Ossntgrtn / orthodontic straight wire technique

GOOD MORNING
GOOD MORNING
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

OSSEOINTEGRATION

CONTENTS
1.Introduction
2. Historical review
3. Foreign body reaction
4. Theories of osseointegration
5. Stages of osseointegration
6. Ultrastructure
7. Factors influencing osseointegration
8. Success criteria
9. Methods of evaluation
10.Risk factors
11. Scope of osseointegration in dentistry
12. Conclusion

Tissue Integration at implant interface
INTRODUCTION

DEFINITION
- “OS” ( Latin ) bone
- “integration” (Latin ) meaning the state of being
combined into a complete whole.

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.

• 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”.

• GPT 8 :
The apparent direct attachment or connection of osseous
tissue to an inert, alloplastic material without intervening
connective tissue.

• 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.

• HISTORICAL REVIEW
Dr. Per-Ingvar Branemark
Professor at the institute for Applied Biotechnology, University of Goteborg, Sweden.

Initial concept of osseointegration
-vital microscopic studies of microcirculation in bone
repair mechanisms.
-Titanium chamber was surgically inserted into the
tibia of a rabbit.

• 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.
•

• 1977 - first clinical report published
• 1982 - Toronto meeting on osseointegration
• Schroeder (Switzerland) – 1970’s - first to
demonstrate osseointegration

• 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.

FOREIGN BODY REACTION
foreign body
Organization Ag-Ab rxn
not with implants

THEORIES OF OSSEOINTEGRATION
LINKOW (1970) BRANEMARK
JAMES (1975)
WEISS (1986)
FIBRO-
OSSEOUS
OSSEO-
INTEGRATION

1. FIBRO-OSSEOUS INTEGRATION
“tissue to implant contact- with healthy dense collagenous
tissue between the implant and the bone”
The fibers …

2. OSSEO-INTEGRATION
direct connection b/w living bone & implant
at light microscopic level
Meffert, et all. 1987
Adaptive Biointegration
osseointegration

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

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.

• 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

REQUIREMENTS FOR OSSEOINTEGRATION
• 1. Adequate cells

• 2. Adequate stimulus
i) dying cells chemical signals undiff.
mesenchymal cells
ii) Matrix molecules( injured bone) + u m c

• iii) peizoelectric signals – movt. of fracture ends

STAGES OF
OSSEOINTEGRATION

11. Osteophytic phase ( 1 month)

• Granulation tissue

• Procallus

• 2. Osteoconductive phase
Woven bone

Lamellar bone

Woven
Lamellarcellularity
rate of formation
mineral content
Collagen fibres
strength
Resistance functional load
implant

3. Osteoadaptive phase
remodelling

• CREEPING SUBSTITUTION
( cortical bone repair)
vessels penetrate the necrotic border
osteoclasts resorb necrotic b.(bone multicellular units)
osteoblasts form new bone around vessel

ULTRASTRUCTURALULTRASTRUCTURAL
LEVELLEVEL
soft tissue
cortical bone
cancellous boneu

Electron microscopically
20-200nm

• 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-)

Factors influencing osseointegration
Loading
conditio
n
ALBREKTSON

WORTHINGTON

I. PRE- OPERATIVE HOST
FACTORS

I. GENERAL HOST FACTORS
Sex of pt.
Bone metabolic diseases
Tobacco smoking
Malabsorption syndromes
Hormonal diseases
Coagulation disorders

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

BONE QUALITY
- bone density, anatomy and volume
• Bone volume does not by itself influence
osseointegration, but is an important determinant of
implant placement

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

• MISCH CLASSIFICATION 1988
D1 D2 D3 D4

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

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

II. PERI-OPERATIVE FACTORS

1. Implant biocompatability
ZONES
Ti
HA
Ti6Al4V
Al2O3
Cu
Ag

MetalsMetals CeramicsCeramics PolymersPolymers
BiotolerantBiotolerant GoldGold PolyethylenePolyethylene
Cobalt-Cobalt-
chromiumchromium
alloysalloys
PolyamidePolyamide
Stainless steelStainless steel PolymethylmethaPolymethylmetha
crylatecrylate
ZirconiumZirconium PolytetrafluoroetPolytetrafluoroet
hylenehylene
NiobiumNiobium PolyurethanePolyurethane
TantalumTantalum
BioinertBioinert
CommerciallyCommercially
pure titaniumpure titanium
AluminumAluminum
oxideoxide
Titanium alloyTitanium alloy
(Ti-6Al-4V)(Ti-6Al-4V)
ZirconiumZirconium
oxideoxide
BioactiveBioactive HydroxyapatiteHydroxyapatite
TricalciumTricalcium
phosphatephosphate
CalciumCalcium
pyrophosphatepyrophosphate

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

Reason for bioinertness of Ti
- surface oxide
- corrosion
- allergy

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.

