Today’s standard implants are titanium screws There are numerous variables that distinguish the implants. For example, titanium can be of various grades, and titanium alloys containing aluminum and vanadium or zirconium are also available. Moreover, implants made of zirconium dioxide (zirconia) have entered the market; they have actually experienced a revival [6,7]. The implant surface can have a rather smooth, turned surface, or a moderately rough surface—combinations of both are also possible Dental implants exist in numerous geometries including short length [10,11] and small diameter Moreover, implants can be cylindrical or have the conic shape of a tapered implant In addition, dental implants have an internal fixation system for prosthetic components, the abutment. The standard is the two-piece implant, consisting of the dental implant and the abutment; the latter holds the prosthodontic restoration. There are even more variables that are considered relevant for osseointegration, such as the surgical approach and the local “quality” of the alveolar bone

2. Dental Implant
By
Romissaa Aly Esmail
Assistant lecturer of Oral Medicine, Periodontology,
Diagnosis and Dental Radiology (Al-Azhar University)

3. Contents:
• Introduction
• Modulating the Initial Responses of Blood/
Inflammatory Cells through Surface Engineering
• Bone–Implant Interactions
• Biological evaluation of bone-to-implant
interaction
• Antimicrobial Surface Engineering for Dental
Implants
• The use of concentrated growth factor in dental
implantology
• Implant survival and surgical modifier
• Artificial intelligence (AI) and dental implant
• Implant with certain precautions
• Adverse drug reaction that prescribed with dental
implant images
• Complication of dental implant
• Implant Failure

4. Today’s standard implants are
titanium screws
There are numerous variables that
distinguish the implants. For
example, titanium can be of
various grades, and titanium alloys
containing aluminum and
vanadium or zirconium are also
available.
Moreover, implants made of
zirconium dioxide (zirconia) have
entered the market; they have
actually experienced a revival [6,7].
The implant surface can have a
rather smooth, turned surface, or a
moderately rough surface—
combinations of both are also
possible
Dental implants exist in numerous
geometries including short length
[10,11] and small diameter
Moreover, implants can be
cylindrical or have the conic shape
of a tapered implant
In addition, dental implants have
an internal fixation system for
prosthetic components, the
abutment.
The standard is the two-piece
implant, consisting of the dental
implant and the abutment; the
latter holds the prosthodontic
restoration.
There are even more variables
that are considered relevant for
osseointegration, such as the
surgical approach and the local
“quality” of the alveolar bone

5. Implant dentistry is particularly
demanding in the esthetic region
with a high lip line, and scores for
evaluating the esthetic outcome of
a treatment have been developed.
The amount of bone is limited and
the buccal bone lamella resorbs
after tooth extraction, leaving a
narrow bone crest that makes
implant installation a challenge
Bone augmentation frequently
becomes necessary, often
combined with a protective
membrane of the defect toward
the rapidly growing soft tissue
Tooth loss also causes atrophy of
the maxillary bone, particularly in
the region below the sinus, and
bone augmentation becomes
necessary
To accomplish this, harvesting and
processing of autologous bone
and/or the use of bone
substitutes, which are usually of
xenogenic or synthetic origin,
become necessary [

11. The use of dental implants in modern dentistry has shown a staggering increase to up to annual numbers of 0.8 million
individual implants in the United States and 1.8 million in the European Union.
These numbers demonstrate the faith that these medical devices have earned after the initial observation of a machined
titanium (Ti) screw becoming integrated within bone tissue over 40 years ago.
The process responsible for this integration is known as ‘‘osseointegration,’’ which was initially defined as ‘‘a direct
contact between implants and bone at the resolution level of the light microscope.’’ In a more practical perspective,
osseointegration refers to ‘‘an anchorage mechanism whereby nonvital components can be reliably and predictably
incorporated into living bone, and that this anchorage can persist under all normal conditions of loading.’’

12. Predominantly due to advances in
surface engineering that improve
this osseointegration, the current
application of dental implants can be
regarded as a clinical success.
Based on evaluations using dental
implant survival and dental implant
success as criteria, rates of >94% for
5-year survival4 and >90% for 10-
year success5 have been reported.
However, these retrospective
numbers do not guarantee clinical
success for dental implants in the
future, as demographic changes in
life expectancy affect implant
osseointegration.
Additionally, peri-implant diseases
are a major concern for the success
of dental implants.8 In view of these
risk factors, surface engineering for
dental implants and prosthetic
components (e.g., abutments)
provides a tool to improve the
biological interactions with the
surrounding tissues along the
artificial dental root.
Necessitating different aspects in
terms of tissue interactions with soft
and hard tissues, we focus, in this
study, on the potential of surface
engineering to promote desired
biological responses.
The surface engineering approaches
not only cover physical and chemical
alterations, but also more advanced
engineering, enabling the release of
signaling factor

13. Modulating the Initial Responses of
Blood/ Inflammatory Cells through
Surface Engineering

14. Once a dental or orthopedic implant
is introduced into bone tissue, a
foreign body response is initiated.
This response includes the following
phases: blood–material interactions,
blood clot formation, inflammatory
responses, callus formation, and bone
remodeling.
During this process, different cells,
including platelets, neutrophils,
monocytes, macrophages,
lymphocytes, stem cells, endothelial
cells, osteoclasts etc. participate and
reciprocally influence each other in
different phases (Fig. 1).

