OSSEOINTEGRATION

Under supervision of prof.

Dr. DALIA RIAD
Done by :
- MOSTAFA MOHAMED RABIE
- AHMED OMAR RAMADAN
- Mohamed Essam El-Deen Abd El

Azeem
- ESSAM MOHAMED MOTEE
- MOHAMED FARRAG MOHAMED
Introduction
 Different types of implant systems has been used to replace
missing teeth, including sub periosteal implants, endosseous
implants with fibrous encapsulation, and endosseous
implants with direct bone contact ( osseointegrated).

 Osseointegration: the direct functional and structural

connection between living bone and the surface of a load
bearing implant.

 Or basically a union between bone and the implant surface.

 Measured histologically as the proportion of the total implant

surface that is in contact with bone.
 Greater levels of bone contact occur in cortical bone
than in cancellous bone, where marrow spaces are
often adjacent to the implant surface.

 In the original two-stage surgical protocol, a two-piece

dental implant is inserted at two separate surgical
sessions with healing periods of 3 - 6 months in
between.

 Thus in order to acquire proper condition for

osseointegration, the implant must exhibit proper
initial fixation following installation in the recipient site.
This initial stability is the result of the contact
relationship or friction that is established following
insertions of the implant, between mineralized bone
( often the cortical bone) at the recipient site and the
metal device.
Implant Attachment

 Periodontal fibers consist of highly differentiated

fibrous tissues with numerous cells and nerve endings
for shock absorption, sensory function, bone formation
and tooth movement.

 Historically implant attachment with low differentiated

fibrous tissues was accepted as a measure of success .

 But later on it was learned that this is a manifestation

of adverse reaction that may lead to implant failure
includes tissue rejection , pain and loss of the implant
Biology of Osseointegration

 Initially, the defect is filled with a fibrin network, derived from

plasma, which leaks from a damaged blood vessel at the
defects edge.

 After 6 to 10 hours granulations cells are present in the wound

. 3 to 4 days after later erythrocytes perfuse the healing
defect.

 Granulation cells stop moving in the wound and their

projections connect with each other to form a cellular network,
which is still perfused with erythrocytes from blood vessels.

 5 to 6 days after the original defect, the wound is perfused by

a large number of broad, winding, thin walled newly formed
capillaries.
 Within 3 to 4 weeks these blood vessels will reduce in
number and diameter, creating a characteristic capillary
network for connective tissue.

 Into this capillary network, fibroblasts from the periosteum,

endosteum and red bone marrow invade and produce a
network of collagen.

 Into this network chondrocytes develop from osteogenic cells

and begin to produce a fibro cartilaginous callus. This stage
lasts for about 3 weeks.

 Osteogenic cells then develop into osteoblasts, which begin

to produce spongy bone trabecullae and are referred to as a
bony callus, which lasts for 3 to 4 months.

 In the final phase or after roughly 4 months, spongy bone is

gradually replaced by compact bone around the periphery.
Contact between the fixture and bone (so called immobilization) (2)
Hematoma in a confined cavity bordered by the fixture and bone (3)
Damaged Bone (4) Sound bone (5) Fixture (6) Hematoma bone tissue heals
through revascularization, demineralization and remineralization (C ) After
the initial healing phase, vital bone in direct contact with the surface of the
fixture without any intermediary tissue (8) Border zone is remodeled in
response to functional loading (9) the case of osseointegration failure, non
mineralized connective tissue forms in the border zone in contact with the
implant
Primary stability
 Stability of the implant following surgery is most important
determinant for osseointegration .

 During treatment planning it is important to ensure a

sufficient number and spread of implants as well as the
stability of adjacent teeth.

 It may be necessary to minimize or reduce occlusal tables.

 Micromotion should not be greater than 100μm while

micro motion over 150μm is thought to be detrimental to
osseointegration.
 When an implant is first placed in the bone
there should be a close fit to ensure stability.

 The space between implant and bone is

initially filled with a blood clot and
serum/bone proteins. Although great care is
taken to avoid damaging the bone, the initial
response to the surgical trauma is resorption,
which is then followed by bone deposition.
 There is a critical period in the healing
process at approximately 2 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. The stability of the implant at the
time of placement is very important and is
dependent upon bone quantity and quality
Factors affecting
osseointegration

 Implant design and material

 Host site

 Surgical technique

 Healing and loading time

Implant design
& material
MATERIAL
 (BIOCOMPATIBLE TO FORM INTIMATE
CONTACT WITH BONE, OSSEO
INTEGRATION) Such as :

• Commercially pure titanium (CPTi, 99.75%).

