OSSEOINTEGRATION

INTRODUCTION

HISTORICAL REVIEW

DEFINITIONS

FIBROOSSEOUS INTEGRATION

MECHANISM OF OSSEOINTEGRATION

BONE TO IMPLANT

INTERFACE

HISTORY OF BRANEMARK

SYSTEM

BONE FORMATION AROUND

IMPLANTS

STAGES

BONETISSUE

RESPONSE

BIOLOGICAL ATTACHMENT

BIOLOGICAL PROCESS OF INTEGRATION

MECHANISM OF INTEGRATION

FACTORS THAT INFLUENCE OSSEOINTEGRATION

METHODS OF EVALUATION

FAILURESCONCLUSIO

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FUTURISTIC CONCEPTS

INTRODUCTION

Osseointegration derives from ‘osteon,’ the Greek word for bone and the Latin word for ‘to make whole’ which is integrate.

This refers to the process that will take place between the living bone and the surface of implant.

HISTORICAL REVIEW

The concept of Osseointegration was developed and the term was coined by Dr. Per-Ingvar Branemark, Professor at the institute for Applied Biotechnology, University of Goteborg, Sweden .

  In 1952 ,Vital microscopy studies in rabbits using titanium optic chambers.

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HISTORY OF BRANEMARK SYSTEM

EARLY STAGE (1965-1968)

DEVELOPMENTAL STAGE (1968-1971)

PRODUCTION STAGE (1971 – PRESENT)

DEFINITIONS

Structurally oriented definition “Direct structural and functional connection between the ordered, living bone and the surface of load carrying implants”. - Branemark and associates (1977)

“The apparent direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening connective tissue”. - GPT 8

“It is a process where by clinically asymptomatic rigid fixation of alloplastic material is achieved and maintained in bone during functional loading” - Zarb and T Albrektsson (1991)

Histologically, Direct anchorage of an implant by the formation of bone directly on the surface of an implant without any intervening layer of fibrous tissue. - Albrektsson and Johnson (2001)

Clinically Ankylosis of the implant bone interface.“Functional ankylosis” -Schroeder and colleagues (1976)

Biomechanically oriented definition “Attachment resistant to shear as well as tensile forces” - Steinmann et al (1986).

  American Academy of Implant Dentistry

(AAID) defined Osseointegration as "contact established without interposition of non-bone tissue between normal remodeled bone and an implant entailing a sustained transfer and distribution of load from the implant to and within the bone tissue"

BONE TO IMPLANT INTERFACE

TWO BASIC THEORIES :

OSSEOINTEGRATION (BRANEMARK 1985)

FIBRO-OSSEOUS INTEGRATION (LINKOW 1976 JAMES 1975 WEISS 1986)

BONE TO IMPLANT INTERFACEMeffert et al (1987)

ADAPTIVE- OSSEOINTEGRATION

BIOINTEGRATION

Osseointegration

In 1986,the American Academy of Implant Dentistry(AAID) defined Fibrointegration as“Tissue to implant contact with interposition healthy dense collagenous tissue between the implant and bone’’

FIBRO-OSSEOUS INTEGRATION

Presence of connective tissue between the implant and bone .

Collagen fibers functions similarly to Sharpey’s fibers found in natural dentition.

The fibers are arranged irregularly, parallel to the implant body, when forces are applied they are not transmitted through the fibers.

“Pseudoligament”, “Periimplant ligament”, “Periimplant membrane”.

FAILURE OF FIBRO-OSSEOUS THEORY

No real evidence

Forces are not transmitted through the fibers - remodeling was not expected .

Forces applied resulted in widening fibrous encapsulation, inflammatory reactions, and gradual bone resorption there by leading to failure.

MECHANISM OF OSSEOINTEGRATION

• Healing process may be primary bone healing or secondary bone healing.

• In primary bone healing, there is well

organized bone formation with minimal granulation tissue formation - ideal

• Secondary bone healing may have granulation tissue formation and infection at the site, prolonging healing period. (Fibrocartilage is sometimes formed instead of bone – undesirable)

The device Two consecutive profiles of the pitch. U shaped circumferential trough. Pitch engages hard tissue walls Void between pitch and body of implant – wound chamber.

Berglundh et al (2003) and Abrahamsson et al (2004).

The wound chamber Blood clot Erythrocytes, neutrophils and monocytes Leukocytes – cleansing process.

Fibroplasia 4 days of healing Coagulum replaced by granulation tissue. Mesenchymal cells, matrix components Angiogenesis. Provisional connective tissue.

Bone modelling 1 week of healing Vascular structures with few inflammatory cells. Cell rich immature (WOVEN) bone. (Centre of chamber and direct contact of implant surface.) 1st phase of osseointegration.

2 weeks woven bone pronounced. Woven bone extends from parent bone into connective tissue. Mature osseointegration Pitch – ongoing new bone formation Recipient site immediate to implant in direct contact – bone

resorption with new bone formation.

4 weeks Cell-rich woven bone covered most of titanium. Central portion – primary spongiosa – vascular structures and

mesenchymal cells.

