Summaries of Dental Implant Research PDF

Vol.18 / No.
1 Jul-Aug 2009
Dental Implant
Summaries
and related areas of research
18/1
www.dentalsummaries.com
Dental Implant Summaries

1 A randomized prospective
multicenter trial evaluating

the platform-switching
technique for the prevention
of postrestorative crestal bone
loss
Int. Journal of Oral and
Maxillofacial Implants June 2009.
Prosper L, Radaelli S, Pasi M.
Zarone F, Radaelli G, Gherlone E.
4 The possible association among
bone density values, resonance

frequency measurements, tactile
sense, and histomorphometric
evaluations of dental implant
osteotomy sites
Implant Dentistry August 2009.
Aksoy U, Eratalay K, Tozum T.
7 Biofilm on dental implants:

A review of the literature

Maxillofacial Implants August 2009.
Subramani K, Jung R, Molenderg A.
Hmmerle C.
2 Agreement of quantitative
subjective evaluation of
esthetic changes in implant
dentistry by patients and
practitioners
Maxillofacial Implants June 2009.
Esposito M, Grusovin M.
Worthington H.
5 A rough surface implant neck
with microthreads reduces the

amount of marginal bone loss:
A prospective study
Clinical Oral Implants Research
August 2009. Bratu E.
Tandlich M, Shapira L.
8 Randomized-controlled
clinical trial of customized

zirconia and titanium implant
abutments for single-tooth
implants in canine and
posterior regions
August 2009. Zembic A, Sailer I.
Jung R-E, Hammerle C.
10 Influence of the height of the

external hexagon and surface
treatment on fatigue life of
commercially pure titanium
dental implants

Gil F, Aparicio C, Manero J, Padrs A.
13 Bone quality assessment
based on cone beam computed

tomography imaging
August 2009. Hua Y, Nackaerts O.
Duyck O, Maes F, Jacobs R.
Managing Editors: Dr. Mark Atkinson, Dr. Michael Norton

Editorial Consultants: Dr. Koray Feran, Dr. Philip Friel
Dr. Stephen Jacobs, Dr. Zaki Kanaan, Dr. Kia Rezavandi,
Dr. Max Suleiman, Dr. Nadeem Zafar
Dental Implant Summaries (ISSN 0967-375X)
Produced bi-monthly by Specialist Dental Summaries Ltd,
104 Harley Street, London, W1G 7JD, United Kingdom.
Tel +44 (0)20 7935-8687, Fax +44 (0)20 7855-0282
Email dissales@dentalsummaries.com
11 Influence of early cover
screw exposure on crestal

bone loss around implants:
Intraindividual comparison
of bone level at exposed and
non-exposed implants
Journal of Periodontology
June 2009. Kim T-H, Lee D-W.
Kim C-K, Park K-H, Moon I-S.
14 Mechanical non-surgical
treatment of peri-implantitis:
A double blind randomized
longitudinal clinical study
Journal of Clinical Periodontology
July 2009. Renvert S, Samuelsson E.
Lindahl C, Persson G.
Vol. 18 / No. 1 Jul-Aug 2009
3 Load fatigue performance of

implant-ceramic abutment
combinations

Nguyen H, Tan K, Nicholls J.
6 Bone strain and interfacial
sliding analyses of platform

switching and implant
diameter on an immediately
loaded implant
July 2009. Hsu J-T, Fuh L-J.
Lin D-J, Shen Y-W, Huang H-L.
9 Is insertion torque correlated
to bone-implant contact
percentage in the early healing
period? A histological and
histomorphometrical evaluation of
17 human-retrieved implants
August 2009. Degidi M, Perrotti V.
Strocchi R, Piattelli A. Iezzi G.
12 Evaluation of nano-
technology-modified zirconia
oral implants: A study in
rabbits
July 2009. Lee J, Sieweke J.
Rodriguez N, Schpbach P.
Lindstrm H, Susin C, Wikesj U.
15 Extent of peri-implantitis
associated bone loss

April 2009. Fransson F, Wennstrom J.
Tomasi C, Berglundh T.
Specialist Dental Summaries Ltd 2008/09. All rights

reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying
or otherwise without written permission from Specialist
Dental Summaries Ltd.
Students receive 25% discount (please include verification

with order).
Subscription rates for Vol.18, 2009 - Jul 2010

UK: GBP 90, Europe: EUR 120, Other: USD 160. Overseas
rates include Air Mail postage. The rate is for 6 issues
payable in advance and includes access to online edition.
While every effort is made to ensure correctness of all

summarised material, no responsibility can be accepted for
accuracy and readers should consult the original articles
on matters of importance.
Back issues GBP 18 or USD 35 per copy (subject to

availability).
Register online at www.dentalsummaries.com
Prosper L.
Redaelli S.
Pasi M.
Zarone F.
Radaelli G.
Gherlone E.
June 2009
Maxillofacial Implants
Vol.24 No.2 pp299-308
Correspondence to:
Prof. Loris Prosper
Via San Gottardo 84
20152 Monza
Milan
ITALY
A randomized prospective multicenter trial evaluating the

platform-switching technique for the prevention of
postrestorative crestal bone loss
Crestal bone loss (CBL) has been an established criterion for long-term implant success.
Several etiological factors have been proposed for CBL such as: surgical trauma, abnormal
occlusal loading, implant-abutment junction variations, bacterial colonization, biologic
width issues and host response to changes in bacterial flora. Conventionally, implants have
been restored with matching diameter abutments with studies showing CBL of up to 2mm,
after the first year of function. Use of the platform switching concept has increased over the
years, with some implants incorporating this in their design. Although there have been some
studies showing favorable bone level changes around platform switched implants, there is
still a need for prospective studies to evaluate this phenomenon more objectively.
This study, therefore aimed to establish whether implants placed posteriorly with an
enlarged platform (EP) results in reduced CBL when compared to standard diameter
implants using the conventional submerged (CS) protocol, the conventional non-submerged
(CNS) protocol and submerged implants with a platform-switched abutment design (SPS).
MaterialandMethods78 patients were enrolled in this multicenter, randomized

prospective study. Main inclusion criteria included: type 2 or 3 bone, non-smokers, good
oral hygiene with no periodontal disease and no clenching or bruxing habit. Microtextured
surface implants were used (Sandblasted and acid-etched, Winxix Ltd. London).
Nonsubmerged implants had machined collars, whereas the submerged implants were
microtextured up to and including the neck. Standard implants had diameters of 3.3, 3.8
and 4.5mm and were slightly conical with spiral coils reducing in depth towards the implant
neck resulting in an almost parallel implant. The EP implants were more conical, with a
similar progressive coil design and implant widths of 3.3, 3.8 and 4.5mm but the implant
necks were 3.8, 4.5 and 5.2mm respectively, with a centralized abutment junction. Both
types of implant were randomly assigned to each group (CS, CNS and SPS). Bone quality
was assessed by 2 to 4 examiners until agreement was reached. Patients were excluded if
agreement was less than 50%, or included type 4 bone. Implants were restored after 3months
in the mandible and 6 months in the maxilla and were assessed at insertion and followed up
annually for 2 years with standard clinical and radiographic assessments. Statistical tests
were utilized to determine the influence of age, sex, treatment protocol and any confounding
variables, both within and between groups. Data was grouped according to CBL values as
follows: < 0mm, 0.1-0.5mm, 0.6-1.0mm, 1.1-1.5mm and > 1.6mm.
ResultsOf the 78 patients recruited, only 68 were included in the study. A further 6
The control implant (3.8mm)

on the left was compared to
a platform enlarged implant
4.5mm/3.8mm on the right
patients experienced implant failures and another 2 withdrew, with their results being
excluded from the analyses. Therefore, 60 patients with 360 implants were included in the
data. 100% of EP implants in the CS and SPS groups exhibited no bone loss over 2 years
compared with 92% in the CNS group (P=0.007). Standard diameter implants in all groups
exhibited more CBL than EP implants, with significant differences for CS and CNS groups
(P=.0006). However, only small increases in CBL were seen for the standard implants in the
SPS group (6.7% > 0 < 1.0mm), which was not significant, but this was significantly different
when compared to standard implants in the other 2 groups (p<0.0001). No other factors
demonstrated any significant influence.
DiscussionandConclusionThere are several factors that have been shown to maintain

