Osseointegration

Dr. Priya Lele

MDS, (Periodontology)
Bharati Vidyapeeth (Deemed to be) University,
Dental College & Hospital, Pune
 CONTENTS
05 - Contact and
01 - Introduction
distance osteogenesis

02 - Definitions 06 - Factors affecting

osseointegration

03 - Theories of
07 - Success criteria
osseointegration

04 - The biology of
osseointegration 08 - Methods of
evaluation

09 - Future directions
 Introduction

 Osseointegration- A major scientific breakthrough

 Documented success and survival rates recorded - 87.8%

over a follow-up period of 36-years.

 Reasons - Osseointegration process

Long-term stability of the implant-bone interface

 Understanding the concept of osseointegration - mandatory.

 The Pioneers

Prof P I Branemark Prof Andre Schroeder

Branemark Group ITI Group
Jane Doe
• University of Gothenberg • University of Bern
Jane Doe
• Sweden • Switzerland

• Used machined implants with smooth surface • Used threaded implants with rough surface

• Completely edentulous patients • Fully and partially edentulous patients

• Two piece implants • One piece implants

• Submerged healing • Non submerged healing

• “Osseointegration” • “Functional Ankylosis”

• Nobel Pharma (Nobel Biocare) • Straumann

 Definitions
3
“Contact established without interposition
of non bone tissue between normal
1 remodelled bone and an implant entailing
Osseointegration a sustained transfer and distribution of
(Greek ) load from implant to and within the bone
Osteon-bone tissue.”
Integrate- to make whole. American Academy of Implant Dentistry
(1986)
4
“A process whereby clinically
asymptomatic rigid fixation of alloplastic
materials is achieved and maintained, in
2 bone during functional loading.”
Zarb and T. Albrektsson (1991)
“A direct structural and
functional connection between
ordered, living bone and the
surface of a load carrying
5
implant”. “A time dependent healing process
whereby clinically asymptomatic rigid
Branemark (1976) fixation of alloplastic materials is
achieved and maintained in bone
during functional loading.”

Zarb and Koka (2012)

 Adaptive Integration/ Biointegration

Adaptive Meffert
Biointegration
Osseointegration (1987)

Osseous tissue approximating

Is a direct biochemical
the surface of the implant
bone surface attachment
without apparent soft tissue
confirmed at electron
interface at light microscopic
microscopic level.
level.
 The Bone Implant Interface
The primary function of interface between bone and the implant is to provide an effective transfer
of occlusal load through the implant to the surrounding bone.

Two theories: Recent theory

1. Fibro osseous 3. A foreign body

integration reaction
2. Osseointegration
 Fibrous Integration

Linkow (1970) “ A tissue-to-implant contact

with healthy dense collagenous
James (1975) tissue between the implant and
bone”.
Weiss (1986).
American Academy of Implant
Dentistry (1986)
 Fibrous Integration
• Periodontal membrane (similar
to PDL in teeth) established
between the implant surface and
the bony osteotomy.

• It cushioned the occlusal loads

placed on the prosthesis and
transmitted these to the
surrounding bone • Later studies proved that

• Fibrous integration could not

withstand the forces applied
under functional load

• It became larger, with an

inflammatory reaction, gradual
bone resorption and finally
resulted in loss of fixture.
Linkow (1970), •So this theory was not accepted
James (1975)

Weiss (1986) .

(Linkow LI. Implant dentistry today: a multidisciplinary approach, Volume III. Italy:Piccin Padua; 1990: 1513-18)
 Osseointegration

After some animal He stated that implant to

experiments, it was
applied clinically for
oral implants in 1965.
1 3
bone contact without a
fibrous interface was
needed for functional
support under occlusal5
loading.

