MATERIALS USED FOR DENTAL IMPLANTS.

REQUIREMENTS FOR
THEM, TYPES OF MATERIALS
Dental implantation is associated with the introduction of foreign bodies into
the tissues of the body and with the tissue reaction to this material. The main
condition for the success of treatment is the engraftment of the implanted material,
therefore strict requirements are imposed on it.
When choosing a material for dental implantation, one should be based on a
deep knowledge of how it will act in the biological environment of the body. At
the present stage of development of dental implantology, there are certain
requirements for implant materials. All requirements can be divided into three
large groups.
The first group provides for the compatibility of the material and the
environment in which it must operate. When selecting biomedical materials, the
most important factor is biocompatibility, both the effect of the material on
surrounding tissues and the effect of the biological environment on the material,
i.e. The material should not:
- cause unwanted, clinical detectable changes in the organs and tissues of the
body;
- the material should not disturb or change the course of the natural process of
osteogenesis;
- do not cause corrosion, do not cause inflammatory processes of surrounding
tissues;
- to react with organic substances and form complex compounds, decompose
in the tissues into ions, atoms, oxides;
- form magnetic and electric pairs, do not change the physical properties in
the body;
- undergo significant mechanical or chemical changes in the surrounding
tissues;
- cause allergic reactions;
- be carcinogenic.
The second group includes the mechanical and physicochemical properties of
the implantation material, which are necessary to perform certain functions. These
are properties such as elasticity, fluidity, ductility, stiffness, deformation, tensile
strength, fatigue, hardness, and wear resistance. The material implanted in the
tissue must withstand pressure, since otherwise tissue irritation occurs, the
processes of resorption in the bone increase and the stability of the implant is
impaired.
The third group, where technology and accessibility are considered. This
group of requirements emphasizes the possibility of strict control of components or
chemicals in the technological process, the homogeneity of the structure, the
homogeneity of the material, the availability of technologies for the perfection or
completeness of a given surface of the material, the minimum technological cost
and the subsequent use of any of the known sterilization methods.
In the manufacture of implants, three main groups of materials are used:
metals, ceramics and polymers. The study of the reaction of living bone and soft
tissues to implantable material made it possible to divide them according to
biocompatibility into three groups: bio-tolerant, bio-inert, and bioactive. For
biotolerant materials (stainless steels, alloys of chromium, cobalt and
molybdenum, as well as the latter with nickel), as a response to the irritating effect
of the implant in the area in contact with the tissues, the appearance of distant
osteogenesis in the bone is characteristic. In this case, a bone from the implanted
implant from these materials separates a layer of soft fibrous tissue. Bioinert
materials (aluminum ceramics, zirconia ceramics, titanium, tantalum, niobium,
carbon) create contact osteosynthesis, i.e. direct connection of these materials with
bone tissue. Bone integration is due to the fact that the surface of such materials is
chemically inert to surrounding tissues and tissue fluids. Bioactive materials
(calcium phosphate ceramics, glass, glass ceramics) cause connective
osteosynthesis, which is a certain type of direct chemical connection of the implant
with its surrounding bone due to the presence of free calcium and phosphorus on
the surface of the material and the adequacy of their interaction with tissue
components of the bone.
Biological compatibility is the absence of immune reactions, inflammatory
processes and, as a result, implant rejection. Bioadhesiveness - characterizes the
ability of the implant material to bind to proteins without substantially changing
their structure. A kinetic model of the surface reactions of organic molecules with
metal implants is known, which takes into account both the properties of the tissue
and the composition of the biological fluid, and the type and properties of the
oxides covering the surface of the implant. It has been proven that for titanium
implants, electron transport across the interface is inhibited by a thick passivating
oxide layer, while protein adsorption is not accompanied by a change in their
native conformation. On the surface of metals or alloys forming a layer of oxides
with electronic conductivity in a biological medium, adsorbed macromolecules
change their conformation due to electrochemical reactions. Thus, high
biocompatibility is due to weak exchange ions on the surface of the "implant -
living tissue" interface, which ensures stable cell regeneration.
According to the leading international centers of dental implantology, more
than 95.0% of implantable structures are made of titanium and its alloys, less and
less cobalt-chromium alloys are used for these purposes, and very rarely alloys of
precious metals, ceramics and composites. The following grades are currently
approved for use: VT-1-0; VT-1-00; VT-6. For example, in the USA and in
England, special grades of implantation titanium such as Ti-35A, Ti-75A are used.
 TYPES AND TYPES OF DENTAL IMPLANTS
Today in the world of practical implantology there are many systems of
implants. A large variety of implants necessitated their systematization. The most
simple and convenient, taking as a basis one or another sign, we can consider the
classification proposed by M.Z. Mirgazizov (1988):

1. According to the biocompatibility of the material used for implantation,

distinguish:
- biotolerant (stainless steel, KHS);
- bioinert (aluminum oxide ceramics, zirconium, titanium, carbon, titanium
nickelide);
- bioactive (hydroxyapatite, tricalcium phosphate, glass ceramic with an
active surface).

