OSSEOINTEGRATION

Guided By: Presented By:

Dr Ajit Jankar Dr Pooja Langote

Dr Suresh Kamble

Dr Bhushan Bangar
“OSSEOINTEGRATION”
Contents :

Introduction
Historical review
Development of concept of osseointegration
Definitions
Scope of osseointegration
Fibrointegration Vs Osseointegration
Ultra structure of osseointegration
Biology of Osseointegration
Mechanism of osseointegration
• Contact osteogenesis vs distant osteogenesis
• Osteoinduction vs osteoconduction

Anchorage mechanism or Bonding mechanism

• Biomechanical bonding
• Biochemical bonding
Key factors responsible for successful osseointegration
Success criteria of implants
Clinical evaluation of osseointegration
• Invasive methods
• Non invasive methods
Failure and loss of osseointegration
Conclusion
References
INTRODUCTION
• Osseointegration, introduced by Branemark in 1952
• Osseointegration is a direct structural and functional connection
between ordered, living bone and the surface of a load-carrying
implant, is critical for implant stability
• The implant–tissue interface is an extremely dynamic region of
interaction

Biomaterial

Mechanical Biocompatibil
Enviroment ity
Process of osseointegration
Initial
interlocking
between
alveolar
bone and
the implant
body

Osseointegr
ation

Biological
fixation through
continuous
bone apposition
and remodeling
toward the
implant
• Histologic appearance resembled a functional ankylosis with no
intervention of fibrous or connective tissue between bone and implant
surface

• Prerequisite for implant loading and long-term clinical success of end

osseous dental implants
 Biocompatibility of the implant material

Macroscopic and microscopic nature of the implant

surface & designs

Success
The status of the implant bed in both a health and a morphologic (bone
quality) context

The surgical technique

The undisturbed healing phase

Loading conditions
 “CONCEPT OF OSSEOINTEGRATION”

History of Branemark system

categorized in three stages
Early stage (1965-1968)
Developmental stage (1968-1971)
Production stage (1971 – present)

Dr. Per-Ingvar Branemark

Orthopaedic surgeon
Professor University of Goteburg, Sweden.
Threaded implant design made up of pure titanium.
Leventhal in 1951:

Bone reaction was studied by the insertion of up to 80

screws into the femora of rats

“at twelve weeks, the screws were more difficult to

remove and at the end of sixteen weeks, the screws were
so tight that in one specimen the femur was fractured
when an attempt was made to remove the screw”

“Since titanium adheres to bone, it may prove to be an

ideal metal for such prostheses”
Many studies followed involving
titanium implants being placed
into jaws of dogs. (1983)

Direct bone anchorage has been

shown to be very strong. A force of
over 100kg was applied to
dislodge an implant
 1952 vital microscopic studies
(Bone marrow of rabbit fibula)

Optical chamber

“Osseointegration”
Repair of major mandibular and tibial defects.
Integrated titanium fixture

Clinical Study
Development of procedures for rehabilitation of edentulism :
Experimental study in dogs

First experimental study

Soft tissue
reaction

Subperiosteal and Transosseous

Use of titanium fixtures

 Two stage procedure

Evidence for osseointegration

Macroscopic level Radiological level

Histological level
 Intact bone to
implant surface

Basic research 1952 to 1965  13-15 year extensive research

1965  First clinical evidence of implant insertion

“Edentulous human patient for resorbed edentulous ridge”

Definitions :
“The apparent direct attachment or connection of osseous tissue to
an inert, alloplastic material without intervening connective tissue”.
- GPT 8
Structurally oriented definition :
“Direct structural and functional connection between the ordered,
living bone and the surface of a load carrying implants”.
- Branemarks and associates (1977)
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.
- Albrektson and Johnson (2001)
Clinically :
• Ankylosis of the implant bone interface.
Schroeder and colleagues 1976
“functional ankylosis”
• “It is a process where by clinically asymptomatic rigid fixation of
alloplastic material is achieved and maintained in bone during
functional loading”
- Zarb and T Albrektson
1991
Biomechanically oriented definition :
“Attachment resistant to shear as well as tensile forces”
- Steinmann et al (1986).
 Scope of osseointegration in dentistry
1) Prosthetic rehabilitation of missing teeth
Complete edentulous maxilla and mandible rehabilitation.