2 4
Direct bone anchorage of The term Osseointegration Most Accepted Theory
metallic implants was was coined by Branemark
discovered by Branemark in 1976
in 1962.
Osseointegration
“It is the direct connection b/w living
bone and and the surface of a load
carrying implant at the resolution level
of a light microscope”

P.I. Branemark, R. Adell, U. Breine, B.O. Hansson, J. Lindström, A. Ohlsson,Intra-osseous anchorage of dental
prostheses. I. Experimental studies, Scand.J. Plast. Reconstr. Surg. 3 (1969) 81–10)
 A Foreign Body Reaction
 A few researchers claimed that any foreign material
placed in bone will either be rejected, dissolved,
resorbed or demarcated with a dense layer of bone/
soft tissue capsule to protect nearby tissues.

 They described that titanium was capable of eliciting

immune responses when placed in tissues.

 They stated that osseointegration was foreign body

reaction where the tissues aimed at embedding the
titanium material in bone as a mode of protection for
nearby tissues.

(Donath K, Laas M, Günzl H. The histopathology of different foreign body reactions in oral soft tissue and bone tissue.
Virchows Arch APathol Anat Histopathol. 1992;420:131-137)

(Susuka F, Emanuelsson L, Johansson A, Tengvall P, Thomsen P. Fibrous tissue capsule formation around titanium and
copper. J Biomed Mater Res A. 2008;85:888-896)
 Osseointegration- A Novel Definition

“Osseointegration is a foreign body reaction where interfacial bone is formed as

a defence reaction to shield off the implant from the tissues.”

(Albrektsson T, Chrcanovic B, Jacobsson M, Wennerberg A. Osseointegration of implants - A

biological and clinical overview. JSM Dent Surg. 2017;2:1-6.)
 The Biology Of Osseointegration
1 2
Bone healing around It starts with woven bone
implants follows the formation and is followed
pattern and sequence later by formation of
of intra membraneous parallel-fibered bone and
osteogenesis. then by lamellar bone.

3
Bone remodelling takes place throughout life
and also involves the bone implant interface.
 The Biology Of Osseointegration
Cellular differentiation
Infilteration of neturophils (osteoclasts, osteoblasts,
Implant insertion and macrophages fibroblasts)

OSTEOPHYLLIC
2 4 6
PHASE
1 3 5
Blood clot formation Release of cytokines Neovascularization
around the implant

Matrix synthesis
2
OSTEOCONDUCTIVE
1
Woven bone formation
(60 μm/day)
Lamellar bone formation (1-5 μm/day) followed by
remodelling

OSTEOADAPTIVE
1
 Osteophyllic Phase

• Implant is inserted into cancellous marrow space of mandible /maxilla.

1

• Metal surface is exposed the fibro fatty marrow

2

• Osetoprogenitor cells/ osetoblasts from endosteal trabacular surface migrate to the

implant surface as an effect of the blood platelets activation and the presence of
3 growth factors such as PDGF, PGE2, and TGF-b and begin osteoid deposition.

• It lasts for about 1 month after implant insertion.

4
 Contact And Distance Osteogenesis
 After implant insertion, new bone formation begins at the osteotomy wall as well as on the implant surface (de

novo bone)

 Bone formation on the ostetomy wall- Distance osteogenesis

 New bone formation on implant surface - Contact ostegenesis

 Both processes result in biologic fixation of the implant in host bone.

(Osborn JF, Newesely H. Dynamic aspects of the implant bone interface.In: Heimke G, ed. Dental implants:

materials and systems. München. Carl Hanser Verlag 1980:111 -23)

 Contact And Distance Osteogenesis
Distance osteogenesis
 A gradual process of bone healing inward
from the edge of the osteotomy towards the
implant.
 Smooth surface implants heal by distance
osteogenesis
Contact osteogenesis
 The direct migration of clot building cells through the
clot matrix onto the implant surface.
 Leads to rapid, de novo bone formation on the
implant surface.
 Rough surface implants heal by both –distance and
contact osteogenesis.
Osteoconductive Phase

 The bone cells spread along the

implant surface laying down osteoid
(woven bone) in thin layers.
 This continues for next three months.
 At three months post-implantation, a
mixed bone texture of woven and
lamellar matrix can be found around
different types of titanium implants.
Osteoadaptive Phase

