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Osseointegration: The direct structural
and functional connection between ordered, living bone and the surface of a loadcarrying implant.
Biologically compatible materials that can be used for manufacturing of implants They include: A. Metals and metal alloys: most widely used material is titanium and its alloy B. Ceramics and carbons: aluminum oxide, carbon, carbon-silicon compound, and hydroxyapatite C. Polymers and composites: includes cross-linked polymers (silicone, rubber, polyethylene) not in general use at present.
The Peri-implant mucosa:
1. Mucosal tissue dense collagenous lamina propria covered by stratified squamous kertinizing epithelium. 2. Implant epithelium junction (junctional epithelium) hemidesmosomes and a basal lamina. 3. Sulculs around the implant sulcular epithelium with 1.5 – 2 mm depth 4. Capillary loops found in the C.T similar to normal periodontium anatomically but with reduced vascularity 5. Collagen fibers nonattached and run parallel 6. The marginal portion of the peri-implant mucosa collagen + fibroblasts
The Implant – Bone interface: 1. Osseointegration: - There is an absence of C.T. or any non bone tissue in the interface between the implant and the bone at the light microscope level. - Successful cases will have 30% and 95% of the implant surface in contact with bone. - After an initial remodeling in the first year that results in .9-1.6 mm of bone reduction, the bone level around healthy functioning implants remains stable. - Compact bone offers a much greater surface area for mineralized tissue- to implant contact than cancellous bone maxilla has lower success rates then mandible. 2. Fibro-osseous integration - In which soft tissue (fibers and/or cells) are interposed between the implant and the bone.
II - Clinical Aspects of Dental Implant
A. Appropriate selection of cases B. Adequate preparation of biomaterials C. Careful handling of patient’s soft and hard tissue
A - Appropriate selection of cases
1. Pt must be in good general health 2. Good oral hygiene 3. Good periodontal health ( bacterial flora in periodontitis can jeopardize the healing of the implant sites) 4. Resteration present 5. Level of decay activity 6. Cause for previous tooth loss 7. Pt motivation 8. Appropriate occlusal forces 9. Bone quantity and quality palpation, bone sounding and radio-graphs (panoramic, periapical, lateral, cephalometric, CT. scan) – minimal width of the jaw bone is 6 mm , minimal height is 10
10. Soft tissue quality and quantity good keratinized, attached mucosa for better functional and aesthetic results for implant restoration
B – Adequate preparation of biomaterials To achieve an osseointegrated implant with a high degree of predictability. The implant must be: 1. Sterile 2. Made of a biocompatible material 3. Inserted with an atraumatic surgical technique (heat) 4. Placed with initial stability 5. Not functionally loaded during the healing period of 4-6 months.
C- Careful handling of patients soft tissues 1. Aviod over heating of bone 2. Good handiling of soft tissues during suturing
Various implant systems
The systems differ in: 1. Biomaterial a) pure titanium b) plasma-sprayed titanium surfaces c) plasma-sprayed hydroxyapatite surfaces 2. Design a) screw-shaped ( threaded ) b) cylinder-shaped c) Tapered screw-shaped 3. Surgical procedures a) Immediate ( at the time of extraction ) b) Delayed ( 2 monthes after extraction to allow for soft tissue healing ) c) staged ------ 1- one stage 2- tow stage ( 4 – 6 monthes after extraction to allow for bone healing ) * Implants come with different lengths (7-20 mm) and widths (3.25-6 mm) to accommodate the available bone quantity.