Fixed prosthesis Removable prosthesis

Partial dental loss replacement Single tooth replacement

 2) Anchorage for the maxillofacial prosthesis

Auricular Prosthesis Nasal prosthesis

Ocular Prosthesis

3) For rehabilitation of congenital and developmental defects

- Cleft palate
- Ectodermal
dysplasia
 Biological process of implant osseointegration

• The healing process of implant system is similar

to primary bone healing.

• Titanium dental implants show three stages of

healing.

1. Osteophyllic stage

2. Osteoconductive phase

3. Osteoadaptive phase
Osteophyllic phase :
Rough surface implant in cancellous bone

Blood initially present between implant and bone

Only small amount of bone is in contact with implant

During initial interaction

Numerous cytokines are released

Generalized inflammatory response

End of first week

Vascular ingrowths from surrounding later developing

into more matured vascular network (during first 3
weeks)
Cellular differentiation, proliferation and activation begins

Migration of osteoblasts

Ossification begins

Lasts about 1 month

Osteoconductive phase :
Bone cells spread along the metal surface

Laying down osteoid

This fibro cartilaginous callus eventually remodeled into

3 months

Bone callus

By the end of 4 months

Maximum surface area of implant covered by bone

Osteoadaptive phase :
After 4 months
Implants are Exposed and loaded

Remodeling occurs

Foot plates or the woven bone thickens in

response to load transmission

Reorientation of vascular pattern

 Bone to implant interface

• Two basic theories

– Fibro-osseous integration by Linkow, James & Weis
– Osseointegration by Branemark

– Meffert divided osseointegration

Adaptive osseointegration Biointegration

 FIBROINTEGRATION OSSEOINTEGRATION

Vs

Concept of soft tissue Concept of Bony

anchorage Anchorage
Linkow (1970), James (1975), Branemark (1969)
Weiss (1986).

 AAID (1986) – “Defined fibrous integration as tissue to implant contact

with interposition of healthy dense collagenous tissue between the implant
and bone”.
 “Direct bone to implant interface without any intervening layer of fibrous
tissue”.
Fibrosseousintegration :
“Pseudoligament”, “Periimplant ligament”, “Periimplant membrane”.
Hypothesis – Collagen fibers function similar to the sharpeys fibers in
the natural dentition.
Fact : The histological difference between the sharpeys fibers and
collagen fibers around the implant.

Natural teeth Implant

Oblique and horizontal Parallel, irregular,
group of fibers complete
encapsulation
Uniform distribution Difficult to transmit
of load (Shock the load
absorber)
Failure : Inability to carry adequate loads
Infection
ULTRASTRUCTURE OF OSSEOINTEGRATION

Soft tissue
interface

Cortical
bone

Spongy
bone
Mechanism of osseointegration
Phase Timing Specific occurrence
1. Inflammatory Day 1-10 Adsorption of plasma proteins
phase Platelet aggregation and activation
Clotting cascade activation
Cytokine release
Nonspecific cellular inflammatory response
Specific cellular inflmmatory response
Macrophage mediated inflammation.
2. Proliferative Day 3-42 Neovascularization
phase Differentiation, Proliferation and activation
of cells.
Production of immature connective tissue
matrix.
3. Maturation After Remodeling of the immature bone matrix
phase day 28 with coupled resorption and deposition of
bone.
Bone remodeling in response to implant
loading
Physiological bone recession.
Contact osteogenesis vs distant osteogenesis :
Osborn and Newesley (1980) : Proposed 2 different phenomena
Distant osteogenesis

Contact osteogenesis
 Distant 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.
 Contact osteogenesis

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.
 Relies on Migration of
Contact Osteogenesis Differentiating Osteogenic cell
to Implant surface
Undifferentiated Differentiating Osteogenic cells
Perivascular connective cells

Osteoconduction :
Migration of differentiating osteogenic cells from the
recipient host bed to implant surface where they attach
and proliferate.

