Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
7. DEFINITION
- “OS” ( Latin ) bone
- “integration” (Latin ) meaning the state of being
combined into a complete whole.
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8. Osseointegration is defined as a direct bone anchorage to an
implant body which can provide a foundation to support a
prosthesis ; it has the ability to transmit occlusal forces
directly to bone
(Alberktsson et al.,1981;Branenmark,1983 ; Carlson ,et
al.,1986)
Osseointegration as defined by Branemark, denotes at
least some direct contact of living bone with the surface of
an implant at the light microscopic level of magnification.
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9. • American Academy of Implant Dentistry defined it as
“Contact established without interposition of non bone
tissue between normal remodeled bone and on implant
entailing a sustained transfer and distribution of load
from the implant to and within bone tissue”.
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10. • GPT 8 :
The apparent direct attachment or connection of osseous
tissue to an inert, alloplastic material without intervening
connective tissue.
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11. • Rigid fixation is a clinical term that means the absence of
observed clinical mobility. It is the clinical aspect of the
microscopic bone contact with an implant & is the absence
of mobility with 1 to 500 gms force applied in a vertical or
horizontal direction.
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12. • HISTORICAL REVIEW
Dr. Per-Ingvar Branemark
Professor at the institute for Applied Biotechnology, University of Goteborg, Sweden.
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13. Initial concept of osseointegration
-vital microscopic studies of microcirculation in bone
repair mechanisms.
-Titanium chamber was surgically inserted into the
tibia of a rabbit.
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14. • 1952 - Branemark implant system
• 1965 - the treatment of first edentulous
patient
• 1973- Cameron et al. - bone may grow on the
surface of a biocompatible material. This only
happens if movement between the implant and
adjacent bone is prevented until osteogenesis is
complete.
•
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15. • 1977 - first clinical report published
• 1982 - Toronto meeting on osseointegration
• Schroeder (Switzerland) – 1970’s - first to
demonstrate osseointegration
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16. • Skalak in 1983 –mere bone growth into irregularities of
implant without any true functional connection is sufficient to
carry load
• Albrektsson et al. (1981)
(1) The biocompatibility
(2) Design
(3) Surface conditions of the implant,
(4) The status of the host bed,
(5) The surgical technique at insertion, and
(6) The loading conditions applied afterwards.
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18. THEORIES OF OSSEOINTEGRATION
LINKOW (1970) BRANEMARK
JAMES (1975)
WEISS (1986)
FIBRO-
OSSEOUS
OSSEO-
INTEGRATION
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19. 1. FIBRO-OSSEOUS INTEGRATION
“tissue to implant contact- with healthy dense collagenous
tissue between the implant and the bone”
The fibers …
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20. 2. OSSEO-INTEGRATION
direct connection b/w living bone & implant
at light microscopic level
Meffert, et all. 1987
Adaptive Biointegration
osseointegration
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21. Adaptive osseointegration –
has osseous tissue approximating the surface of the
implant without apparent soft tissue interface at the light
microscope level
Biointegration
is a direct biochemical bone surface attachment
confirmed at the electron microscopic level
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22. Contact osteogenesis vs distance osteogenesis :
Osborn and Newesley (1980)
Distance osteogenesis
Osteogenic cells line the old bone surface. The blood
supply to these cells is between the cells and the
implant. Hence the bone is laid down on the old bone
surface itself.
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23. • Osteogenic cells are first recruited to the implant surface.
The blood supply is between the cells and old bone,
hence new (de novo) bone is laid down.
Contact osteogenesis
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35. • CREEPING SUBSTITUTION
( cortical bone repair)
vessels penetrate the necrotic border
osteoclasts resorb necrotic b.(bone multicellular units)
osteoblasts form new bone around vessel
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38. • Intermolecular forces
• Bio-mechanical bond
• Interactions are electrostatic
• Oxide layer is highly polar and negatively charged
thus, it provides a strongly attractive alternative to
water for the charged bodies ( Ca++ & PO4-)
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42. I. GENERAL HOST FACTORS
Sex of pt.
Bone metabolic diseases
Tobacco smoking
Malabsorption syndromes
Hormonal diseases
Coagulation disorders
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43. II . LOCAL HOST TISSUE CONDITIONS
1.Local bone quality and quantity –Initial stability
2.Local anatomy – max. tuberosity – not fav.
canine,zygomatic , pterygoid areas
anterior mandible- fav.
