RESIN-BONDED COMPONENTS
sented in this study is limited, the results have been
encouraging.
REFERENCES
1. Buonocore M. A simple method of increasing the adhesion of
acrylic filling materials to enamel surfaces. Dent Res 1955;
34:849-53.
2. Thanos C E, Munholland T, Caputo AA. Adhesion of metal-base
direct bontding brackets. Am J Orthod 1979;75:421-30.
3. Jordan R. Suzuki M, Gwinnett A, Hunter J. Restoration of
fractured <andhypoplastic incisors by the acid-etch resin tech-
nique: A three-year report. J Am Dent Assoc 1977;95:795-
803.
4. Rochette AL. Attachment of a splint to enamel of lower anterior
teeth. J PROSTHET DENT ‘1973;30:418-23.
5. Howe DF, Denehy GE. Anterior fixed partial dentures utilizing
the acid-etch technique and a cast metal framework. J PROSTHET
DENT 1977;37:28-31.
6. Livaditis G. Cast metal resin-bonded retainers for posterior teeth.
J Am Dent Assoc 1980;101:926-9.
7. Wong R, Nicholls JI, Smith DE. Evaluation of prefabricated
lingual res: seats For removable partial dentures. J PROSTHET
DENT 1982;48:521-6.
Bone-implant interface structures after nontapping
and tapping insertion of screw-type titanium alloy
endosseous implants
Keiichi Satomi, D.D.S.,* Yasumasa Akagawa, D.D.S., Ph.D.,**
Hiromasa Nikai, D.D.S., Ph.D.,*** and Hiromichi Tsuru, D.D.S., Ph.D.****
Hiroshima University, School of Dentistry, Hiroshima, Japan
ndirect bone-implant interface has been recognized as
an indication of a successful endosseous dental im-
plant.‘” To ac.hieve this interface in the jaw bone, the
two-stage procedure has been recommended by which
the,implant is inserted into the bone and sufficient time
is allowed between the first fixture placement stage and
the second functional stage.2s4Pure titanium,‘~2 titanium
alloy,5 and single-crystal sapphire’ have been reported to
induce a direct bone-implant interface after the two-
stage procedure.
The screw-type implant has been considered more
appropriate than the smooth-type implant for distribut-
ing stress to the surrounding bone to achieve a direct
*Graduate student, Department of Removable Pmsthodontics.
**Assistant Professor, Department of Removable Prosthodontics.
***Professor and Chairman, Department of Oral Pathology.
****Professor and Chairman, Department of Removable Prosthodon-
tics.
THE JOURNAL OF PROSTHETIC DENTISTRY
8. Hebel KS, Graser GN, Featherstone JDB. Abrasion of enamel
and composite resin by removable partial denture clasps.
J PROSTHET DENT 1984;52:389-97.
9. Toth RW, Fiebiger GE, Mackert JR, GoIdman BM. Shear
strength of lingual rest seats prepared in bonded composite.
J PROSTHETDENT 1986;56:99-104.
10. Toth RW, Fiebiger GE, Mackert JR, Goldman BM. Load
cycling of lingual rest seats prepared in composite resin.
J PROSTHETDENT 1986;56:239-42.
11. Fiebiger GE, Rahn AO, Lundquist DO, Morse PK. Movement
of abutments by removable partial denture frameworks with a
hemimaxillectomy obturator. J PROSTHET DENT 1975;34:
555-61.
12. Desjardins RP. Obturator prosthesis design for acquired maxil-
lary defects. J PROSTHETDENT 1978;39:424-35.
13. Firtell DN, Grisius RJ. Retention of obturator-removable par-
tial dentures: A comparison of buccal and lingual retention.
J PROSTAETDENT 1980;43:212-7.