crestal bone, and platform switching is one such factor, and this study corroborates this
view demonstrating that it plays an important role in maintenance of crestal bone particularly
for standard diameter implants. It can also be concluded that the use of an enlarged platform
implant had a beneficial effect on maintenance of crestal bone levels irrespective of whether
a one or two stage protocol was utilized and that it further enhanced the effects of platform
switching. Additional studies are needed to evaluate long term results of platform switching
under various conditions.
Dental Implant Summaries, Specialist Dental Summaries www.dentalsummaries.com
Vol.18/ No.1 Jul-Aug 2009
Esposito M.
Grusovin M.
Worthington H.
June 2009
Vol.24 No.2 pp309-315
Correspondence to:
Prof. Marco Esposito
Dept. of Oral and
Maxillofacial Surgery,
University of Manchester
Higher Cambridge Street
Manchester
M15 6FH
UK
Agreement of quantitative subjective evaluation of

esthetic changes in implant dentistry by patients and
practitioners
The ultimate goal of implant therapy is not only to provide function but to also have the best
esthetic outcome. Several techniques have been suggested to improve implant esthetics
ranging from simple gingival grafting to more complex grafting involving hard tissues.
Unfortunately, very few trials have evaluated the esthetic outcome of implant treatment
from both a patient and dentist perspective. One objective method of assessment was the
Jemt Index or Papillary Score that was modified by others and formed the basis of many
studies. Newer indices (the implant crown aesthetic index, the pink esthetic score and the
California Dental Association criteria) have been developed, with varying degrees of
reliability and ease of use. The current study aimed to determine the reliability of a subjective
quantitative method of assessing esthetic changes after implant therapy, from a patient and
clinician viewpoint. It also set out to determine whether a similarity existed between the
perception of esthetics between clinicians and patients.
MaterialandMethodsPre- and post-operative photos of 32 partially edentulous patients

were selected. Although a good esthetic outcome was achieved with most patients, cases
varied in the final result from poor to good, allowing discrimination between cases. Photos
were standardized as much as possible and included the full smile and close up views of the
treated area, giving 4 photos for each patient. Written instruction was given to 10 clinicians
and 30 patients who then assessed all photos. The remaining 2 patients acted as the test
sample. Photos were assessed in the same order by everyone and repeated 14 days or more
later. The tasks included: 1. Identifying the pre-treatment photo, 2. Rating treatment
outcome on a (VAS) visual analogue scale (from 1=poor to 10=excellent), 3. Rating the
perception of esthetics on an ordinal scale (0=poor to 4=excellent), 4. Deciding whether the
observer was pleased with the outcome. Data was subject to statistical analysis.
ResultsFor distant smile photos, patients correctly identified preoperative photos in 83%
It was found in this study that

patients and practitioners saw
the esthetic qualities of their
treatment quite differently
of cases initially but this went up to 90% at the follow up test. For the close up photos correct
identification occurred for 83% at both tests. Clinicians fared better with the overall smile
readings of 87-100% initially and 83-100% at the second test. Two clinicians identified all
photos correctly, on both occasions. When intra-observer agreements were looked at, both
on the VAS scale and categorical (kappa) scale, there was slight agreement for 3 clinicians,
fair agreement for 5 clinicians, moderate for 1 clinician and substantial for 1 clinician. For
close up photos, the readings were 87-97% initially and 90-100% at second test. One clinician
gave slight agreement, 5 were fair, 2 were moderate and 2 were substantial. Poor patientpractitioner agreement as well as poor agreement between practitioners was observed on all
levels. The overall Kappa values for comparison between clinicians were poor for magnified
and distant photos. Both patients and clinicians gave very high esthetic satisfaction ratings
for all before and after photos preventing a meaningful kappa statistic to be ascertained.
DiscussionandConclusionThis study is in agreement with previous studies which

show that patients give better ratings for the esthetics than clinicians. Due to the nature of
subjective analyses, it is difficult to determine which group is more accurate in their
judgments. However, it is clear that the parameters that clinicians consider important (soft
tissues, contralateral teeth and gingival height variations) may not be important to the
patient. This suggests that the patient may be better placed to give their subjective opinion
in such studies. It was also notable that using the smile images was more reliable than the
close-up images, possibly due to the fact that the overall smile is what can be seen in everyday
situations. Although patients were generally in agreement, they only assessed their own
photos. In contrast, there was less agreement between clinicians but this may have been due
to them assessing photos of all patients. In conclusion, this study showed that clinician and
patient agreement was poor indicating that they perceive esthetics quite differently.
Nguyen H.
Tan K.
Nicholls J.
August 2009
Vol.24 No.4 pp636-646
Correspondence to:
Dr. Keson B. Tan
Department of Restorative
Dentistry,
Faculty of Dentistry
National University of
Singapore,
5 Lower Kent Ridge Road
Singapore 119074
REPUBLIC OF SINGAPORE
Load fatigue performance of implant-ceramic abutment

combinations
In pursuit of enhanced esthetic outcomes in implant therapy there has been an increase in
the use of ceramic abutments to avoid grey shine-through in the peri-implant tissues.
Densely sintered yttrium-stabilized zirconium dioxide (Y-TZP) abutments have the
advantage of being tooth colored, biocompatible, and compared to alumina exhibit high
strength and chemical resistance. Disadvantages include brittleness under tensile forces.
While previous studies have shown that zirconia abutments were twice as resistant to
fracture as alumina abutments, they have not been subjected to rotational load testing. This
in-vitro study aimed to determine the load-fatigue performance of 4 implant systems and
their respective zirconia abutments.
MaterialandMethodsThe 4 implant systems with their corresponding zirconia

abutments tested were: 1. Replace Select internal-connection (Nobel Biocare); 2. Brnemark
Mark III external-connection (Nobel Biocare); 3. Osseotite NT external connection (3i) and
4. Osseotite NT Certain internal-connection (3i). Diameters ranged from narrow (3.3mm,
3.5mm), regular (4.0mm, 4.3mm) and wide (5.0mm) for Nobel Biocare implants and 4.1mm
and 5.0mm for 3i implants. This resulted in 10 groups, with 5 samples in each. Procera
Zirconia abutments (Nobel Biocare) were standardized to match those of the preformed
ZiReal Osseotite (3i) abutments.
Implants were secured in the test apparatus and their respective abutments secured to
the recommended torque value. A customized brass crown was also cemented to each
abutment (Panavia F). Fatigue testing was carried out at 45 to the long axis of the sample
with a 21N load at 10Hz. All samples were checked for concentricity during cyclic loading
with a limit of 5 million cycles. Light and scanning electron microscopy was used to analyze
the fractured surfaces. Two way analysis of variance (ANOVA) was used, with the system
and diameter being the independent variables and the number of fatigue cycles to failure
the dependent variable. Significant subsets in the 10 test groups were determined by oneway ANOVA and Tukey highly significant difference (HSD) post-hoc test at p<0.05.
Results58% of all samples failed with 36% exhibiting abutment fracture. No failures were
recorded for any of the 5.0mm diameter 3i samples or for one 4.1mm 3i sample. Screw
fracture featured in all samples except the wide diameter implants from all systems. Overall
there were 7 implant fractures in narrow and regular platform Replace Select, as well as 4.1
diameter Osseotite NT implants. There were significant differences between implant
diameters but not between implant systems.
DiscussionandConclusionImplant fractures were seen at the thinnest part of the
Four implants and their

respective zirconia abutments
were subjected to rotational
load testing to examine
comparative performance
internal tri-channel of 5 Replace Select implants. This concurs with other finite element
analysis studies. Interestingly when abutment screw fracture occurred these were at the
first thread for all samples, with scratches indicating screw loosening prior to failure. Screw
loosening was also observed in the Brnemark group prior to fracture, but the most common
cause of failure was abutment fracture. There were 2 gold screw fractures in the Osseotite
NT group and one combined implant and screw fracture. Again implant fracture also
occurred at the thinnest aspect of the internal thread. Osseotite Certain implants also
exhibited abutment and screw fractures as well as separation of the titanium insert from the
zirconia abutment. It was notable that there was no damage to the zirconia/abutment
interface when there was a titanium insert. Three zirconia abutments failed after
comparatively few cycles suggesting that there were pre-existing cracks. The failure rate in
this study was 58%. Previous studies on titanium abutments using similar testing methods
yielded failure rates of 20% and 30%. Data from the current study indicates that zirconia
abutments are more prone to failure than their metal counterparts particularly on narrow
and regular diameter implants, suggesting that their performance may be dependent on
abutment dimensions and design characteristics.
Aksoy U.
Eratalay K.
Tozum T.
August 2009
Implant Dentistry
Vol.18 No.4 pp316-21
Reprint requests to:
Dr. T. Tozum
Dept. of Periodontology
Faculty of Dentistry
Hacettepe University
Sihhiye, TR-06100
Ankara
TURKEY
The possible association among bone density values, resonance

