The Biology of Dental Implants

The Biology of Dental The Biology of Dental ImplantsImplants

James Q. Swift, DDSDivision of Oral and Maxillofacial Surgery

University of Minnesota

Concepts of Connective Concepts of Connective Tissue Healing Around Tissue Healing Around

ImplantsImplants Osseous Integration / Osseointegration

Fibrous Integration Fibro-osseous Integration

Bone HealingBone Healing

Phase I: Inflammatory Phase Phase II: Proliferative Phase Phase III: Maturation Phase

Phase I Bone Healing:Phase I Bone Healing: Day 1-10 Day 1-10

Absorption of plasma proteins Platelet aggregation and activation

Clotting cascade activation Cytokine release

Phase I Bone Healing:Phase I Bone Healing: Day 1-10 Day 1-10

Nonspecific cellular inflammatory response

Specific cellular inflammatory response

Macrophage mediated inflammation

Phase II Bone Healing:Phase II Bone Healing: Day 3-42 Day 3-42

Neovascularization Differentiation, proliferation and activation of cells

Production of immature connective tissue matrix

Phase III Bone Phase III Bone Healing:Healing:

After Day 28 After Day 28 Remodeling of the immature connective tissue matrix with coupled resorption/ deposition of bone

Bone remodeling in response to implant loading

Physiologic bone recession

Mucoperiosteal HealingMucoperiosteal Healing

Phase I: Inflammatory Phase Phase II: Proliferative Phase Phase III: Maturation Phase

Phase I Mucoperiosteal Phase I Mucoperiosteal Healing Inflammatory Healing Inflammatory

Phase: Day 1-10Phase: Day 1-10 Platelet aggregation and activation

Clotting cascade activation Cytokine release Nonspecific cellular inflammatory response

Macrophage mediated inflammation

Phase II Mucoperiosteal Phase II Mucoperiosteal Healing Proliferative Healing Proliferative

Phase: Day 2-42Phase: Day 2-42 Neovascularization Differentiation, proliferation and activation of cells

Deposition of immature collagen, elastin, and ground substance

Phase III Mucoperiosteal Phase III Mucoperiosteal Healing Maturation Healing Maturation Phase: After Day 21Phase: After Day 21

Connective Tissue Remodeling

Bone Implant InterfaceBone Implant Interface

Dependent on implant material Calcified bone, unmineralized osteoid matrix, and connective tissue

Zone of amorphous material– Proteoglycans and glycosaminoglycans– 100-3000 angstroms

Collagen filaments

Chemical Bonds Between Chemical Bonds Between Bone and ImplantsBone and Implants

van der Waals Local direct chemical bonds (ionic, covalent)

Chemical bonding well described with calcium phosphate ceramics

Some materials have no chemical bond but have excellent bone contact

(CP titanium vs. HA)

Factors Affecting Factors Affecting HealingHealing

Surgical technique Premature loading Surgical fit Extraction sites

Factors Affecting Factors Affecting HealingHealing

Peri-implantitis Bone quality Staged healing

Logic CONTROLLogic CONTROL

-10

0

10

20

30

40

50

60

0 200 400 600 800

ExperimentExperiment ControlControl12 Pigs12 Pigs 6 Pigs6 Pigs

5 Months 5 Months Controlled Controlled

LoadingLoading

1 Month1 Month

HealingHealing

4 Month4 Month2 Month2 Month

5 Months 5 Months Non-LoadingNon-Loading

HealingHealing

(4)(4)

(4)(4)(4)(4)

1 Month1 Month

4 Month4 Month2 Month2 Month (4)(4)

(4)(4)(4)(4)

3 Healing Groups

One Month Healing

Four Months Healing

Radio-Subtraction (S3D, MDRCBB)Radio-Subtraction (S3D, MDRCBB)