 After about 4 months, a steady state

(no gain or no loss of bone against
metal )

 Remodelling of bone around the

implant begins and continues
throughout the lifetime of the
implant.
 Factors Affecting Osseointegration

BIOCOMPATIBILITY STATUS OF HOST

BED

IMPLANT DESIGN SURGICAL

AND TECHNIQUE
MACROGEOMETRY (PRIMARY STABILITY)

IMPLANT SURFACE LOADING

CHARACTERISTICS CONDITIONS

Albrektsson T, Branemark P-I, Hansson H-A, Lindstrom J. Osseointegrated titanium implants. Requirements for ensuring a long lasting
direct bone-to-implant anchorage in man. Acta Orthop Scand 1981 ;52:155–170.
 Biocompatiblility
 Biocompatibility is the capacity of a material to exist in harmony with the surrounding biologic

environment .

 Commercially pure Titanium (CpTi) , Titanium Zirconium (Ti15Zr), Ti alloy (Ti6Al4Va) - extremely

biocompatible due to

 Increased resistance to corrosion

 Diminished inflammatory response in peri-implant tissues.

 Lack of toxicity to macrophages and fibroblasts

 Biocompatiblility
 Upon exposure to air, a thin (5–10 nm thick) layer of titanium dioxide (TiO2) develops spontaneously

on the surface of titanium metal.

 This TiO2 layer -

 Restricts the release of ionic/molecular Ti species into the surrounding tissues (Passivation)

 Has the ability to repair itself by re-oxidation when damaged.

 Improves wear resistance

 Ca++ and PO4 3- ions are adsorbed more readily on a TiO2 coated surface.
 Grouping Of Materials According To Their
Compatibility To Bony Tissues

Degree of
Characteristics of Reactions of Bony Tissue Materials
Compatibility

Implants separated from adjacent bone by a Stainless steel, Co Cr Mo and

Biotolerant soft tissue layer along most of the interface: Ni alloys
distance osteogenesis

Direct contact to bony tissue contact Alumina ceramics, zirconia

Bioinert osteogenesis ceramics, titanium, tantalum,
niobium, carbon.

Bonding to bony tissue: bonding osteogenesis Calcium phosphate- containing

Bioactive glasses, glass- ceramics, ceramics,
titanium (?)
 Implant Biomechanics
 Compressive forces- push masses
towards each other
 Tensile forces- pull objects apart
 Shear forces- cause sliding
 Bone is strongest when loaded in
compression, 30% weaker under
tensile and 65% weaker under shear
forces.
 Compressive forces tend to maintain
the integrity of the bone implant
interface
 Tensile and shear forces can disrupt
the interface
 Implant Design
Dental implants should be designed to maximize favourable stresses and to minimize undesirable stresses
along the bone-implant interface to ensure long term osseointegration.
THREADED IMPLANTS
SMOOTH CYLINDER IMPLANTS
 Rigidly fit into the osteotomy
 Shear type of force at the implant – bone
interface  Resist micromotion
 Result in bone loss  Increase the surface area / BIC%
 Facilitate the dissipation of stresses at
the bone implant interface
 Implant Design- Macrogeometry
 Implant shape (cylindrical/ tapered)
 Implant length Implant thread designs
 Implant diameter  Square shaped thread / buttress thread transfer
compressive forces to the bone at the interface and have
 Thread design higher BIC and reverse torque values
 Pitch  The v shaped sharp threads are self tapping , however the
shear forces on these threads are 10 times greater than
 Thread depth those on a square thread.
can affect long term
osseointegration.
 Implant Surface Topography
1. Machined/ smooth/turned implant surface
2. Modified implant surfaces (Mechanical and Machined
Chemical)
A. Additive surface treatments
 Ti plasma sprayed surface (TPS)
 HA coated surface
B. Subtractive surface treatments
 Acid etching- (HCL, H2SO4, HF, HNO3)
 Sand blasting- (Al2O3, SiO2, TiO2)
 Anodising - (voltage /electrolyte)
 Sand blasting and acid etching- (SLA
surface)
 LASER microtexturing

3. Modified implant surfaces (Biological)

Implant surfaces coated with growth factors,
peptides, drugs etc.
 Implant Surface Roughness
 The turned (machined), relatively smooth surfaces - modified to moderately rough surfaces.
 Surface roughness modifications have been performed at different resolution, variations at the μm and at the
nano meter levels to -
 1. Speed up the bone healing process
 2. Provide a strong primary stability to permit early loading .
 3. Promote use in compromised bone densities.

