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induce a micromovement of more than 150 mm. The 150-mm dimension may be important for integrated implants as well. It is known that an osseointegrated implant may be at risk if it is subjected to chronic, severe, direct nonaxial (eccentric) forces of occlusion (8,9).These damaging occlusal forces are chronic and variable in magnitude, direction and frequency. Interestingly, short implants canbe used for anchorage for the small, uni-directional and constant forces for orthodontic tooth movement (10). If a force does not cause failure of an implant immediately, it may rst fracture the implant or a component screw on the rst occasion. The tensile strength of the implant abutment screws varies according to the alloy, manufacturer design, size and manufactured lot (11,12). An impacting force couldpossibly fracture the overlying bone housing an implant. The interaction of the bone and implant interface under an external sudden force is unknown. A study in rabbit femurs showed that the torque removal force of implants at 3-month post-insertion ranged from 27 to 59 N (13). Titanium oxide layer thickness, micropore congurations and crystal structures of titanium oxide apparently aect bone tissue response with respect to removal torque. Oxide layers 600^1000 nm demonstrated signicantly stronger bone responses in evaluation of removal torque than implants with an oxide layer less
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Trauma to dental implants than 200 nm; however, whether these properties have their eect individually or synergistically is unknown (14). It has been suggested that a placement torque force of greater that 42 N cm allows a newly installed implant tobe immediately subjectedto non-functional loading. That is, a newly placed single implant can be tted immediately with a provisional crown but so as to be out of the path of movement of the opposing teeth. Most of these cases were reported to be in anterior sites, and therefore likely in an area of increased bone density which enhances initial implant stability. These areas are also subjected to lesser forces than in posterior areas (15^17). In these cases, the occlusal forces of the opposing dentition are not in direct contact with the new crown/implant complex.The forces to bear are usually those of the soft tissues (tongue and mucosa) and compressed food boluses from mastication. The bone around the newly placed implant is probably able to resist these lesser forces and would not move the newly placed implant more than 150 mm in the required rigid bone that encases it. Schnitman et al. (18) reported that immediate placement and true functional loading was possible with cross-arch stabilization but the survival rate was 85%. Implant immobilization brought about by the arc of the prosthesis and distribution of the force of occlusal load are probably the key factors. This arch form distribution and multiplicity of implants probably prevents any implant movement beyond 150 mm. Ithasalsobeenreportedthatdentalimplantsplacedin the anterior mandibular interforaminal area can be placedinimmediatetruefunctionandprovideimmediate retention foranoverdenture (19). In maxillary overdentures with four to six implants, the forces of occlusion can loosen component screwsbut apparently do not readily cause implant loss in the short term of 3.2 years (20). Interestingly, implants fracture at the samerateinthemaxillaandmandible,andimplantfractures occur more frequently in partially edentulous restorationsthan in completelyedentulous arches (21). It is not known if the 150-mm limit of movement in bone for newly placed implants holds for osseointegrated implants as well. Dental implants are subjected to a multiplicity of force parameters that need to be studied. Case report A 30-year-old woman required extraction of tooth #9. The root had sustained a lingual root fracture; endodontic and full crowntreatmentswereperformed but this treatment failed and the tooth was deemed unrestorable. The tooth was extracted and a 4.5 15 Frialit-2 implant (Frident, Mannheim, Germany) was immediately placed. A 1-mm gap at the lingual
was lled with Bio-Gran, a bioactive glass ceramic (Fig.1). A provisional removable denture replacing #9 was adjusted, relieved over the implant site and delivered. Six months later, an abutment was placed, torqued into place and restored with a cemented porcelain-fused-to-metal crown. The patient did well and was satised with the results of the treatment. Thirteen months later, she presented for emergency treatment with a chief complaint of a fractured #9 crown and`loose implant' She stated that she had sus. tained trauma to the implant crown at #9 by a strike from a bottle 2 days before the emergency visit. The crown appeared mobile and had an incisal porcelain fracture (Fig.2). She had no pain. There was a slight facial gingival margin swelling and redness (Fig.3). The crown appeared to be in its original position. A discussionwas heldasto possible removal andreplacement of the implant xture if it was no longer integrated. Amoxicillin 500 mg tid for 10 days was prescribed. At the next appointment, the crown was cut and removed from the abutment. The implant was found to be immobile, apparently still integrated and undamaged from the trauma of the bottle strike. The abutment retaining screw had apparently loosened from the trauma. The abutment and retaining screw were removed, inspected, found to be undamaged and replaced to their original positions. The abutment screw was again seated with a torque wrench. A new porcelain-fused-to-metal crown was constructed and cemented. The implant has not exhibited any adverse eects from the trauma 5 months laterandthere hasbeen no unusualbone loss or loosening (Fig.4).
