Osseointegration and more e A review of literature

S. Nubesh Khan
a,
*
, Mythili Ramachandran
b
, Swaminathan Senthil Kumar
c
,
Viswanathan Krishnan
c
, Rajasekar Sundaram
c
ABSTRACT
Implant placement in bone is presently associated with dened expectations of success based on dened clinical and
radiographic endpoints. This successful outcome has been correlated to the histologically represented bone-implant
interface and is commonly referred to as "osseointegration". The concept of osseointegration has thus signicantly
broadened fromits original sense to its denition as a direct structural and functional connection between living alveolar
bone and the dental implant as a load-carrier. Today, osseointegration is a term regarded as synonymous with clinical
success. To explain the micromechanisms involved in osseointegration, it is necessary to know concepts of biology,
physiology, anatomy, surgery and tissue regeneration. Osseointegration is observed in several areas, including not only
dental implants, but also maxillofacial implants, replacement of damaged joints and placement of articial limbs. Among
the important requirements for osseointegration are the existence of a biocompatible surface, the presence of alveolar
bone in the potential recipient sites and no traumatic surgery. According to Brnemark et al, the phenomenon of
osseointegration is due to new bone formation in close contact with the implant. To achieve this end, protocols were
developed, since several parameters havetobe dened, fromthe choice of the metal tothe placement andpreservationof
the prosthesis. Thus, osseointegration depends on the material used in the implant, the machining conditions, the surface
nish, the type of bone that receives the implant, the surgical technique, design of the prosthesis and the patient care.
The aim of the present review is to discuss current status of osseointegration in the eld of dental implants.
2012 Indian Journal of Dentistry. All rights reserved.
Keywords: Bone, Dental implants, Osseointegration, Stability
INTRODUCTION
Dentists and scientists have for a long time been research-
ing materials and techniques for providing predictable, ef-
cient and effective methods of restoring a depleted
dentition. Amongst the most versatile of these are osseoin-
tegrated implants.
1
It is of great clinical importance, as it
would provide early xation with long-term implant
stability, and it would minimize the risk of aseptic loos-
ening; a serious complication in reconstructive surgery,
thus reducing patient morbidity and health care cost. Dental
implant in the past offered limited hope with an inconsistent
prognosis. However, as a result of 30 years of biological
and technical research and 20 years of clinical research in
osseointegration, there is dependable hope. However,
because osseointegrated implants make direct contact with
bone, with no intervening connective tissue the traditional
concepts of xed and removable dentures may not apply.
2
Implant surfaces have been developed in the last decade
in a concentrated effort to provide bone in a faster and
improved osseointegration process. Several surface
modications have been developed and are currently used
with the aim of enhancing clinical performance, including
turned, blasted, acid-etched, oxidized, plasma-sprayed and
hydroxyapatite-coated surfaces, as well as combinations of
these procedures. Among the several parameters inuencing
the success of the implants, implantebone interface plays an
important role in prolonging the longevity and improving
the function of the implant-supported prosthesis. There are
several modalities to improve implantebone interface to
promote faster and more effective osseointegration. Despite
impressive gains in long-term predictability with titanium
a
Post Graduate Student,
b
Professor & HOD,
c
Professor, Department Of Periodontia, Annamalai University, Chidambaram, Tamil Nadu, India.
*
Corresponding author. Tel.: 91 9095130825, 91 9995333320, email: drnubesh@gmailcom
Received: 27.12.2011; Accepted: 30.3.2012
2012 Indian Journal of Dentistry. All rights reserved.
doi: 10.1016/j.ijd.2012.03.012
Indian Journal of Dentistry 2012 AprileJune
Volume 3, Number 2; pp. 72e76
Review Article
dental implants, achieving immediate xation in soft bone is
a continuing challenge to implant dentistry. It is, therefore,
important to have an open mind as more is learned about
the principles of osseointegration.
OSSEOINTEGRATIONeA REALITY
In 1952, Professor Per-Ingvar Branemark, a Swedish
surgeon, while conducting research into the healing patterns
of bone tissue, accidentally discovered that when pure tita-
nium comes into direct contact with the living bone tissue,
the two literally grow together to form a permanent biolog-
ical adhesion. He named the phenomenon osseointegration.