frequency measurements, tactile sense, and histomorphometric
evaluations of dental implant osteotomy sites: A preliminary study
The ability to determine bone quality (density) in a quantitative manner, prior to, or at the
time of implant placement is considered useful as a prognostic indicator for implant success.
CT scans provide quantifiable bone density measurements which may relate to actual bone
quality found at the time of surgery using non-invasive techniques such as tactile sense,
insertion torque and resonance frequency analysis (RFA). A more specific analysis would be
achieved using histology to determine the actual percentage of trabecular bone by volume
(TBV) in the region where the implant is to be placed. If this measurement could be shown
to correlate to CT or to other non-invasive analyses then it might be possible to predict
outcome in relation to bone density. Consequently, this preliminary clinical study was
carried out in order to determine if a relationship exists between CT values, histological
TBV, tactile measurements, and stability measurements using RFA.
MaterialandMethods10 healthy, non-smoking patients received a total of 11 posterior

mandibular and 12 posterior maxillary implants. All patients had a basic clinical and
conventional radiographic examination followed by a CT scan for pre-operative planning. A
measurement in Hounsfield units (HU) was made to give a value of bone density at each of
the proposed implant sites as indicated by markers placed into custom scanning guides.
The implants (SwissPlus, Zimmer Dental, Carlsbad, CA) were inserted via a crestal
incision. At the time of placement an initial trephine bur 2mm x 5mm was used to remove a
core biopsy. At the same time a measurement of tactile sensation was made according to the
Misch classification for bone quality (D1 to D4). After implant insertion RFA was performed
(Osstell Mentor, probe version 2, Sweden) to evaluate the implant stability quotient (ISQ)
for each of the 23 implants. Thereafter, a healing abutment was placed and flaps sutured.
Patients were reviewed at 7-10 days and restorations placed after 6 months.
Biopsies were prepared for histomorphometric evaluation of TBV, which represented
the percentage of trabecular bone present in the area of the specimen. Statistical analysis
was carried out to assess the presence or absence of a correlation between CT values (HU),
RFA values, tactile sense and TBV using the Spearmans correlation coefficient.
ResultsAll implants were restored successfully. The average bone density from all the
sites was 554.87302.045 HU. The mean RFA and TBV were 72.286.194 ISQ and 41.017
12.552% respectively. While males had a higher mean CT value than females this was not
significant. Females had significantly higher RFA values (P=0.011) than males but
significantly lower TBV values (P=0.008). Maxillary sites yielded significantly lower CT
values (P=0.046) compared with mandibular sites, and although not significant, the TBV
values in the mandible were higher than those in the maxilla. Yet RFA values were lower in
the mandible compared to the maxilla. The only significant correlation found for all implants
in all patients was between tactile sensation and CT values (r=-0.52, P=0.009). Analysis by
gender revealed that male subjects showed correlation between RFA and tactile sensation
(r=-0.53, P=0.042), while females showed correlation between CT values and TBV (r=0.810,
P=0.015), and between RFA (r=0.807, P=0.015) and tactile sense (r=-0.756, r=0.030).
DiscussionandConclusionBone quality classifications have given practitioners the
ability to make assessments at the time of surgery. However, the use of CT measurements
has been proposed as providing a pre-operative evaluation which is directly related to
histological values for bone density and non-invasive tactile measurements. While some
correlations were evident, this study, as with previous studies, was unable to demonstrate a
correlation between ISQ and CT values. As the surgeon in the present study was experienced
a correlation was shown between tactile sensation and CT values. However, a correlation
between CT and TBV was only apparent in females. An important limitation which may
affect the significance was the small sample making it clear that further studies with larger
sample sizes are required.
Bratu E.
Tandlich M.
Shapira L.
August 2009
Clinical Oral Implants
Research
Vol.20 No.8 pp827-832
Dr. L. Shapira
Faculty of Dental Medicine
Hadassah Medical Centre
PO Box 12272
Jerusalem
ISRAEL
A rough surface implant neck with microthreads reduces

the amount of marginal bone loss: A prospective study
All implants display some degree of marginal bone remodeling (MBR) after insertion. This
tends to occur in 2 phases, early (after uncovery and abutment connection) and late (during
the rest of the life of the implant). The latter is regarded as having an inflammatory and
possibly overloading etiology. Early MBR is attributed to re-establishment of the biologic
width apical to the implant / abutment connection and can be influenced to a certain extent
by implant design. Machined implant necks tend to exacerbate MBR whereas roughened
and micro-threaded necks tend to retain more bone over time. The objective of this study
was to compare MBR in two similarly designed tapered implant systems and compare MBR
and the initial stability of the implants due to the thread design and the influence this may
have on MBR during early implant function.
MaterialandMethodsTwo tapered, threaded implant designs from the same company

(MIS-Implants Inc., Israel) were used. One had a 1mm polished collar (P) and one a
microthreaded moderately rough collar (M). Implant dimensions were identical though
threads patterns varied. One of each implant matched for identical size (10 or 11.5mm length
and 3.75 or 4.2mm ) was inserted as a pair (P mesially and M distally) utilizing a two-stage
standardized protocol in to the posterior mandibles of 48 patients (ages 23 - 65) seeking
replacement of missing posterior teeth. Thus 48 pairs of implants were inserted with 8
patients receiving bilateral pairs but only having one side analyzed. All implants were
inserted to depth such that the necks of the implants were placed at the bone crest. A
PerioTest (Medizintechnik Gulden) reading (PTR) was used to assess stability at implant
insertion and at prosthetic connection after 4 months. MBR was measured on dental
panoramic tomograms at baseline (prosthesis connection), and after 6 and 12 months of
functional loading, using the shoulder of the implant as a reference and a baseline value of
zero since the shoulder was leveled with the bone crest. Any occurrence of premature
dehiscence during healing was noted but not treated further. All prosthetic treatment was
carried out after the same time period (4 months) using a cemented crown over a standard
milled abutment. MBR was evaluated as the primary variable, while PTR values, incidence
of premature exposure and associated bone loss were secondary variables. MBR around
each implant at each time point and PTR results were subjected to statistical analysis with
significance set at P=0.05.
Results2 patients were lost to follow up and thus only 46 pairs of implants in 46 patients
were analyzed. Dehiscences during healing occurred in both groups (P: n=8, M: n=4) but all
implants osseointegrated. All implants lost statistically significant amounts of marginal
The implant on the left had
bone (P<0.05) with more loss evident in the first 6 months of function. The comparative
a 1mm polished collar and
values of MBR (mm SD) for P and M groups were 0.77 (0.46) and 0.21 (0.19) at 4 months,
no micro-grooves. This was
compared to an implant on the 1.2 (0.44) and 0.56 (0.23) at 6 months and 1.47 (0.4) and 0.69 (0.25) at 1 year respectively.
right with the same surface
The P group lost significantly more bone than the M group (p<0.05). Dehiscence led to a
treatment but with microgrooves and no polished collar statistically significantly increase in MBR in the P group (P<0.05) but had no impact on the
M group of implants at any time in the study. PTR values improved for both groups between
insertion and final readings (P<0.001) but were significantly better (more negative) in the
M group. There was no correlation between size of implant and PTR value.
DiscussionandConclusionIn the current study, implants that varied in their neck
design and surface topography exhibited statistically significant differences in the degree of
marginal bone remodeling after abutment connection and up to one year in function. Since
the chemical composition and neck dimensions of the implant pairs in each site were
identical, this study supports previous investigations that show that polished implant collars
are less successful at retaining marginal bone than roughened collars. However, this study
could not determine whether the surface roughness or the microthread design enabled
better bone retention in the M group, and this warrants further investigation.
Bone strain and interfacial sliding analyses of platform

switching and implant diameter on an immediately loaded
implant: Experimental and 3-D finite element analyses
Hsu J-T.
Fuh L-J.
Lin D-J.
Shen Y-W.
Huang H-L.
July 2009
The effect of platform switching and varying implant diameter on the stresses transmitted
to bone during immediate loading are largely uninvestigated. This study uses a combination
of load testing on standardized lithographic models and 3-D finite element analysis (FEA)
to compare effects on bone strain at the implant-bone interface (IBI) of varing implant
diameters and platform switching (PS).
Vol.80 No.7 pp1125-1132
MaterialandMethodsData from a CT scan of an edentulous mandible from a dried

