OSSEO-INTEGRATION

INTRODUCTION

‘osteon,’ -the Greek word for The concept of osseointegration

bone was developed and the term was
integrare. -Latin word for ‘to coined by DR.PER INGVAR
make whole’ BRANEMARK.
 HISTORY
1940 -
Osseointegrati 1983 -Toronto
1952 - 1970 -
on first Branemark Conference
Branemark +
observed by experiment on accepted
Bofors
Bothe & rabbit bone Branemark’s
(Swedish DC)
Davenport work

Nobel Pharma

Nobel Biocare
 DEFINITIONS

Osseointegration is initially defined as the direct structural

and functional connection between living bone and the
surface of a loadbearing artificial implant, typically made of
titanium. [Branemark and associates (1977)]

The apparent direct attachment or connection of osseous

tissue to an inert, alloplastic material without intervening
connective tissue”. - GPT 8
“American Academy of Implant Dentistry (AAID) defined
Osseointegration as "contact established without interposition of
non-bone tissue between normal remodeled bone and an implant
entailing a sustained transfer and distribution of load from the
implant to and within the bone tissue“

“It is a process where by clinically asymptomatic rigid fixation of

alloplastic material is achieved and maintained in bone during
functional loading” - Zarb and Albrektsson (1991)
Histologically, Direct anchorage of an implant by the formation of
bone directly on the surface of an implant without any intervening
layer of fibrous tissue. - Albrektsson and Johnson (2001)

Clinically, Ankylosis of the implant bone interface. "Functional

ankylosis” -Schroeder and colleagues(1976)

Biomechanically oriented definition “Attachment resistant to shear as

well as tensile forces” - Steinmann et al (1986).
Bone to Implant Interface
Two Basic Theories :-

Fibro-osseous integration (Weiss 1986)

Osseointegration (Branemark 1985)
Tissue to implant contact
Tissue to implant contact without
with interposition of healthy
interposition of non osseous tissue
dense collagenous tissue
- sustained distribution of load from the
implant to and within the bone tissue
FIBRO-OSSEOUS INTEGRATION (WEISS 1986)

■ Collagen fibers at the interface

■ “peri-implant membrane” with an osteogenic effect

also called pseudo ligament

■ peri-implant ligament similar as periodontal membrane in natural dentition

Failure of Fibro osseous theory

■ No evidence to support this theory.

■ Since fibres are arranged parallel to the implant surface, do not
help in force transfer
■ Forces applied widening of fibrous encapsulation,
inflammatory reaction and gradual bone resorption failure
• MECHANISM OF OSSEOINTEGRATION
proposed by:

MISCH
BRANEMARK
OSBORN & NEWESLY
 Misch’s concept
■ 2 stages of osseointegration , each stage divided into 2 sub stages

1.Surface Modelling (sub stages 1 and 2)

■ Sub stage 1 -Woven callus (0-6 weeks)
■ Sub stage 2 -lamellar compaction , remodelling and maturation (6-18
weeks)
2.Remodelling and maturation ( sub stages 3 and 4)
■ Sub stage 3 - interface remodelling (6-18 weeks)
■ Sub stage 4 - compact maturation (18-54 weeks)
Sub stage 1 -Woven callus

■ Woven bone is formed at the implant site

■ Primitive type of bone tissue and characterized by random

orientation of collagen fibrils.

■ Irregularly shaped osteocytes and low mineral density

Sub stage 2 -Lamellar compaction ,
remodeling and maturation
■ Lamellar compaction

■ Maturation of woven bone results in replacement by lamellar

bone.

■ This stage helps in achieving sufficient strength for loading

 Sub stage 3 - Interface remodeling

■ Interface Remodeling

■ Callus starts resorbing and remodeling of devitalized interface begins

■ Establishes a viable interface between implant and original bone

 Sub stage 4 - Compact maturation

■ Compact bone maturation

■ Compact bone matures by series of modelling and remodeling process.