Fibrin

Smooth surface Rough surface

Osteoinduction :
Phenotypic conversion of undifferentiated mesenchymal cell
osteoprogenitor cell  Bone forming cell (Osteoblast &
osteocyte)

Albrektsson and Johanson (2001) : The term osteoconduction and

osteoinduction are inter related but not the identical phenomena
that occurs during wound healing.
Osseointegration vs Osseocoalescence
• Osseointegration refers to pure mechanical interlocking between the
implant and bone

• This mechanical interlocking will not withstand tensile forces

• Osseocoalescence refers to chemical integration of implants in the bone.

• This is achieved by bio active materials such as hydroxyapatite and bio

active glass

• Physicochemical interaction between the bone and HA layer causes

direct deposition of bone on the implant surface
 The neuromuscular system as it relates
to the osseointegrated implant

• A fixture site does not have periodontal ligament but has nerve
endings located near the fixture, sensing pain and temperature.

• Patients with osseointegrated implants have a high threshold and

low sensitivity for discriminating thickness. As the periodontal
ligament is lost the fixture remains with reduce amount of
receptors.

• Impulses from the fixture sites are transmitted through motor

nucleus of trigeminal nerve.
Futuristic concepts of Osseointegration
• OSSEOPERCEPTION

– The interaction between the

osseointegrated fixture bone
tissue, receptor systems and
nervous system has to be
studied.

“Owing to the nature of osseointegration it is not

easy to dissect the system of anchorage from the
clinical level down to the molecular level or even the
real interface which is still largely a mystery”
 Biological Considerations for
Osseointegration
• Bone implant interface
– When compared to compact bone
spongy bone has less density and
hardness is not a stable base for
primary fixture fixation.
– In the mandible the spongy bone is
more dense than maxilla.
– With primary fixation in compact
bone, osseointegration in the maxilla
require a longer healing period.
 Biological process of implant osseointegration

• The healing process of implant system

is similar to primary bone healing.
Mechanism of Osseointegration
Blood clot (between fixture & bone)

Clot transformed by phagocytic cell

(1st to 3rd day)

Procallus formation
(containing fibroblasts & phagocytes)

Procallus becomes dense connective tissue

(Differentiation of osteoblasts & fibroblasts)
 Callus (Osteoblasts on the fixture)

Fibro cartilagenous callus (between fixture & bone)

Bone callus (Penetrates & matures)

Prosthesis attached to the fixtures stimulating bone

remodeling
 Implant material
biocompatibility
Implant design
characteristic
Loading
conditions
Key factors responsible for
successful osseointegration

Implant surface
characteristic
Surgical
considerations

State of the implantation or

host bed
Implant materials

Chemical composition

Metals Ceramics Polymers

Biological compatibility

Bio tolerant Bio inert Bio active

 Biological Chemical composition
biocompatibility Metals Ceramics Polymers

Biotolerant Gold Polyethylene

Cobalt-chromium Polyamide
alloys
Stainless steel Polymethylmethacrylate
Zirconium Polytetrafluoroethylene
Niobium Polyurethane
Tantalum
Bioinert Commercially pure Aluminum oxide
titanium
Titanium alloy (Ti- Zirconium oxide
6Al-4V)
Bioactive Hydroxyapatite
Tricalcium
phosphate
Calcium
pyrophosphate
Fluorapatite
Carbon:vitreous,
pyrolytic
Metals :
Commercially pure titanium (CPTi) : 99.75%
Most biocompatible material  excellent long term clinical function

