Since tooth loss from disease and trauma has always been a feature of
mankinds existence, it is not surprising that the history of tooth replacement
is a long one. Evidence from ancient civilizations shows that attempts were
made to replace missing teeth by banding artificial tooth replacements to
remaining teeth with metal many centuries ago. For the mechanism of
attachment, clinicians have long sought an analog for periodontal ligament.
Experiments were made to develop a fibrous attachment that could serve the
same purpose as the periodontal ligament but all in vain. The periodontal
ligament in a specialized structure which serves not only as an efficient
attachment mechanism but also as a shock absorber and sensory organ, so it
was impossible to reproduce.
HISTORY OF OSSEOINTEGRATION :
Implants may indeed be anchored in bone by means of surrounding
sheath of connective tissue, but in general this has not shown the degree of
organization and specialization that would allow it to pass as a substitute for
the periodontal ligament. In most cases, loading leads to gradual widening
of fibrous tissue layer and loosening of implant, with consequent implant
failure. In contrast to periodontal ligament, a fibrous tissue sheath is a
poorly differentiated layer of scar tissue.
Dr. Per Ingvar Branemark, an anatomist is credited as the person who
has coined the term osseointegration. Branemark along with his team was
working in the laboratory of the vital microscopy (1952), laboratory of
experimental Biology, University of Goteberg Sweden, (1960), Institute of
Applied biotechnology, Goteberg (1978). The main study of his group was
to understand the mechanism of bone healing and bone response to the
thermal, mechanical, chemical injuries by using vital microscopy.
Vital microscopy, is a type of the miniature microscope, which is
introduced in to the living organisms. E.g. Rabbit in their study the titanium
(Ti) chambers were used for placing the vital microscope into the rabbits
fibula. After the studying of the bone biomechanics in one animal, the team
used to recover the vital microscope and place it into the other animal
model. While recovering Branemark observed that the Ti chambers were
firmly adherent to the bone. By this observation they concluded that the
titanium was firmly integrated to the bone and later they used Ti screws and
Ti bars for reconstruction of the long bones and mandibles of the dogs.
After ensuring the favourable bone response to the Ti, the team tried
to replace the teeth for the dogs. The Ti implants also showed good response
for the mucosa and skin penetrating implants. The implants, which used for
replacement of the teeth in the dogs showed good integration upto 10 years
and the implants could bear the load of upto 100 Kgs without failure at the
bone-implant interface. By observing this property the integration between
the bone and Ti screws was termed as osseointegration.
The Ti vital microscopic chambers were used to analyze
microcirculation in the healthy and diabetic human volunteers without any
signs of inflammation around the Ti chamber. In 1965, first human
edentulous patient was treated by using the Ti screws (implants) by
reconstruction of resorbed edentulous arches using autologus tibial bone
grafts.
The salient features of Branemark and his teams work
About more than 50 designs of Ti screws (Implants) were tested
and used.
The surgical protocol followed was : two stage surgery, which was
proved beneficial.
Minimal trauma during the surgery results in bone regeneration
rather than bone repair at the implant site.
Non-contaminated implants (sterile and clean implants) proved
good integration.
The next events noted to occur during this phase of wound healing
consist of a cellular inflammatory response. Initially, it is nonspecific in
nature and consists mainly of neutrophil emigration into the area of
damaged tissue. Its duration is variable but generally peaks during the first 3
to 4 days following surgery. The role of this cell is primarily phagocytosis
and digestion of debris and damaged tissue. Neutrophils are accompanied by
smaller numbers of eosinophils. Eosinophils have a similar phagocytic
function and they can also digest antigen antibody complexes. These cells
are attracted to the local area by chemotactic stimuli and then migrate from
the intravascular space to the interstitial space by diapedesis. End products
of this phagocytic process are carried away from the local area by the
lymphatic circulation. Neutrophils and eosinophils are end state cells and
thus further division is not possible. They act as a type of first stage cellular
defence and their duties are later augmented by the lymphocyte and the
monocyte.
Toward the end of the first week, the generalized inflammatory
response becomes more specific in nature. Increasing numbers of thymus
dependent lymphocytes (T cells) bursa equivalent lymphocytes (B cells),
killer (K) cells, natural killer (NK) cells and macrophages are found in the
wound at this time. These cells respond to foreign antigens such as bacteria
and plaque debris that have been introduced into the area during the surgical
procedure. These antigens are processed and presented to the B and T cell
populations by macrophages. Four functionally distinct T cell populations
respond and perform regulatory, inflammatory, cytotoxic and augumentary
functions resulting in a variety of effector modalities. Cellular
intercommunication is essential for effective immunoregulatory function
and this is accomplished with the release of soluble signal molecules called
lymphokines. Lymphokines are specific cytokines released from local
cellular elements that effect immunologic function.
enzymes,
prostaglandins,
complement
and lymphokines.
arrives at a relatively steady state by the sixth to eight week. Long term
follow up (> 1 year) of these unloaded implants reveals little change from
the picture seen at the 6 to 8 week period with only some condensation of
bone and some reorientation of the vascular pattern.
