS FOUND
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

36. Loading should not be done
before 3-4 months(12-16 weeks),
while mostly woven bone is present.
After several months,the woven bone is progressively replaced by lamellar bone.
However, a steady state is reached after about 1½ year.
INTERFACE: BIOLOGIC CONSIDERATION—INITIAL HEALING PHASE

37. [ Nevins &Mellonig,1998 ]
TITANIUM
BONE
IMPLANT-BONE
INTERFACE

38. Conventional Implant Therapy
(Branemark’s procedure)
Surgery (1st ):Implant Placement in osteotomised hole
Healing: 4-6-8 months within bone under mucosal coverage
Delayed Loading: Fitting of Abutment and Occlusal load
through Prosthesis
Surgery (2nd ): Uncovering the osseointegrated implant
& placement of Gingival Former

40. Swedish school
Vs
Swiss school

41. In 1997, the first paper ever presented on immediately loaded
implants by Swiss group* won the first research prize at the
European Association for Osseointegration.
*Weber HP et al.(1997)Clinical and histometric analysis of osseointegration of immediately
loaded free standing implants in dogs (abstract).Clinical Oral Implants Research;Vol.8,page434.
After 30 years of Branemark’s discovery in 1967……….

42. In 1997, the first paper ever presented on immediately loaded
Implants by Swiss group won the first research prize at the
European Association for Osseointegration.
Later in the same year in November
First World Convention
Exclusively Focused on immediate loading of implants
The whole world observed the possibility of
loading implants immediate to it’s insertion in bone

43. Implant Loading
Delayed Loading: Conventional
4-6-8 months healing period
Immediate Loading: For last 16 years,
enough clinical documents have
suggested to load the implant
immediately/near immediately after
implant placement
a)to meet the pt.’s desire, and/or
b)to save the clinician’s time.

44. Implant Loading
Delayed Loading: Conventional
4-6-8 months healing period
Immediate Loading is now a
predictable treatment option
Immediate Loading: For last 16 years,
enough clinical documents have
suggested to load the implant
immediately/near immediately after
implant placement to meet the pt.’s
desire and/or to save the clinician’s
time.

45. The central factor between these two procedures is of course the
TIME

46. The central factor between these two procedures is of course the
TIME
Can healing of bone and then effective contact with implant body
be done simultaneously under loading ( a kind of disturbance!) ?
If the answer is YES…….It is the reality (New concept)
If the answer is NO……..Branemark’s postulation

48. Loading
Delayed Loading: Conventional 4-6-8 months
healing period
Immediate Loading
Fresh Extraction Socket Osteotomised Bed
(Fresh drill-cut)
Branemark New concept

49. Initial stability
•Good Bone Quality
•Appropriate implant morphology
•Apical drilling of ext. socket(3-5 m.m.)
•Under preparation of implant site

50. Bone quality & quantity

51. W
Cortical bone=100-200 MPa
Vs.
Cancellous bone = 5-6MPa
(Trabecular bone)

52. Middle 1/3
Apical 1/3
Coronal 1/3
More & Large marrow spaces:
More osteogenic potential
More bone mass
Less marraw space

53. Width of trabeculum at various
anatomical locations #
0.26
0.49
1.05
0
0.2
0.4
0.6
0.8
1
1.2
Coronal Middle Apical
Dimension
in
mm.
Dimensions of marrow space of
Various anatomic locations #
# Human data Ref. Pal,T.K. & Debnath,S.(1994)

54. ti Ti
Bone-Implant Contact(BIC)

55. i
BIC decreases BIC increases
Osteogenic
potential
increases
Osteogenic
potential
decreases
Implant with roughened surface

56. Difference between smooth and rough surface
Tolerance of micromovements

58. Implant insertion
Primary objective : Initial stability
Torque of 45-50 N-cm for initial stability of implant
More than this (in order to achieve more stability) is detrimental

59. Bone to heal
For initial stability optimal torque range up to 45-50 N-cm
Generates unfavorable
strain to peripheral bone
Compression : Bone resorption
If more If within
Generates favorable
strain to peripheral bone
Lamellated Bone formation

60. [ Pal et al,1995 ]
AREASELECTED
FOR IMPLANT EXPERIMENT
CADAVER GOAT MANDIBLE
AREA SELECTED FOR
HISTOMETRIC ANALYSIS
[Pal et al,1997 ]

61. Implant
(dia. in mm.)
Implant
insertion
without tapping
Implant insertion with tapping
Tap Implant
3.5 23.72 1.26 14.0  1.66 15.48 1.84
3.5 (Coated) 91.52  14.03 12.7  1.58 25.92 5.07
4.0 38.66  8.31 15.65  1.28 19.90 2.37
4.0 (Coated) 194  45.33 22.40  1.40 91.00 9.67
Mean Torque (N-mm.) with S.D. required for tapping and
insertion of implant in fresh cadaveric Goat Mandible :
(drill dia. = 3.18 mm., n = 20, SS-tap of dia. = 3.3 mm.) #
# Pal,T.K. and Chakraborty,A (1998)

62. 12.7 22.4
25.92
91
91.52
194.5
0
50
100
150
200
250
Torque
(N-mm.)
3.5 mm. dia. 4.0 mm. dia.
Tap
Implant with tap
Implant without tap
14
15.66
15.48
19.9
23.72
38.66
0
5
10
15
20
25
30
35
40
45
Torque
(N-mm)
3.5 mm. dia. 4.0 mm. dia.
Tap
Implant with tap
Implant without tap
Mean Torque (N-mm.) with S.D. required for tapping and
insertion of implant in fresh cadaveric Goat Mandible :
(drill dia. = 3.18 mm., n = 20, SS-tap of dia. = 3.3 mm.) #
Uncoated implants
Coated implants
# Pal,T.K. and Chakraborty,A (1998)

63. By careful housing of implant into bone
Depended on quality of bone
D1, D2, D3, D4
Compact bone Spongy bone
I n b e t w e e n
A foreign element has to stay in bone: Requirements
1. Immediate Primary stability, and
2. Osteogenesis for fastening of implant to bone

64. Favorable implant-bone interface: Attributed by…….
•Strictly following the basic fundamental surgical protocol
for one-stage one-piece implant
•Bone drilling at a very very low speed
•Use of surgical tap in D1 & D2 type of bone
•Immediate temporaries: out of occlusion

65. Dogmar Dasgupta,March,2009

80. Immediately after operation
On 11th.March,2009.

81. 2
9
April,2012

82. Thank you