- There are more than 50 types of implant
systems world wide, many lack short – and long data . Examples of implant systems with good clinical and experimental research are : 1- Nobel Biocare System 2- International Team for Oral Implantology (ITI) System 3- 3i ( Implant Innovations ) System 4- Astra dental Implant System
Nobel Biocare System developed by Branemark in sweden in the early 1960s - it is a machined pure titanium screw-shaped implant - Tiunite-------- TPS coating - SteriOss system --------Replace (tapered titanium implant which comes in an acidetched, TPS, HA coatin )
• Intrnational Team for Oral Implant ( ITI ) System - developed in Switzeriand by Schroeder and colleagues in the early 1970s - it comes in different designs ( hollow cylinder, full-body screw ) - surface characteristic-----befor it was plasma-sprayed titanium coating, now it is sand-blasted, acid-etched surface - implant protrudes through the mucosa adva.------- no second surgery, disadva.----- 1- premature loading 2- danger of titanium showing in the marginal mucosal area
3i (Implant Innovations ) System - developed by Lazzara and Beaty in 1988 - it 1or 2-stage commercially pure titanium screw and cylinder implant with either an acid etched, TPS, HA coated surface - new implant------- rough middle and apical part ( for better bone integration ) and smooth coronal part ( for better maintenance properties )
Astra Dental Implant System - developed in the 1980s in Swedwn - it is a pure titanium screw shaped implant with an oxide-blasted coating - it comes with conical abutment that fits tightly into the coronal part of the implant
Surgical Aspects of Dental Implants
The Root form implants can be divided according to their : - I - body shapes (macrodesign) - II - surface topography (microdesign)
I ‒ Macrodesign
a) Threadless b) Threaded - Provide superior initial stability - In dense bone they need taping - Some are shaped conically to minimize apical bone fenestration - Good for in anterior immediate placement
II ‒ Microdesign - Textured surface (HA, TPS) - Provide secondary stability - If surface is exposed to oral fluid and microorganisms progressive bone loss - Smooth surface implant is more resistant to bacterial contamination and progressive bone loss but provides weaker secondary stability
Staged Implant placement
One Stage: The coronal portion stays exposed through gingiva during the healing period Two Stage: The top of the implant is completely submerged under gingiva
Advantages of one-stage implant surgery 1-easier mucogingival management 2-patient comfort ↑ because ↓ surgeries are involved 3-esthetic management is easier
Recommendations for two-stage implant surgery 1-if there is extensive bone loss at the implant site 2-if vertical bone augmentation is necessary 3-if interproximal bone of the adjacent teeth is lacking
For both one and two-stage implant approach the implant should not be loaded for 2-3 months in the mandible and for 4-6 months in the maxilla
Immediate Implant Placement
It is the placement of the implant immediately after tooth extraction • Advantages 1. Reduction of the healing time 2. Enhancement of the bone-to-implant contact (implant is placed in a high osteogenically active site) • Disadvantages 1. The Need for mucogingival surgeries (in twostage implant surgeries) 2. The need for bone grafting around the implant 3. Potential for preexisting infections associated with the extracted tooth.
• Delayed implant placement
Placement of the implant 2 months after the extraction to allow for soft tissue healing
Advantages 1. Easier mucogingival management 2. We have more osteogeneis adjacent to the implant 3. Reduction of the treatment time 4. Allows time for resolution of infection from the extracted tooth
Adjunctive Advanced Surgical Techniques
There are anatomic limitations of the jaw that complicate oral implantology, e.g.: 1. Narrow and short ridge 2. Pneumatization of the maxillary sinues 3. Severely resorbed ridges
Narrow and Short Ridge
Bone augmentation techniques (horizontal and vertical) 1. Particulate bone grafts 2. Monocortical block grafts (symphysis, ramus, iliac, tibia) 3. Distraction osteogenesis ( vertical )
Pneumatization of the Maxillary Sinuses
• Sinues lift augmentation 1. Internal
‒ If the bone height is more then 5mm ‒ Implant is placed at the time of the lifting ‒ If the bone height is less then 5mm ‒ Implant is placed after 6 months of the augmentation
Severely Resorbed Ridges
• Mandibular nerve repositioning
‒ Paresthesia and dysesthesia of the lower lip normal after 6 months
Implant Reconstruction 1. Fully edentulous arches A - Fixed (Screwed cemented) B - Overdenture (clips + bar) 2. Partially edentulous 1 - Single tooth 2 - Multiple teeth
1. Early onset (during the treatment phase) mobility after the healing period 2. Late onset (during the maintenance phase) mucosal inflammation, progressive bone loss and mechanical problem
- Proper oral hygiene and appropriate occlusal forces are critical for long-term function of an implant prosthesis. - Recalls should be every 3 months for the first year, and then every 6 months - Evaluation of oral hygiene, occlusal harmony implant and prosthesis stability, overall soft and hard peri-implant tissue health, and radiographic follow up.