Remodelling After 6-12 weeks – mineralised bone. Primary and secondary osteons Bone marrow, adipocytes and mesenchymal cells.

BIOLOGICAL PROCESS OF INTEGRATION(BRANEMARK)

OSTEOPHYLIC STAGE

OSTEOCONDUCTIVE

OSTEOADAPTIVE

STAGES OF OSSEOINTEGRATION

According to Misch,

there are two stages in osseointegration, Each stage been again divided into two

substages.

SURFACE MODELING (Stage1 and 2)REMODELLING AND MATURATION(Stage 3 and 4)

STAGE 1: WOVEN CALLUS (0-6 WEEKS)

STAGE 2: LAMELLAR COMPACTION (6-18 WEEKS) REMODELING, MATURATION

STAGE 3: INTERFACE REMODELING (6-18 WEEKS)

STAGE 4: COMPACT MATURATION (18-54 WEEKS)

Stage 1:

Woven callus Woven bone is formed at implant

site. Primitive type of bone tissue and

characterized Random, felt-like orientation of collagen fibrils

Numerous irregularly shaped osteocytes

Relatively low mineral density

Stage 2:

Lamellar compaction The woven callus matures as it is

replaced by lamellar bone. This stage helps in achieving

sufficient strength for loading.

Stage 3:

Interface remodeling This stage begins at the same time

when woven callus is completing lamellar compaction.

During this stage callus starts to resorb, and remodeling of devitalized interface begins.

The interface remodeling helps in establishing a viable interface between the implant and original bone.

Stage 4:

Compact bone maturation During this stage compact bone

matures by series of modeling and remodeling processes.

The callus volume is decreased and interface remodeling continues.

BONE TISSUE RESPONSEOsborn and Newesley (1980) : Proposed 2 different phenomena

Distance Osteogenesis :A gradual process of bone healing inward

from the edge of the osteotomy toward the implant. Bone does not grow directly on the implant surface.

Contact Osteogenesis

• The direct migration of bone-building cells through the clot matrix to the implant surface.

• Bone is quickly formed directly on the implant surface.

MECHANISM OF INTEGRATION:(Davies - 1998) Contact

osteogenesis : DE NOVO BONE FORMATION

BONE REMODELING AT DISCRETE SITES.

FACTORS THAT INFLUENCE OSSEOINTEGRATION

PATIENT RELATED FACTORS

SURGICAL FACTORS

IMPLANT RELATED FACTORS

IMPLANT RELATED FACTORS

Implant Biomaterial(Biocompatibility) Implant Biomechanics Implant Design Implant Taper Apical Design Implant Width Crest module design Implant Surface Topography(Surface roughness) Implant Surface Modifications Contamination Heat Production Implant Loading

SURGICAL FACTORS THAT AFFECT OSSEOINTEGRATION

PATIENT FACTORS

METHODS OF EVALUATION OF OSSEOINTEGRATION

OTHER METHODS TO ASSESS  OSSEOINTEGRATION

  Cone beam CT Periotest Dynamic model testing Impulse testing 

FAILURES OF OSSEOINTEGRATION

Revised Albrektsson Success Criteria

Int J Oral Maxillofac Implants. 1986 Summer;1(1):11-25.The long-term efficacy of currently used dental implants: a review and proposed criteria of success.Albrektsson T, Zarb G, Worthington P, Eriksson AR.

OSSEOPERCEPTIONOsseoperception is defined as mechanoreception in the absence of a functional periodontal mechanoreceptive input but derived from temporomandibular joint (TMJ)

CONCLUSION•Thorough understanding and application of factors affecting the osseointegration and biological process of osseointegration in clinical practice is the key factor for success.• The “osseointegration” is a multifactorial

entity.

• Achieving the osseointegration of the endosteal dental implants needs understanding of the many clinical parameters.

REFERENCES Hobo, Ichida, Garcia “Osseointegration and

occlusal rehabilitation” Quintessence Publishing.

Jan Lindhe “Clinical periodontology and implant dentistry” 4th edition, Blackwell Publishing.

Elaine McClarence “Branemark and the development of osseointegration” Quintessence publication

Carl E. Misch “Implant dentistry” 2nd edition, Mosby.

Charles M.Weis “Principles and practice of implant dentistry” Mosby.

Per Ingvar Branemark “Osseointegration and its experimental background” JPD 1983 Vol. 50, 399-410.

Hanson, Alberktson “Structural aspects of the interface between tissue and titanium implants” JPD 1983 vol. 50, 108-113.

T. Alberktson “Osseointegrated dental implants” DCNA Vol. 30, Jan 1986, 151-189.

Richard Palmer “Introduction to dental implants” BDJ, Vol. 187, 1999, 127-132.

Geroge A. Zarb “Osseointegrated dental implants: Preliminary report on a replication study”. JPD 1983, Vol 50, 271-276.

Bergman “Evaluation of the results of treatment with osseointegrated implants by the Swedish National Board of Health and Welfare”. JPD 1983, vol. 50, 114-116.

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