Dr. Heng-Li Huang
School of Dentistry
China Medical University
91 Hsueh-Shih Road
404 Taichung
TAIWAN
skull was used to construct 5 standardized resin impregnated powder models of the premolar
and molar regions using rapid prototyping stereolithographic techniques. The models and
implants were tested to determine mechanical properties for FEA. One implant (13mm
long, external hex ICE, 3i Biomet) was inserted into each model. The implants were either
3.75mm or 5mm diameter and were passively screwed into the models (SC) or cemented
with cynoacrylate (CA) to represent either an immediately placed implant or an
osseointegrated implant respectively. An abutment of either 4mm or 5mm was then
attached to each implant to give 5 samples with (PS) or without a platform switch (NPS): A:
3.75/SC/NPS; B: 5.0/SC/PS; C: 5 /SC/NPS; D: 5/CA/PS and E: 5/CA/NPS. A custom jig in
a universal testing machine (JSU-H1000, Japan Instrumentation Systems) was used to
vertically and obliquely (45 buccal to lingual) load each abutment with 130N at 1mm/min.
Peak tensile and compressive bone strains were recorded with rosette strain gauges cemented
to the buccal and lingual aspects of each sample. Each reading was taken 3 times and
analyzed using standardized software. A frictional coefficient of 0.6 was used to simulate
sticking and sliding friction between implant and bone in the immediate loading scenario.
Implant and bone nodes were merged to simulate osseointegration in the integrated implant
scenario. The lingual and lower borders of the mandible were regarded as fixed.
ResultsThere were no significant differences (p>0.05) noted in bone strain values
Vertical and lateral loading

forces were examined on FE
models in order to compare
standard and wide body
implants with platform
switching on the latter as
shown above
between models with and without PS. Bone strains were higher in A, B and C compared to
D and E and these were concentrated mainly on the lingual aspect of each implant. Peak
compressive strain values exceeded peak tensile strain values in magnitude. Peak compressive
strain values under vertical and oblique loads were 7% and 8.3% lower respectively in B
when compared to A. C exhibited a 90% increase in bone strain under vertical load when
compared to A but a 48.3% reduction under lateral loading. FEA showed that C had 28.5%
and 30.8% higher compressive and tensile strains under vertical loading when compared to
D and E respectively, and a 54% higher compressive strain under oblique loading. PS did
not influence peak bone strains under vertical loading. Compressive strains for B & D (PS
samples) were 9% and 5% lower than those for C and E (NPS samples). Bone strain under
vertical and oblique loading for B and C (5mm implant) was 26.1% and 28.4% lower
respectively when compared to A (3.75mm implant). Sliding and gap distances varied by
less than 3m between A, B and C.
PS led to concentration of stress in the abutment/external hex interface but bone strain
distribution did not differ significantly between PS samples and NPS samples.
DiscussionandConclusionWithin the constraints of this study (static load and

relatively homogeneous materials), the data suggest that a wider diameter implant reduces
crestal bone strain. Most strain in the immediate loading model is seen where implant to
bone contact occurs directly and is minimal in areas of no contact. It is speculated that this
may lead to overload or atrophic resorption respectively though more clinical data is
required. Micromovement of <3m is well below the 50-150m of movement traditionally
quoted as being necessary for prevention of integration. PS leads to a small but insignificant
reduction of <10% in crestal bone strain. Peak compressive and tensile strains in bone are
higher in immediately loaded implants than in integrated implants. However, PS does not
significantly influence crestal bone strain or micromovement.
Subramani K.
Jung R.
Molenderg A.
Hmmerle C.
August 2009
Vol.24. No.4 pp616-626
Correspondence to:
Dr. K. Subramani
Department of Fixed and
Removable Prosthodontics,
Dental Material Science
Center for Dental and
Oral Medicine and CranioMaxillofacial Surgery,
University of Zurich
Zurich
SWITZERLAND
Biofilm formation on different

implant surfaces and implant
designs was compared in this
literature review
Biofilm on dental implants: A review of the literature
Oral biofilms that form on transmucosal implant components are composed of a complex
microbial flora that is supported by an extracellular matrix of bacterial and salivary origin.
Their presence can lead to inflammation of the marginal tissues that may ultimately result
in peri-implantitis and bone loss. The purpose of the present review article was to discuss
biofilm formation on dental implant surfaces and the influence of surface characteristics,
material, and design of implants and abutments on biofilm formation and its sequelae.
MaterialandMethodsA MEDLINE literature search was performed of studies published

over a 40 year period up to 2007. Fifty three in vitro and in vivo articles were identified.
These included studies on biofilm formation on teeth and implants, as well as the effect of
implant and abutment design, and the influence of implant surface characteristics on biofilm
formation. Since these articles were mostly descriptive it was not possible to perform a
comprehensive meta-analysis on this topic.
ResultsBiofilm formation on teeth and implants follows the same initiation and maturation
process, the difference being that the surface properties of implants have an impact on early
microbial adhesion. The early bacterial colonizers, namely streptococci give way to a diverse
flora of gram-ve anaerobes and filamentous species which form over a 24 week period.
Hence, the initial colonizers provide a favorable environment for the growth of
periodontopathic microorganisms that can lead to periodontitis and peri-implantitis. A
number of in vitro and in vivo studies have confirmed that surface roughness of the implant
encourages bacterial attachment. It has been reported that titanium with a low roughness
average of (Ra)0.088m strongly inhibits plaque accumulation and maturation after 24
hours. By contrast titanium surfaces that are hydrophobic, due to the adhesion of impurities
following repeated dry sterilization, are more readily colonized. Hard coating implants with
titanium or zirconium nitride can reduce bacterial adhesion. Furthermore, an increase in
surface free energy of implants and abutments together with surface physicochemical
characteristics of the colonizing bacteria also affects the rate of biofilm formation.
In addition to the above, rough abutments and over contoured restorations can lead to
increased plaque accumulation. In fact rough abutments have been reported to harbour 25
times more sub-gingival bacteria than pristine abutments. However, reducing roughness
below a threshold Ra of 0.2m has not been shown to have an impact on biofilm formation
in the long-term. Furthermore it has been reported that a higher prevalence of anaerobic
bacteria is associated with cement-retained prostheses compared with screw-retained
prostheses. The presence of a microgap at the implant-abutment junction is also known to
be associated with bacterial colonization and has been implicated as a risk factor for bone
loss. There are conflicting data regarding the bacteriostatic effect of titanium on oral
microflora, however, some data has been presented supporting the antimicrobial properties
of titanium oxide which forms on implant surfaces in vivo. This has been shown to lead to
reduced staphylococcal colonization and increased osteoblast adhesion. Silver-coated
titanium surfaces have also been examined showing antimicrobial activity without any
adverse effects on osteoblast and epithelial cells, as has a vancomycin-modified titanium
surface, which has been shown to limit bacterial colonization in vitro and to be stable.
DiscussionandConclusionThis literature review suggests that rough implant and

abutment surfaces increase bacterial adhesion and speed of biofilm formation as well as
sheltering bacteria against shear forces in the oral environment. In addition the presence of
a microgap and over contouring of restorations aids biofilm formation. Therefore optimizing
implant abutment design as well as provision of easily cleansable restorations would reduce
the likelihood of plaque accumulation. Although some data on silver and vancomycinmodified surfaces in available, the effects of these in vivo on osteoblasts and cells from the
periodontium is unclear and requires further investigation.
Zembic A.
Sailer I.
Jung R-E.
Hammerle C.
August 2009
Research
Vol.20 No.8 pp802-808
Correspondence to:
Dr. Irina Sailer
Department of Fixed and
Removable Prosthodontics,
Dental Materials Science
Center for Dental and Oral
Medicine,
University of Zurich
Plattenstr. 11
8032 Zurich
SWITZERLAND
Randomized-controlled clinical trial of customized

zirconia and titanium implant abutments for single-tooth
implants in canine and posterior regions: 3-year results
Titanium and ceramic abutments are commonly used today. Titanium (Ti) is resistant to
distortion and works well in all areas of the mouth. Despite titaniums colour, which can
cause a greyish discoloration of the gingival tissues, it is generally considered to be the goldstandard for implant-borne reconstructions. More recently high strength ceramics such as
alumina and zirconia have been used in the esthetic zone but there remains concern over
their brittleness. The aim of this study was to assess the survival and complication rates
between CAD/CAM customized zirconia (Zr) and titanium abutments (Procera, Nobel
Biocare) in the canine and posterior regions of the mouth.
MaterialandMethods22 patients treated with 40 implants (Brnemark RP, Nobel