III - Diagnosis and Treatment of PeriImplant Disease
Pathologic changes of the peri-implant tissues - Peri-implant mucositis: inflammatory changes which are confined to the soft tissue surrounding an implant - Peri-implantitis: progressive periimplant bone loss in conjunction with a soft tissue inflammatory lesion. the over all frequency of periimplantitis is in the range of 5% to 10% - the mean crestal bone around an implant decreases 0.9 to 1.6 mm during the first year of implant function
A. Bacterial infection B. Biomechanical factors C. Cofactors
A - Bacterial infection
Plaque accumulation of the implant surface subepithelial C.T becomes infiltrated by large number of inflammatory cells ulcerated and loosely adherent epithelium plaque migrates more apically clinical and radiographic signs of tissue destruction - Bacterial flora in adult periodontitis and peri-implantitis have great similarities - Bacterial flora in totally edentulous and partially edentulous mouth is different. Q: Why is the size of the soft tissue inflammation and bone loss greater around implants than around teeth? A: 1. Low vascularity soft tissue band around the implant 2. Difference in the collagen-to-fibroblast ratio of the gingival tissue (affects the defense mechanisms) 3. Implant surface characteristics (Hyroxyapatite coated implant vS. Titanium coated implants) -
B - Biomechanical Factors
- Excessive biomechanical forces that lead to high stress or microfractures in the coronal bone – to – implant contact which lead to less of osseointegration around the neck of the implant - The role of loading has increased influence in: 1. The implant is placed in poor-quality bone 2. Poor load distribution 3. Parafunction 4. The prosthetic superstructure does not fit the implants precisely.
C – Co factors
1. Traumatic surgical techniques 2. Inadequate amount of host bone 3. Compromised host response 4. Smoking
Signs of peri-implant disease
1. Pocket formation ( normal probe
penetration is 3 to 4 mm )
2. Radiographic bone destruction
(normal periimplant bone level is 1 mm apical to the position of the probe tip)
3. 4. 5. 6. 7. 8.
Suppuration Calculus build up Swelling Color changes Bleeding on probing mobility
Treatment of peri-implantitis A – Occlusal Therapy
1. Analysis of the fit of the prosthesis change in the prosthesis design 2. Analysis of the number and position of the implants force distribution 3. Occlusal evaluation occlusal adjucment
B – Anti-infective therapy
1. Removal of plaque and polishing with high-pressure air powder abrasive ( sodium bicarbonate and sterile water ) 2. O.H. Re-inforcment 3. Subgingival irrigation of the peri-implant pockets with chlorhexidine 4. Systemic antibiotics for 10 days ( doxycycline and metronidazole )
C – Surgical Therapy 1. Resective therapy To pocket + correct negative osseous architecture + the area of keratinized gingiva 2. Regenerative therapy to pocket with regeneration of lost bone tissue
Morphology of Osseous Defect
• Group I = moderate horizontal bone loss with minimal intrabony component • Group II = moderate to severe horizontal bone loss with minimal intrabony component • Group III = minimal to moderate horizontal bone loss with an advanced circumferential intrabony lesion • Group IV = moderate horizontal bone loss with an advanced circumferential intrabony lesion + the buccal and \ or lingual plate has been lost
Indication for Nonsurgical Therapy
1. Mucosal inflammation 2. Radiographic bone level stable 3. Phase I therapy before surgery
Indications for Resective Therapy 1. Moderate to advanced horizontal bone loss 2. Moderate vertical bone defect ( < 3mm ) 3. One and two wall defects 4. Implant position in nonaesthetic area
Indications for Regenerative Therapy 1. Implant allows complete closure with flap 2. Moderate to advanced vertical defects 3. Two and three wall bone defects 4. Detoxification of implant surface possible
Indications for Implant Removal 1. Severe peri-implant bone loss (> 50%) 2. Unfavorable advanced bone defect (one wall) 3. Rapid, severe bone destruction (within 1 year of loading) 4. Non surgical or surgical therapy ineffective 5. Esthetic area precluding implant surface exposure
Surgical Aspects of Dental Implants At the end of the lecture, students should be able to: Know how to select suitable cases for implant cases therapy Know complications of implants and how to maintain implant patients Know the different techniques of endosseous implant surgeries Explain how to diagnose and treat peri-implant disease
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