■ Callus volume decreases and interface remodeling continues

Branemark’s concept
 STAGES OF OSSEOINTEGRATION

Osteophylic stage Osteoconductive stage Osteoadaptive stage

• Clot • Immature CT matrix • Remodelling &

• Inflammatory cells • Immature woven Maturation happens
• Neovascularisation bone(FOOT PLATE)
• Lamellar bone
Bone Tissue Response - Osborn & Newesly 190

■ Peri-implant new ■ Implant surface new

bone formation bone formation
 KEY FACTORS FOR SUCCESSFUL
OSSEOINTEGRATION –(Alberktsson)
1. Implant biocompatibility
2. Implant design
3. Implant surface characteristics
4. Bone factors
5. Host factors / patient factors
6. Surgical considerations
7. Loading conditions
8. Prosthetic considerations
 IMPLANT BIOCOMPATIBILITY

Classification:
■ Bio tolerant: fibrous capsule(distant Osteogenesis)

■ Bioinert: close bone apposition(contact osteogenesis)

■ Bioactive : New bone formation(bonding osteogenesis)

Based On Chemical Composition:
■ metals
■ ceramics
■ polymers
 CHEMICAL
COMPOSTON BIOLOGICAL RESPONSE

BIOTOLERANT BIOINERT BIOACTIVE

Gold Co-Cr alloys Commercially pure

Stainless steel titanium Titanium alloy
METALS Niobium Tantalum (Ti-6AL-4U)

zirconia, Hydroxyapatite
alumina Tricalcium phosphate
CERAMICS Bio glass
Carbon-silicon

methyl methacrylate
PEEK ,PTFE,
POLYMERS Polyurethane,
Polyethylene
Titanium & Ti Alloys
• One of the most biocompatible material- excellent corrosion resistance
• Oxide layer - 2-10nm in 1 sec provides corrosion resistance
• Most commonly used Ti-6Al-4V. Also called Extra Low Interstitial
• Modulus of elasticity 5 -10 times rigid than cortical bone.
• ELI contains low oxygen- improved ductility
• Newer Ti alloys ( Nb-Zr, & Mo-Nb ) provides greater corrosion resistance
 Cp Titanium Grade I - 0.18% Oxygen
 Cp Titanium Grade II - 0.25% Oxygen
 Cp Titanium Grade III - 0.35% Oxygen
 Cp Titanium Grade IV - 0.40% Oxygen
 Polymers
■ First used in 1930s

■ Low mechanical strength,& susceptibility to fracture during function

■ Physical properties of polymers are much influenced by changes in

temperature, environment and composition.

■ Contamination of polymers high, due to the electrostatic charges that

attract dust and other contaminants.
■ Biocompatibility issues

■ Sterilization accomplished only by gamma radiation / ethylene

oxide gas.

■ Advances in polymers – PEEK, yet not considered as an ideal

choice of implant biomaterial.
CERAMICS

■ Bio inert - Al2O3, TiO2, Zr2O3

■ Bio active -
• Calcium Phosphate
– Tri calcium Phosphate,
– Hydroxy apatite
• Glass ceramic
– Bioglass
■ Al2O3 – gold standard for ceramic implants because of its inertness and no
evidence of immune reactions.
■ Zr2O3- high degree of inertness, High strength , stiffness & hardness
Advantages

• Excellent biocompatibility
• Minimal thermal & electrical conductivity
• Esthetic – matching with bone enamel and dentine
• Chemical composition similar to natural biological tissues
• Tolerate high degree of compressive stresses.