Adherent, self repairable

Steinman (1988) referred this layer as Biologically inert

On Histological investigation  intimate contact between
the titanium surface and the periimplant bone.
(Branemark 1977, Albrektsson et al 1984)
Chemical purity, surface cleanliness  Osseointegration
Titanium alloys : Ti6Al4V(90%Ti, 6% Al, 4% V)
Johonson (1992) - Cp titanium higher torque removal values than
Ti6Al4V screw 23 vs 16N/cm.
- Higher bony contacts 59 vs 50% after 3
months implant insertion
Experimental investigation at 3, 6 and 12th month
 Significantly stronger bone reaction to Cp
 Retarded bone formation around the Ti6Al4V leaked out Al
ion competing with calcium during early stage of calcification
causing osteomalacia
Tantalum and Niobium : High degree of osseointegration
There was evidence of exaggerated macrophage reaction compared
to Cp titanium.
 CERAMICS

(Calciumphosphate hydroxyapatite, Al2O3, Tricalcium phosphate)

• Makeup the entire implant

• Applied in the form of coating

Hydroxyapatite coated implant

• Gottlander 1994 – short term and longterm reaction

Short term reaction – Positive, enhanced interfacial bone formation

Long term reaction – Cp titanium 50-70% more interfacial bone compared to HA coated.

• Hahn J (1997) HA coated implant – 97.8%(6 yrs) clinical success.

Matter of concern.

HA coating loosening – macrophage activation and bone resorption

• Beisbrock + Edgertson – Microbial adhesion, Osseousbreakdown, coating failure.

 POLYMERS
Not used
•Inferior mechanical properties
•Lack of adhesion to living tissues
•Adverse immunological reaction
Limited to
•Shock absorbing components – supra structure component
Implant Design characteristic :
Implant design refers to the three dimensional structure of the
implant.
Form, shape, configuration, geometry, surface macro structure,
macro irregularities.
Cylindrical Screw shaped implants.

Threaded Non threaded.

 “Precision fit in the vital bone” Osseointegration

Cylindrical implants / press fit implants :

Severe bone resorption

Lack of bone steady state – micro movements

Alberktsson 1993 – continuing bone saucerization of 1mm -first

year, 0.5mm anually and thereafter increasing rate of resorption
upto 5 year followup.
Threaded implants :
Documentation for long term clinical
function.
Alteration in the design, size and pitch of
the threads can influence the long term
osseointegration.
Advantages of threaded implants
More functional area for stress load
distribution than the cylindrical implants.
Threads improves the primary implant
stability avoids micromovement of the
implants till osseointegration is achieved.
 Non threaded Threaded

•Tendency for slippage •No slippage tendency

•Bonding is required •No bonding is required
 Currently available implant thread pattern types
Basic implant macrodesign features
The effect of thread pattern upon implant osseointegration. Clin. Oral Impl. Res. 21, 2010; 129–136.
• (Misch et al. 2008) three types of loads are generated at the interface; compressive, tensile and shear
forces

• An ideal implant design should provide a balance between compressive and tensile forces while
minimizing shear force generation

• Tapered implants have been shown to produce more compressive force than cylindrical implants which
have more shear forces (lemons 1993)

• Implant thread shape has also been found to influence the type of force transferred to the surrounding
bone.

• Misch et al. (2008) suggested that V and reverse buttress thread have 30˚and 15˚ angle, respectively

• (Barbier & schepers 1997; bumgardner et al. 2000), in squared and buttress threads, the axial load of
these implants are mostly dissipated through compressive force

• (Misch et al. 2008) V-shaped and reverse buttress-threaded implants transmit axial force through a
combination of compressive, tensile and shear forces

The effect of thread pattern upon implant osseointegration. Clin. Oral Impl. Res. 21, 2010; 129–136.
 Implant surface characteristics

Topographic properties Physical properties

Implant surface texture
Surface energy and charge
& roughness

Physiochemical properties
Implant surface chemistry
Surface topography
Orientation of irregularities on the surface
Degree of roughness of the surface

