The students should be able to

•Understand the Periimplant bone formation process: theory proposed

by John Davis
•Understand, discuss and differentiate when to use one of the following
protocols:
•Delayed loading proposed by PI Branemark
•Immediate loading proposed by Tarnow
•Progressive bone loading proposed by Carl Misch
•Understand the mechanism of action of recent devices characterizing
the bone-implant interface.
•Understand the implant protective occlusion concept as an application
of sound loading technique.
 Introduction
Dental implants have reported success rates of
over 90 % over long periods of time. However failures
still occur and seem to be unpredictable. One factor
that is being increasingly considered in failure of
dental implants is occlusal loading.
 Bone healing around Dental Implants
Schematic summary of the biology of osseointegration:
1. Old explanation by Branemark
2. Recent explanation by John Davis
 Schematic summary of the biology of osseointegration
1. Old explanation by Branemark
•Immediate stability after insertion and during the
prolonged healing phase permits the transformation of
hematoma into bone .
• Micromotion can lead to fibrous tissue formation.

(1) Contact between the fixture and bone (so

called immobilization).
(2) Hematoma in a confined cavity, which is
bordered by the fixture and bone.
(3) Bone, despite careful preparation is thermally
and mechanically damaged.
(4) bone tissue.
(5) Fixture.
 During the initial healing phase the
haematoma is transformed into new
bone through in situ bone formation.
(6) Damaged bone tissue heals through
revascularisation, demineralisation and
remineralisation. (7).
After the initial healing phase
vital bone is in direct contact with
the surface of the fixture without
any intermediary tissue. (8)
Border zone is remodelled in
response to functional loading.
 Schematic summary of the biology of osseointegration (cont.)
2. Recent explanation by John Davis

In distance osteogenesis (A) the secretorily active osteoblasts, anchored

into their extracellular matrix by their cell processes, become trapped between
the bone they are forming and the surface of the implant.

On the contrary, in contact osteogenesis (B) , de novo bone is formed directly on

the implant surface, with the cement line in contact with the implant and is
equivalent to the osteonal interface .
 The Cement Line and De Novo Bone Formation
The result of de novo bone formation is that the implant/
bone interface, in an identical fashion to remodeling bone
surfaces, is occupied by a cement line matrix as first
described by von Ebner in 1875.
This de novo bone formation cascade can be
arbitrarily subdivided into a four-stage process: .
1. osteogenic cells initially secrete a collagen-free
organic matrix. two non-collagenous bone
proteins have been identified, osteopontin and
bone sialoprotein, and two proteoglycans .
2. Calcium phosphate nucleation
3. Crystal growth and the initiation of collagen
fiber assembly.
4. Finally, calcification of the collagen
compartment will occur.
 Loading protocols
• Delayed loading:
1. A tow-stage surgical protocol (submerged
implants)
2. One-stage surgical protocol (Non-
submerged implants)
• Immediate loading:
1. Immediate occlusal loading (placed within
48 hours postsurgery)
2. Immediate non-occlusal Loading (in single-
tooth or short-span applications)
3. Early loading (prosthetic function within
two months)
• Progressive Bone Loading
 Conventional (Delayed) loading
History
Branemark: 3-6 months (3-4 in mandible, 4-6 in maxilla)

Historically, the Branemark protocol favored a prolonged healing

period, to avoid early loading of the implant which may induce
micromotion leading to fibrous tissue formation around the
implant, and the subsequent implant loss .
Bone adaptation to loading (Frost‘s mechanostat theory)
Frost described four micro-strain zones and
related each zone to a mechanical adaptation:
1. the disuse atrophy: When peak strain
magnitude fall below 50-200 μ-strain,
disuse atrophy is proposed to occur, a
phenomenon that is likely to explain ridge
resorption after tooth loss.

2. steady state: comprises the range between disuse atrophy and physiologic overload
zone, and is associated with organized, highly mineralized lamellar bone.
3. physiologic overload and
4. pathologic overload zones: peak stain magnitude of over 4000 μ-strain may result in
net bone resorption.
 Immediate Loading
History
Tarnow 1997: 96% success
Rationale:
control of the following factors can justify immediate loading

1. Surgical trauma: drilling (38-41 C) then returns in 34 to 58

seconds, the more insertion torque the more microstarins
2. Bone microstrain: pathologic overload zone leads to fibrous
encapsulation ( see Frost model )
3. Implant factor: increase number and width, surface
treatment (surface topography and coatings) , and better
design
4. Patient force factors: bruxism and clenching should be
controlled or avoided.
Advantages of immediate loading :
1. No stage II surgery
2. Teeth back immediately
3. When splinted : superior mechanics for healing
4. The patient does not have to wear a transitional removable
prosthesis
5. Improved patient psychology

Guidelines for immediate loading

A. Completely edentulous patients
B. Partially edentulous patients
A. Completely edentulous patients
To reduce stress and microstarins at the developing interface
a) Surface area factors
1. Implant number : 8 splinted or more for maxilla, and 6 splinted or more for
the mandible
2. Implant size: large diameter, if not possible, then 2 implants for each molar
3. Implant design: threaded, …., …., ….
4. Implant surface: improved with treatments
b) Force factors:
1. Patient condition: parafunction, bruxism, contraindicates
2. Implant position:
maxilla: bilateral canines, first and second molar to increas the AP
mandible: 3 implants anterior and one on each side posteriorly also to increas
the AP distance
3. Occlusal load direction:
Narrow occlusal table
No posterior offset load on transiotional prostheses
No posterior cantilever
B. Partially edentulous patients
Nonfunctional immediate tooth (N-FIT) concept primarily for
esthetics