18. EMERGING EVIDENCE
INDICATES THAT THE
IMMUNE RESPONSE
REGULATES THE INITIAL
TISSUE BEHAVIOR AROUND
THE IMPLANT AND AFFECTS
ITS LONG-TERM
INTEGRATION.
CONTINUED IMMUNE
ACTIVATION LEADS TO
CHRONIC INFLAMMATION
THAT RESULTS IN THE
REJECTION OF THE IMPLANT.
HOWEVER, WITHOUT AN
INFLAMMATORY RESPONSE,
DEBRIS WILL REMAIN,
BACTERIAL INFECTIONS
MIGHT EXAGGERATE, AND
THE EVENTUAL
INTEGRATION OF THE
IMPLANT AND GENERATION
OF NEW BONE TISSUE WILL
BE NEGATIVELY AFFECTED.
THEREFORE, RESEARCHERS
NOW RECOGNIZE THE
IMPORTANCE OF THE INITIAL
BIOLOGICAL RESPONSE AS
THE STARTING POINT FOR
DESIGN OF NOVEL IMPLANT
SURFACES WITH IMPROVED
FUNCTIONALITY.

19. Surface engineering to direct the
immune response and enhance the
success of implants generally builds
upon two directions, that is, regulating
the blood–material interactions or
directly regulating the cell behavior of
immune cells.
Blood–material
interactions lead to
protein deposition on the
implant forming a
provisional matrix, which
can affect subsequent
recruitment of immune
cells to the injury site.
The type, quantity, and
conformation of
adsorbed proteins is
governed by features of
the implant surface,
including surface
roughness, topography,
free energy, charge, and
exposed functional
groups.11,12
It is well accepted
that hydrophobic
surfaces adsorb
more proteins
compared with
hydrophilic ones.
The hydrophilicity
further affects the
conformation of
adsorbed proteins.
For example,
complement factor 3
(C3) adsorbed on
hydrophobic rather
than hydrophilic
surfaces shows a
conformation exposing
antigenic epitopes that
are biologically
activated.
Hong et al. speculated that a
hydrophilic surface adsorbs
proteins such as fibrinogen in
a misfolded way, which in
turn promotes platelet
binding, enhanced
thrombogenicity, and
osseointegration.
Their work additionally
demonstrated the importance of
surface chemical properties by a
simple fluoride ion modification
augmenting the thrombogenic
properties of titanium implants.
Similarly, morphological features of surfaces, such
as roughness, grain size, and crystallinity, can
influence protein adsorption

20. The host response to
implants is controlled by
neutrophils, macrophages,
and B- and T-lymphocytes.
Many of these cell types
have distinct phenotypes to
play complex, multifaceted
roles in inflammation and
regeneration through
signaling through diverse
cytokines, chemokines, and
growth factors that act on
themselves or in
combination on other cell
types.
Macrophages are well
characterized for displaying
either of two distinct
phenotypes in inflammatory
responses: the classically
activated proinflammatory
(M1) and the alternatively
activated anti-inflammatory
(M2) macrophage.
An optimal balance
between M1 and M2
macrophage activation is
required for desired
responses, including bone
formation and implant
integration.
Similarly, neutrophils,T-
helper cells (Th cells), and
dendritic cells24 can be
divided into different
phenotypes, which have
functionally disparate
immune responses and
proregeneration capacity.
Advances in material
biology has led to the
consensus that
manipulating surface
properties of implantable
materials can regulate cell
behavior ranging from cell
adhesion, proliferation,
activation, and
differentiation.
Accordingly, designing
implants with the proper
physicochemical surface
properties, which provide
an
osteoimmunomodulatory
capacity is the foremost
consideration for
endosseous dental
implantsteraction between
surface roughness and
immune cells

21. Figure 2: (a–f ) Immune system and
inflammation’s role in
osseointegration build-up RBC: red
blood cell; WBC: white blood cell
(Reproduced with permission from
Albrektsson et al. [9])

22. Surface
topography
represents
another
parameter to
influence
inflammatory
cells.
Several reports
addressed the
potential effect of
Ti surface
topography on
macrophage
functions.
These studies
demonstrate that
titanium surface
topography,
especially at the
nanoscale level,
can be
implemented to
influence immune
cell function.
Hydrophilicity is
another important
surface parameter
to modulate
immune cells for
implant
integration.
The
OlivaresNavarrete’
s group found that
hydrophilic rough
Ti surfaces
reduced
neutrophil
inflammatory
response
Furthermore, this
surface showed
more potential to
polarize
macrophages into
the M2
phenotype and
can create
changes in the
adaptive immune
response by
altering Th2 cell
populations and
stem cell
recruitment.