Orientation of irregularities may give :

-Isotopic surface and anisotropic surface
Wennerberg (1996) Ivanoff (2001) : Better bone fixation
(osseointegration) will be achieved with implants with an
enlarged isotropic surface as compared to implant with turned
anisotropic surface structure.
Different machining process results in different surface topographies

1) Turned surface/ machined surface

2) Acid etch surface - HCl and H2SO4

3) Blasted surface – TiO2 / Al2O3 particles
4) Blasted + Acidetch surface (SLA surface)
- Al2O3 particles & HCl and H2SO4
- Tricalcium phosphate & HF & NO3
5) Hydroxyapatite coated surface (HA)

6) Titanium plasma sprayed surface (TPS)

7) Oxidized surface
8) Doped surface
9) Nanosized hydroxyapatite coated surfaces
Additive surface treatment :

Titanium plasma spraying (TPS) hydroxyapatite (HA) coating

Substractive surface treatment :

Blasting with titanium oxide / aluminum oxide and acid etching

Modified surface treatment :

Oxidized surface treatment

Laser treatment

Ion implantation
Machined / turned surfaces : gold standard.
Moderately rough implant surfaces
• Roughness parameter (Sa)
0.04 –0.4 m - smooth
0.5 – 1.0 m – minimally rough
1.0 –2.0 m – moderately rough
> 2.0 m – rough
• Wennerberg (1996) – moderately rough implants developed
the best bone fixation as described by peak removal torque
and bone to implant contact.
• In vivo studies
Smooth surface < 0.2 m will – soft tissue no bone cell
adhesion  clinical failure.
Moderately rough surface more bone in contact with
implant  better osseointegration.
Carlsson et al 1988, Gotfredsen (2000) – positive correlation
between increasing surface roughness and degree of implant
incorporation (osseointegration).
Advantages of moderately rough surface :
Faster osseointegration, retention of the fibrin clot,
osteoconductive scaffold, osteoprogenator cell migration.
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 periimplantitis
Increased risk of ionic leakage / corrosion
 Machined / turned surface
Cp Titanium
Surface roughness profile 5 m

SEM x 1000 SEM x 4700

 Titanium plasma sprayed coating (TPS)

The first rough titanium

surface introduced
Coated with titanium powder
particles in the form of
Plasma flame spraying technique titanium hydride

Roughness Depth profile of about 15m

 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
- Greater bone to implant
contact area
- Type IV bone
- Fresh extraction sites
- Newly grafted sites
SEM 100X
 Sand blasting Acid etch
The objective
Sand blasting – surface roughness
(substractive method)
Acid etching – cleaning
Wennerberg et al 1996. superior bone fixation and bone adaptation

Lima YG et al (2000), Orsini Z et al (2000).

- Acid etching with NaOH, Aq. Nitric acid,
hydrofluoric acid.
Decrease in contact angle by 100 – better
cell attachment.
Acid etching with 1% HF and 30% NO3
after sand blasting – increase in
osseointegration by removal of aluminium
SEM 7000X particles (cleaning).
SEM 1000X
 Laser induced surface roughening

Eximer laser – “Used to create roughness”

Regularly oriented surface roughness configuration compared
to TPS coating and sandblasting

SEM x 70 SEM x 300

SEM x 300
Physical characteristic :
•Physical characteristic refers to the factors such as 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, being
conductive to tissue integration.
Charge affects the hydrophilic and hydrophobic characteristic of
the surface.
A hydrophilic / easily wettable implant surface : Increases a
initial phase of wound healing.
Fact : Increase surface energy would disappear immediately
after implant placement.
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.
• Alkali + Heat treatment.
• Ionization, implantation of calcium ion, floride ions
• 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.
Based on :
• Design characteristic  Macrostructure
(Threads, vent, slots)
• Surface characteristic  Microstructure.
(Chemical surface treatment
 Surface roughness at the micrometer level / nanometer level

Requirement :
Minimum size of
•50-100m cavities or pores
 complete bone tissue
(ground substance + cellular
components + Haversion
system)
• 1-10m for calcified bone
ground substance.