Biocare) for replacement of missing canines, premolars and molars, were randomly assigned
to either a test group (TG: zirconia abutments + Procera All-Ceramic Crowns, ACC) or
control group (CG: titanium abutments + Metal Ceramic Crowns, MCC). Implants were
placed using a 2-stage protocol with abutments connected 4-6 months after surgery and
torqued to 32Ncm. The test group (n=20) consisted of 17 ACC and 1 MCC cemented onto the
Zr abutments, and 2 screw-retained ACC crowns. The control group consisted of 20 Ti
abutments with cemented MCC crowns. Resin (Panavia 21, Kuraray; Rely X, 3M ESPE) and
glass ionomer (Ketac Cem, 3M ESPE) cements were used. Clinical and radiographic
examinations were carried out at crown insertion and at 6, 12, and 36 months post-loading.
Clinical examination involved assessment for material fractures of abutments or crowns,
abutment screw loosening/fracture, break of cement seal, or chipping of ceramic; in addition
a biological examination to assess probing depths (PD), plaque retention (PR) and bleeding
on probing (BOP) at 4 points around each implant and control teeth was undertaken. Mesial
and distal marginal bone levels (MBL) were also recorded from digitized radiographs by 2
independent examiners. Finally an esthetic examination was performed using a spectrometer
(Spectroshade, MHT, Switzerland) to assess the colour of gingiva 1 mm below the gingival
margin. Soft-tissue thickness (using a size 20 endodontic file with a stopper) and the height
of the papilla (mesially and distally) were also recorded. The data was analyzed using Student
unpaired t-tests and Mann Whitney rank tests at 95% confidence levels.
Results18 patients with 18 test and 10 control abutments were followed up to 36 months.
There were no cases of de-cementation, screw loosening, or fractured abutments, however,
2 MCCs in the control group exhibited minor chipping. Clinical parameters for both groups
were very similar to each other and also to natural teeth, although the PD values were higher
at the implants. There was little change in MBLs over the 3-year period for either group and
the color evaluation revealed no significant difference between the test and control groups
(EZr=9; ETi=7), although both materials induced a visible colour change compared to
The clinical performance
natural teeth. Furthermore, no significant differences were found between soft-tissue
of single-tooth CAD/CAM
designed zirconia and titanium thickness or papilla height between groups, although the soft-tissue thickness around the
abutments was compared over implants (~1.80.7mm) was greater than at teeth (~1.50.9mm).
a 3-year period
DiscussionandConclusionResults demonstrate that there were no complications for

either Zr or Ti abutments, over a 3-year period. Only minor chipping of the MCCs was found
on Ti abutments. This study exhibited excellent results for Zr abutments (68% premolars,
18% molars), which is similar to previous studies. However, one must be cautious as it has
been shown that Zr can decrease its fracture toughness by 50% over longer periods of time
in a humid environment. The slightly worse value recorded for visible discoloration of the
gingiva with Zr abutments was surprising.
Screw loosening was not observed in the present study probably due to the exceptional
fit of both CAD/CAM abutments and the comparable biological parameters and esthetic
evaluation reinforce the absence of clear differences between these two abutment materials
over a 3-yerar period. More randomized studies are required.
Degidi M.
Perrotti V.
Strocchi R.
Piattelli A.
Iezzi G.
August 2009
Research
Vol.20 No.8 pp778-781
Correspondence to:
Prof. Adriano Piattelli
Via F. Sciucchi 63
66100 Chieti
ITALY
Is insertion torque correlated to bone-implant contact

percentage in the early healing period? A histological and
histomorphometrical evaluation of 17 human-retrieved implants
In areas of good bone quality and quantity, dental implants can expect to achieve high
primary stability. The primary stability of a dental implant has been proposed as a good
indicator for long term success and is related to bone structure and biomechanics, bone
density, percentage of bone to implant contact (%BIC), implant geometry, and surgical
technique. A stable implant in dense bone allows optimal distribution of any loads placed
upon the implant during the healing phase. Accurate histomorphometric assessment can be
used to assess the bone-implant interface and primary stability of implants, but requires
destructive, invasive implant removal and therefore cannot be used in clinical practice. An
established alternative method of assessing the primary stability of an implant is the peak
insertion torque (PIT). This study aimed to compare the values for PIT and the %BIC in
humans to determine the presence or absence of correlation.
MaterialandMethodsA retrospective evaluation of implants which had been placed

and retrieved from the posterior mandible for various reasons was undertaken. Reasons for
retrieval included psychoses, nerve damage, restorative complications and hygiene. All
implants (N=17) had a sand-blasted, acid etched surface, were self tapping and had been
placed according to the manufacturers instructions (Ankylos Plus and Xive, DentsplyFriadent; NanoTite, 3i; SLActive, Straumann). Various placement protocols were utilized
depending on the case requirements at the time of surgery and 7 of the implants had been
immediately loaded. The PIT value had been recorded for each implant and the value
recorded in the patients records. The implants were removed within an 8-week period of
placement using a 5mm trephine bur. Specimens were dehydrated, fixed, and sectioned
longitudinally to a thickness of 30m. Sections were stained with von Kossa and acid fuchsin
and one section stained with silver nitrate and basic fuchsin. Histomorphometric analysis of
%BIC was carried out under light microscopy using three slides for each implant and the
results assessed using a histomorphometry software package. Results were subject to
statistical analysis using the Friedman test at a level of p < 0.05 to assess correlation between
%BIC and PIT.
ResultsAll of the implants were osseointegrated and stable at the time of removal, with
no radiographic bone loss. Histological evaluation highlighted numerous cellular and
structural markers of bone repair, healing and turnover with no evidence of inflammatory
cell infiltrate, apical epithelial migration or dense connective tissue at the bone-implant
interface. Many marrow spaces were observed on the implant surface, where osteoid matrix
was evident. There was no statistically significant correlation between PIT and %BIC for
any of the implants, regardless of the time of implant retrieval.
DiscussionandConclusionThe benefits of high initial implant stability are well
documented, but the exact level of insertion torque necessary to effect an adequate degree
of primary stability remains undetermined and the principle mechanism of this early
stability is as yet unclear, but likely to be multifactorial. Despite numerous studies
investigating the factors thought to be responsible and recording these parameters using a
variety of techniques, a significant relationship between PIT and %BIC has yet to be
determined. Whilst the precise relationship between PIT and primary stability is as yet
undetermined, it is known that increasing PIT values correlate to increasing bone density
and quality; however, cadaver studies have demonstrated that the torque required for
implant insertion and removal may vary irrespective of bone mass or density. Considering
the likely multifactorial relationship between PIT and %BIC, the present study has many
limitations with respect to sample size, implant uniformity and removal time. Given the
importance of primary implant stability further controlled studies may be useful in
understanding the precise relationship between primary implant stability, PIT and %BIC.
10
Influence of the height of the external hexagon and

surface treatment on fatigue life of commercially pure
titanium dental implants
Gil F.
Aparicio C.
Manero J.
Padrs A.
August 2009
Dental implant fracture is a rare occurrence but can be catastrophic. The factors predisposing
to fracture can be classified into geometric design and the material properties of the implant,
where the goal will be to increase its fatigue resistance to prevent fracture in the implant
body and the external hexagon (HEX). Poor prosthesis fit, peri-implant bone loss and too
few implants for the required clinical situation are all factors that will contribute to increased
stress along the body of an implant, potentially leading to fracture, with the size of the HEX
having been shown to influence the mechanical stability of the restoration. In addition the
micro-geometry of the implant can also affect its fatigue resistance in that a rough surface
topography would seem more prone to generate small cracks at centers of stress concentration,
which could propagate through the implant leading to fracture. Logically it would seem that
rougher surfaces would induce more surface cracks, and the potential dilemma arises
because it has been established that these surfaces increase bone to implant contact and
enhance osseointegration. Therefore the aim of this study was to compare different HEX
heights and surface topographies of titanium implants on their fatigue resistance.