 Surface roughness values  Smooth implant surface → no bone cell adhesion → implant
 0.04 - 0.4 μm- smooth failure
 0.5-1.0 μm- minimally rough  Moderately rough surfaces →more bone in contact with implant
→ better osseointegration
 1.0- 2.0μm - moderately rough
 >2.0 μm- rough  Rough surface →increased corrosion/ion leakage
Wennerberg (1996) –moderately rough implants developed the best bone fixation

Wennerberg A, Albrektsson T, Andersson B. Bone tissue response tocommercially pure titanium implants blasted with fine and course
particles of aluminium oxide. Int J Oral Maxillofac Implants 1996;11:38-45
Microrough Surfaces - Why Are They Superior?

 Improved clot retention (Davies, 1998)

 Initial absorption of plasma proteins is enhanced

(fibronectin, vitronectin etc) (Kohavi (2010)

 MSC differentiate much faster on microrough surfaces as

compared to smooth surfaces (Ogawa et al, 2003)

 Micro-rough surfaces change gene expression of the

differentiating osteoblasts (Ogawa and Nishimura 2006)

 Bone deposited on micro-rough surfaces is harder and

stiffer than bone deposited on machined surfaces
(Butz,2006; Takeuchi et al, 2005)
 Hydrophilicity
 When a drop of water or blood immediately spreads and wets the surface, the biomaterial is said to be
hydrophilic

 Hydrophilicity / wetability- is recorded by water contact angle measurement. ( 00 – hydrophilic, >1400 –

hydrophobic)

 Hydrophilic surfaces more desirable as they influence the interactions with biologic fluids, cells and tissues.

 Wetability promotes protein adsorption, initial cell adhesion (platelets, PMNs, macrophages, monocytes) &
fibrin adhesion which provides contact guidance for the osteoblasts migrating along the surface.

 (D. Buser, R.K. Schenk, S. Steinemann, J.P. Fiorellini, C.H. Fox, Influence of surface characteristics on bone
integration of titanium implants, J. Biomed.Mater. Res. 25 (1991) 889–902
 Hydrophilicity

To achieve a super hydrophilic surface following methods are used

 Cleaning with plasma treatment

 Irradiation with uv-light

 Incorporation of Ca++, Mg++ and Fl - - ions into the TiO2

 Sandblasting, acid etching ad immersion in isotonic saline

 Surface Energy

 A surface with high energy →high affinity for protein adsorption →stronger osseointegration

 Glow discharge (plasma cleaning) results in high surface energy and also implant surface sterilization.

Baier RE, Meyer AE. Implant surface preparation. Int J Oral Maxillofac Implants 1998;3:9-20
 Summary of the Different Implant Systems Available and Their Surface Coatings and Main Characteristics

Implant System Surface Coating Characteristics

SLA Created by grit blasting + acid etching
Straumann SLActive
Same as above + rinsed with nitrogen and stored in NaCl

Nobel Biocare TiUnite Produced by Anodic Oxidation

TPS Titanium plasma sprayed

Zimmer MP-1 HA-coating HA coating
MTX (microtextured titanium) Grit blasting with HA particles
+ washing in non etching acid

RBM Sandblasted with soluble particles

BioHorizons HA coated HA coating
Laser-Lok Micro channels laser machined onto an implant surface

OsseoSpeed Nano surface 50-100 nm

TiOblast Created by titanium oxide blasting + chemical modification
Astra
by HF acid Titanium oxide-blasted surface

3i Nanotite CaP nanosurface 20-100 nm

TPS Titanium plasma sprayed
 Primary And Secondary Stability
 Osseointegration requires bone apposition on the implant surface without any micromovement.