• Titanium alloys.
•Zirconium.
SURFACE COMPOSITION &
STRUCTURE
 1. The endosteal dental implant may be: •
None threaded implant (press fit implants).
• Threaded implant (pre-tapped or self
tapping implants).

 2. Press fit implant is positioned into its site

and gently tapped into place with a mallet.
 3. Pre-tapped implant is screwed into its site
after threading of the bone to produce
threads to avoid excess torque during
implant placement, is done at very slow
speeds (15 rpm).

 4. Self tapping implant is screwed into its

site without threading the bone to avoid
excess torque to avoid bone necrosis or
microfractures.
:Implant length
 Within the anatomical it is better to place the longest Implant
to have maximum surface area then maximum implant-bone
contact resulting in more osseointegration.

 Implants are generally available in lengths from about 6 mm

to as much as 20 mm. The most common lengths employed
are between 8 and 15 mm, which correspond quite closely to
normal root lengths. There has been a tendency to use longer
implants in systems such as Branemark compared with, for
example, Straumann. The Branemark protocol advocated
maximizing implant length, where possible, to engage bone
cortices apically as well as marginally in order to gain high
initial stability. In contrast, the concept with Straumann was to
increase the surface area of shorter implants by design
features (e.g. hollow cylinders) or surface treatments.
:Implant diameter
 Narrow diameters can be used in small and compromised
spaces; larger diameters can be used in posterior area of
the jaw increasing surface area and osseointegration.

 Most implants are approximately 4 mm in diameter. A

diameter of at least 3.25 mm is recommended to ensure
adequate implant strength. Diameters up to 6.5 mm are
available, which are considerably stronger and have a
much higher surface area. They may also engage lateral
bone cortices to enhance initial stability. However, they
may not be so widely used because sufficient bone width
is not commonly encountered in most patients‘ jaws.
The host site
:Bone factor
 Higher ratio of compact to cancellous bone
exists in the mandible; bone density is an
important factor for initial stability and
prevention of micromovement of the implant

 CT scan can provide an accurate measure of

bone density

 Quality of bone can be assessed during surgery

based on subjective feel during cutting and
drilling
 General health:
Patients having variety of systemic conditions may be
successfully treated with dental implants with some
precautions.

 Age:
- Minimum age preferred for implant placement after
completing growth. Completion of growth is usually
earlier in females than in males
- No upper age limit for implant placement as long as
the patient is fit and able to undergo the necessary
surgical procedures

Radio therapy:
Lower success rate with patient with a history of
irradiation
BONE QUALITY (DENSITY)
 Type I (D1):The entire jaw is composed of
homogenous compact bone (anterior
mandible).

 Type II (D2):Thick layer of cortical compact

bone surrounds a core of dense trabecular
cancellous bone (posterior mandible and
anterior maxilla).
 Type III (D3):Thin layer of cortical compact
bone surrounds a core of dense trabecular
cancellous bone (posterior maxilla and
posterior mandible).

 Type IV (D4):Thin layer of cortical compact

bone surrounds a core of low density
trabecular cancellous bone (posterior
maxilla).
: BONE QUANTITY
 A: Most of the alveolar ridge is present.

 B: Moderate alveolar ridge resorption.

 C: Severe alveolar ridge resorption and only

basal bone remains.

 D: Some resorption of the basal bone.

 E: Severe resorption of the basal bone.

 Surgical
technique
Operative conditions •

 Surgery has to be highly controlled;

contamination of implant surface must be
avoided even from patient saliva as it has
negative effect on osseointegration.
 Adequate aseptic technique as:

• Oral rinsing with chlorohexidine gluconate

for 30 seconds immediately before the start
of surgery.

• Peri-oral facial preparation using

chlorohexidine-based antiseptic solution

• Isolate the field with sterile towels.

• Sterile technique using masks, sterile

gloves and sterile instruments.
Incision technique •

 The choice of best incision for each case is a

key of success
Drilling technique •
 Friction between bone and drill during
drilling procedures cause rise in bone
temperature, if it exceeds 47 degree for 1
minute this leads to bone necrosis.