Vol.24 No.4 pp583-590
Correspondence to:
Dr. Francesco Gil
Department of Materials
Science and Metallurgical
Engineering,
ETSEIB Technical University
of Catalonia,
Av. Diagonal 647
08028 Barcelona
SPAIN
MaterialandMethods5 groups with 7 implants in each group were created. The first
three groups had an electropolished surface with HEX heights of 0.6mm, 1.2mm and 1.8mm
(EP1, EP2 and EP3 respectively), group 4 had the larger HEX height but with an acid etched
surface (AE3) and group 5 had a grit-blasted surface (GB3). Each implant was clamped at a
level of 3mm below the HEX, simulating the bone level with a degree of bone remodeling,
and an abutment connected at 25Ncm, immersed in artificial saliva and a cyclical force
applied at 10Hz between 10 and 225N at 30 to its long axis. The deformed/fractured
implants were examined by both scanning and transmission electron microscopy and an
analysis of variance with the multiple comparison Fisher test used to compare the groups
with regard to fatigue life and fracture resistance.
ResultsMean implant surface roughness measured 0.20m for EP<2.1m for AE<4.29m
for GB. The number of force cycles necessary to cause implant deformation/fracture differed
between the groups to a statistically significant degree with fatigue life ordered as follows:
EP1<EP2<AE3<EP3<GB3. The mode of failure also differed with the 0.6mm HEX causing
internal abutment screw fracture and shearing of the HEX, with the remaining groups
demonstrating fracture within the implant body. Appearance and propagation of cracks was
also of interest as the cracks were generally initiated on the surface of all the groups except
the GB3 surface, where the cracks were initiated 20m sub-surface.
DiscussionandConclusionThe tolerance of fit at the implant/abutment interface was
Various HEX heights were

tested under 30 deg loading
conditions until failure
consistent amongst the groups in this study which necessitates the identification of other
factors that might impact upon fatigue life. The fatigue life of the shorter HEX sizes was less
than half that for the 1.8mm HEX (p<.02), this being explained by the area of contact
between the implant and abutment which is proportional to the resistance to bending.
The grit blasted implants showed the longest fatigue life of all (p<0.0001). This is the
opposite of what was hypothesized. The explanation lies in the analysis of the surface cracks,
where all the groups, except GB3, had the cracks initiate at the surface, whereas cracks in
the GB3 group were at a depth of 20m. This is explained by the method of blasting where
the particles contact the surface and compress the metal. Cracks can only propagate from a
tensile state and therefore this compressive area increases the resistance to cracking. The
favorable osseointegration of acid etched implants as compared with smoother surfaces has
been well established, but this study showed that they would be more prone to fractures
under fatigue. It was shown that hydrogen from the acid solutions can diffuse into the
surface and form metal hydrides, which can also cause a greater degree of brittleness within
commercially pure titanium. In summary, greater HEX sizes will increase fracture resistance
of implants, especially when combined with a grit blasted surface.
11
Influence of early cover screw exposure on crestal bone

loss around implants: Intraindividual comparison of bone
level at exposed and non-exposed implants
Kim T-H.
Lee D-W.
Kim C-K.
Park K-H.
Moon I-S.
June 2009
Conventional placement of dental implants using a submerged (2-stage) or non-submerged

(1-stage) protocol creates an ideal environment for the development of osseointegration and
the maintenance of marginal bone tissues. In the submerged protocol oral hygiene measures
are unnecessary as the implant should not normally be exposed the oral environment and in
the case of non-submerged protocols the design of the permucosal abutment allows a strict
oral hygiene regimen to be implemented. However, where a previously submerged implant
becomes exposed spontaneously to the oral environment strict hygiene measures may not
be in place creating the risk of marginal bone loss through plaque mediated infection and
inflammation. Authors such as Adell et al. (1981), Toljanic et al. (1999) and Tal (1999) have
reported spontaneous exposure rates of between 5 and 15% for submerged implants.
The aim of this study was to evaluate the influence of spontaneous early exposure of
cover screws on crestal bone loss around dental implants.
Vol.80 No.6 pp933-939
Correspondence to:
Dr. Ik-Sang Moon
Gangam Severance Dental
Hospital,
College of Dentistry
Yonsei University
Seoul
KOREA
MaterialandMethodsA total of 781 implants were placed in 355 medically healthy

patients between 2000 and 2007. From this group it was found that 24 of them had
developed spontaneous exposure for 28 of their implants. In a sub-set of this group, 19
patients (14 male, 5 female; mean age 54, range 34 to 82) it was also possible to compare on
an intraindividual basis comparative bone loss between their exposed and their other nonexposed implants. All implants had been placed more than 3 months after tooth extraction.
Initial placement was at or below the bone crest and no augmentation materials were used.
No brushing was permitted post-surgery and all patients rinsed 2x daily with an antiseptic
mouth rinse until suture removal 10 days later. Mandibular implants were scheduled for
exposure 3 months post-placement and after 6 months for maxillary implants. All patients
were reviewed at 1, 3 and 7 weeks post-placement. Any implant that became spontaneously
exposed was immediately provided with a healing abutment. In all cases healing abutments
were placed without raising a flap via a mini crestal incision and patients were asked to
implement thorough hygiene maintenance. Final prostheses were placed 3 to 4 weeks after
the planned healing periods of 3 and 6 months.
Mean marginal bone levels were calculated from mesial and distal values collected from
digitized radiographs to an accuracy of 0.10mm. These measurements were made by a single
investigator whose results were subjected to calibration by an independant supervisor. All
data was subjected to statistical analysis with P value significance set at 0.05.
ResultsMean crestal bone loss for spontaneous/early exposed implants was 0.40
0.53mm (range -0.15 to 2.15mm) and for the non-exposed group was 0.180.26mm (range
-0.03-0.85mm). The difference between the groups was statistically significant (P=0.02).
Images showing a typical

example of a spontaneous
exposure before placement of a
healing abutment
DiscussionandConclusionThe additional crestal bone loss observed at spontaneously

exposed implants, it is suggested, was mainly due to continuous plaque and food debris
accumulation during the phase between occurrence and surgical placement of a cleansible
healing abutment. It was assumed in this study that there would be no differences in
marginal bone levels, however, it was found there was a considerable elapse of time before
the exposure was found and then treated with the placement of a healing abutment. During
this interval there was considerable potential for bone damage. Van Assche et al. (2008)
reported bone loss of 1.96mm compared to 0.49mm when early exposure of implants was
recorded. However, in their study unlike this one, no attempt was made to place the healing
abutments ahead of the planned healing interval.
A limitation of this study was that the exact period of time the cover screw was exposed
for was not known and in any case it would be unethical to deliberately leave such exposures
untreated. Animal studies with deliberate untreated exposure may shed light on the rate of
bone loss, however, on the basis of this study the authors recommend regular post-surgical
checks in order to minimise any deleterious impact of spontaneous exposure.
12
Evaluation of nano-technology-modified zirconia oral

implants: A study in rabbits
Lee J.
Sieweke J.
Rodriguez N.
Schpbach P.
Lindstrm H.
Susin C.
Wikesj U.
July 2009
The macro and micro-geometrical modifications of an implant surface are known to enhance
its osteoconductivity, important for early loading strategies. Recently, the application of
nanotechnology has been claimed to enhance these surface properties further.
One problem with the metallic implant materials currently used is that they can cause a
grey hue in the cervical gingival tissue, and this has led workers to begin looking at alternative
base materials to titanium, with the strength and bio-compatibility of zirconia being at the
forefront. The aim of this study was to combine nanotechnology with a zirconia implant, to
test osteoconductivity potential in the rabbit model.
Journal of Clinical
Periodontology
Vol.36 No.7 pp610-617
Correspondence to:
Dr. Jaebum Lee
Laboratory for Periodontal
and Facial Regeneration,
Department of Periodontics
and Oral Biology,
Medical College of Georgia
School of Dentistry
1120 15th Street AD 1432
Augusta
Georgia 30912
USA
MaterialandMethodsForty male adult New Zealand white rabbits received one implant
in each femoral condyle of their hind leg. Two test groups received a zirconia implant with
one of two surface modifications using nanotechnology. The control groups consisted of a
regular zirconia surface (ZiUnite, Nobel Biocare) and a titanium implant (TiUnite, Nobel
Biocare). The nanosurfaces were prepared with a calcium phosphate (CaP) coating, using
two differing methods (Zi/CaP1 and Zi/CaP2), while the zirconia control implant had a
pore-forming sintered surface (ZiC) and the titanium control implant had an anodized
microtextured surface (TiC).
The animals were anesthetized and implants placed in a standardized technique with 20
animals receiving Zi/CaP1 and Zi/CaP2, half of which were sacrificed at 3 weeks with the
remainder at 6 weeks. The control animals, receiving ZiC and TiC were also split into two
groups of ten, and were subject to the same healing times. The implants were all removed,
sectioned, stained and prepared for histometric analysis, with photomicrographs produced
using scanning electron microscopy. Statistical analysis of variance at a level of p<0.05, was
used to evaluate the bone density remote from the threads (BDRT), bone density inside the
threads (BDIT) and the percentage bone to implant contact (%BIC).
ResultsFour animals were excluded from the study and replaced for various reasons.
The %BIC of control group TiC (77%) was significantly better than both test groups Zi/
CaP1 (65%) and Zi/CaP2 (62%) at 3 weeks (p<0.05) but not significantly different to the ZiC
group (70%). There was no statistical difference between the ZiC and the two test nano
surfaces for %BIC but there were significant differences for both BDRT, BDIT (p<0.05). No
such differences were noted between the ZiC and TiC control groups.
At 6 weeks, there were no differences in %BIC, BDRT, BDIT, between any of the test or
control groups.
DiscussionandConclusionFrom a histometric viewpoint, all surfaces used in this