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Fig. 3. Porcelain fracture and slight facial gingival margin inflammation 2 days after trauma.
Discussion When a natural tooth is avulsed, the bone is suddenly compressed against the conical root and the tooth is propelled occlusally breaking the supporting periodontal ligament. A dental implant has no periodontal ligament but can have threads and/or a rough surface that may preclude avulsion or at least make it an unlikely event. A tooth that is luxated may fully recover by temporarily splinting the injured tooth to its neighbors for support for healing. The treatment for a luxated, mobile implant xture is probably removal. A disosseointegrated implant xture may develop infec-
tion, brous encapsulation or epithelial down-growth and be exfoliated. Natural teeth that are fractured can be restored unless a root fracture necessitates extraction. Apparently from the case now presented, an integrated implant xture can sustain some magnitude of external trauma and survive. It is possible that the bone housing an implant can bend or fracture. A component part can bend or fracture or loosen under trauma. It seems that component parts loosen or fracture before the implant or the integrated bone housing fractures (21). Component screw loosening and fracture can occur before bone loss around implant xtures restored in occlusal disharmony. Occlusal forces are variable, frequent, multidirectional and increase the risk of failure if non-axial (22). These occlusal forces always produce stress at the neck of an implant. Axial forces produce the lowest stress (23). Occlusal prosthetic design should, at best, prevent or minimize exposure to non-axial forces. T oughness is that property of a material that measures the energy necessary to fracture the material (24). The molecular basis of the toughness and strength of bone is largely unknown. Bone is a nanocomposite of hydroxyapatite crystals and a collagen matrix. The crystals of hydroxyapatite cannot dissipate much energy from an impact, so the collagen matrix remains as the probable energy-absorbing entity. Reducing collagen cross-linking causes reduced bone strength. Apparently during an impact event, the collagenpolymer containsbonds thatbreak
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Trauma to dental implants so as to absorb the energy of the impact that protects the main polymer chain. These bonds are thought to be responsible for the toughness of bone (25^27). Microfractures of bone around implants are associated with oblique loads, high occlusal stress magnitudes and an absence of cortical bone (28). Bone microcracks are precursors to fracture.The way bone is structured helps prevent crack initiation in transverse fracture under tension, shear and tear (29). It would appear that an osseointegrated implant encased in adequate cortical bone could successfully survive a severe sudden traumatic impact of substantial force (30). Conclusions Dental implants seem to be well protected in cortical bone from traumatic impact. There is a molecular polymeric mechanism of collagen, the matrix ofbone, that helps to protect bone from fracture. The vulnerable areas of implant-restored dentition with respect to trauma seem to be in the implant xture, implant components and prostheses. It appears that the force that was incurred in this case was strong enough to fracture the porcelain of the fused-to-metal crown and loosen the abutment retaining screw. The impact force caused no apparent damage to the bone, the implant or its components except abutment screw loosening.The force delivered at the incisal edge of the crown probably induced a reverse torque to the implant and did not result in its failure or subsequent bone loss. References
1. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH. Timing of loading and effect of micromotion on bone^ dental implant interface: review of experimental literature. J Biomed Mater Res 1998 (Summer);43(2):192^203. 2. Baker D, London RM, O'Neal R. Rate of pull-out strength of dual-etched titanium implants: comparative study in rabbits. Int J Oral Maxillofac Implants 1999 (September/ October);14(5):722^8. 3. Haas R, Mailath G, Dortbudak O, Watzek G. Bovine hydroxyapatite for maxillary sinus augmentation: analysis of interfacial bond strength of dental implants using pull-out tests. Clin Oral Implants Res 1998 (April);9(2):117^22. 4. Kido H, Schulz EE, Kumar A, Lozada J, Saha S. Implant diameter and bone density: effect on initial stability and pull-out resistance. J Oral Implantol 1997;23(4):163^9. 5. Cook SD, Salkeld SL, Gaisser DM, Wagner WR. An in vivo analysis of an elliptical dental implant design. J Oral Implantol 1993;19(4):307^13. 