At nanometer level - no experimental evidence

Some investigators – nanometer size rough surface can carry proper
load.
Biochemical bonding
Seen with certain bioactive implant
surfaces like :
• Calcium phosphate coated implant surfaces
• HA coated implant surfaces
• Oxidized/ anodized surfaces
Bone bonding / Bonding osteogenesis

Biointegration :
•“Strong chemical bond may develop between the host bone
and bioactive implant surfaces and such implants are said to be
biointegrated”.
 Doped surfaces

Doped surfaces that contain various types of bone growth factors or

other bone-stimulating agents may prove advantageous in
compromised bone beds. However, at present clinical documentation
of the efficacy of such surfaces is lacking : BMP = Bone
morphogenetic protein.
 BONE FACTOR

Initial implant stability

• Bone quality  bone with well formed

cortex and densely trabaculated
medullary spaces

• Bone quantity  Refers to the dimension

of available bone in reference to length,
width and depth.
 Branemark system (5 year documentation)
Mandible – 95% success
Difference in bone
Maxilla – 85-90% success composition

Aden et al (1981) – 10% greater success rate in anterior

mandible compared to anterior maxilla.

Schnitman et al (1988) – lower success rate in posterior mandible

compared to anterior mandible
- posterior maxilla higher failure rates.

•Factors compromising the bone quality

Infection ,Irradiation &Heavy smoking
 LIKHOM AND ZARB CLASSIFICATION 1985

Class I : Jaw Class II : Class III : Class IV :

consist almost Thick compact Thin cortical Thin cortical
exclusively of bone surrounds bone surrounds bone surrounds
homogeneous highly highly loose, spongy
compact bone trabecular core trabecular core core

MISCH CLASSIFICATION 1988

D1 D2 D3 D4
According to Branemark and Misch

D1 and D2 bone  initial stability / better osseointegration

D3 and D4  poor prognosis

D1 bone – least risk Loss of

osseointegration
D4 bone - most at risk

Jaffin and Berman (1991) – 44% failure in type IV bone

Selection of implant

D1 and D2 – conventional threaded implants

D3 and D4 – HA coated or Titanium plasma coated implants

Smoking and osseointegration :

• History of smoking may affects the healing response in

osseointegration.
• Lower success rates with oral implants
• Mechanism behind
Vasoconstriction
Reduced bone density
Impaired cellular function
• Mean failure rates in smoker is about twice than in non smoker.
Radiation therapy and osseointegration :
• Jacobsson (1985) previous irradiation – relative contraindication
for implant placement.
• Expected success rate 10-15% lower than the non irrradiated
patients.
Number of factors to be considered :
• Dose and fraction of irradiation
• Timing from radiotherapy to implant surgery
• Anatomic region in which the implant to be inserted
• Loading factors and handling of the soft tissue.
Full course radiotherapy (50-65Gy)  Not contraindicated.
> 65 Gy  critical for implant survival.
 SURGICAL CONSIDERATIONS
Objective:
Minimum tissue violence – osseointegration
 Controlled surgical technique  Violent surgical techniques
 Surgical skill / technical excellence
Parameters :
• Profuse irrigation for continuous / Adequate cooling

•Use of well sharpened drills and use of graded series of drills

• Slow drill speeds
• Proper drill geometry
• Intermitent drilling
Eriksson R.A :
• Drill speed < 2000 rpm, tapping at 15 rpm.
• Cooling during tapping and insertion of screw
Others
• Cooling the irrigants
• Using internally irrigated drills
Violent surgical technique
• Frictional heat / overheating  increased temperature rise in
bone  wide zone of necrosis  fibrous tissue, primary failure
of osseointegration.
Erickson RA
 Critical temperature for bone necrosis
• Previously 560 to 700 for 1 min.
• 560C critical temperature for bone necrosis  Irreversible
bone damage.