Originally, osseointegration was dened as direct bone
deposition on the implant surfaces, a fact also called func-
tional ankylosis.
3
Albrektsson et al dened
osseointegration as a phenomenon where intimate contact
between bone and biomaterials occurs at the optical
microscopy level, enabling surgical implants to replace
load bearing organs restoring their form and function.
Osseointegration can be compared with direct fracture
healing, in which the fragment ends become united by
bone, without intermediate brous tissue or brocartilage
formation. A fundamental difference, however, exists:
osseointegration unites bone not to bone, but to an
implant surface: a foreign material. Thus the material
plays a decisive role for the achievement of union.
3
Since
Branemark initial observations, osseointegration has been
intensively studied and the research is ongoing. Currently,
an implant is considered as osseointegrated when there is
no progressive relative movement between the implant
and the bone with which it has direct contact. Essentially,
the process of osseointegration reects an anchorage
mechanism whereby non-vital components can be reliably
incorporated into living bone and which persist under all
normal conditions of loading.
4
PREREQUISITES FOR OSSEOINTEGRATION
1) Material and surface properties
Osseointegration requires a bio-inert or bioactive mate-
rial and surface congurations that are attractive for bone
deposition. Titanium, either commercially pure or in certain
alloys, is generally recognized as being bio-inert and used
extensively in both dental and orthopedic surgery. A bioac-
tive material is thought to cause a favorable tissue reaction,
either by establishing chemical bonds with tissue compo-
nents (hydroxyapatite) or by promoting cellular activities
involved in bone matrix formation.
Cooper et al suggested that surface topography may affect
the amount of bone formed at the interface.
5
In a meta-
analysis by Cochran et al, the maxillary arch success rates
for rough-surface implants were observed to be signicantly
greater than the success rate in mandible for these implants,
which may suggest that difference in success rates due to
implant surface characteristics are more likely to be found
in lower bone densities.
6
Glauser et al in a clinical study
compared the implant stabilities of machined and oxidized
implants subjected to immediate loading in the posterior
maxilla during 6 months by means of Resonance Frequency
Analysis.
7
The results found surface-modied implants to
maintain implant stability during the rst 3 months of healing
in contrast to the machined surface implants.
Glauser et al reported a failure rate of 17.3% after 1 year
and analysis of the losses showed that most failures occurred
in the posterior maxilla.
8
Rocci et al also reported more
failures with machined implants than with oxidized
implants when subjected to immediate loading in the
posterior mandible.
9
It may be that although surface
texturing of implants do not directly contribute to initial
implant stability, it may reduce the risk of stability loss
and consequently facilitating wound healing (secondary
osseointegration).
10
2) Primary stability and adequate load
Primary implant stability is considered to play a funda-
mental role in successful osseointegration.
11
In a review
by Sennerby L. et al, primary implant stability has been
reported to be inuenced by the bone quality and quantity,
the implant geometry, and the site preparation technique.
12
Friberg et al reported an implant failure rate of 32% for
those implants that showed inadequate initial stability.
13
Ivanoff et al in a rabbit study investigated the inuence of
primary stability on osseointegration by placing titanium
implants so that some were primarily stable, some showed
rotational mobility, and some were totally mobile.
14
Primary implant stability is now generally accepted as an
essential criterion for obtaining osseointegration. By
means of Resonance Frequency Analysis, initial implant
stability can be quantitatively assessed and followed with
time as a function of implants stiffness in bone.
STAGES OF OSSEOINTEGRATION
Direct bone healing, as it occurs in defects, primary fracture
healing and in osseointegration is activated by any lesion of
the pre-existing bone matrix. Once activated, osseointegra-
tion follows a common, biologically determined program
that is subdivided into 3 stages.
3
1) Incorporation by woven bone formation;
2) Adaptation of bone mass to load (lamellar and parallel-
bered bone deposition);
Osseointegration and more e A review of literature Review Article 73
3) Adaptation of bone structure to load (bone remodeling).