3.Degree of resorption
4. Congenital defects
5. irradiation bone- healing depressed
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44. BONE QUALITY
- bone density, anatomy and volume
• Bone volume does not by itself influence
osseointegration, but is an important determinant of
implant placement
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45. LIKHOM AND ZARB CLASSIFICATION 1985
Class I : Jaw
consist almost
exclusively of
homogeneous
compact bone
Class II :
Thick compact
bone surrounds
highly
trabecular core
Class III :
Thin cortical
bone surrounds
highly
trabecular core
Class IV :
Thin cortical
bone surrounds
loose, spongy
core
Bone density
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47. Bone anatomy
Branemark system (5 year documentation)
Mandible – 95% success
Maxilla – 85-90% success
Aden et al (1981) – 10% greater success rate in anterior
mandible compared to anterior maxilla.
Schnitman et al (1988) – lower success rate in posterior
compared to anterior mandible
- posterior maxilla higher failure rates.www.indiandentalacademy.com
48. According to Branemark and Misch
D1 and D2 bone → initial stability / better osseointegration
D3 and D4 → poor prognosis
Selection of implant
D1 and D2 – conventional threaded implants
D3 and D4 – HA coated or Titanium plasma coated implants
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52. METALS
Commercially pure titanium (CPTi) : 99.75%
Most biocompatible material
Adherent, self passivating titanium dioxide (TiO2/ TiO)
layer. (50-100A)
(10A0
within seconds, 100A0
within a minute.)
Steinman (1988) referred this
layer as Biologically inert
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53. Reason for bioinertness of Ti
- surface oxide
- corrosion
- allergy
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54. CERAMICS
(Calciumphosphate hydroxyapatite, Al2O3, Tricalcium phosphate)
• Develop a chemical bond of a cohesive nature
• Applied in the form of coating onto the metallic core.
Hydroxyapatite coated implant
Adv: rapid bone response
Disadv: coat loosening
• Hahn J (1997) HA coated implant – 97.8%(6 yrs) clinical
success.
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56. Non threaded
•Tendency for slippage
•Bonding is required
•No slippage tendency
•No bonding is required
Threaded
2. Implant design
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57. Implant Design characteristic : 3 D structure of the implant.
Form, shape, configuration, geometry, surface macro structure,
macro irregularities.
Cylindrical Screw shaped implants.
Threaded Non threaded.
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58. Threaded implants :
Alteration in the design, size and pitch of
the threads can influence the long term
osseointegration.
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66. Machined / turned surface
SEM x 1000 SEM x 4700
Cp Titanium
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67. Titanium plasma sprayed coating (TPS)
Coated with titanium powder
particles in the form of
titanium hydride
Plasma flame spraying technique
6-10 times increase
surface area. Steinemann
1988, Tetsch 1991
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68. Hydroxyapatite coatings
HA coated implant bioactive
surface structure – more rapid
osseous healing comparison
with smooth surface implant.
↓
Increased initial stability
Can be Indicated
- Type IV bone
- Fresh extraction sites
- Newly grafted sites
SEM 100X
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69. 2. Physical characteristic :
•
•Surface energy and charge.
Hypothesis : A surface with high energy →high affinity for
adsorption → show stronger osseointegration.
Baier RE (1986) – Glow discharge (plasma cleaning) results in
high surface energy as well as the implant sterilization,
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70. 3. Implant surface chemistry :
• Chemical alteration → increases bioactivity → increase implant
bone anchorage.
Chemical surfaces :
• Ceramic coated – hydroxyapatite (HA), Calcium phosphate
• Oxidized/anodized surfaces with electrolytes containing
phosphorous, sulfur, calcium, magnesium and flouride.
• Doped surfaces with the BONE stimulating factors / growth
factors.
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71. Anchorage Mechanism or Bonding Mechanism in Osseointegrated
implants :
Biomechanical bonding
In growth of bone into small surface
irregularities of implant surface → three
dimensional stabilization
Seen in :
• Machined / turned screw implant
• Blasted /Acid etch surface → moderately
rough implant surface.
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72. Biochemical bonding
Seen with certain bioactive implant
surfaces like :
• Calcium phosphate coated implant surfaces
• HA coated implant surfaces
• Oxidized/ anodized surfaces
Biointegration :
•“Strong chemical bond may develop between the host bone
and bioactive implant surfaces and such implants are said to be
biointegrated”.
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73. Doped surfaces that contain various types of bone growth factors
or other bone-stimulating agents may prove advantageous in
compromised bone beds.
*BMP = Bone morphogenetic protein.