• Recently 470C for 1 min.

Denaturation of alkaline phosphate enzyme  inhibition of
Alkaline Ca synthesis  Loss osseointegration (Errickson
1986, Albrektsson 1984)
 Insertion torque

Moderate torque should be used

45 N/cm
 Insertion torque is high – removal torque is low.

Poor osseointegration

 High torque is used  stress / compression in bone

 Holding power of implant will fall.
 Loading condition
Objective : “No loading while healing”  successful
osseointegration.
Movement of the implant within the bone – fibrous tissue
encapsulation rather than osseointegration.

Premature loading The end result “Bony interface”

leads to implant “Soft tissue
movement interface”
 Titainum
• Titanium has grades 1 to 5
• Grades 1 to 4 are the unalloyed CP-Ti and grade 5 is the alloyed
Ti-64 (Ti6Al4V)
• commercially pure titanium (CP-Ti) and titanium alloy Ti6Al4V
• Grade 2 titanium is the main unalloyed Ti used in dental implant
applications.
• Grade 5 Ti-64 is the most widely used titanium alloy in biomedical
implants where high strength is required

Sidambe AT. Biocompatibility of Advanced Manufactured Titanium Implants-A Review. Materials (Basel).
2014 Dec 19;7(12):8168-8188. doi: 10.3390/ma7128168. PMID: 28788296; PMCID: PMC5456424.
 Suface treatment
TPA
Additive
HA
Surface
treatment SLA

Substravtive RBM

DAE

Ref: Elkhaweldi A, Lee DH, Wang W, Cho SC. The Survival Rate of RBM Surface versus SLA Surface in
Geometrically Identical Implant Design. J Oral Bio. 2014;1(1): 8
 SLA RBM
• Sand blasting + acid etching • Formed through propelling resorbable
• 1.7µm coarse bioceramics (calcium phosphate)
• 98% survival rate in 10 year follow up followed by passivation process
• Calcium phosphate particles eliminate the
risk of leaving contaminated debris
• 1.5µm
• Higher bone implant contact compared to
SLA,TPS, HA
• 95.37% survival rate in 7 year follow up
Sterilization
 • ethylene oxide (EO) sterilization method is often used for cellulose-
based biomaterials and plastic products, it can leave toxic residues
on the device surface which could negatively impact the cells
growing on the titanium surface.

Park JH, Olivares-Navarrete R, Baier RE, Meyer AE, Tannenbaum R, Boyan BD, Schwartz Z. Effect
of cleaning and sterilization on titanium implant surface properties and cellular response. Acta
Biomater. 2012 May;8(5):1966-75.
Different Philosophies regarding Loading conditions

• Three types of loading protocol :

• Immediate loading

• Early loading

• Delayed loading

• Branemark, Albrektson – Two stage implant insertion.

– First stage – Installation of fixture into bone

– Second stage – Connection of abutment to the fixtures

• Maxilla 6 months

• Mandible 3 months

• Misch – Progressive / Gradual loading

Immediate loading
This type of loading is feasible when implants are placed in good quality bone (anterior
mandible)

When implants are placed in posterior quadrants ,where bone sites are less dense and all
occlusal loads are borne by the implants ,immediate loading is inadvisable.

If the initial bone anchorage is not good and if it is loaded ,the implant may become
mobile and fail to osseointegrate.

If the implant moves during the early period of healing ,a fibrous connective tissue capsule
develops around the body of implant.
Immediate functional loading protocol
Clinical trials successful osseointegration
(95-100% success rate- Completely edentulous patients)
 Bone quality is good
Functional forces are controlled
More favourable in mandible compared to maxilla

Over loading – Stress concentration, undermining bone

resorption without apposition (Branemark 1984)

To decrease the bio mechanical load

Prosthetic design considerations
Cantilever length may be shortened or eliminated
Narrow occlusal table
Minimizing the offset load
Increasing the implant number
Use of wider implant with D4 bone compared to D1 & D2
Delayed loading
It is essential that the healing period be respected both in duration and in
avoidance of any transmitted load which can impair implant stability.

