IMPLANTS & IMPLANTOLOGY… – FROM EXOTIC TO EVERYDAY

Dr.P.R.GANESH Periodontist & ImplantologistChennai.

Lecture by

This Lecture Covers -

1. What did the profession believe in late 1970's about the then new field of implantology?

2. What do we believe now in 2015 and why?

3. Where do we believe that osseointegration research and the practical applicability of oral implants will go in the next 5–10 years?

W. R. Laney - International Journal of Oral and Maxillofacial Implants (JOMI)

An Implant Is Defined As ….

An Artificial Material Or Tissue That Shows

Biocompatibility Upon Its Surgical Implantation

Ankylotic Anchorage of a CP Titanium Implant

has been accepted as the desirable interface

between bone as a living tissue

and a metal implant.

(Albrektsson et al. 1981; Brånemark et al. 1969/77)

OSSEOINTEGRATION……

Osseo-integration & Dentistry…in The Beginning

From Transplants To Implants….Who on earth was the first to come up with the idea of using an ARTIFICIAL tooth root to replace a missing natural tooth?

•The idea of replacing a missing tooth with someone else's NATURAL tooth goes back to Ancient Egyptian Times.

•But it didn't work very well! In fact, transplanting a tooth from one person to another has never really worked, even nowadays with all the advances in transplant medicine.

So the technology simply moved on from transplants to implants

1st Historic Record of Implant

The first person to publish a description of the technique

of modern dental implants was a French dentist,

MAGGIOLO J IN 1809.

Maggiolo described a method to implant 18-karat gold alloy, with

three branches into the jawbone and to install a porcelain

crown as a superstructure in his book:

“Le Manuel de l’Art du Dentiste” (1809)

1st Historic Record of Implant…

Maggiolos’s Implant Model

In 1850’s …..to 1890’s

• Harris constructed a socket in the jawbone to insert a

column made of PORCELAIN - coated with a rough layer of lead

in order to increase the supporting strength (so ceramic implants are not that

new an idea)

• Berry constructed a root-form porcelain implant that was Lead-free.

• Pajime - Silver implant.

• Bonwil - Gold And Iridium implant.

The 20th century…..• 1905 - Scholl made a root-form, porcelain implant.

• 1937 – Stock used Vitallium, a cobalt-chromium-

molybdenum alloy .

• 1940- Dahl was the first to attempt subperiosteal implant.

And we all know who had the bright idea

for an artificial titanium dental implant in 1969.

RIP …a tribute….

Branemark’s Original research – titanium chambers in rabbit bone- Osseointegrated

• Per-Ingvar Brånemark (May 3, 1929 – December 20, 2014) a Swedish physician, touted as the "FATHER OF MODERN DENTAL

IMPLANTOLOGY". 

• In 1982 in Toronto, Brånemark presented work that had begun 15 years earlier in Gothenburg.

• Brånemark's investigations into the phenomenon of  OSSEOINTEGRATION or the biological fusion

of bone to a foreign material, in this case TITANIUM, reinvigorated the field of implantology.

• The Toronto conference brought widespread recognition to the Brånemark implant methods and is one of the most significant

scientific breakthroughs in dentistry.

“A vast number of patients are indebted to the Toronto

Osseointegration Conference in Clinical Dentistry in May

1982. This singular initiative rendered the use of implant

interventions for edentulousness available to

the general public much earlier than usual for new

treatment modalities, which often take years to be

implemented.”

Dr,Asbjørn Jokstad

Implantologist

33 Years (1982-2015) since …..

Professor Branemark

introduced Osseo-integration and founded the field of

Implantology...

Why The Excitement About Implant Rehabilitation?

Firstly, in earlier days, old age was associated with almost

INEVITABLE EDENTULISM, with consequences for personality,

nutrition, communication etc. Now even those patients can receive

rehabilitation of oral function, with the same results and prognosis as

for any other patient.

Secondly, through OSSEOPERCEPTION, the dentate mouth

communicates with the brain, improving not only daily function, but

also being an important factor in NEURONAL STIMULATION- another

reason to include the mouth in considerations of overall health

In Branemark’s own words….

• The mouth is a much more important part of the human body than modern medicine recognizes.

The edentulous patient is an amputee, an oral invalid, whom we

should help with rehabilitation.

