Osseointegration - dental implants training by Indian dental academy /certified fixed orthodontic courses by Indian dental academy

OSSEOINTEGRATION -- DENTAL IMPLANTS

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS:
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INTRODUCTION.
DEFINITION.
HISTORICAL REVIEW.
NORMAL BONE STRUCTURE AND PHYSIOLOGY.
BIOLOGICAL PROCESS OF OSSEOINTEGRATION.
BIOLOGICAL ATTACHMENT OF OSSEOINTEGRATION.
THERIES OF OSSEOINTEGRATION.
FACTORS INFLUENCING OSSEOINTEGRATION.
REVIEW OF LITERATURE.
FUTURE CONCEPTS OF OSSEOINTEGRATION.
CONCLUSION.

INTRODUCTION
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The ideal goal of modern dentistry is to restore the normal function,
form, and esthetics of oral structures.

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Implant dentistry is unique because of its ability to achieve this goal.

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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.


DEFINITION
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“Direct

structural and functional connection between

ordered, living bone and surface of a load carrying
implant”. -- Brane mark 1956.

• A time dependent healing process whereby clinically
asymptomatic rigid fixation of alloplastic materials is
achieved, and maintained, in bone during functional

loading.-- Zarb 1991.

HISTORICAL REVIEW

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Dr. Per-Ingvar Branemark- 1956

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Professor at the institute for Applied Biotechnology, University of Goteborg.


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Initial concept of osseointegration stemmed from vital
microscopic studies of microcirculation in bone repair
mechanisms.

Titanium chamber surgically inserted into tibia of rabbit


EXPERIMENTS ON DOGS TIBIA

Dog tibia with titanium stabilizer

Reconstructed tibia 3 years latter


Integrated titanium screws

EXPERIMENTS ON DOGS MANDIBLE

Segmental defect of dog mandible
reconstructed with titanium plate

Reconstructed area 6 months later


Formation of bone around implants

Indentation of implant on bone

Scanning electron micrograph after 9 months.

BONE PHYSIOLOGY AND STRUCTURE


Bone is Continuously Remodeling


BIOLOGICAL PROCESS OFOSSEOINTEGRATION

• OSTEOPHYLIC PHASE.
• OSTEOCONDUCTIVE PHASE.
• OSTEOADAPTIVE PHASE.


OSTEOPHYLIC PHASE:
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Blood clot formation.
Inflammatory cells infiltration.
Neovascularisation – 3rd day.
Ossification begins during first
week.
This phase lasts about one
month.


OSTEOCONDUCTIVE PHASE:
• Woven bone – foot plate.
• Lamellar bone formation.
• Lasts for 4 months.

osteoblasts

Neovascularization

Callus

OSTEO ADAPTIVEPHASE:
• A balanced remodeling
occurred.
Remodeling bone
• The foot plate/ woven
bone thickened in
response to the load
transmitted through the
implant.
• Some reorientation of
vascular pattern may be
seen.


BONE FORMATION AROUND IMPLANT:
• OSTEOGENESIS: Formation of new bone from
osteocompetent cells.
• OSTEOCONDUCTION: Formation of bone along
scaffold from hosts osteocompetent cells.
• OSTEOINDUCTION: Formation of new bone from the
differentiation and stimulation of mesenchymal cells
by bone inductive proteins.

BIOLOGICAL ATTACHMENT OSSEOINTEGRATION
GINGIVA-TITANIUM OXIDE CONTACT ZONE.

Hemidesmosome like structures anchoring the epithelial cells to the implant surface

SUBGINGIVAL CONNECTIVE TISSUE – TITANIUM CONTACT ZONE.
fibroblast


INTERFACE BETWEEN CORTICAL BONE AND TITANIUM.
Osteocyte


INTERFACE BETWEEN CANCELLOUS BONE AND IMPLANT

Osteoblastic processes
Fibroblastic processes


THEORIES OF OSSEOINTEGRATION
• BIOMECHANICAL BOND
• Branemark, Zarb, Albrektsson, 1985.


VAN DER WALLS BONDING


HYDROGEN BONDING


CHEMICAL BOND


CHEMICAL PROCESSES THAT CAN TAKE PLACE AT THE INTERFACE AT A MOLECULAR SCALE

CHEMICAL BOND-BIOINTEGRATION
• Sul etal – 2002.
• Electrostatic ion bonding of calcium ions with
polyanioinic molecules of bone matrix proteins
will occur.
• The calcium cations will stimulate particular
surface receptors and trigger further recruitment
of osteoprogenitor cells and osteoblasts through
calcium signaling pathway.

The neuromuscular system as it relates to
the
osseointegrated implant
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A fixture site does not have periodontal ligament but has nerve endings located
near the fixture, sensing pain and temperature.