 During implant insertion, stability that the implant achieves is completely mechanical and is called
primary stability.

 Secondary stability begins with the deposition of bone on the implant surface , thus achieving
biologic fixation.

 Primary stability is a pre requisite to achieve secondary stability.

 The sum total of primary stability which decreases over time and secondary stability which increases
over time accounts for total stability.

 A transient decrease in total implant stability is commonly observed 3 – 4 weeks after implant
placement as a consequence of loss of primary stability.
 Insertion Torque (IT)
 Torque is a measure of the turning force of an object e.g. bolt

 Expressed in Ncm(Newton centimeter) units.

 The force used to insert a dental implant into the prepared osteotomy is called the insertion
torque.

 Measured using calibrated torque wrench, electronic devices.

 Indirect measure of primary stability

 IT- 20-25 Ncm- indicates a good level of primary stability

 IT 35Ncm- optimum for immediate loading-

 IT ≥50 Ncm- peri implant bone loss (due to hypoxia and cell death & ↓angiogenesis due to
high compressing forces)
Loading Conditions Loading micromotion soft tissue
healing poor function

 Implant loading leads to micro-motion at

the bone-implant interface.
 Within certain limits, mechanical loading
stimulates bone formation.
 However, excessive micro-motion
compromises implant osseointegration. No micromovement bone healing
loading long term function
 Osseointegration was observed in the
presence of elastic interface micro-
motions of up to 30 µm, whereas micro-
motions larger than 150 μm were reported
to compromise or inhibit the biological
integration of the implant .

Cameron HU, Pilliar RM, MacNab I. The effect of movement on the bonding of porous metal to bone. J Biomed Mater
Res 1973;7:301-11
 Status Of Host Bed

A healthy bone bed with minimal surgical trauma is important since it is the
source of cells, local regulatory factors, nutrients, and vessels that contribute to
the bone healing response.

A high-quality bone (bone density and volume) is also important for the initial
implant stability
 Heat
 Bone - very sensitive to heat.
 The critical time temperature
relationship for bone tissue
necrosis is 470 C for one minute.
 Temperature ≥ 470 C results in
cell death and denaturation of
collagen.
 ≥ 560 C for 1 min. - denaturation
of the enzyme alkaline
phosphatase which is essential in
osteogenesis.

Eriksson RA, Albrektsson T (1984) The effect of heat on bone regeneration. J Oral Maxillofacial Surg 42:701–711
 Heat

 More frictional heat generated

during drilling in dense bone e.g.
mandible may reach these levels.
 No bone formed at the implant
bone interface.
 Implant surrounded by fibrous
capsule.
 Heat

 Prevent temperature rise -

 Use sharp drills
 Refrigerated coolant
 Slow drilling speeds
 (max.2000 rpm during creation of
osteotomy and 15-20 rpm during
implant insertion.)
 Graded series of drills.
 Contamination
Contamination of the implant surface can prejudice
achievement of osseointegration.

This may happen due to

Necrotic tissue

Bacteria

Chemical reagents

Debris from drills

 Drugs Inhibiting
Osseointegration
 NSAIDs especially selective COX-2
inhibitors
 Cyclosporin A
 Glucocorticoids
 Proton pump inhibitors (PPIs)
 Methotrexate
 Cis-platinum
 Warfarin and low molecular weight
Heparins
 Selective Serotonin Reuptake inhibitors
(SSRIs)- fluoxetine and venlafaxine
 Alcohol
 Anti VEGF- ranibizumab,bevacizumab
Drugs Promoting
Osseointegration
 Statins
 Antihistamines
 Calcium channel blockers
 Vitamin D
 Parathyroid hormone peptides
 Monoclonal RANK L inhibitors-
denosumab
 Selective estrogen receptor
modulators (SERM)
 Clinical Evidence Of Successful
Osseointegration
 Healthy peri implant soft tissues

 Implant not mobile when tested clinically.