Edentulousness And Its Aftermath

So Rehabilitation – according to Brånemark et al. 1977

should include…

Restoring FORM,

FUNCTION, AND

AESTHETICS has always

been the goal of oral

rehabilitation .

The 33rd anniversary of

Osseointegration (1982-2015) is an

appropriate time to take stock of

what has been achieved and to

focus on what is emerging as new

and innovative developments in the

field of osseointegration.

So What’s New After 30 Years ?

30 years ago we did not have answers to questions such as:

1. Does The Technology Work?- Effectiveness

2. How Does The Technology Work?- Process

3. Does It Matter To Patients? – Salience

4. Will It Do More Good Than Harm? - Safety 5. Is It Worth Paying For The Intervention?- Cost

Effectiveness.

These clinical questions of relevance now have a few answers after 30 years.

So what has changed in 30 years ?

In 1982 the protocol advocated by Dr. P.I.Branemark

A. 1- Implant Design, B. Made From 1- Grade Of Titanium, C. Using 1- Surgical Procedure, D. For 1 Indication i.e. Completely Edentulous Jaws.

Today, we are confronted with a phenomenal diversity of products, materials, techniques and applications of

technologies built on osseointegration.

Original Branemark Protocol -

Changes in Treatment Planning/ Indications

Original Protocol - Fully Edentulous Patients

Modern Protocol - All types of Indications -extraction & immediate implant

Changes in Indications & Criteria

Original Protocol –Strict

Inclusion & Exclusion

Criteria

1. Bone Height of 10mm

2. Bone Width of 7-8mm

Modern Protocol –Rare

Exclusion criteria-

A. Guided Bone

Regeneration

B. Sinus Lift

C. Bone Expansion

No more “Ideal” implant criteria..

Modern Protocol - GBR

Modern Protocol -

GBR

Modern Protocol – Sinus Lift

Modern Protocol – Sinus Lift

Either Lateral Window or Trans-Alveolar

Modern Protocol – Ridge

Expansion

Changes in Treatment Planning

Original Protocol -

1. OPG

2. Lateral Cephalogram

3. Periapicals

Modern Protocol –

1) CT

2) CBCT

3) Guided Implant

Placement

Modern Diagnostics- Using CT & CBCT

Accurate Treatment Planning…..

Taking into account Anatomical Landmarks

Modern Protocol – Surgical Guides

Modern Protocol- Risky Patients?

• SMOKING may be associated with a greater incidence of

implant failure, but studies have often analyzed data at the

implant rather than the patient level, thereby biasing

conclusions.

• DIABETIC patients may have greater risk of implant failure,

but evidence is not strongly supportive.

• Compelling evidence does not exist to link OSTEOPOROSIS or

use of oral bisphosphonates to implant failure, yet concern does

exist with possible post-surgical side effect of osteonecrosis

with bisphosphonates.

Changes in Surgery – Quirynen etal Perio 2000 Vol.66, 2014

Original Protocol

a) Pre-surgical & Post

Surgical Antibiotics

b) Low speed placement/

excessive cooling

c) Two-Stage Surgery

d) Delayed Loading

e) Screw retained Prosthesis

Modern Protocol

1) Only Pre-surgical

Prophylaxis

2) Higher Speed Placement/

cooling not essential

3) One-Stage Surgery

4) Immediate Loading

5) Cemented Prosthesis

Are prophylactic antibiotics effective in reducing postoperative infections and failures? Esposito et al. 2008.

•A meta-analysis suggested that 2 G Of Amoxicillin given 1

hour pre-operatively significantly reduces early failures of

dental implants.

•Therefore it might be sensible to suggest the routine use

of one dose of prophylactic amoxicillin just before placing

dental implants.

•It remains unclear whether an adjunctive use of post-

operative antibiotics is beneficial.

So Modern Protocol- Pre-op YES and Post-op NO for Antibiotic Prophylaxis.

1-Stage Vs. 2-Stage… ? ? ?

Is A One-Stage Implant Placement Procedure As Effective As A Two-Stage Procedure Submerging The

Implants Under Soft Tissue For Undisturbed Healing? Esposito 2008

NO RELEVANT CLINICAL DIFFERENCES

appear to exist between a One- Or a Two-stage Implant Procedure.

The major clinical implication is that the one-stage approach might be preferable since it has only one

surgical intervention and shortens treatment times.