Disadvantages

• Low tensile and shear strength, under fatigue loading

• Not a suitable substrate for some of the coating materials .–
cracking and low adherence.
 Bio glass

■ Widely used as a bone graft material

■ Very brittle , not suitable as stress bearing implants

■ Excellent chemical bond with surrounding bone

Migration of Initiates
Ca, P, silica Silica gel migration of Initiates cell adherence Promotes
and Na ions Layer is Ca and P migration, over the new bone
towards Formed ions from proliferation implant formation
tissue bone
BioHybrid implants

■ Coating the implants with stem cells/ totipotent mesenchymal

cells which can differentiate and proliferate into osteoblasts for
new bone formation
■ Coating the surface with bioactive molecules like bone growth
factors
• Extracting the dental follicle intact , and embedding / coating the implant
with the follicle, which helps in true osseointegration, and the implant
functions as good as natural tooth.
IMPLANT DESIGN (MACRO DESIGN)

 Implant length
 Implant width
 Implant shape/geometry
 Threaded/ non threaded
IMPLANT LENGTH

■ Length - total surface area

■ The shorter and smaller diameter implants had lower survival

rates than their longer or wider counter parts
 IMPLANT WIDTH
■ Implant width - functional surface area

■ Diameter corresponding to ridge width

■ Crestal bone anatomy most often constraints implant width to less than 5.5
mm

■ Wider forms increases bone contact than narrower forms

■ Improved emergence profile

■ Enhances the fracture resistance.

 IMPLANT MACROGEOMETRY /SHAPE

■ Smooth sided cylindrical implant

 Ease in surgical placement
 Greater shear at interface
 A smooth surface cylinder depends on a coating or microstructure for load
transfer to bone.
■ Smooth sided tapered implants
 component load to be delivered to the bone implant interface greater the
taper of smooth sided implant the less the overall surface area taper should not
exceed 30º
 THREADED/ NON THREADED
Thread geometry Parameters – thread pitch,
shape , width and depth
Threaded implants
■ Ease of surgical placement
■ Governs the initial stability of the
implant.
■ Greater functional surface area – better
compressive loads transmission
■ Limits micro-movement during healing
IMPLANT SURFACE CHARACTERISTICS

■ Physical properties (surface energy/roughness)

-micro
-Nano
■ Biochemical properties ( surface chemistry)
Wennerberg and Alberktsson (2004) Roughness values

1. Smooth; <0.5µm
2. minimally rough: 0.5-1 µm
3. intermediately rough: 1-2 µm
4. rough: 2-3 µm
 IMPLANT SURFACE TREATMENTS
Need for surface modification:
■ To increase surface area
■ To bring better bonding
■ To increase surface roughness of metal
■ To make the metal more passive
■ To remove surface contaminants
Micro-modifications (mechanical & chemical)

Additive Subtractive Nano-modifications

1.Sintering 1.Grit Blasting 1.Ion Implantation
2.Ti plasma Spraying 2.Acid etching (Nitrogen ion)
3.HA coating 3.Laser Peening 2. Ion Beam Deposition
4.Anodization(TiO2)
4.Mechanical polishing (TiO2)
5.Electropolishing 3. Nano Crystal Coating
- Ca Phosphate coating
- HA coating
BONE FACTORS

• BONE QUALITY
• BONE QUANTITY
BONE QUALITY

• Skeletal size
• Architecture
• 3-D orientation of the trabeculae
• Matrix properties
• Mineralization & structure
The four macroscopic bone qualities are:
 PATIENT RELATED FACTORS

 Age
 Effect of drugs on osseointegration
 Medical history-
-Relative contraindications
- Absolute contraindication
 Oral hygiene
 Tobacco usage/smoking
 Parafunctional habits
 State of the host bed
 Age of the patient

■ Avoided for patients below age of 18 as it affects growth of

maxilla and mandible.

■ In such a cases, a temporary partial denture (RPD), or a non

invasive fibre reinforced composite (FRC) bridge is indicated
until patient turns 18
Drugs promoting osseointegration
SIMVASTATIN

■ It is a liposoluble statin with Osteo anabolic ( bone building) effects.