One MonthTwo MonthsFour Months

Micro-CT ImagesMicro-CT Images

One MonthTwo MonthsFour Months

Stevenel’s Blue and Van Gieson’s Picro-Fuchsin Stain

Issues Relating to Issues Relating to Physical Status of Physical Status of

RecipientRecipient Nutritional status Age Hematologic issues

Issues Relating to Issues Relating to Physical Status of Physical Status of

RecipientRecipient Diabetes Corticosteroids Radiation

51 year old man51 year old man

CC- “I ‘ve been referred for evaluation and treatment for a growth in my jaw”

HPI– 2 month duration– mobile teeth– facial swelling


PMH– Hypertension-well controlled

PDH Imaging findings

– 4 cm x 2 cm radiolucent lesion left mandibular body causing tooth displacement


Problem list– Radiolucent lesion– Teeth vital– Buccal plate perforation– No paresthesias– Differential diagnosis

ameloblastoma central giant cell lesion

odontogenic myxoma


Treatment plan– Incisional biopsy for histologic typing

– Prosthodontic consultation– Definitive imaging (CT scan)

Biopsy results– Acanthomatous ameloblastoma


Treatment– Arch bars/surgical stent construction

– Transcervical approach for exposure and lateralization of IAN/Mental nerve

– Transoral marginal resection preserving inferior border

– Reconstruction plate applied for stabiliation


Treatment– Healing interval 6 weeks– Mandibular reconstruction of 4cm x 2cm x1.5 cm defect with transcervical approach and AICBG (PCMB)

– Healing interval 3 months


Treatment– Placement of 5 osseointegrated dental implants left parasymphysis and body with prosthodontic guidance

– Transoral removal of reconstruction plate

– Healing interval 5 months


Treatment– Second stage implant surgery with temporary healing abutments placed and preservation of attached gingiva

– Prosthodontic reconstruction with fixed detachable prosthesis


Results– Minimal paresthesia– No recurrence of lesion– Fixed prosthesis with lip support and excellent masticatory function


Rationale for treatment– Alternative reconstructive surgery harbors greater potential morbidity

– Fixed partial denture not ideal span too great

– Removable partial denture not ideal blunting of vestibular and sulcular depths

16 year old woman16 year old woman

CC- “I was in a car accident and hit the steering wheel.”

HPI– Patient referred from emergency department

– Injury had occurred > 16 hours prior to presentation

– No other injuries identified (C-spine negative)


PMH– Non contributory

PDH– Had just completed orthodontic therapy and was in retention phase


Clinical findings– Lip laceration– # 6 , 7 and 8 not visible– Palpable step defect of alveolus– Coagulum in socket sites of 6 & 7


Imaging findings– #6 & 7 superiorly displaced and rotated

– #8 absent– 9 abnormalities in the PDL– Radiolucent transverse fracture line superior to apices of anterior teeth


Diagnosis– Trauma to the anterior maxilla

Lip abrasion/ laceration Maxillary alveolar fracture Avulsion # 8 Traumatic displacement # 6, 7, & 9 Incisal edge fractures # 6, 7 & 9


Treatment– IV sedation– Surgical exploration of injured area with preservation of alveolar bone

– Reduction of alveolar fractures– Repositioning of #6, 7 & 9 into normal dental arch relationship and stabilization with splint and pontic placed

– Closure of laceration and surgical wound


Treatment– Referral to orthodontist

Replaced stabilization wire with arch wire

– Referral to endodontist RCT # 6 & 7


Referral to prosthodontist– Consultation for dental reconstruction

– Options FPD RPD Implant # 8 area


Treatment– After stabilization for 4 months

Implant inserted # 8 area (internal hex)

Presevation of attached tissue Preservation of bone Osteotome technique


Treatment– Integration time 5 months– Second stage surgery with preservation of soft tissue

– Temporary healing abutment and temporary crown

– Implant crown constructed


Results– Acceptable cosmetic outcome

Rationale for treatment– Preservation of natural teeth, bone and soft tissue

– FPD would require preparing endodontically treated adjacent teeth with uncertain prognosis

– Patient and parents desires

Thank youThank you

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The Biology of Dental Implants