Implants are placed into their endosteal position through incisions in the
mucoperiosteum. They can be placed using a one stage technique, in
which the endosteal and transmucosal portions of he implant are
allowed to heal as a single unit, or a two staged technique, in which the
endosteal component is placed initially followed some time later by the
placement of the transmucosal portion after a period of healing. Healing
of the mucoperiosteal complex around implants is of paramount
importance for the longevity of prosthetic reconstructions. An
understanding of the biologic processes involved in generalized wound
repair and how soft tissue wounds heal around implant fixtures is vital
information for appropriate management of implant patients. As in the
previous section on bone healing, there are also three phases of wound
healing in soft tissue wounds : inflammatory, proliferative and
maturation phases. In addition, there is also significant overlap between
these phases as they pertain to mucoperiosteal wound healing.
Phase one inflammatory phase :
The inflammatory phase of wound healing for the mucoperiosteal
complex is essentially the same as that mentioned in the previous
section on bone healing. It involves an initial vascular response followed
by platelet aggregation and activation, the clotting cascade and then an
initial non-specific cellular inflammatory response consisting of
infiltrates of predominantly neutrophils. This is followed shortly
thereafter by a more specific cellular inflammatory response consisting
of infiltrates of predominantly neutrophils. This is followed shortly
thereafter by a more specific cellular inflammatory response marked by
increased number of lymphocytes and macrophages. Cytokines also play
an important role in the healing of soft tissue wounds.
Phase two proliferative phase :
cellular
elements,
including
platelets
and
macrophages.
and
glycoproteins.
Glycoproteins
are
adhesive
2. Design characteristics
3. Surface characteristics
4. The state of the host bed
5. The surgical technique and
6. The loading conditions
There is a need to control these factors more or less simultaneously
to achieve the desirable goal of a direct bone anchorage.
IMPLANT BIOCOMPATIBILITY :
The main aim of the careful surgical preparation of the implant bed is
to promote regenerative type of the bone healing rather than reparative
type of the bone healing. If too violent a surgical technique is used,
frictional heat will cause a temperature rise in the bone and the cells
that should be responsible for bone repair will be destroyed. Bone
tissue is more sensitive to heat than previously believed. In the past the
critical temperature was regarded to be in the 56 0C range, as this
temperature will cause denaturation of one of the bone enzymes,
alkaline phosphatase. However, the critical time / temperature
relationship for bone tissue necrosis is around 470C applied for one
minute. At a temperature of 500C applied for more than one minute we
are coming close to a critical level where bone repair becomes severely
and permanently disturbed. This critical temperature should be seen
against observed frictional heat at surgical interventions. In the
orthopaedic field, despite adequate cooling, temperatures of 90 0C have
been measured. High drilling temperatures in the dental field are to be
expected when drilling, particularly in the dense mandible.
Erickson R.A. recommended the importance of using well sharpened
drills, slow drill speeds, a graded series of drills (avoid making, for
instance, a 4mm hole in one step) and adequate cooling by profuse
irrigation. By using such a controlled technique it has been
demonstrated in clinical studies that overheating may be totally
avoided. The mechanical injury will of course remain and is quite
sufficient to trigger a proper healing response. Erickson also
recommended bone cutting speed of less than 2000 rpm and tapping at
a speed of 15 rpm with irrigation.
Hence, the surgical preparation sequences as well as the instruments
depend upon the quality of the bone as shown in the diagram.
and
colleagues
(1998)
histologically
confirmed
2)
3)
The vertical bone loss around the fixtures should be less than 0.2 mm
per year after first year of implant loading.
4)
5)
The success rate of 85% at the end of 5 year and 80% at the end of 10
service.
BIBLIOGRAPHY :
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CONTENTS
INTRODUCTION
HISTORY OF OSSEOINTEGRATION
DEFINITIONS AND OTHER TERMINOLOGIES
MECHANISM OF OSSEOINTEGRATION
INFLAMMATORY PHASE
PROLIFERATIVE PHASE
MATURATIVE PHASE
FACTORS RESPONSIBLE FOR OSSEOINTEGRATION
MATERIAL BIOCOMPATIBILITY
IMPLANT DESIGN : MACRO STRUCTURE
IMPLANT SURFACE : MICRO STRUCTURE
STATE OF HOST BED
SURGICAL CONSIDERATIONS
LOADING CONDITIONS
CLINICAL EVALUATION OF OSSEOINTEGRATION
SCOPE OF OSSEOINTEGRATION
CONCLUSION
REFERENCES
DEPARTMENT OF PROSTHODONTICS
INCLUDING CROWN AND BRIDGE
COLLEGE OF DENTAL SCIENCES
DAVANGERE
SEMINAR ON
OSSEOINTEGRATION
Presented By
DR. NITIN GAUTAM
(2001 2002)