■ Anti resorption drug

■ They stimulate expression of Rh-BMP2, thereby enhancing Osseo

integration

■ It also improves cancellous bone mass, bone mineral density and bone
compressive strength.
Other drugs promoting osteointegration are:

■ parathyroid hormone (PTH) peptides,

■ prostaglandin EP4 receptor antagonist,
■ vitamin D,
■ strontium ranelate
■ newer therapies such as DKK1-antibody and anti-sclerostin
antibody, also known as romosozumab.
 Drugs Inhibiting Osseointegration

WARFARIN

■ Anticoagulant

■ Patients ( under warfarin) who underwent dental implant surgery with

uncoated porous cobalt chromium molybdenum alloy showed poor
ingrowth of bone and an increased rate of failure.
HEPARIN

■ Decreases the formation of type 2 collagen matrix and leads to

inhibition of osseointegration and is considered as an inhibiting
factor

■ CyclosporinA, Methotrexate, Cis- Platin

■ NSAIDS like selective Cox-2 inhibitors

MEDICAL HISTORY

RELATIVE CONTRAINDICATIONS

■ Active malignancies

■ Bleeding disorders -coagulopathies ( deficiency of clotting factors)

■ Blood cell disorders - anemia, neutropenia, thrombocytopenic

purpura, polycythemia vera

■ Cardiac complications- recent MI, unstable angina, decompensated

CHF, severe valvular diseases or recent cardiovascular surgery
• Infections: HIV- implants are avoided.
- however, if CD-4 counts are above 200 cells / mm3 implants are
considered as a treatment

•Radiotherapy -implants should be avoided if patient received over 45-50

Gy of radiation in total.

•Other systemic disease-Chronic Osteomyelitis, Pagets disease,

uncontrolled Kidney disease , Liver disease etc
ORAL HYGIENE
• relative contraindication
• has direct effect on prognosis of the therapy.
• However, implant therapy is advised if patient is
compliant and oral hygiene can be maintained
PARAFUNCTIONAL HABITS
• Bruxism : most significant factor.
on a risk scale of 1 to 10 rated 10.
Relative contraindications until and unless supported by adjunct
therapy for their habits.
• Clenching : Long term clenching can induce immense loads on
the prosthesis.
rated 9 on risk scale
ABSOLUTE CONTRAINDICATIONS:
•Age : Below 17 years
•Smoking and radiation
•Leukemic patients with a positive ZAP 70 marker
•Osteoradionecrosis - due to poor bone healing

SMOKING
Affect the prognosis of the implant therapy.
Can lead to failure of implant as it directly affects healing and
osseointegration
Also associated with wound dehiscence and graft failure.
Also constricts blood vessels and decreases angiogenesis.
Before placement, patient is put on smoking cessation controls.
STATE OF THE HOST BED

Ideal host bed- Healthy and with an adequate bone stock, bone height ,
bone density , bone length and width
Undesirable host bed states for implantation:
• Previous irradiation
• Ridge height resorption
• Osteoporosis.
 SURGICAL FACTORS

■ Tissue handling - minimum tissue trauma improves health

■ Controlled surgical technique is important Profuse & continuous

irrigation is necessary to prevent bone heating and necrosis.

■ Use of sharp drills with a drill speed of less than 2000 rpm is desired

■ 47°C for 1minute is the critical temperature for bone overheating

The critical measurements specific to implant
placement include the following:

1. At least 1 mm inferior to the floor of the maxillary and nasal sinuses

2. Incisive canal (maxillary midline implant placement) to be avoided
3. Five millimeters anterior to the mental foramen
4. Two millimeters superior to the mandibular canal
5. Three millimeters from adjacent implants
6. One and one half millimeters from the roots of the adjacent teeth
Incisions
• A, Papilla-sparing, mid -crestal incision
with conservative release.

• B, Incision, with an anterior-releasing

incision providing greater exposure.

• C, Papilla-sparing incision, with mesial

and distal-releasing incisions allowing
more exposure.
LOADING FACTORS

 Immediate /direct loading: provisional /definitive prosthesis s

attached within 24hrs of implant being placed.