POLYMERS
Not used
•Inferior mechanical properties
•Lack of adhesion to living tissues
•Adverse immunological reaction

Non threaded
•Tendency for slippage
•Bonding is required
•No slippage tendency
•No bonding is required
Threaded
2. Implant design

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.

Threaded implants :
Alteration in the design, size and pitch of
the threads can influence the long term
osseointegration.

• Cylindrical implants

Topographic
properties
Implant surface
texture & roughness
Physical properties
Surface energy and
charge
Physiochemical properties
Implant surface chemistry
3.Implant surface characteristics

1) Turned surface/ machined surface
2) Acid etch surface - HCl and H2SO4
3) Blasted surface – TiO2 / Al2O3 particles
4) Blasted + Acidetch surface
- Al2O3 particles & HCl and H2SO4
- Tricalcium phosphate & HF & NO3
1. Surface topography

5) Hydroxyapatite coated surface (HA)
6) Titanium plasma sprayed surface (TPS)
7) Oxidized surface
8) Doped surface
9) Nanosized hydroxyapatite coated surfaceswww.indiandentalacademy.com

Roughness parameter (Sa)
0.04 –0.4 µm - smooth
0.5 – 1.0 µm – minimally rough
1.0 –2.0 µm – moderately rough
> 2.0 µm – rough
• Wennerberg (1996) – stated that moderately rough implants
developed the best bone fixation.
Smooth surface < 0.2 µm – soft tissue →no bone cell adhesion
→ clinical failure.
Moderately rough surface more bone in contact with implant →
better osseointegration.www.indiandentalacademy.com

Advantages of moderately rough surface :
Faster osseointegration, retention of the fibrin clot,
osteoconductive scaffold
Increase rate and extent of bone accumulation → contact
osteogenesis
Increased surface area renders greater osteoblastic proliferation,
differentiation of surface adherent cells.
Increased cell attachment growth and differentiation.
Increased rough surfaces :
Increased risk of peri-implantitis
Increased risk of ionic leakage / corrosion

Additive surface treatment :
Titanium plasma spraying (TPS) hydroxyapatite (HA) coating
Substractive surface treatment :
Blasting with titanium oxide / aluminum oxide and acid etching

Machined / turned surface
SEM x 1000 SEM x 4700
Cp Titanium

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

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

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,

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.

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.

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”.

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

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

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

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

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.

• Critical temp. – 47 C
• Maintain vitailty – 43 C ( alk. Phosphatase)
• Ideal – 39 C

III.POST- OPERATIVE CONSIDERATIONS

• Healing time
3 months – dense bone
6 months – cancellous bone

• 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

• Fibrous tissue formation (Albrektson)
• Direct loading- 40%- 90% contact (Adell)

• Medication
• Calcium carbonate , antibiotics

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.

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.

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.

Methods of evaluation
ofosseointegration
Invasive method
•Histological section
•TEM (transmission electron microscopy)
•Pullout test

Non-invasive methods :
•Radiographs - OPG, CT Scan, Dentascan
•Periotest
•Reverse torque

•Resonance frequency analysis

• Risk factors for
osseointegration
SUBJECT IMPLANT
IMPLANT
SITE

1. subject risk
1. - nicotine - v.c – blood supply reduced
- impaired wound healing
- 1996 heavy smoking – absolute C/I
- Bain & Moy implant failure rate- 11.3%
2.
- decrease bone density
- contradictory results

3. - relative C/I
- hypergycemia& angiopathies – dec.
immune response , dec. healing
reduced bone remodelling
4.
- antiosteoporosis drugs, diphosphonates

5. - rapid progressive periodontal dis.
higher risk of peri- implant dis.
6.
- inc. peri- implantitis
- inc. marginal bone loss

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

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

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

2) Anchorage for the maxillofacial prosthesis
Auricular Prosthesis
Ocular Prosthesis

3) For rehabilitation of congenital and developmental defects
- Cleft palate
- Ectodermal
dysplasia
4) Complex maxillofacial defect rehabilitation

5) Orthodontic anchorage.

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

• 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

10. Atlas of implant dentistry, Cranin
11. DCNA 1989; 33(4) : 537
12. DCNA 1986;30(1) :151
13. JPD 1987;57(5):599
14. JPD1983;50(1):108
15. JPD 1983;50(1):101
16. JPD1983;50(3):399
17. JPD1983;49(6):838

Ossntgrtn / orthodontic straight wire technique

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