Reprint requests to:
DR. THOMAS D. TAYLOR
UNIVERSITYOF WASHINGTON
SCH~CILOF DENTISTRY
SEATTLE,WA 98195
bone-implant interface. ’ The screw-type implant en-
ables the transmission of axial tensile or compressive
loadings to the surrounding bone, particularly by com-
pression through an inclined plane of the screw. On the
other hand, stress concentration arises more or less at the
marginal site of the screw-type implant by the screwing
down of the implant and continuous tightening of the
bone: which may cause a loss of marginal bone.9 Thus,
to avoid stress concentration on the surrounding bone
during insertion of the implant, nontapping insertion
combined with the two-stage procedure seems to be
preferable to tapping insertion.
This experiment in monkeys was designed to clarify
whether direct bone apposition on the implant could be
produced by nontapping insertion, by comparing the
structural differences of bone-implant interfaces after
nontapped and tapped insertions for submerged endos-
seous implants using titanium oxide (TiOJ coated and
noncoated screw-type titanium alloys.
339

Fig. 1. Direct bone interface between bone and TiOz
coated implants by tapping insertion. (Hemotoxylin
and eosin stain, original magnification x40.)
MATERIAL AND METHODS
Two monkeys (Macaca fuscata) were used as subjects.
The first and second premolars and the first molar of the
mandible were extracted bilaterally from each animal.
The sites was allowed to heal 3 months for implant
insertion. Two kinds of screw-type implants were fabri-
cated from titanium alloy (Ti6A14V) (diameter, 4 mm
and length, 9 mm) with a central-threaded interior
channel to accept the transgingival core. A thickness of
approximately 3000 to 5000 A of TiOz was coated on the
surface of the alloy by means of the anodic oxidation
method. Each of the TiOz coated and noncoated
Ti6A14V implants was inserted into the edentulous
region on each side of the mandible. In total, eight
implants were done. All surgical procedures were per-
formed with the monkeys under intramuscular anesthe-
sia with 5 mg/kg of ketamine hydrochloride, 0.03 mg/kg
of atropine sulfate, and 0.5 mg/kg of chlorpromazine
hydrochloride. A mucoperiosteal flap was raised at the
implant site and, by using special cutting devices
equipped with an internal cooling system and screw-
stock, nonthreaded and threaded sockets were made in
the mandible. Damage to bone tissue was reduced by low
speed and pressure on the drilling instrument with
internal water cooling and external continuous saline
irrigation. Finally, four implants were inserted into
340
SATOMI ET AL.
Fig. 2. Direct bone apposition to noncoated implant by
tapping insertion. Bone tissue along surface of implant
was artificially torn through grinding of histologic
preparation. (Toluidine-blue stain, original magnifica-
tion X40.)
nonthreaded sockets manually and the remaining four
implants were inserted into the threaded sockets by
manual tapping with a wrench. The central threaded
site of the implant was locked with a filler screw
fabricated from the same Ti6A14V to prevent bone
tissue infiltration. The full thickness of the mucoperios-
teal flap was sutured tightly to completely cover the
implants by the gingiva.
The animals were killed 3 months after implant
insertion and were perfused with 10% neutral formalin
through the aorta. The mandibles were removed and
gross dissection of the tissue samples was done en block
and reduced to provide less than 2 mm thickness of tissue
between the implant and the external surface of the
tissue. The blocks were cut in half along the long axis of
the implant and divided into two groups. In one group,
the implants were carefully removed and the remaining
tissues were immersed in a decalcifying solution (K-Cx,
Falma, Tokyo, Japan) for 3 days. Then tissues were
passed through a series of graded ethanol rinses, em-
bedded in paraffin, and 6 pm sections were stained with
hematoxylin and eosin. The block containing the
implant in the other group was dehydrated through a
series of graded ethanol rinses, cleared with styrene
monomer, and embedded in polyester resin (Rigolac
resin, Oken, Tokyo, Japan). The resin block was cut
MARCH 1988 VOLUME 59 NUMBER 3
BONE-IMPLANT INTERFACE STRUCTURES

Fig. 3. Dense fibrous connective tissue interface Fig. 4. Poor bone apposition to noncoated implant by
between bone and TiOz coated implant by nontapping nontapping insertion. (Toluidine blue stain, original
insertion. (Hemotoxylin and eosin stain, original mag- magnification X40.)
nification X40.)