study demonstrated high levels of osseointegration in a rabbit model, where the 3 and
6-week healing times would correlate to early and conventional loading in humans.
The test Zirconia implants used
Due to the difficulty in sectioning and preparing zirconia, backscatter scanning electron
in this study were prepared
microscopy has been shown to be an effective alternative to histometric analysis and hence
with a CaP nano-layer coating
a combination of both was used in this study.
CaP nanotechnology has been shown to accelerate bone healing and it is hypothesized
that the CaP nano-coating used on the test implants in this study has not significantly altered
the surface texture, but just changed the composition of the zirconium surface, leading to a
lower risk of the problems previously observed with CaP on titanium implants, where
detachment from the implant surface led to failure.
Zirconia as an implant surface, shows good osteoconductive properties, is biocompatible,
mechanically strong and shows reduced microbial colonization. It shows a high level of
osseointegration. However, the current study shows that the addition of CaP nanotechnology does not seem to enhance the osteoconductivity of the test zirconia surfaces over
conventional zirconia or titanium surfaces.
13
Bone quality assessment based on cone beam computed

tomography imaging
Hua Y.
Nackaerts O.
Duyck O.
Maes F.
Jacobs R.
August 2009
Low bone quality has been identified as one of the potential factors related to biological
failure of implants. Osteoporosis can be an etiological factor in low or reduced bone quality.
From a clinical viewpoint, spiral 3D CT scans can be used to provide Hounsfield units (HU)
for regions of interest as a way of assessing bone mineral density. Fractal analysis, an
approach using texture, can be used to determine fractal dimension (FD) and this has been
shown to be useful in comparing normal and osteoporotic bone. Currently, the use of cone
beam computed tomography (CBCT) has increased with widespread use in dentomaxillofacial
radiology. CBCT does however, have certain limitations that can affect bone quality
assessment. Technical constraints of image datasets exist and CBCT data can be associated
with larger amounts of scattered x-rays that can increase the noise in reconstructed images.
It is also know that beam hardening in CBCT is a phenomenon that can affect the relative
HU values for soft and hard tissues. As a result, measuring HU may not be an ideal method
to assess bone mineral density when CBCT is used. The aim of the current study was to
assess the validity of other parameters such as fractal analysis or morphometry as indicators
of bone quality assessment.

Research
Vol.20 No.8 pp767-771
Correspondence to:
Dr. Reinhilde Jacobs
Oral Imaging Center School
of Dentistry,
Oral Pathology and
Maxillofacial Surgery,
Faculty of Medicine
Universiteit Leuven
Kapucijnenvoer
7,3000 Leuven
BELGIUM
MaterialandMethods19 human mandibular dry bone specimens were divided into

three groups. A control group (CG) consisting of two samples, Group 1 (n=5) had artificial
bone lesions of approximately 11.5mm created with a spoon excavator. In Group 2 (n=12),
decalcification in order to simulate the osteoporotic condition was effected using a HCl
solution. CBCT images were obtained using an i-CAT scanner by placing the samples into a
polystyrene container containing water in order to simulate soft tissue. Bone mineral density
(BMD) was determined using dual-energy X-ray absorptiometry (DXA). Surface roughness
(FD) was quantified using 2D fractal analysis (FD). Regions of interest were divided into
both cortico-cancellous samples or restricted to the trabecular bone. 3D fractal analysis was
carried out using similar methods. Standard morphometric techniques were used to
determine mean density value (MDV) using gray values and area of bone structure (ABS)
based on image pixellation. Statistical analysis using Spearmans was applied to calculations
of FD, BMD and MDV. Changes in FD and MDV were subjected to descriptive statistics.
ResultsAll test specimens showed a reduction in weight after modification. Calculations
of the mean FD for 2D fractal analysis showed that values decreased for Groups 1 and 2 after
sample modification. With 3D fractal analysis, a reduction in FD was noted for corticocancellous samples but increases in FD observed for trabecular bone samples. Reductions
after modification were noted for ABS with increases in MDV. A statistically significant
correlation existed between FD and BMD (p<0.05) as well as BMD and ABS (p<0.05).
However, correlation between BMD and MDV was not statistically significant (p>0.5).
DiscussionandConclusionThe current study used in vitro methods to attempt to

Image showing the i-CAT cone validate and assess the accuracy of CBCT scans in determining the quality of bone and in
beam CT scanner used to aquire particular osteoporotic bone. The study found that 2D fractal analysis significantly related
the data in this study
to BMD with 3D fractal analysis allowing decalcification or the presence of bone lesions to
be quantified. The fact that FD increased for trabecular bone is contrary to expectations but
has been shown before. The significance of this is as yet unknown. Nonetheless morphometric
measurements confirmed decreases in bone area. The absence of correlation between
density, based on gray values and BMD (using DXA) would appear to be due to intensity
inhomogeneity and may affect the ability for CBCT images to be used for such measurements.
Based on the results of this in vitro study, there is some doubt as to the validity of density
measurements using CBCT. In contrast, fractal analysis and bone area measurements would
appear to demonstrate potential as parameters for bone quality assessment. Further studies
are required to verify these findings.
14
Mechanical non-surgical treatment of peri-implantitis:

A double blind randomized longitudinal clinical study
1: Clinical results
Renvert S.
Samuelsson E.
Lindahl C.
Persson G.
July 2009
The prevalence of implant mucositis has been reported as >60% with the potential for periimplantitis cited between 28-56%. Peri-implantitis appears to be related to the presence of
biofilms and the management of these would seem to be important in the control of periimplant infections. Treatment protocols have developed from those relating to periodontitis
with implant surface debridement seen as the prerequisite for treatment. The need therefore
exists to have specific knowledge of adequate intervention methods for the treatment of
these conditions around dental implants. The aim of the current study was to compare the
efficacy of two methods for mechanical debridement in the treatment of peri-implantitis.
Journal of Clinical
Periodontology
Vol.36 No.7 pp604-609
Correspondence to:
Prof. S. Renvert
Dept. of Health Sciences
Kristianstad University
SE-29188 Kristianstad
SWEDEN
MaterialandMethodsIn total 37 patients were enrolled into this double blind

randomized longitudinal study. The inclusion criteria were based on radiographic evidence
of bone loss <2.5mm and a periodontal probing depth (PPD) of 4mm around one dental
implant with bleeding and or pus on probing. Patients with bone loss in excess of 2.5mm,
poorly controlled diabetes mellitus, on anti-inflammatory medication or antibiotic
administration in the previous three months were excluded. Any existing periodontal lesions
were treated and the subjects were subsequently randomly divided into two treatment
groups. Group 1 (n=19), including 3 smokers, was treated with mechanical debridement
using titanium curettes, while in Group 2 (n=18), with 2 smokers, ultrasonic debridement
was undertaken using the Vector System equipped with an implant specific ultrasonic tip
(LM Instruments, Finland). In both groups, the implants were subsequently polished with
rubber cups and polishing paste.
Oral hygiene instructions and clinical measurements were carried out at baseline, 1, 3
and 6 months post-operatively. Measurements included presence of hyperplasia, bleeding
on probing graded on extent (BOP), PPDs and full mouth plaque scores. Sterile paper points
were used to gain microbiological samples at relevant intervals to calculate a total bacterial
load. Data was subject to appropriate statistical analysis.
ResultsData was obtained for 17 subjects in Group 1 and 14 in Group 2. Mean bone loss
around the implants at the commencement of the study was 1.5mm1.2mm. During the
course of the study mean PPD varied from 2.8 - 5.5mm. No statistically significant differences
(p>0.05) were noted between the two groups with relation to the study parameters. Merged
data for the two groups comparing baseline with six month data showed a significant
improvement in oral hygiene measures from a mean plaque index (PI) of 73% down to 53%.
Reductions in peri-implantitis were also recorded with a mean difference of 27.2%7.9% as
well as with a reduction in the mean BOP score (p<0.05). No significant differences were
noted for PPDs between baseline and six months for either group. Microbiological analysis
revealed a significantly lower total bacterial count for Group 1 (p<0.01), but only at week 1.
DiscussionandConclusionThe findings of this study would seem to confirm that no