23. Modulating immune response with bioactive molecules.
Efforts have been made to endow implant surfaces with anti-inflammatory
properties by immobilization of bioactive molecules by either physical
adsorption or covalent bonding.
Quan et al. coated Ti discs with phospholipids and found macrophage
behavior was significantly changed with the concentration of loaded
phospholipids.
As macrophages exert diverse functions in sequence by switching from a
proinflammatory state to a proreparative state in bone regeneration,
modulating macrophage phenotypes through sequential delivery of M1-
/M2-activation molecules along with the bone formation process would
be a promising strategy to promote osseointegration

24. To achieve this goal, Alhamdi et al. designed a
biomimetic CaP (bCaP) coating layer to cover and
separate simvastatin from IFN-g to stimulate M2
macrophages following the M1 phenotype for
controlling macrophage activation in bones of
older patients.38
Except for proteins, peptides have shown higher
stability and easier control of surface density for
this approach. Peptide LL-37, a biomimetic
osteogenic peptide, and antimicrobial peptide
(AMP) GL13K were separately immobilized on Ti
surfaces to facilitate osteointegration by
modulating macrophage inflammatory status.

25. For instance, Bai et al.
designed a multifaceted
coating on Ti, which had
hybrid micro/nano
morphology,
superhydrophilicity, and
highly crystalline HA
nanoparticles.42
This unique coating
significantly
downregulated gene
expression of
inflammatory cytokines
to decrease the
inflammatory response.
This multifaceted coating
eventually enhanced
implant osseointegration
through favorable
regulation of
osteoimmunomodulatory
processes, osteogenesis,
and angiogenesis.
Moreover, combined
surface treatments for
roughness and
hydrophilicity resulted in
a combination of high-
energy and altered
surface chemistry present
on Ti surfaces; this
surface was able to
promote macrophages to
the antiinflammatory
phenotype and reduce
the expression of
proinflammatory factors

26. Bone–Implant Interactions

27. Osseointegration is
resulting in ultimate bone-
to-implant contact (BIC)
without an intermediate
fibrous tissue.
As such, osseointegration
can be so much alike with
bone fracture healing.
However, the process of
osseointegration is highly
complexed.
Immediately after implant
insertion, bone vessels are
damaged and the implant
surface is quickly covered
with blood components
and inflammatory cells
Thereafter, implant healing is
coordinated with unique
interactions between the
material surface, bone cells,
and extracellular matrix (ECM)
proteins.
Accordingly, the surface
characteristics of Ti
implants should play a
major role in
osseointegration.
Ti implants went through
several surface-
modification revolutions in
the past 50 years (Fig. 2).
Bra˚nemark implant was
initially machined with
smooth surface.
Afterward, a roughened
surface has been proven to
provide increased BIC.
Also, surface coatings with
bioactive materials have
been studied in the last
decade.
Additionally, smart-engineered surfaces have been
extensively investigated in recent years. Such smart
surface modifications can also be used to carry out
specific local drug release to treat and promote the
osteogenicity of Ti implants in patients suffering from
systemic diseases

36. Biological evaluation of bone-to-
implant interaction

37. As in Figure 3, histological/histomorphometric examination remain the ‘‘gold standard’’
methods for evaluating the bone–implant healing.
However, the histological analytic method has several limitations.
Consequently, searching for novel analysis methods using microcomputed tomography
(micro-CT), atomic force microscopy, confocal microscopy, confocal Raman microscopy,
scanning electron microscope, and scanning tunneling microscopy is mandated to enable in-
depth investigations toward the biological and physical characteristics of engineered implant
surfaces at different levels of resolution.
Still, micro-CT is the most commonly applied three-dimensional imaging technique,
especially for the ex vivo as well as in vivo biomaterial bone research.
The potential applications and limitations of micro-CT imaging are extensively
reviewed and described in literature.109 However, routine micro-CT imaging
often falls short in characterization of the BIC.1