 This can be avoided by the use of sharp

drills, low drilling speed, graduate drill size
and use of profuse water cooling
Healing and
loading time
Delayed Loading

 Implant placement after 3-6 months

approximately gives better results regarding
osseointegration

 During the first stage of this protocol, a

surgical flap is raised, the implant is
inserted into the bone, and the flap is
sutured back into position. After about 3-6
months, when osseointegration has taken
place, the surgical site is exposed again to
uncover the implant.
Early loading •
 Such implant surface treatments specially
bio treatment, allow implant placement in 6
weeks but implants

 should be placed in a very good quality of

bone and under favorable circumstances.
Immediate Loading •
 With a good quality, quantity of alveolar bone, primary stability of
the implant and enough length of implant immediate loading can be
achieved with caring of occlusal loads in first 3 months starting 48
hours after the implant placement

 Osseointegration, provided that the bone quality is good and the

functional forces can be Controlled adequately. In studies on
restorations, the crowns are usually kept out of contact in intercuspal
and lateral excursions, thereby almost eliminating functional loading
until a definitive crown is provided.

 In contrast, fixed bridgework allows connection of multiple implants,

providing good splinting and stabilization, and therefore has been
tested in immediate loading protocols, with some success.
However,the clinician should have a good reason to adopt the
early/immediate loading protocols particularly as they are likely to be
less predictable.
EPITHELIAL GROWTH (SOFTTISSUETO
IMPLANT INTERFACE)
 Successful dental implant should have
mucosal seal between the soft tissue and
the implant abutment surface.

 To achieve this seal, good oral hygiene

should be maintained.

 If this seal is lost, the area is subjected to

peri-implant gingival disease (peri-implant
pocket formation).
 Recall visits should be scheduled at least
every 3 months for the 1st one year.The
sulcular area should be debrided of calculus
by plastic or wooden scalers.

 Implant mobility & gingival bleeding upon

probing should be evaluated.
PERIMPLANT
MUCOSA
 Mucosal tissues around intraosseous implants
form a tightly adherent band consisting of a
dense collagenous lamina propria covered by
stratified squamous keratinised epithelium.

 Implant epithelium junction is similar to the

junctional epithelium around the natural teeth in
that the epithelial cells attach to the titanium
implant by means of hemidesmosomes and a
basal lamina.
 • The depth of normal non inflamed sulcus
around an intraosseous implant is assumed to
be between 1.5-2mm.

 • The sulcus around an implant is lined with

sulcular epithelium that is continuous apically
with the junctional epithelium.

 N.B:The junctional epithelium (JE) is

located immediately apical to the sulcular
epithelium. The sulcular epithelium lines
the gingival sulcus from the base to the
free gingival margin.
Main difference between perimplant
:periodontal tissues is that

 1. Collagen fibers are non-attached & run

parallel to the implant surfaces owing to the
lack of cementum.

 2. Marginal portion of the perimplant

mucosa contains significantly more collagen
& fewer fibroblasts than the normal gingiva.
 The implant bone interface
 The relationship between endosseous implants
& the bone consists of two mechanisms:-

1-OSSEOINTEGRATION :
Bone is in intimate but not ultra structural
contact with the implant.

2-FIBROSSEOUS INTEGRATION :
Soft tissue such as fibers or cells are interposed
between the two surfaces
 :Implant integration
 1- Ankylotic-like relationship between the implant
and the bone which means osseointegration and bio-
integration.

 2- development of intermediate ligamental or fibrous

like system (fibro osseous retention) cause by:
-Inaccurate primary stability when loading the implant
-Traumatic surgical protocol
-Excessive loading
-Premature loading
-over heating the bone
 There is never 100% bone-implant contact

 Johansson and Alberktsson 1987 reported:

• Fibrous tissue interface at 1 month following implant

placement

• 50% bone-implant contact at 3 months

• 65% bone-implant contact at 6 months

• average of 85% bone to implant contact 1 yr after

Sequence of events leading to osseointegration. Note
that although multiple critical events occur shortly after
placement, long-term maturation also takes place
Implant Physiology

 Implants are not teeth and differ from teeth

in some important ways. However, by virtue
of their position in the mouth, they also
share some significant concerns with teeth,
such as the attachment of bacteria and the
growth of calculus.
Difference between implants
and teeth
 Unlike teeth, implants lack healing
capacities.

 Implants do not have a periodontal

ligament.