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As the periodontal ligament is lost the fixture remains with reduce amount of
receptors.

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Impulses from the fixture sites are transmitted through nucleus of trigeminal
nerve.


FACTORS INFLUENCING THE
OSSEOINTEGRATION
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BIOCOMPATIBILITY
BIOMECHANICS.
IMPLANT DESIGN.
SURFACE ROUGHNESS OF IMPLANT.
SURFACE MODIFICATION OF IMPLANT.
HEAT PRODUCTION DURING OSTEOTOMY.
CONTAMINATION.
PRIMARY STABILITY OR INITIAL STABILITY
LOADING

BIOCOMPATIBILITY
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Biocompatibility has been defined as the
capacity of a material to exist in harmony
with the surrounding biologic environment;
not having toxic or injurious effects on
biologic functions.

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Key factors that influence the benefits and
maintenance of biocompatibility:

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Corrosion resistance.

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Cytotoxicity of corrosion products.

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Metal contamination.


BIOMECHANICS IN IMPLANTS
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Compressive forces attempt to
push masses towards each other.

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Tensile forces pull objects apart.

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Shear forces on implants cause
sliding.


IMPLANT DESIGN
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A smooth cylinder implant body
results in essentially a shear type
of force at the implant-to-bone
interface.


Threaded implants:
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More surface area.
Maximum initial bone contact.
Facilitate dissipation of
stresses at bone -implant
interface.
Rigidly fixed initially to limit
micro movement during
healing.


THREAD PITCH:
• The number of threads per
unit length.
• The finer the pitch, the
more threads on implant
body for a given unit length.
• The greater the number of
threads, the greater the
functional surface area.


THREAD SHAPE:
• The shear force on a Vthread face is about 10
times greater than the
shear force on a square
thread.


THREAD DEPTH:
• Is the distance between the
minor diameter and major
diameter of implant.
• The deeper the thread
depth, functional surface of
the implant body.


IMPLANT TAPER:
• A smooth sided tapered implant allows for a component of
compressive load to be delivered to the bone-to-implant
interface, depending on degree of taper.
• The larger the taper, the greater the component of
compressive load delivered to the interface.
• The amount of taper cannot be greater than 30°.
• Tapering of threaded implant has no advantage.


APICAL DESIGN OF IMPLANT:
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Round cross cross sections at
apex of implant do not resist
torsional or shear forces when
abutment screws tightened.

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As a result, an anti rotational
features are incorporated, usually
in the apical region of implant
body, with a hole or vent being
the most common design.

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Another antirotational features
are flat sides or grooves at apical
region.


IMPLANT WIDTH:
• Most implants falls with in the range of 3.5 to 6 mm.
• Increased implant width adequately increases the area over
which occlusal forces may be dissipated.


LENGTH OF IMPLANT:
• Most common lengths are
between 8 to 15 mm.
• As the length of implant
increases, the total surface
area increases.
• Within anatomical
limitation it is good practice
to use the longest implant.


CREST MODULE DESIGN:
• A smooth parallel, sided crest module
will result in shear stresses.
• An angled crest module of more than
20° will impose beneficial compressive
component.
• Crest module of an implant should be
slightly larger than the outer thread
diameter.
• Thus the crest module seats fully over
the implant body osteotomy,
providing a deterrent for ingress of
bacteria.

SURFACE ROUGHNESS OF IMPLANT
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Moderately rough implants
developed the best bone fixation –
Wennerberg, 1996.


IMPLANT SURFACE MODIFICATION
NEED FOR SURFACE MODIFICATION:
• To increase surface area.
• To remove surface contaminants.
• To bring better bonding.
• To increase surface roughness of metal.
• To increase corrosion resistance of metal.
• To make the metal more passive.

TECHNIQUES OF SURFACE MODICATION OF TITANIUM:
GRIT BLASTING:
• 250 µm diameter Al₂O₃ particles for 6 seconds at o.8
Mpa pressure.
• It provides a defined roughness.
• Micro-retentive surface pores are formed
ACID ITCHING:
• Done in a solution of Hcl at 40⁰c.
• The resulting surface textures, ranging in dimension from
1µm to 50µm micro retentive pits.


ANODIC OXIDATION:
• An electrochemical method of treatment.
• The sample is placed in an electrolyte bath, and a
potential is applied, a current will flow through the
electrolyte due to ion transport.
• The transport of oxygen ions through the electrolyte
builds up a passivating oxide layer on the surface of
sample.


PLASMA OXIDATION:
• An oxygen plasma is used instead of liquid
electrolyte.
• Plasma oxidation is a cleaner method than anodic
oxidation.
• Increased surface cleanliness usually results in an
increase in surface energy.
• Increases surface area of bone-to-implant interface.
• Stimulate osteogenesis.
• Resist shear forces and improve load transfer.