Indications:
1. Patient with centric occlusal contacts on anterior teeth
2. Division D1, D2, careful with D3 and not with D4 ( D1: anterior
mandible, D2: posterior mandible, D3: anterior maxilla, D4:
posterior maxilla)
3. Screw threaded 4 mm or more diameter implant

Contraindications
Severe parafunction: crestal bone loss and implant failure
Bone can be classified according to structure, composition, density and volume.
Lekholm, Zarb et al. have classified bone quality and volume in to four types,
expressed as type I, II, III and VI. This classification closely resembles a more recent
classification by Misch. Misch separates bone quality and volume in to two distinct
classifications that can be combined for patient specific diagnostic purposes and drill
protocol procedures. Bone quality is classified in to four groups D1, D2, D3, and D4
whereby the Misch classification suggests a location, composition and a measurable
density reading (Hounsfield units) for each type of bone.
D1 bone is composed of almost all cortical bone mass located primarily in the anterior
mandible. A Hounsfield unit reading of 1250 and above indicates D1 bone.
D2 bone is composed of a thick crestal layer of cortical bone and coarse trabecular
bone underneath the cortical bone. This type of bone can mostly be found in the
anterior and posterior mandible. A Hounsfied reading between 850 to 1250 units is
indicative of D2 bone.

D3 bone is composed of a porous crestal layer of cortical bone and fine trabecular bone
underneath the cortical bone. This type of bone can mostly be found in the anterior and
posterior maxilla but also in the posterior mandible. A Hounsfield reading between 350
and 850 units is indicative of type D3 bone.

D4 bone is composed of primarily fine trabecular bone and often the absence of cortical bone.
This type of bone can mostly be found in the posterior maxilla and poses the greatest challenge
in implant placement. A Hounsfield reading between 150 and 350 units is indicative of D4 bone.
 Progressive Bone Loading

Described by Misch in 1980 to decrease failure in

conditions using fewer implants in softer bone through
control of:
1. Time of loading: more healing time for softer bone
2. Diet consistency: begin with soft to harder food
3. Occlusal material: acrylic then metal or porcelain
4. Prosthesis design: RP-5 then FP-3

However, pbl is best used with cemented restorations rather

than implant overdenture ????
 The Mechanism of Action of Recent Devices
Characterizing the Bone-implant Interface.
Testing of the Bone–Implant Interface

testing of ex-vivo samples

1. Pushout and pullout tests
2. Torque tests
evaluation of the dental implant bone interface in human
subjects
1. Percussion test
2. Radiography
3. Periotest
4. Reverse torque
5. Resonance frequency analysis
6. Finite Element Analysis
Percussion test:

tapping the implant healing abutment with a tool such as a mirror

handle and listening for a good tone:
a) A high-pitched, as a positive sign for integration.
b) a muddy, low-pitch sound feels that the implant is not well-integrated.

Using tone as a measure of implant stability in terms of its pitch

(frequency) and clarity (duration of tone) is a crude method. Hearing skills
vary by operator, which make it subjective.

This test remains an elementary indicator of implant integration,

however, and plays a partial role in the traditional testing methodology, as
well as the new technology described later.
Radiography:
As a longitudinal monitor, periapical and panoramic radiographs provide fairly
accurate information about the bone levels around implants, considering that
most radiographs are taken in a standardized manner that exactly duplicates
the cone placement an dangle.

Since radiographs are two-dimensional interpretations of a three-dimensional

structure, a false sense of security may be conveyed, as various osseous
defects such as buccal dehiscence may not be fully visualized.

While more sophisticated technology, such as tomograms, may offer improved

diagnostic performance:

a) CT: their routine use generally is neither practical nor cost-effective.

b) CBCT: faster, cheaper, however, bone density is not determined.
Periotest:

Periotest (Seimens, AG, Bensheim,Germany) quantifies the mobility of

an implant by measuring the reaction of the peri-implant tissues to a defined
impact load.

The instrument’s handpiece has an electronically controlled translational

hammer bearing an 8-gram rod with a sensor at its tip. When activated, the rod
taps the implant abutment up to 16 times in four seconds with an action similar
to that of a retractable ballpoint pen.

The rod decelerates when it touches the implant and accelerates when it first
rebounds off the implant. Periotest measures elapsed time from initial contact
to the first rebound off the implant.

The greater the implant stability, the shorter the elapsed time is. Conversely, the
longer the rod is in contact with the implant, the less stable the implant is.
Periotest
Reverse torque:

It attaches a handpiece to the implant by means of a coupling.

The handpiece operates in reverse at 20 Newton centimeters, and

attempts to remove the implant.

Should the implant survive, the integration is sufficient to warrant

restoration.

This “pass-fail” test has the potential for the implant to be lost, is not
quantitative and is not suitable for longitudinal testing.
Resonance frequency analysis: Osstell
This technique uses a hand-held frequency response
analyzer connected to a transducer by a wire.

The transducer is screwed directly to the implant body and

shakes the implant at a constant input and amplitude,
starting at a low frequency and increasing in pitch until
the implant resonates.
Finite Element Analysis (FEA)

A model has to be created to perform a, the geometric data of the implant, the
mechanical properties of the bone and the parameters of the bone-implant
interface have to be determined, a so-called finite element network has to be
created.
 Implant protective occlusion
Guidelines:
1. Timing of occlusal contact
2. Influence of surface area
3. Mutually protected articulation
4. Implant body orientation and load direction
5. Bone mechanics
6. Crown cusp angle
7. Cantilevers
8. Crown height
9. Occlusal contact position
10.implant crown contour
11.Design to the weakest arch
12.Occlusal materials