2. In form:
- cylindrical (solid, hollow);
- helical;
- leaf-shaped (lamellar);
- conical;
- in the form of the root of a natural tooth.

3. According to the structure of the material:

- non-porous;
- surface porous;
- with through porosity;
- combined.

4. According to the property of the material:

- without the effect of "memory" of the form;
- with the effect of "memory" of the form.

5. By localization:
- cross-root;
- submucous;
- subperiosteal;
- intraosseous;
- transosseous;
- combined.

6. By function:
 - substitute;
- supporting;
- supporting and replacing.

7. The perception of chewing pressure:

- with a shock absorber (extraosseous, intraosseous, combined);
- without shock absorber.

8. According to the design of the intraosseous part:

- collapsible;
- non-separable.

9. According to the design of the connection of the implant with the

superstructure:
- one-piece connection using magnetic systems.

10. According to the manufacturing method:

–Standard;
- individual.

11. At the place of production:

- in factories;
- in the laboratory (in the dental laboratory)
Structurally, three main parts are distinguished in the implant: the root part,
the neck and the head (support head). Other terms are also used: the root part is
called the intraalveolar or intra-support structure, the neck - the cervical region of
the implant, the neck and head together - the extra-alveolar coronal part of the
implant. In individual structures, shoulders, implant legs, frame, etc. are
distinguished.
Depending on the relationship of the implant with soft and hard tissues,
endodonto-endoossal implantation is distinguished. Such implantation is carried
out with significantly damaged teeth by introducing screw or with a figured surface
of implants in the form of a pin through the tooth channel into the underlying
tissue.
The types of intraosseous implants offered to date, there are over three
hundred. Due to significant design differences, they are quite difficult to clearly
systematize. Fundamentally, the majority of dental implants in the form of the
endossal part are assigned either to lamellar structures or to cylindrical and conical
devices resembling the root of a tooth. Those and other implants are made
collapsible (mainly for two-stage implantation), or non-collapsible (only for one-
stage installation). Nevertheless, their choice is dictated by the state of the bone
tissue of the alveolar process (Figure 1).

Figure 1. The choice of dental implants depending on the architectonics of the bone
(type I - increased density, type II - medium density, type III - low density) according to
V.L. Paraskevich.

In cylindrical implants (the diameter of their intraosseous part often varies

from 3.0 to 5.0–6.0 mm, height - from 7.0 to 18.0 mm), the problem of increasing
their fixation and retention properties is usually solved by external threading,
rough or porous surfaces, holes and cavities, as well as changes in the area of the
support by original design solutions (Figure 2).
A

C
a - two-stage implants: 1 - screw implant Branemark; 2 - IMZ with depreciation system; 3 -
Smirnov implant (porous); 4 - conical screw "Radix".

b - collapsible one-stage implants: 1 - Bonefi t with plasma spraying; 2 - implant SSDI

Branemark; 3 - implant Radix-DM; 4 - lamellar Radix-BL.

c - non-separable implants: 1 - Ghercheve implant; 2 - screw implant L. Linkow; 3 - TRS

with plasma spraying; 4 - implant type "gimlet" Tramonte; 5 - Radix-1 with anti-rotation
protection; 6 - plate implant L. Linkow

Figure 2. The main design options for intraosseous dental implants

according to V.L. Paraskevich.
The surface modification of titanium implants is carried out by removing
material (sandblasting, acid treatment, laser), or by adding material (plasma
spraying).
Roughness, including porosity, is a factor conducive to the formation of bone
on the surface of the implant, but is unable to make changes in its density.
The problem of support and transmission of chewing pressure in all endo-
Russian implants is solved mainly by expanding the area of their contact with the
bone. Thus, the intraosseous part of plate-shaped perforated structures usually has
a thickness of 1–1.5 mm, and their cross-sectional shape varies from smooth
rectangular to very complex: serpentine, sawtooth, scaly, with club-shaped
protrusions, etc. - first of all, to increase the area of implant support on the bone
(Figure 3). Perforations serve the same purpose. In cylindrical implants (the
diameter of their intraosseous part often varies from 3 to 5–6 mm, height - from 7
to 18 mm), the problem of increasing their fixation and retention properties is
usually solved by external threads, rough or porous surfaces, holes and cavities,
and also changes in the area of the support by means of original design solutions
(Figure 1). The surface modification of titanium implants is carried out by
removing the material (sandblasting, acid treatment, laser) or by adding material
(plasma spraying). Roughness, including porosity, is a factor conducive to the
formation of bone on the surface of the implant, however, unable to make changes
in its density.
A

C
а – longitudinal sections of root system implants; b - anchor implant of V.V. Trofimov; in -
and cylindrical "threaded" compression implant A.S. Massarsky; c - according to A.F.
Konyakhin
Figure 3. Profile shapes of lamellar intraosseous implants
EXAMINATION OF PATIENTS INDICATIONS AND
CONTRAINDICATIONS TO DENTAL IMPLANTATION

An assessment of the patient’s overall health should be made up of the following

data:

1. Anamnesis:
- an anamnesis of life (earlier severe illnesses or operations, occupational hazards,
bad habits).
- medical history (terms and causes of tooth loss);
- health status questionnaire - assessment of the functional state of the body (all
organs and systems).

