Teeth and Implants

TEETH AND IMPLANTS
An understanding of the nature of osseointegration and the important fundamental

differences between the dental implants and natural teeth is a must prior to using dental
implants.
• Gingiva versus periimplant soft tissues:

In healthy teeth- The Healthy Teeth Healthy implants
Gingival sulcus depth Shallow in health Dependent upon abutment
length and restoration margin
Junctional epithelium On enamel On titanium

Gingival fibres Complex array inserted No organized collagen fibre
into cementum above attachment- parallel fibres.
crestal bone
Crest of bone 1 to 2mm apical to CEJ According to implant design
eg:- at or about first thread in
threaded implants or at the
level of change in surface
morphology
Connective Well organized collagen Bone growing into close

tissue fibre bundles inserted as contact with implant
attachment sharpens fibres into surface: oxide layer / bone
alveolar bone and pioteoglycan and collagen
cementum
Physical Physiologic mobility caused Rigid connection to bone-as

characteristics by viscoelastic properties of if ankylosed.
the ligament
Adaptive Width of ligament can alter No adaptive capacity to

characteristics to allow more mobility with allow mobility.
increased occlusal forces Orthodontic movement
Proprioception Highly sensitive receptors No ligament receptors

present within the
periodontal ligament
In the case of an implant, a transmucosal element protrudes through the overlying mucosa which
adapts around it without a cementum attachment. The collagen fibres within the periimplant mucosa
run parallel to the abutment with no insertion into the abutment surface.
The papillae around an implant may be supported by collagen fibres attached to the adjacent natural
teeth. But in cases where the adjacent teeth is also an implant, the papillae is dependent upon
adequate thickness of soft tissues, bone height, implant spacing and contouring of crown profiles.
1. Junctional epithelium:
In healthy teeth the Junctional epithelium is attached to enamel by hemidesmosomal

contacts and a basal- like structure formed by epithelial cells. The biologic attachment mechanism is
through particular adhesins or integrms. Junctional epithelium attaches to cementum, dentin and
various dental materials (implants also ).
2. Biological width:
In teeth, the biological width is a zone of attached connective tissue that separates the underlying
alveolar bone from the apical termination of the junctional epithelium. The connective tissue zone is
about 2mm wide and length of junctional epithelium is about 1.5mm.
Two different designs of implants and corresponding biological width. The first design is a two
stage system ( branemark ) The bone margin is usually located at the first thread (one year in function ).
The junctions epithelium is located on the abutment and a zone of non-arranged connective tissue (l-
2mm) intervenes. The join between abutment and implant head is located within this zone. The second
design is of a single stage system (ITI Stranmann ) non-submerged implant. Here the roughest surface is
placed within bone and the smooth neck which is part of the implant performs the function of
transmucosal element. The implant/abutment joint is located coronal to this level. The join within the
submerged (Two stage) systems may influence the level of soft tissues attachment and biologic width.
This may be caused by micromovement between the two components or by allowing microbial
penetration of the microgap between implant and abutment.
3. Probing depth examination:
The probe is stopped by the most coronal intact gingival connective tissue fibres about 2mm
from bone in natural teeth. Probing depths in implants are generally deeper than in natural teeth, but
penetration of the soft tissue at the base of the sulcus occurs to a similar degree with the probe tip
finishing short of the bone margin by about 2mm.
Periodontal ligament versus osseo integration:
1) Periodontal ligament:
The periodontal ligament is a complex structure, about 0.1 to 0.2mm in width, providing support to the
teeth in a viscoelastic manner. The periodontal ligament has a sensitive proprioceptive mechanism which can
detect minute changes in forces applied to the teeth. Force transmitted can result in remodeling, tooth
movement, widening of ligament and also tooth mobility.
2) Osseoinlegration:
At light microscopic level there is a very close adaptation of the bone to the implant surface.
At the higher magnifications possible with electron microscope, there is a gap ( about 100NM in
width ) between the implant surface and bone. This is occupied by an intervening collagen rich zone
adjacent to the bone and a more amorphous zone adjacent to the implant surface. Bone
proteoglycans may be importnat in the initial attachment of the tissues to implant surface.
Osseointegration can be measured as the proportion of the total implant surface that is in contact
with the bone. Greater levels of bone contact occur in cortical bone than in cancellous bone, where
marrow spaces are often adjacent to the implant surface. When an implant is placed in bone there
should be close fit to ensure stability. The space between implant and bone Is initially filled with
blood clot and bone proteins. The initial response to the surgical trauma is resorption, followed by
bone deposition. There is a critical period in the healing process at around two weeks post implant
insertion when bone resorption will result in a lower degree of implant stability than that achieved
initially. Subsequent bone formation will result in an increase in the level of bone contact and stability.
Excessive forces applied to the implant result in remodeling of the marginal bone ,that is, apical
movement of the bone margin with loss of osseointegration.
Periodontitis and peri-implantitis:
Bacteria which are implicated in periodontitis, such as porphyryromonas gingivalis, are also
major pathogens in destructive inflammatory lesions around implant (peri-implantitis ). Thus there is a
possibility of colonization or infection of the implant surfaces from pre-existing periodontopathic
bacteria.
Peri implantitis affects the entire circumference of the implant resulting in a 'gutter' of bone loss
filled with inflammatory tissue extending to the bone surface. In contrast, periodontitis - affected teeth
commonly have irregular loss of supporting tissues, often confined to proximal surfaces and resulting in
complex infrabony defects.
Conclusion:
Osseointegrated implant are a useful alternative to natural teeth. There are fundamental
differences between them, and an understanding of the attachment mechanisms of hard and soft tissues
and their responses to the harsh environment of the oral cavity is essential to the dental surgeon who is
involved in providing this form of treatment.

Teeth and Implants

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TEETH AND IMPLANTS

An understanding of the nature of osseointegration and the important fundamental

• Gingiva versus periimplant soft tissues:

Junctional epithelium On enamel On titanium

Connective Well organized collagen Bone growing into close

Physical Physiologic mobility caused Rigid connection to bone-as

Adaptive Width of ligament can alter No adaptive capacity to

Proprioception Highly sensitive receptors No ligament receptors

In healthy teeth the Junctional epithelium is attached to enamel by hemidesmosomal

Periodontal ligament versus osseo integration:

Periodontitis and peri-implantitis:

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