 The barrier to the oral cavity is rather

different around implants, principally
because of a missing connective tissue
attachment.
 Bacterial attachment and
calculus formation
 Bacteria attaches to implants and abutments in the
same way it attaches to dental surfaces. Calculus
formation also occurs in a similar fashion.

 The presence of teeth in the oral cavity is a source

of implant bacterial colonization.

 Edentulous patients that receive implants rapidly

develop a bacterial flora similar to dentate patients.
Plaque accumulation and bacterial infiltration may
result in peri-implantitis
Peri-implant mucosa
 The mucosa surrounding implants is
clinically similar to the mucosa surrounding
teeth.

 The gingival attachment is comprised of a

junctional epithelium (1-2 mm) and a
connective tissue attachment (∼1 mm).

 Unlike teeth, connective tissue fibers are

not perpendicular to the implant surface,
but parallel.
 Blood supply to peri-implant connective
tissue is limited. While the blood vessels
that lead to the connective tissue
surrounding teeth originate in both the
periodontium and periosteum, peri-implant
blood vessels originate from the periosteum
only.

 The peri-implant features have important

clinical consequences − probing resistance
is decreased, and early inflammatory
response is limited.
While the implant prosthesis is removed, peri-implant sulcus health can
be seen. Note that an epithelium faces the abutment. Insertion of a probe
finds little resistance in this area.
Peri-implant coronal bone
 After implant placement and exposure to
the oral cavity, coronal bone remodels.

 In two-stage implants, bone remodels to the

first thread within the first year of exposure.

 In one-stage implants that have high,

smooth collars, coronal bone remodels to
the smooth/rough surface connection.
 Even when an implant is placed deep in the
bone, remodeling takes place to create a
biological dimension. This reaction is similar
to the biologic width on teeth.

 This normal physiological change resembles

bone loss. During maintenance, it should
not be mistaken with bone loss related to
peri-implantitis.

 New implant designs and platform switching

have emerged to avoid peri-implant bone
loss.
Histology of an implant after bone remodeling has occurred. Note that
bone/implant contact occurs at the level of the first thread, although the
implant was placed deep in bone (I: Implant; B: Bone; Black arrow:
Original bone level; White arrow: Remodeled bone at the first thread).
Adjacent Teeth and Osseous
Architecture
 Teeth that are adjacent to implants maintain
their periodontal support. Papillae are
maintained, resulting in an aesthetically pleasing
outcome.

 Two adjacent implants in close proximity result in

a flattened osseous architecture. In this case,
papillae lose their shape.
 However, it is possible to maintain osseous
architecture between adjacent implants. If 3
mm or more are left between implants,
bone height will be maintained.

 Note that when an implant is placed more

apically than the adjacent tooth, a normal
bony angle results, accompanied by a peri-
implant deep sulcus. This is more common
on anterior teeth where implants are
purposely placed more apically. This state is
stable, and should not be mistaken with a
pocket.
Histological section of an implant next to a tooth. Note that periodontal
height is maintained against the tooth (arrow bottom right), even when
bone is apical to the implant (arrow on left). I: Implant; B: Bone; C:
Cementum; D: Dentin; P: Periodontal ligament. (Reproduced frp, Sarment,
et al, Real Clin, 2003.)
Diagram demonstrating the difference between an implant adjacent to a
tooth and two adjacent implants in close proximity. Osseous architecture
is maintained with the natural tooth, but not when the two implants are
close together.
Beveled Implants and Platform
Switch
 In order to prevent bone remodeling downwards along
the implant, displacement of the implant/abutment
connection towards the centre of the implant has been
advocated.

 This connection displacement has been achieved with

implant designs, by creating a bevel, or by platform
switch which consists of placing an abutment narrower
than the implant platform.

 There is evidence that such designs and abutment

choices prevent bone loss with possible bone
remodeling towards the abutment.
Peri-implant bone remodels differently when a platform switch design is
utilized. (A, B) An osseous cuff forms over time around this traditional
implant. (C, D) By bringing the implant/abutment connection away from
bone, maturation occurs without cuff formation. (A and B adapted from
Sarment D and Meraw S, Int J Oral Maxillofacial Imp, 2008, 23:99-104.)
Long term physiology of
osseointegration
 Osseointegration is a physiological state
that undergoes maturation over the life of
the implant. During implant function,
surrounding bone continually remodels in
response to biting forces. In rare cases,
excessive forces may cause loss of
osseointegration.

 The implant surface also undergoes long-

term changes − the ceramic oxide layer
thickens with time.
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