1) Incorporation by woven bone formation
The rst bone tissue formed is woven bone. It is often
considered as a primitive type of bone tissue and character-
ized by a random, felt-like orientation of its collagen brils,
numerous, irregularly shaped osteocytes and, at the begin-
ning, a relatively low mineral density. Woven bone is the
ideal lling material for open spaces and for the construc-
tion of the rst bony bridges between the bony walls and
the implant surface. Woven bone usually starts growing
from the surrounding bone towards the implant, except in
narrow gaps, where it is simultaneously deposited upon
the implant surface. Woven bone formation clearly domi-
nates the scene within the rst 4e6 weeks after surgery.
2) Adaptation of bone mass to load (deposition of parallel-
bered and lamellar bone)
Starting in the second month, the microscopic structure
of newly formed bone changes, either towards the well-
known lamellar bone or towards an equally important but
less known modication called parallel-bered bone.
Lamellar bone is certainly the most elaborate type of
bone tissue. Packing of the collagen brils into parallel
layers with alternating course (comparable to plywood)
gives it the highest ultimate strength. Parallel-bered bone
is an intermediate between woven and lamellar bone: the
collagen brils run parallel to the surface but without a pref-
erential orientation in that plane. As far as the growth
pattern is concerned, both parallel-bered and lamellar
bone cannot form a scaffold like woven bone, but merely
grow by apposition on a preformed solid base. Considering
this last condition, three surfaces are qualied as a solid
base for deposition of parallel-bered and lamellar bone:
woven bone formed in the rst period of osseointegration,
pre-existing or pristine bone surface and the implant
surface.
Woven bone formed in the rst period of osseointegra-
tion: Deposition of more mature bone on the initially
formed scaffold results in reinforcement and often concen-
trates on the areas where major forces are transferred from
the implant to the surrounding original bone.
Pre-existing or pristine bone surface: This becomes
obvious in sites where implants are surrounded by cance-
lous bone. Quite frequently, the trabecule become necrotic
due to the temporary interruption of the blood supply at
surgery. Reinforcement by a coating with new, viable
bone compensates for the loss in bone quality (fatigue),
and again may reect the preferential strain pattern resulting
from functional load.
The implant surface: Bone deposition in this site
increases the bone-implant interface and thus enlarges the
load-transmitting surface. Extension of the bone-implant
interface and reinforcement of pre-existing and initially
formed bone compartments are considered to represent an
adaptation of the bone mass to load.
3) Adaptation of bone structure to load (bone remodeling
and modeling)
Bone remodeling characterizes the last stage of osseoin-
tegration. It starts around the third month and, after several
weeks of increasingly high activity, slows down again, but
continues for the rest of life. In cortical, as well as in can-
celous bone, remodeling occurs in discrete units, often
called a bone multicellular unit, as proposed by Frost.
Remodeling starts with osteoclastic resorption, followed
by lamellar bone deposition. Resorption and formation
are coupled in space and time.
Remodeling in the third stage of osseointegration
contributes; to an adaptation of bone structure to load in
two ways:
a) It improves bone quality by replacing pre-existing,
necrotic bone and/or initially formed more primitive
woven bone with mature, viable lamellar bone.
b) It leads to a functional adaptation of the bone struc-
ture to load by changing the dimension and orienta-
tion of the supporting elements.
FACTORS WHICH DETERMINE THE SUCCESS
OF OSSEOINTEGRATION
Albrektsson et al rst referred to the six important factors
which determine the success of osseointegration. These
are: implant biocompatibility, design characteristics,
implant surface characteristics, state of the host bed,
surgical technique, and implant loading conditions. LeG-
eros and Craig categorized these factors into biomaterial,
biomechanical and biologic determinants.
1
1) Biomaterial factors
The biocompatibility of the material is of great impor-
tance and a predictor of osseointegration, as it is essential
to establish stable xation with direct bone-implant contact
and no brous tissue at the interface. Pure Titanium (Ti) is
widely used as an implant material as it is highly biocompat-
ible, it has good resistance to corrosion, and no toxicity on
macrophages or broblasts, lack of inammatory response
in peri-implant tissues and its surface is composed of an
oxide layer and has the ability to repair itself by reoxidation
when damaged. Other materials have also been proposed
either as alternative to Ti or as alloy systems, including
tantalum, aluminum, nionium, nickel, zirconium, and
hafnium.