 No s/o pain, infection, parasthesia, violation of mandibular canal, sinus drainange etc.

 Stable crestal bone levels- (Annual rate of bone loss less than 0.2mm after the first year of implant
loading)

 Absence of peri implant radiolucency.

 Successs rate of 85% at 5 years and 80% at 10 years of service.

(Albrektsson T, Jansson T (1986) Osseointegrated dental implants. Dent Clin North Am 30:151)
 Implant Stability Assessment Methods

Non invasive
Invasive methods

 Radiographic imaging
 Histology

 Insertion torque measurement

 Pull out / push out test

 Reverse torque analysis

 Removal torque analysis

 Periotest

 Resonance frequency analysis

 Periotest
 Mechanical device for determining implant rigidity.

 Projects a rod against the implant or abutment using a magnetic pulse at a certain speed.

 Measures the deceleration time needed before the rod comes to a standstill.

 This is transformed into an arbitrary unit, which reflects the rigidity of the bone implant interface

 Osseointegrated implants demonstrate increased rigidity over time

Periotest Device
 Periotest Values

Periotest value range(PTU) Interpretation

-8 to 0 Good osseointegration.
Implant can be loaded
+1 to +9 A clinical examination is required.
Loading of the implant might or might
notbepossible depending on the implant
type and clinical situation

+10 to +50 Insufficient osseointegration

Implant cannot be loaded
 Resonance Frequency Analysis (RFA )
 Non invasive diagnostic method to measure implant stability
 It uses a small L shaped transducer that is tightened to the implant or abutment by a screw
 Transducer has 2 ceramic elements- one which is vibrated by a sinusoidal signal (5-15k Hz)and the other serves as a receptor.
 Transducer vibrates the implant at a constant input and amplitude starting at a low frequency and increasing in pitch until the
implant resonates
 High frequency resonance indicates stronger bone implant interface. (ISQ values- 0 -100)
 E.g.- Ostell, Ostell Mentor, Implatest, Implomates

RFA Device
 Future Directions
1. Nanotextured implant surfaces

 Most of the surfaces currently available have random topography with a wide range of thicknesses,
from nanometers to millimeters.

 The exact biological role of these features is unknown because of the absence of standardized
surfaces with repetitive topography at the nano-sized level.

 The future of dental implantology should aim at developing surfaces with controlled and
standardized topography or chemistry.

 This approach is the only way to understand protein, cell and tissue interactions with implant
surfaces
Implant Design- Nano Features

 Nano modification of implants is

an emerging field with significant
potential for implant surface
modification.

 Laser-based, thermo-chemical
and electrochemical techniques
are used to achieve nano
topographies
Implant Design- Nano Features

 An attempt to mimic the natural Mesenchymal Stem cell (MSC)

structure of bone and soft tissues and
therefore to enhance the bone
healing process.

 Nano structured surfaces have

been found to promote MSCs
osteogenic differentiation and limit
fibroblast differentiation
 Future Directions

2. Incorporation of biologically active agents

 These include

 A. Growth factors- BMPs, PDGF, IGF-1 and 2

 B. Adjunction of a plasmid containing the gene coding for a BMP

 C. Arg–Gly–Asp (RGD) - A mediator of attachment of cells to several plasma and

extracellular matrix proteins, including osteopontin, bone sialoprotein, fibronectin.
 Future Directions

3. Drug doped implant surfaces

 Statin coating – local liberation of BMPs

 Biphosphonates – Bone antiresorptive drugs for use in severely compromised bone sites.

 Tetracycline-HCl coated implants- Antimicrobial agent

 Concluding Remarks

 There are a huge number of implant surfaces in the market, from different implant manufacturers,

all of them claiming to have better clinical results.

 It is important that the clinician selects for use in their patients the surfaces that have shown good

results in the scientific literature.

Thank You

Dr. Priya Lele

MDS, (Periodontology)