When loading is eventually applied ,it must be within certain physiologic limits to
provide the bone with stimulation without causing overload.

The natural wound healing processes are harnessed and respected.

Implant placement on extraction socket
Since tooth extraction often results in alveolar ridge resorption or collapse , this
immediate implant placement concept is gaining momentum.

Another primary advantage of immediate implant placement is reduced healing

time.

When implant is placed at the time of extraction, the bone to implant healing
begins immediately.

This type of bone forming activity may enhance the bone to implant contact
compared with an implant placed in a less osteogenically active site.
Success criteria of implants
Schnitman and Schulman criteria (1979)

• The mobility of the implant must be less than 1mm when tested
clinically
• There must be no evidence of radiolucency

• Bone loss should be less than 1/3rd of the height of the implant

• There should be an absence of infection, damage to structure or

violation of body cavity, inflammation present must be amenable to
treatment

• The success rate must be 75% or more after 5 years of functional

service.
Albrektson and Zarb (1980)

• The individual unattached implant should be immobile when tested

clinically

• The radiographic evaluation should not show any peri-implant

radiolucency

• Vertical bone loss around the fixtures should be less than 0.2mm
annually after first year of implant loading

• The implant should not show any sign and symptom of pain,
infection, neuropathies, parastehsia, violation of mandibular canal
and sinus drainage

• Success rate of 85% at the end of 5 year observation period and

Failure of Osseointegration
Local risk factors

The main contributing factor to bone resorption are

local inflammation from plaque and trauma from
occlusion
Systemic risk factors
Endocrine disease particularly diabetes.

Postmenopausal women because of decreased estrogen and

progestrone levels and altered bone metabolism.

Smokers, where there is vasoconstriction, tissue hypoxia, reduced

PMN’s enhanced inflamatory mediator and persistent biofilm..
Failure of osseointegration
Sign and symptoms

1. Horizontal mobility beyond 0.5 mm or any clinically observed vertical

movement under less than 500 gm force

2. Rapid progressive bone loss regardless of the stress reduction and

periimplant therapy .

3. Pain during percussion or function

4. Continued uncontrolled exudate in spite of surgical attempts at correction.

5. Generallised radiolucency around an implant
6. More than one half of the surrounding bone is lost around an
implant
7. Implant insertion in poor position, making them useless for
prosthetic support
 METHODS OF EVALUATION OF OSSEOINTEGRATION
Invasive method
•Histological section •Histomorphometric

•By using torque gauges

•TEM (transmission electron microscopy)

•Pullout test
Non-invasive methods :
•Radiographs

•Periotest

•Reverse torque
•Resonance frequency analysis

•Dynamic model testing

•Impulse testing
List of References :
 Osseointegration in clinical dentistry – Branemark, Zarb, Albrektsson

 Osseointegration and occlusal rehabilitation – Sumiya Hobo

 Contemporary Implant Dentistry – Carl. Misch

 Endosseous implants for Maxillofacial reconstruction – Block and Kent

 Implants in Dentistry –Block and Kent

 Dental and Maxillofacial Implantology – John. A. Hobkrik, Roger Watson

 Endosseous Implant : Scientific and Clinical Aspects – George Watzak

 Optimal Implant Positioning and Soft Tissue management – Patrik Pallaci

 Osseointegration in craniofacial reconstruction. T. Albrektssson.

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 IJOMI 2005; 20(2): 307-311

 IJOMI 2005; 20: 425-31

 IJP 2004; 17: 536-543

 Osseointegration in dentistry : an introduction : Philip Worthington, Brein. R. Lang, W.E. Lavelle

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