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1. Osseointegration in Dental Implants

2. Introduction : A Successful Replacement Of Missing Natural Tooth By Dental Implants Prosthesis is a Major Clinical Advancement in Dental treatment. The Successful Outcome of the Treatment Depend upon the Degrees of Osseointegration. Osseointegration in the Dental Implants depends on Understanding of Healing and Reparative Capacities of Hard and Soft Tissue. It’s Objective is a Predictable tissue Response to Tooth Root Analogue.

3. Definition: “ Direct Structural and functional Connection between the ordered, living bone and the surface of load carrying implants ” Branemark and Associates (1977) GPT 8 : “The apparent attachment or Connection of osseous tissue to an inert ,alloplastic material without intervening connective tissue “

4. Theories of Osseointegration 1 ) Fibro-osseous integration ( Linkow & James 1976) 2 ) Osseointegration ( Branemark 1985 )

5. Fibro-osseous integration Fibro-osseous integration refers to a presence of connective tissue between the implant and bone. In this theory, collagen fibers functions similarly to Sharpey’s fibers found in natural dentition. The fibers affect bone remodeling where tension is created under optimal loading conditions.

6. Reasons for Fibro-osseous integration 1 ) Premature loading of implant 2) Apical migration of junctional epithelium into the Interface followed by connective tissue elements 3) Over heating during site preparation. 4) Implant and site size difference 5) High Torque during implant placement

7. Mechanisms of Osseointegration 1) Primary Bone Healing . Ideal Minimal Granulation Tissue . Well Organised Bone Formation 2) Secondary Bone Healing. Most Undesirable . More Granulation Tissue . Infection and Prolonged Healing

8. Mechanisms of Osseointegration Blood Clot (between bone implant) Procallus Formation (fibroblasts and phagocytes) Dense Connective tissue (osteoblast & fibroblasts) Callus (osteoblast on the fixture) Mature Bone

9. Phases of Bone Healing in Osseointegration PHASE TIMING SPECIFIC OCCURRENCE 1) Inflammatory Phase 1 to 10 Days Adsorption of Plasma protein Platelet aggregation Cytokine relase Macrophages mediated information 2) Proliferation phase 1 to 4 Weeks N eurovascularization, Immature Connective tissue 3) Maturation Phase 8 to 12 Weeks Bone remodeling

10. Biological Process of Integration ( Branemark ) 1) Osteophylic Stage: 2) Osteoconductive Phase Blood Clot Formation. Woven and lamellar bone Inflammatory Cells Infiltration. Formation in around implant . Neovascularisation Ossification last for 1month 3) Osteo adaptive Phase . A balanced remodelling . Woven bone thickened . Vascular reorientation

11. Bone to Implant Interface Maffert et al (1987) Adaptive Osseointegration Osseointegration Bio – integration

12. Bone Tissue Response Distance Osteogenisis A gradual process of bone healing inward from the edge of osteotomy towards the implant. Bone doesn’t grow directly on the implant surface. The direct migration of bone building cells through the clot matrix to the surface implant surface. Bone is quickly formed directly on the implant surface. Distance Osteogenesis Contact Osteogenesis

13. Factors influencing Osseointegration 1) Implant Biomaterials Biocompatible 2) Implant Biomechanics 3) Implant Design Width, Taper, 4) Implants Surface design 5) Crest Module Design 6) Implant Surface Modification 7) Surgical Protocols 8) State Of Host Bed 9) Patient General Health 10) Post Operative Care

14. Bicompatibility Its a capacity of a material to exist in harmony with suronding biological environment without causing any damage to the tissue. Biotolerent Biotolerent Bioactive Implant seperated from bone, Direct Contact Osteogenisis Bonding Osteogenisis Distant Osteogenisis, Stainless steel, Co-Cr Titanium, Aluminium Zirconia Calcium Phosphate Titanium

15. Implant Biomechanics 3 distant clinical axes exist in Dental Implants which results from single occlusal contact Mesodistal Faciolingual Occlusoapical A good understanding of biomechanics can lead higher success rates in Implants supported Prosthesis

16. Implant Design , Width and Taper Non – Threaded 1) Tendency to Slip 2) Bonding is Required 3) Results in a Shear type of force 4) At the Implant to bone interface Threaded 1) More number of threads more is the surface area 2) Increases area for bone to Implant contact, max initial Bone contact, dissipation of stresses 3) No Bonding is Required

17. Implant Surface Topography Surface topography relates to the orientation of surface irregularities and degree of roughness, which increases bone to Implant Surface bond . Increases biomechanical interaction with bone of the implant. Smooth Surface results in reduced bone cell adhesion leads to failure.

18. 1) Longer the implant length better the primary stability 2) V –Shaped implant transfer vertical force in an angulated Path 3) Wider diameter Implant transmit less stress on crestal bone 4) Platform switching concept also preserve the marginal bone loss

19. Technique Of Surface Modification Subtractive Process 1) Acid Etching . 2) Sand Blasting . 3) Titanium Blasting 4) Laser Lithography 5) Grit Blasting Additive Process 1) Hydroxy Appetite . 2) TCP (Tri Calcium Phosphate) 3) Zirconia Coating . 4) Titanium Plasma Spray . 5) Sintered Implants . 6) Anodization

20. Method of Evaluation of Osseointegration INVASIVE METHODS 1 ) Histomorphometric 2) Tensional Test 3) Push & Pull Test 4) Removal Torque Analysis NON INVASIVE METHODS 1) Percussion Test 2) Radiographs 3) Reverse Torque Test 4) Periotest 5) Resonance Frequency Analysis

21. Surgical Protocols All Standard Surgical Protocols should be followed Optimum Surgical Procedure Graduated Drilling Protocol Slow Drill Speed (<2000Rpm) Copious Irrigation ( 0.9 % NACL) to prevent bone necrosis Moderate power used to insert implant

22. State of Host Bed Favorable Bone Site Micro and Macro Anatomy . Should be Favorable . D1 & D2 Bone Density as per Misch is Favorable Unfavourable Bone Site Osteoporosis . Previous Irradiation . Compromised Macro and micro Anatomy Infection