1-Stage Vs. 2-Stage

However, a two-stage submerged approach is

preferable ….

A. When an implant has not obtained an optimal

primary stability or

B. When barriers are used for guided tissue

regeneration.

Flap Vs. Flapless ? ? ?

Flap Vs. Flapless ? ? ? - Esposito 2008 -Systematic Review

• Evidence suggests that flapless procedures cause less

postoperative pain, edema and consumption of analgesics

than conventional flap elevation.

• Flapless surgery performed by skillful clinicians in

properly selected cases can be as successful and

complication-free as conventional.

• However clinicians should select patients for flapless

implant placement with a great deal of caution in relation

to their own clinical skills and experience

Flapless- is like a banana peel…only with good clinical skills

When Brånemark et al. (1977) introduced the

principles of osseointegration 30 years ago –

a. Primary Stability

b. Lack Of Micromotion

were considered to be the Two Main Factors

necessary for achieving predictable high successes

of 92–98% for Osseointegrated implants after 10

years in the maxilla and mandible, respectively

(Adell et al. 1990)

Loading…Original Protocol

Delayed Vs..…Immediate Loading

Loading……Why Immediate?

Mechanical loading is known

to be a

particularly potent stimulus

for

bone cells if it does

not exceed certain values

(Robling et al. 2006)

Loading……Why Immediate?Controlled implant loading leads to a positive effect

on the initial bone formation.

Gotfredsen et al. 2001- reported that static continuous loads on implants resulted in

Increased Bone Density.

Heitz-Mayfield et al. 2004 - transient functional loads act physiologically as a

Trigger For Bone Remodeling

Modern Protocol- Immediate Loading beats Delayed Loading

Esposito et al - Systematic Review (2009) - came to the following

conclusions:

“It is possible to successfully load dental implants

immediately or early after their placement in selected

patients, though not all clinicians may achieve optimal results

when loading the implant immediately” {CLINICAL SKILLS}

“A high degree of primary implant stability (high value of

insertion torque) seems to be one of the prerequisites for a

successful immediate/early loading procedure.” {PRIMARY

STABILITY}

Loading – Immediate Vs Delayed

Screw Vs Cemented….

In the early era of osseointegration most prostheses were screw-

retained as the long-term predictability of implants, was

questionable.

But once it became evident that implants, once osseointegrated,

maintained stability within bone – it reduced the emphasis on

retrievability of prostheses.

Increase in popularity of cement-retained restorations.

Cement-retained restorations - provide aesthetic

advantages over screw-retained restorations and

fewer mechanical complications.

Screw Vs. Cemented Prosthesis

The Future Of Implantology? ? ?

Next Few Years….

• Short Implants- 8mm & Extra Short Implant of 5mm (Renouard, Nissand etal Clin Oral Implant Res 2006)

• Recombinant Proteins - recombinant Bone Morphogenic Protein 2 (rhBMP-2) and Recombinant Platelet Derived Growth Factor (rhPDGF-BB) that potentiate the ability to manage bone deficiencies

From PRF to Stem Cells…just a step away..

Now we have seen the Positives lets look at some Negatives…

We have today close to 600 different implant systems

produced by at least 146 different manufacturers

located in all corners of the globe.

Every year at least 27 new implant companies surface

in the market.•

So How Many Implant Systems are there after 30 years ? ? ?

FDI Science Committee was asked to investigate the issue and the findings were

rather alarming (Jokstad et al. 2003).

Not only did the quantitative issue cause concern, but also the QUALITATIVE

ASPECTS - many manufacturers did not appear to follow international standards for

manufacturing their products.

How Effective are these Different Implant Systems ? ? ?

Were these new implants clinically documented ? ? ?

• NO, according to Albrektsson and Sennerby (1991);

• NO, according to the American Dental Association (ADA 1996);

• NO, according to Eckert and colleagues (1997);

So who, if anyone has been doing anything about this?

• None- according to the best of my knowledge.

• And I leave it to this esteemed audience to think over it.

• And I urge those who can- to do something about this.

Do think it over….

After this 33 years journey of implantology …we are still to taste the

nectar fully..

Change Is

Mandatory…

Adaptation Is Optional

My Conclusion…..

WHEN IT COMES TO DOING IMPLANTS….

Thank You

For all further doubts, queries and general advice

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