39. Antimicrobial Surface Engineering for
Dental Implants

42. Although antimicrobial-
loaded surfaces induce
biofilm reduction, their
toxicity and burst
release limited the
clinical translation.
Because peri-implant
infection is mediated by
polymicrobial
accumulation, host
response, cell-material
interaction, and
environmental
status,154,155 there is
considerable interest in
engineering infection-
targeted antimicrobial
surfaces.
These smart surfaces
address multiple
biological functions
without compromising
the ecological
interaction between the
microbials and the host
in healthy conditions.
The antibacterial
efficacy of smart surface
engineering follows a
timely, controllable, and
site-specific biofilm
reduction in response to
‘‘on-demand’’
internal/external stimuli
(Fig. 4B).
Their working
mechanisms are
supported through
bioresponsive surfaces
sensing microbial
dysbiotic environmental
changes (pH, enzymatic
activity, and redox
function), or external
stimuli triggered by safe
and easy controlled
devices (temperature,
light, ultrasound, and
Recent research
suggests that grafting a
polymer that responds
to environmental
changes holds potential
for dental implants.
For example, knowing
that biofilm formation
leads to an acidic local
environment that
further skews immune
cell function toward
implant-associated
infections, efforts have
focused on developing
pH-responsive
polymeric coatings as
antimicrobial
compounds carriers

47. The challenge for the
development of
antibacterial abutment
surface

48. Chemical design strategies have been
followed for a wide range of natural
and/or synthetic coatings aimed to fight
bacteria through direct contact or drug
delivery.180
A straightforward approach to engineer
antimicrobial surfaces is to synthesize
polymeric layers that incorporate both
large and small antibacterial molecules,
based on the layer-by-layer (LbL)
assembly method.187–189
The ability to incorporate drugs in high
concentrations within a multilayer thin film,
without changing the topography required for
developing of a dense epithelial barrier at the
tissue–abutment interface, makes LbL assembly
an advantageous system to coat overall implant
devices without geometrical limitations.
Although the encouraging outcomes of
these approaches still remain limited to
laboratory studies,172,188 the knowledge
acquired in the field of antibacterial
surfaces has made large contributions to
the advancement of basic science to
clinical application

49. An alternative and versatile surface
modification technique is magnetron
sputtering.
Several studies have reported
encouraging findings using this
technique to improve physicochemical
and biological properties of implant
surfaces.
For instance, tantalum oxide thin films
deposited onto Ti demonstrated
increased surface roughness that
improved preosteoblastic cell
spreading and morphology, but
importantly did not increase the
number of bacteria adhering to the
surface.
To date, no abutment with
antibacterial surface properties is
commercially available.
Engineering antibacterial surfaces
hence remains a big challenge in the
dental field, as engineering approaches
remain restricted to laboratory
investigations.
The immobilization of antibacterial
molecules in films is clearly an effective
strategy to prevent disease initiation
and/or disease progression.
However, the major challenge is still
attributed at least partly to the related
cytotoxicity, that is, most surfaces
capable of fighting pathogenic bacteria
also have undesirable effects on human
cells.
Additionally, material stability issues
and maintenance of prolonged
antibacterial effect of the surface
treatment on implant abutment
surfaces remain as challenges toward
the translation of antibacterial
surfaces for abutments.

50. The use of concentrated growth factor in dental
implantology

51. Platelets are a natural source of GFs including
platelet-derived GF, transforming GF (TGF)-β1
and β2(TGF-β2), fibroblast GF, vascular
endothelial GF, and the insulin-like GF which
stimulate cell proliferation, matrix remodeling,
and angiogenesis.
Concentrated GF (CGF) was developed by
Sacco in the year 2006.[5] It is produced by
centrifuging venous blood, as a result of which
the platelets are concentrated in a gel layer,
comprising of a fibrin matrix rich in GFs and
leukocytes.
CGF acts by degranulation
of the alpha granules in
platelets which play a vital
role in early wound
healing.[7]
It has been found that CGF contains
more GFs than the other platelet-based
preparations such as platelet rich fibrin
(PRF) and platelet-rich plasma (PRP), and
unlike PRP, CGF does not dissolve rapidly
following application.
Qin et al. proved that CGF
could release GFs for at
least 13 days.
In vitro studies have
established the beneficial
effects of CGF in promoting
bone regeneration around
implants.
Animal studies have also
reported its potential
merits.

57. • Implant placement and loading protocol

64. Implant survival and
surgical modifier

75. Artificial intelligence (AI) and dental implant

76. Artificial intelligence
(AI) is a field of
computer science
aimed at performing
various specific
functions that require
human intelligence.
It imitates human
intelligence and
improves its these
features acquired over
time using the deep
learning methods
In radiological
diagnostic clinics, using
the AI has provided to
emerge the computer-
aided diagnosis (CAD)
systems.
Ten the development
of this system has
gained momentum in
many fields of
medicine and its use
also has become
widespread in health
sectors such as
dentistry in recent
years
A deep convolutional
neural network
method (DCNN) is a
powerful deep learnin
application used on
medical diagnostic
images

81. Dynamic navigation system
and dental implant

86. MRI and dental
implant

90. Implant with certain
precautions

106. Adverse drug reaction that
prescribed with dental
implant

118. dental implant failure