along the long axis of the implant by special thin-section Table I. Quantitative difference of direct
equipment (Exakt-Cutting Grinding System, Exakt bone-implant interface
Apparatebau, ‘West Germany) and the final ground
Nontapping Tapping
sections were made by manual grinding. These sections insertion (%) insertion (%)
were stained with toluidine-blue. All specimens of both
groups were examined by light microscopy. TiO? coatedalloy 29.0 + 31.8 74.5 + 11.4
Noncoated alloy 28.9 + 6.0 68.4 Z!I 10.0
An attempt was made to determine the quantitative
differences in the bone-implant interfaces by using
computer-assisted morphometry. Scaled pictures were
obtained from ground sections and these were put on the by the tapping procedure insertion (Fig. 1). From the
digitizer. Direct bone apposition and thin and dense ground sections, the direct bone-implant interface was
fibrous connective tissue layer between bone and implant clearly seen along the surface of the screw-shaped
were distinguished by scribing with a special marker implant (Fig. 2). No difference was observed between
pen, and the ratio of this different quality of interface TiOz coated and noncoated implants, whereas in the
was calculated by following an originally programmed implants by nontapping insertion a direct bone interface
microcomputer system. was scarcely found. Connective tissue layer of variable
thickness with rich collagenous fibers existed at most
RESULTS regions between the bone tissue and the implant (Figs. 3
All of t.he implants except one were well covered by and 4).
the gingiva duri.ng the experiment. No sign of destructive Table I shows the ratio of direct bone-implant inter-
or degenerative tissue reaction was seen from the general face as the quantitative expression of direct bone apposi-
impression. One of the filler screws penetrated the tion. This direct bone-implant interface was pre-
gingiva to the oral cavity and this gingiva showed a slight dominantly seen in the implants by tapping insertion,
inflammatory reaction to the plaque and debris. From whereas dense fibrous connective tissue interfaced much
paraffin sections, direct bone apposition appeared at of the implants by nontapping insertion. No clear
most regions of the implants, and fatty bone marrow difference was observed between TiO, coated and non-
interfaced the implants at some regions in the implants coated implants.

THE JOURNAL OF PROSTHETIC DENTISTRY 341


DISCUSSION
Our results indicate that the quality of bone-implant
interface induced by nontapping and tapping insertions
differ. Because of nonloading of the implants, the factors
determining such differences might be the biocompatibil-
ity of the material used and surgical insertion. The
material Ti6A14V has been reported to be well tolerated
by bone tissue and shown to be tissue-compatible.5 TiOz
is known to be one element of the tightly adherent
oxidative layer on the surface of titanium.5*1o In the
present study, TiOz was artificially coated on the surface
of Ti6A14V, which is the most common oxide.‘O The
procedure makes this material resemble a ceramic and
makes it resistant to corrosion. Thus, the material was
considered biocompatible.
The surgical insertion technique might well be
responsible for the appearance of different bone-implant
interfaces, as Albrektsson’ indicated. Excessive surgical
trauma at the time of implant insertion is known to
result in connective tissue deposition around the
implant.” Indeed, one of the main features of bone
surgery is thermal injury, which leads to osteonecrosis.”
In the present study, to prevent a temperature rise in the
bone, careful and gentle tissue handling was performed
during surgical operation as Albrektsson’ suggested, in
addition to the use of sharp bone-cutting devices. Thus,
thermal injury was limited as much as possible. The
finding of direct bone apposition to the implant inserted
by the tapping procedure would confirm this sugges-
tion.