 Early functional loading: within days / weeks ( in cases with

associated lesions)

 Delayed loading- prosthesis attached-3-6months

 PROSTHETIC CONSIDERATIONS

TIME

the functional load

exceeds the load- bone loss around progress around the
bearing capacity of the coronal portion entire implant to Ultimate failure
the implant–bone of the implant cause it to loosen.
interface

LOAD
The load-bearing capacity of implants
is qualified by several factors:

The number
The amount
and size of
The volume of the implant
the implants,
The length, and quality of surface area Angulation of
the
and diameter the bone– to which the occlusal
arrangement
of the implant implant high-quality forces.
and
interface. bone has
angulation of
attached.
the implant
Mechanical overload can result in-

breakdown of osseointegration,
cement failure at the natural abutment,
screw or abutment loosening,
 fracture of restoration/ implant prosthetic components.
Iatrogenically by placing non- passive ill-fitting frameworks on implants.
Over-tightened screws will often lead to bone loss and implant failure.

The assessment for prosthetic treatment is multifactorial, is unique to each

patient, and can range from straightforward to highly complex
 Radiograph

Cutting
Pulsed torque
oscillation resistance
waveform
Analysis

METHODS TO
DETERMINE
OSSEOINTEGRATI
Percussion ON Resonance
test frequency
analysis

Insertion
Reverse
torque
Torque test
analysis
Radiographs
Non invasive method , one of the first
method applied to evaluate the condition of
implants
Advantage :
can be performed at any stage to evaluate the
state.
Disadvantage:

1) If the central ray does not pass through the center of the implant, it
results in a distorted image , thereby yielding incorrect information.
2)Since 2 D, it does not give information about facial and lingual bone
levels.
3) Cannot quantify the density of bone nor the quality
4) Can assess changes only when demineralization exceeds 40 %
Cutting Torque Resistance Analysis

The energy (J/ mm3) required in cutting off a unit

volume of bone during implant surgery is measured.
This energy is correlated with the bone density which
in turn is an indicator for primary stability

Adv :
Determine bone density and quality during surgery
Disadv :
Cannot be used to assess bone quality and density after
implant insertion
Insertion Torque Analysis
• Evaluates the amount of force that is applied to
• the implant as it is inserted.
• widely used technique.
• Measured manually using a torque wrench
Disadvantages:
Estimating quality of bone is impossible.
Cannot be used for selection of implant sites
Cannot be used to follow implant healing and
osseointegration procedures
Reverse Torque Test

Proposed by Robert et al in 1984

Measures the Removal Torque Value ( RTV)
Procedure: At the time of surgery, the torque screw driver is
placed and reverse torque is applied. The amount of torque applied
is measured via the torque wrench.

DISADVANTAGES :
• It is a destructive method. Risk of irreparable plastic deformation to
the peri - implant bone.
• Increases risk of failure after the test, especially in poor quality
bone
Percussion test

Simplest method for testing implant stability

Based on the sound heard from the percussion of
the implant with metallic instrument.

Disadvantage:
Relies on the skill of the examiner , more
Ringing sound- Osseo integrated
subjective Dull sound - fibrous integration
Cannot be used as a standard testing method.
Pulsed oscillation waveform

 Used to analyze the mechanical and vibrational characteristics of the

implant bone interface.
 Works based on the frequency and amplitude of the implant vibration
induced by a small pulsed force.

Disadv:
Extremely sensitive and varies from position to position
Resonance Frequency Analysis

•Non-invasive and objective method

•Measures via vibration and structural analysis.
•A two piece transducer is placed on the implant or abutment following which
a signal is used to vibrate one component of the transducer.
•Other component act like a receptor for the signal and after conversion , is
displayed in the monitor as implant stability quotient (ISQ).

•ISQ: ranges from 0 and 100

ISQ >65 : Well osseointegrated
ISQ <50: Poorly osseointegrated
FAILURES OF OSSEOINTEGRATION

 Early : Failure to establish close bone to implant contact

 Late : Disruption of established contact.
 Biologic :Bacterial / aseptic
 Mechanical :Due to overload and fracture.
 CONCLUSION
■ As osseointegration is a multifactorial entity, achieving
osseointegration of the endosteal dental implants needs understanding
of the many clinical parameters.

■ Thorough understanding and application of forces affecting

osseointegration, the mechanism, factors and biological process of
osseointegration in clinical practice is the key factor of success.
THANK YOU