HYDROXYAPETITE COATING:
Advantages:
• Faster healing bone interface.
• Enhances gap healing.
• Stronger interface.
• Less corrosion of metal.
Disadvantages:
• Flaking, cracking on insertion.
• Increased plaque retention when above bone.
• Increased bacteria and nidus for infection.
• Increased cost.

CONTAMINATION:


HEAT PRODUCTION DURING
OSTEOTOMY:
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Heating of bone to a temperature in
excess of 47°C during implant surgery
can result in cell death and
denaturation of collagen.

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As a result, osseointegration may not
occur, instead the implant becomes
surrounded by a fibrous capsule.


LOADING
• Minimum integration time:
Region of implant
time

Minimum

Anterior mandible

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3 months

Posterior mandible

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4 months

Anterior maxilla

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6 months

Posterior maxillary

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6 months

Bone graft

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6-9 mon


PATIENT FACTORS:
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Age.
Compromised oral hygiene.
Heavy smoking.
Anemia.
Vitamin-c deficiency.
Uncontrolled periodontal disease.
Psychological problem.
Uncontrolled diabetes.
Radiation treatment.
Chemotherapy.
Bone density.
Available bone

BONE DENSITY:
CLASSIFICATION: Misch in 1988.
• D1 bone is primarily dense cortical bone.
• D2 dense to thick cortical bone on the crest and coarse
trabecular bone underneath.
• D3 bone has thinner porous cortical crest and fine trabecular
bone within.
• D4 bone has almost no crestal cortical bone.


• Increased bone density – provides mechanical
immobilization of implant and also permits
distribution and transmission of stresses.


REVIEW OF LITERATURE


IJOMI 2007;22:533-551.
•T-CAM, Tetra cell adhesion molecules enhanced the
differentiation of osteoblast like cells.
•T-CAM coating significantly enhanced the peri implant bone
formation in rabbit femur.


•Phosphated titanium has the potential to accelerate implant
osseointegration by increased TGF-b1 production.
•EMD did not accelerate osteoblast function


• Three different surfaces were evaluated. A machined
surface (Ti-M), was consider as control.
• The second surface was acid itched Ti-AE.
• Third surface was prepared by exposing Ti-AE to
NaOH solution.
• Third surface exhibited greater efficiency for
enhancing cell differentiation, and in turn, may
speed up the process of osseointegration

FUTURE CONCEPTS OF OSSEOINTEGRATION


Combining the concept of biomimetics and dental implants may change the world
of implant dentistry as we know it today.
BMP’s may act as growth and differentiation factors and as chemotactic agents.
They stimulate angiogenesis, migration, proliferation and differentiation of stem
cells from the surrounding mesenchymal tissues into bone forming cells in an
area of injury.
Coating implants with BMP’s may also accelerate initial healing time during
integration of the dental implant, thereby reducing overall treatment times and
improving overall success rate.


Research and development in this field will require attention to three main
aspects.
1.Selecting the appropriate surface texture.
2.Developing efficient carrier vehicles or surface precoating agents for initial
retention of the biomimetic substances and their controlled release.
3. Identifying appropriate biomimetic agents.


INTEGRINS
– Receptor proteins
which permit
cells to bind &
respond to the
extracellular
matrix.


BENEFITS
• Same-Day Teeth.
• Eliminates discomfort during a long
healing period.
• Fixtures are inserted in the
morning and the final prosthesis is
anchored in the afternoon.
• No rejection

OSSEOPERCEPTION :
The interaction between the osseointegrated
fixture bone tissue, receptor systems and
nervous system has to be studied.


CONCLUSION:

# THOROUGH UNDERSTANDING AND APPLICATION OF
FACTORS AFFECTING THE OSSEOINTEGRATION AND
BIOLOGICAL PROCESS OF OSSEOINTEGRATION IN CLINICAL
PRACTICE IS THE KEY FACTOR FOR SUCCESS.#


REFERENCES
• Dental implants in Prosthodontics
– Carl E.Misch.
• Textbook of Dental Implants
– Weiss.
• Textbook of Periodontology
– Langden.
• Textbook of implantology
-- Branemark.


ACKNOWLEDGEMENT
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Dr. L. Krishna Prasad – Professor & Head.
Dr. P. Srinivas chakravarthy
Dr. K. Naga Neelima Devi
Dr. M. Sridhar
Dr. Suprakash
Dr. Ram Kumar.
Dr. Sumanth Krishna.
Dr. Raja Satish.

THANK U
Leader in continuing dental education


Osseointegration - dental implants training by Indian dental academy /certified fixed orthodontic courses by Indian dental academy

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