As Lavelle et al.” reported, implant stability or the
gap between bone and implant is a determinative factor
for the connective tissue interface. Actually, nontapping
and tapping insertions alike had initial implant stability
in the bone. Implants made by tapping insertion were
placed tightly and showed no mobility in spite of the
inaccuracy between the size of the threaded socket and
the size of the implant. The implants made by nontap-
ping insertion were loosely fit because the bony receptor
site was 0.1 to 0.3 mm larger in diameter than the size of
the implant despite the use of accurate manual cutting
devices. Therefore, such a gap between bone and im-
plant by nontapping insertion procedure was too wide to
be bridged by osteogenesis, and predominant connective
tissue interface resulted.
Minimal tissue violence is essential to obtain direct
bone apposition to the implant’s2 and the results obtained
on the implant by tapping insertion was in agreement
with this concept. The endosseous implant system re-
quires further development to minimize the risk of
failure. A simplified nontapping insertion could contrib-
ute to a less traumatic placement of the implant in the
bone. It could also diminish the stress concentration
exerted during pretapping in bone preparation and the
self-tapping procedure in implant insertion reported by
Haraldsson.8 Marginal bone loss of the implant’ might
342
SATOMI ET AL.
be prevented. A direct bone-implant connection by the
nontapping procedure could not be achieved in our
study. A new coated material that enables direct bone
apposition by nontapping insertion is required.
SUMMARY
To compare different surgical insertion procedures,
histologic and histometric studies were made on the
structure of the interface between jaw bone and implants
in two monkeys. Two materials were tested; Ti02 coated
and noncoated, screw-type titanium alloy endosseous
implants. All implants by tapping insertion were healed
with direct bone apposition whereas implants by nontap-
ping insertion revealed some degrees of fibrous connec-
tive tissue intervention between bone and implant. No
difference was found between Ti02 coated and non-
coated materials.
REFERENCES
1. Albrektsson T. Direct bone anchorage of dental implants. J
PROSTHETDENT 1983;50:255-61.
2. Brinemark P-I. Osseointegration and its experimental back-
ground. J PROSTHETDENT 1983;50:399-410.
3. Adell R, Lekholm U, Rockier B, Brinemark P-I. A 15-year
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3:83.
5. Parr GR, Gardner LK, Toth RW. Titanium: the mystery metal
of implant dentistry. Dental materials aspects. J PROSTHET DENT
1985;54:410-14.
6. Akagawa Y, Hashimoto M, Kondo N, Satomi K, Takata T,
Tsuru H. Initial bone-implant interfaces of submergible and
supramergible endosseous single-crystal sapphire implants. J
PR~~THETDENT 1986;55:96-100.
7. Skalak R. Biomechanical considerations in osseointegrated pros-
theses. J PR~~THET DENT 1983;49:843-8.
8. Haraldson T. A photoelastic study of some biomechanical factors
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Stand J Plast Reconstr Surg 1980;14:209-14.
9. Adell R, Lekholm U, Rockier B, Brinemark P-I, Lindhe J,
Eriksson B, Sbordone L. Marginal tissue reactions at osseointe-
grated titanium fixtures (I). A 3-year longitudinal prospective
study. Int J Oral Maxillofac Surg 1986;15:39.
10. Kasemo B. Biocompatibility of titanium implants: surface science
aspects. J PR~~THET DENT 1983;49:832-7.
11. Lavelle CLB, Wedgwood D, Love WB. Some advances in
endosseous implants. J Oral Rehabil 1981;8:319-31.
12. Eriksson A, Albrektsson T. Temperature threshold levels for
heat-induced bone tissue injury: a vital-microscopic study in the
rabbit. J PROSTHETDENT 1983;50:101-7.
Reprint requests to:
DR. KEIICHI SATOMI
HIWXHIMA UNIVEWIY
SCHOLLOF DENTISTRY
WUMI l-2-3, MINAMI-KU
HIROSHIMA 734
JAPAN
MARCH 1988 VOLUME 59 NUMBER 3