Doped surfaces
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74. 4. Fixture site position
• Bicortical initial stablization
• min. Width of the bone
• min. distance between fixtures
• min distance from adjacent teeth
• Min. distance from anantomic structures
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75. 5. Number of fixture sites
In mandible – 1st
molar area to other not recommended
1 fixture – 1 crown
2 fixtures – bridge
4 fixtures- full arch bridge
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76. 6.Trauma to host tissues
Objective:
Controlled surgical technique
Surgical skill / technical excellence
Parameters :
1. Profuse irrigation for cooling
2. Use of well sharpened drills and use of graded
series of drills
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77. 3. Slow drill speeds
4. Proper drill geometry
5. Intermitent drilling
Eriksson R.A :
• Drill speed < 2000 rpm, tapping at 15 rpm.
• Cooling during tapping and insertion of screw
Violent surgical technique
• Frictional heat / overheating → increased temperature rise in bone
→ wide zone of necrosis → fibrous tissue, primary failure of
osseointegration.
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78. • Critical temp. – 47 C
• Maintain vitailty – 43 C ( alk. Phosphatase)
• Ideal – 39 C
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80. • Healing time
3 months – dense bone
6 months – cancellous bone
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81. • Loading condition
“ No loading while healing”
• Delayed loading: an implant prosthesis with an
occlusal load afer more than 3 months after implant
insertion.
• Early loading:an implant supported restoration in in
occlusion between 2 weeks and 3 months
• Immediate / Direct loading:implant supported
prosthesis in occlusal contact within 2 weeks of
implant insertionwww.indiandentalacademy.com
84. Success criteria of implants :
Schuitman and Schulman criteria (1979)
1) The mobility of the implant must be less than 1mm when
tested clinically.
2) There must be no evidence of radiolucency
3) Bone loss should be less than 1/3rd
of the height of the
implant
4) There should be an absence of infection, damage to structure
or violation of body cavity, inflammation present must be
amneable to treatment.
5) The success rate must be 75% or more after 5 years of
functional service.
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85. Albrektson and Zarb G (1980)
1) The individual unattached implant should be immobile when
tested clinically
2) The radiographic evaluation should not show any peri-implant
radiolucency
3) Vertical bone loss around the fixtures should be less than
0.2mm annually after first year of implant loading.
4) The implant should not show any sign and symptom of pain,
infection, neuropathies, parasthesia, violation of mandibular
canal and sinus drainage.
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86. Smith and Zarb (1989)
6) Implant design allow the restoration satisfactory to
patient and dentist.
5) Success rate of 85% at the end of 5 year
observation period and 80% at the end of 10 year
service.
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93. 5. - rapid progressive periodontal dis.
higher risk of peri- implant dis.
6.
- inc. peri- implantitis
- inc. marginal bone loss
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94. 2. Implant risk
• 1. - diff. I/O sites- diff. implant survival rates
- bone density
- state of host bed
• 2. - threaded implants
- shorter implants prone to overload
- HA coated – higher failure
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95. 3. Site- specific risk
1. - absence of bleeding on probing
- F applied – 0.2N .
- higher probing F – attachment
2.
- decreased – inc. peri-implant dis.
- non- ker. Mucosa – succeptible to
progression of peri-implantitis
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96. Scope of osseointegration in
dentistry
1) Prosthetic rehabilitation of missing teeth
Complete edentulous maxilla and mandible rehabilitation.
Single tooth replacementPartial dental loss replacementwww.indiandentalacademy.com
97. 2) Anchorage for the maxillofacial prosthesis
Auricular Prosthesis
Ocular Prosthesis
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98. 3) For rehabilitation of congenital and developmental defects
- Cleft palate
- Ectodermal
dysplasia
4) Complex maxillofacial defect rehabilitation
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100. Conclusion
Osseointegration has been a breakthrough in oral
implantology previously regarded as non lege artis.
The success of osseointegration has been proven
beyond doubt, but achieving successful
osseointegration depends on careful planning ,
meticulous surgical technique & skilled prosthetic
management
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101. • References
1. Contemporary implant dentistry 3rd
edn. , Carl .E. Misch
2. Fundamentals of implant dentistry, Weiss& Weiss
3. Dental implants- art & science , Babbush
4. Tissue integrated prosthesis-osseointegration in clinical
dentistry , Branemark/ Zarb
5. Implant & restorative dentistry – Scortecci
6. Clinical periodontology and implant dentistry,
Lindhe,Karring, Lang
7. Theory & practice of osseointegration, S. Hobo
8. Advanced osseoinegration surgery- Worthington
9. Color atlas of dental & maxillo-facial implants , Hobkirk
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Biotolerant – not necessarily rejected when implanted into living tissue, but are surrounded by a fibrous layer in the form of capsule .bioinert – allows close apposition of bone on their surface ,leading to contact osteogenisis . bioactive –allows formation of new bone which is chemically bonded.