6. Boggan RS, Strong JT, Misch CE, Bidez MW. Influence of hex geometry and prosthetic table width on static and fatigue strength of dental implants. J Prosthet Dent 1999 (October);82(4):436^40. 7. Richter EJ. In vivo vertical forces on implants. Int J Oral Maxillofac Implants 1995 (January/February);10(1): 99^108. 8. Rangert B, Renouard F. Practical guidelines based on biomechanical principles. In: Palacci P, editor. Esthetic implant dentistry: soft and hard tissue management. Quintessence Books: Chicago; 2001. p. 58. 9. Gold berg PV, Higginbottom FL, Wilson TG. Periodontal considerations in restorative and implant therapy. Periodontol 2000, 2001;25:100^9. 10. Majzoub Z, Finnotti M, Miotti F, Giardino R, Aldini NN, Cordioli G. Bone response to orthodontic loading of endosseous implants in the rabbit calvaria: early continuous forces. EurJ Orthod 1999 (June);21(3):223^30. 11. Rambhia KR, Nagy WW, Fournelle RA, Dhuru VB. Defects in hexed gold prosthetic screws: a metallographic and tensile analysis. J Prosthet Dent 2002 (January);87(1): 30^9. 12. Jaarda MJ, Razzoog ME, Gratton DG. Effect of preload on the ultimate tensile strength of implant prosthetic retaining screws. Implant Dent 1994 Spring;3(1):17^21. 13. Klokkevold PR, Johnson P, Dadgostari S, Caputo A, Davies JE, Nishimura RD. Early endosseous integration enhanced by dual acid etching of titanium: a torque removal study in the rabbit. Clin Oral Implants Res 2001 (August);12(4): 350^7. 14. SulY-T, Johansson CB, JeongT,Wennerberg A, Albrektsson T. Resonance frequency and removal torque analysis of implants with turned and anodized surface oxides. Clin Oral Implants Res 2002 (June);13:252. 15. Wohrle PS. Single-tooth replacement in the aesthetic zone with immediate provisionalization: fourteen consecutive case reports. Pract Periodontics Aesthet Dent 1998 (November/December);10(9):1107^14. 16. Kupeyan HK, May KB. Implant and provisional crown placement: a one-stage protocol. Implant Dent 1998;7(3): 213^9. 17. Andersen E, Haanaes HR, Knutsen BM. Immediate loading of single-tooth ITI implants in the anterior maxilla: a prospective 5-year pilot study. Clin Oral Implants Res 2002 (June);13(3):281. 18. Schnitman PA, Wohrle PS, Rubenstein JE, Silve JD, Wang N-H. T year results for Branemark implants en immediately loaded with fixed prostheses at implant placement. Int J Oral Maxillofac Implants 1997;12: 495^503. 19. Gatti C, HaefligerW, Chiapasco M. Implant-retained mandibular overdentures with immediate loading: a prospective study of ITI implants. Int J Oral Maxillofac Implants 2000 (May/June);15(3):383^8. 20. Keiner P, Oetterli M, Mericske E, Mericske-Stern R. Effectiveness of maxillary overdentures supported by implants: maintenance and prosthetic complications. Int J Prosthodont 2001 (March/April);14(2):133^40. 21. Eckert SE, Meraw SJ, Cal E, Ow RK. Analysis of incidence and associated factors with fractured implants: a retrospective study. Int J Oral Maxillofac Implants 2000 (September/October);15(5):662^7. 22. Renouard F, Rangert B. In: Risk factors in implant dentistry: simplified clinical analysis for predictable treatment. Quintessence Books: Chicago;1999. p. 45. 23. Meijer HJ, Starmans FJ, Steen WH, Bosman F. A threedimensional, finite-element analysis of bone around dental implants in an edentulous human mandible. Arch Oral Biol 1993 (June);38(6):491^6. 24. Craig RG, Powers JM, Wataha JC. In: Dental materials: properties and manipulation. 7th edn. Mosby: St. Louis; 2000. p. 25. 25. ThompsonJB, KindtJH, Drake B, Hansma HG, Morse DE, Hansma PK. Bone indentation recovery time correlates with bond reforming time. Nature 2001 (December); 414(6865):773^6.
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26. Vashishth D, Tanner KE, Bonfield W. Contribution, development and morphology of microcracking in cortical bone during crack propagation. J Biomech 2000 (September); 33(9):1169^74. 27. Wang X, Bank RA, T eKoppele JM, Hubbard GB, Athanasiou KA, Agrawal CM. Effect of collagen denaturation on the toughness of bone. Clin Orthop 2000 (February);371: 228^39. 28. Papavasilou G, Kamposiora P, Bayne SC, Felton DA. Three-dimensional finite analysis of stress-distribution around single tooth implants as a function of bony support, prosthesis type and loading during function. J Prosthet Dent 1996 (December);76(6):633^40. 29. Feng Z. Fracture toughness of cortical bone in tension, shear and tear ^ comparison of longitudinal and transverse fracture. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi 1997 (September);14(3):199^204. 30. T olman DE, Keller EE. Management of mandibular fractures in patients with endosseous implants. Int J Oral Maxillofac Implants 1991;6:427^36.
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