1
Two forms of titanium (Ti) are principally used
74 Indian Journal of Dentistry 2012 AprileJune; Vol. 3, No. 2 Khan et al.
for endosseous dental implants. They are commercially pure
titanium (cpTi, at least 99.5% pure Ti) and a titanium alloy,
titanium-aluminum-vanadium (Ti-6AI-4V). CpTi is
available in four grades which vary in their oxygen
content. Grade I cpTi is the purest and therefore the
softest. Grade 4 cpTi has the most oxygen at 0.4% by
weight, and is the material used for dental implants. Ti is
the material of choice in implant dentistry. Its excellent
corrosion resistance is due to the surface which oxidizes
spontaneously upon contact with air or tissue uids. This
layer, normally approximately 2e5 nm thick is primarily
TiO
2
. Williams described a biocompatible material as
one which possesses the ability to perform an appropriate
host response in a specic application, and consequently,
Stanford and Keller proposed that the term
osseointegration reects the results of a lack of
a negative tissue response to Ti, rather than the presence
of an advantageous one.
1
Rahal et al showed that Ti does
not have the ability to induce osteogenesis from potential
osteogenic precursor cells in mice marrow.
15
Larsson et al
showed that bone healing around machined Ti implants
takes place by a gradual mineralization process directed
towards, but does not start, at the implant surface.
16
Ti is
a reactive material, and Hanawa found that it naturally
forms calcium phosphate on its oxide layer in a neutral
electrolyte solution simulating body uids.
1
2) Biomechanical factors
There are numerous designs of implant systems
currently available. However, the original Branemark
implant system is the best documented and researched
implant system in current use. The Branemark implant
system was based on a two stage surgical procedure fol-
lowed by the construction of either a xed or removable
precision attached prosthesis. It is assumed that when an
implant is osseointegrated, the titanium implant and bone
may be regarded as having a perfect t, similar to the anky-
losis of teeth in bone, with no stress in either material prior
to loading.
1
3) Biologic factors
Esposito et al (1999) dened biological failures related
to biological process, and mechanical failures related to
fractures of components and prostheses.
17
Patient factors
are important determinants of implant failure. Ekfeldt
et al (2001) identied the patient risk factors leading to
multiple implant failures and concluded that
a combination of several medical situations could provide
a contraindication to implant treatment.
17
Diabetic patients experience delayed wound healing,
which logically affects the osseointegration process. Fiorel-
lini et al (2001)
18
demonstrated a lower success rate of only
85% in diabetic patients, while Olson et al (2000)
19
found
that the duration of the diabetes had an effect on implant
success: more failures occurred in patients who had
diabetes for longer periods. Fiorellini et al (2001)
18
also
observed that most failures in diabetic patients occurred
in the rst year after implant loading.
The adverse effects of cigarette smoking on implant
treatment are well documented. A longitudinal study by
Lambert et al (2000) found more failures in patients who
smoked, Bain and Moy and Lindquist et al showed that
smoking may be directly related to the soft tissue changes
and marginal bone loss around dental implants.
1
Theoretically, patients with increased age will have more
systemic health problems, but there is no scientic evidence
correlating old age with implant failure. Although Salonen
et al (1993) stated that advanced age was a possible contrib-
uting factor to implant failure; other reports have showed
no relationship between old age and implant failure.
4
THE FUTURE
The search for improved osseointegration in soft bone has
helped propel more than 20 years of post-Branemark
research in implant design, materials and surfaces. The
future now seems to be looking to nanotechnology, like
the recent introduction of a chemically-modied implant
surface, or biotech concepts such as the possible incorpora-
tion of bone morphogenetic proteins onto the implant
surface to enhance osseointegration. Certainly it seems
there is more development and evolution to come, which
will ultimately add to the history of these small metal
devices, but only until such time as the very notion of
screwing metal into bone becomes historical itself, which
it surely will as genetic engineering gathers pace.
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