2. Dental status:
Visual inspection:
- the condition of the skin, visible mucous membranes;
- symmetry of the bones of the facial skull, the presence of injuries;
- assessment of facial and chewing muscles;
- TMJ movement.
Oral examination:
- condition of the mucous membrane;
- condition of the jawbone;
- the condition of the remaining teeth and periodontal tissues, the nature of the
closing of the teeth;
- the condition of other organs of the oral cavity (salivary glands, tonsils, tongue,
etc.),
- measuring the thickness of the mucous membrane at the site of the operation and
determining the width of the alveolar part of the jaw.

3. X-ray tomographic research:

- intraoral radiography;
- radiovisiographic examination;
- panoramic radiography;
- X-ray computed tomography;
- densitometric radiovisiography - measuring the amount of minerals in a certain
volume of bone tissue - BMD (bone mineral density), evaluation of the reparative
process.

4. Laboratory examination methods:

- detailed blood test;
- blood test for sugar;
- blood to the Wasserman reaction, HIV, hepatitis.

5. Additional methods:
- carrying out biopotentialometry of the tissues of the oral cavity, especially when
prosthetics and implantation using dissimilar metals, gnatodynamometry,
electromyography, etc.

1. Studies of diagnostic models:

- taking casts from both jaws;
- determination of implant placement sites, their inclination angles;
- use of marking balls;
- the use of analogues, laboratory implants.
In preoperative preparation of the patient, complete sanitation of the oral
cavity with the elimination of all sources of infection is mandatory! A correctly
conducted examination of the patient will accurately determine the presence of
indications and contraindications for dental implantation, as well as choose the
optimal method and design of the implant.
Acquaintance with patients begins with a thorough history taking. About the
state of the body as a whole, past diseases and the presence of concomitant
pathology that could affect the postoperative course, are judged by a specially
designed questionnaire. In the presence of any pathology, an appropriate
examination and consultation of specialists is carried out. The study of local status
begins with the soft tissues of the patients' faces to detect infiltration, painful areas
in the area of missing teeth, temporomandibular joints, pay attention to the nature
of facial expressions, especially the speech of patients. Visually examine the
condition of the soft tissues of the oral cavity and the functions of the salivary
glands, the state of oral hygiene, the presence of odor from the mouth, and the
stability of existing teeth is checked. A radiological examination is mandatory - an
orthopantomography of the jaw is performed, an intraoral dental radiography of the
lower jaw in the area of the implantation is planned. Diagnostic plaster models are
cast for most patients to determine the location and direction of implant
placement..

Indications for implantation:

- the absence of one tooth in the dentition;
- the presence of limited inclusions of defects in the dentition;
- the presence of bilateral end or unilateral defects of the dentition in the absence of
three teeth or more;
- intolerance to removable prostheses due to hypersensitivity to acrylates or with a
pronounced vomiting reflex.

Contraindications for implantation:

Absolute:
- autoimmune diseases (systemic diseases of the connective tissue of collagenosis,
rheumatism, etc.);
- systemic diseases of the blood and blood-forming organs;
- diseases of the endocrine system (insulin-dependent form of diabetes,
decompensated forms of thyroid disease, pathology of the pituitary gland, etc.);
- systemic and chronic inflammatory diseases of the skeletal system (osteomyelitis,
osteoporosis, bone tuberculosis, etc.);
- malignant tumors;
- infectious diseases (HIV, etc.);
- allergic diseases (allergy to metals);
- diseases of CVD, gastrointestinal tract, liver, kidneys in the stage of
decompensation;
- diseases of the central and peripheral nervous system (epilepsy, bruxism);
- mental illness (schizophrenia, paranoia, neurosis, etc.);

Relative:
- electrochemical incompatibility of metals (the presence of metal fixed structures
of dentures in the oral cavity, the presence of metal structures of implants in the
body);
- contraindications for dental status (generalized forms of periodontitis, severe
forms of TMJ, jawbone tumors, chronic forms of diseases of the oral mucosa,
especially precancer, macroglossia);
- age-related contraindications;
- contraindications to the social plan;
- occlusion pathology and secondary deformations of the dentition;
- pregnancy.