differences exist between hand and ultrasonic mechanical debridement of peri-implantitis
sites. In addition, neither treatment modality appeared to have an affect on the bacterial
counts associated with diseased implant sites. It is possible that the nature of implant design
and surface, together with the morphology of the superstructure can hamper efforts to
disturb and remove the biofilm. It was also observed that although improvements in oral
hygiene were noted, overall oral hygiene remained poor and this may have accounted for
the results obtained. One possible explanation for the differences for bacterial counts at
week 1 could be that hand instrumentation may be more aggressive, inducing a host response
of limited duration. The results of this study demonstrate that no differences exist between
hand and ultrasonic debridement methods. They would also seem to suggest that mechanical
debridement in early cases of peri-implantitis may not be clinically relevant. Further studies
using surgical intervention with or without adjunctive antimicrobial and/or antiinflammatory drugs would be of interest.
15
Extent of peri-implantitis associated bone loss
Fransson F.
Wennstrom J.
Tomasi C.
Berglundh T.
April 2009
Peri-implantitis has been defined as an inflammatory process affecting the tissues around a
functioning implant that results in the loss of supporting bone. In contrast peri-implant
mucositis has been defined as reversible inflammatory changes of the peri-implant soft
tissues without accompanying bone loss. The purpose of this retrospective study was to
assess the amount of peri-implantitis induced bone loss relative to implant position for a
given patient population.
Journal of Clinical
Periodontology
Vol.36 No.4 pp357-363
Correspondence to:
Dr. Christer Fransson
The Sahlgrenska Academy
Gteburg University
Box 450
S-405 30 Gteburg
SWEDEN
MaterialandMethods182 patients (previously treated, identified, and reported upon

by Fransson 2005, 2008) with a total of 1070 implants of which 39% (419 implants) exhibited
peri-implantitis induced bone loss were analyzed in this study. Patient radiographs were
analysed 1 year post-operatively (or 2 year post-op when the 1 year radiographs were absent)
and at the end point (5 - 23 years) using a magnifying glass (x7) and a 0.1mm graded scale.
The implant positions were noted relative to jaw position (upper posterior (UP), upper
anterior (UA), lower posterior (LP), lower anterior (LA)) and also relative to their position
within a fixed prosthesis (end implants (E) and those in between mid (M) positions),
which was classified as either a full arch prosthesis (FAP) or partial prosthesis (PP). The
mean bone loss was calculated for each patient and was divided into 2 categories: a)<2mm;
b)2mm. Statistical analyses included Fishers exact test (95% confidence levels) for the
amount of bone loss between the different implant positions (within the jaw and the
prostheses) as well as the distribution of affected and non-affected implants. Using a
multilevel model (MLwiN2.1, London, UK) the influence of implant position and risk of
peri-implantitis associated bone loss was evaluated.
ResultsThe most popular site for implant placement was the first premolar region
followed by the incisors, canines and the molars, of which only a few were placed.
Approximately 2 implants (42%) per patient were affected by peri-implantitis. 88% of
patients had 1 affected implant in the LA region and this was the most frequent area for
peri-implantitis, with 52% of implants being classified as affected compared with UA (39%),
LP (35%), and UP (30%) respectively. The LA area was statistically more associated with the
condition compared to the other areas, p < 0.05. In addition the highest frequency of 2mm
bone loss was found in the LA region (37%) followed by UA (33%), UP (29%) and LP (25%).
However, this result was not statistically significant. The number of M implants affected
(44% where n=619) was significantly higher than for the E implants (32%; n=451), although
this may be due to the larger number of FAP where the majority of implants were in the M
position. However, the results were similar when comparing within the 2 types of prostheses
(FAP: 43% vs 31% and PP:49 vs 35%).
DiscussionandConclusionIn the present study there was an even spread of anterior
and posterior implants of which 42% exhibited bone loss due to peri-implantitis. The range
of implants presenting with bone loss varied from 30-52%, the highest prevalence being in
the LA region, which is similar to findings published in other studies. On examination of the
different prostheses the M positioned implants appeared to experience greater bone loss
and could be deemed to be at a higher risk than implants placed as distal abutments (E).
Previous studies have stated that poor oral hygiene and smoking are major factors in
peri-implantitis induced bone loss, whereas occlusal load, tooth cleansing and the length of
the cantilever are of minor importance.
The data collated in this study concurs with many previous studies and confirms that it
is possible to suffer peri-implantitis at all locations in the oral cavity, but that perhaps the
anatomy of the anterior mandible and a middle abutment position within a fixed prosthesis
renders an implant more susceptible to peri-implant bone loss.

Summaries of Dental Implant Research PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Summaries of Dental Implant Research PDF

Uploaded by

Copyright:

Available Formats

Vol.18 / No.

Dental Implant Summaries

multicenter trial evaluating

4 The possible association among

bone density values, resonance

7 Biofilm on dental implants:

Int. Journal of Oral and

5 A rough surface implant neck

with microthreads reduces the

clinical trial of customized

10 Influence of the height of the

Int. Journal of Oral and

13 Bone quality assessment

based on cone beam computed

Managing Editors: Dr. Mark Atkinson, Dr. Michael Norton

11 Influence of early cover

screw exposure on crestal

Vol. 18 / No. 1 Jul-Aug 2009

3 Load fatigue performance of

Int. Journal of Oral and

6 Bone strain and interfacial

sliding analyses of platform

9 Is insertion torque correlated

Journal of Clinical Periodontology

Specialist Dental Summaries Ltd 2008/09. All rights

Students receive 25% discount (please include verification

Subscription rates for Vol.18, 2009 - Jul 2010

While every effort is made to ensure correctness of all

Back issues GBP 18 or USD 35 per copy (subject to

A randomized prospective multicenter trial evaluating the

MaterialandMethods78 patients were enrolled in this multicenter, randomized

The control implant (3.8mm)

DiscussionandConclusionThere are several factors that have been shown to maintain

Vol.18/ No.1 Jul-Aug 2009

Agreement of quantitative subjective evaluation of

MaterialandMethodsPre- and post-operative photos of 32 partially edentulous patients

It was found in this study that

DiscussionandConclusionThis study is in agreement with previous studies which

Vol.18/ No.1 Jul-Aug 2009

Load fatigue performance of implant-ceramic abutment

MaterialandMethodsThe 4 implant systems with their corresponding zirconia

Four implants and their

Vol.18/ No.1 Jul-Aug 2009

The possible association among bone density values, resonance

MaterialandMethods10 healthy, non-smoking patients received a total of 11 posterior

Vol.18/ No.1 Jul-Aug 2009

A rough surface implant neck with microthreads reduces

MaterialandMethodsTwo tapered, threaded implant designs from the same company

Vol.18/ No.1 Jul-Aug 2009

Bone strain and interfacial sliding analyses of platform

MaterialandMethodsData from a CT scan of an edentulous mandible from a dried

Reprint requests to:

ResultsThere were no significant differences (p>0.05) noted in bone strain values

Vertical and lateral loading

DiscussionandConclusionWithin the constraints of this study (static load and

Vol.18/ No.1 Jul-Aug 2009

Biofilm formation on different

Biofilm on dental implants: A review of the literature

MaterialandMethodsA MEDLINE literature search was performed of studies published

DiscussionandConclusionThis literature review suggests that rough implant and

Vol.18/ No.1 Jul-Aug 2009

Randomized-controlled clinical trial of customized

MaterialandMethods22 patients treated with 40 implants (Brnemark RP, Nobel