Dental implants

Dent 305

Introduction
Modern dental implantology is less than 30 years old Placement of a material into bone creates a unique interface between implant and body, so: The implant material needs to be biocompatible
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Implant components

Important principles
Implant surgery involves careful and methodological surgical technique to ensure minimal trauma and inflammation. Placing an implant involves: Bone removal with titanium alloy-slow speed water-cooled burs Placement of implant and healing cap (6-8 weeks healing) Re-open and placement of abutment caps Placement of abutments Placement of crown or prosthesis
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Osseointegration
Osseointegration: refers to the lack of intervening fibrous tissue and as little space as possible between bone and metallic implant. This needs:
Biocompatible implant material Atraumatic surgical technique

This leads To almost no mobility (ankylosis)

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Biointegration
Requires a chemical degradation of the implant which favors bone formation and is able to integrate with the surrounding bone Occurs in association with ceramic implant materials

Implant and force

Implant is used to restore esthetics and function Excessive forces on the implant intra-orally may lead to failure Unlike natural teeth, occlusal forces are directly transmitted to bone as compressive forces leading to bone resorption Implants supported prosthesis are designed to minimize excessive load
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Clinical considerations
Clinical uses: early implants were Subperiosteal or Transosteal. Endosseous implants were not as successful due to lack of proper osseointegration or biointegration.

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Implants maybe:
Single Multiple Maxillary Mandibular Support complete dentures Replace bridges and partial dentures
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Uses of implant

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Clinical success criteria

Osseointegrated or biointegrated interface No measurable mobility Implant is able to withstand forces over time while maintaining integration

Success rate maybe lower if:

Bone quantity or density is less Implant is loaded immediately One step placement of implant
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Implants are expected to last for 10 years Ongoing horizontal bone loss is expected (less than 0.5mm/yr) Horizontal bone loss greater than 0.5mm/yr or vertical bone loss indicates failure
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Clinical maintenance
Peri-implantitis: inflammatory process occurring around implants due to microorganisms similar to those that cause periodontitis. Maintaining good oral hygiene is important (tooth brushing, flossing, scaling with plastic scalers and using mild abrasives)
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Implant materials
Early material:
Polymers: limited use due to lack of osseointegration or biointegration, and lack of strength. examples:
Polymethylmethacrylates Polytetrafluoroethylene (Teflon) Polyethylene Polysulfones polyurethanes
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Implant materials
Carbon based materials: have been introduced in several forms such as carbon silicates, crystalline carbon forms. They had low toxicity but the biological response is not suitable for Endosseous implants. Also, they are brittle so, weak in tension

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Current materials
Pure titanium:
Titanium (99% pure titanium, small amounts of oxygen, traces of iron, carbon, hydrogen and nitrogen. Amount of oxygen affects strength and ductility. The other trace elements affect strength, corrosion resistance and structure of the alloy
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Types and grades of titanium alloys

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Titanium alloys: similar to pure titanium, contains 6% aluminium and 4 % vanadium. These increase the tensile strength. Melting range and modulus are similar to commercially pure titanium.

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To promote osseointegration, the surface of the implant is coated with oxides of titanium and oxygen. The oxide layer is 20-100 . Oxygen rich oxides are closer to the surface. This layer should be free of contaminants
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Trace elements from the implant materials maybe released into the surrounding tissue and maybe found in lungs, liver, spleen but no ill-effect has been reported.

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Implant materials
Ceramics:
Brittle: can withstand high compressive loads but low tensile stresses. High stiffness Inert Function well as Subperiosteal and Transosteal implant Aluminum oxide based Zirconia based
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Ceramic coatings
On titanium alloy implants to promote biointegration and strong implant-bone bonds. Combine strength of the titanium alloy and biointegration. Thickness of the ceramic coating 50100 m

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Ceramic coating materials

Calcium phosphates: Hydroxyapatite (HA), tricalcium- phosphate (TCP): these can be used as ceramic coating materials The more crystalline (less amorphous) these material are, the more resistant to dissolution they become Ion exchange between coating and tissue occurs (some say that this might lead to weakening of the bond later).
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Ceramic coatings
Even though ceramic coated implants promote biointegration, some studies showed that they were unstable and may lead to bone damage Their rough surface may lead to plaque accumulation and microorganisms colonization Failures maybe caused by inflammation and loss of the coating
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Criteria for selection of materials

(ref. Phillip's science of dental materials)

Strength requirements Availability Implant design Bone height

Examples: for posterior implants, strength is vital so the material of choice could be Titanium grade IV or any titanium alloy material
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In some cases such as compromised bone height, HA coated implants proved In some studies to be more successful than titanium implants Another indication for ceramic coated implant materials is implantation in fresh extraction sites (studies showed high success rates)
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Summary
The performance and choice of appropriate material is controversial Some studies show better performance for one material over the other (short term and long term) Other studies show no measurable difference after certain time periods when titanium or ceramic coated titanium is used.
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Summary
The implant systems currently available are diverse Despite the biocompatibility of the mentioned implant material, the exact bone-bonding mechanisms are not fully understood When mechanisms that ensure stability and bio-acceptance are fully understood, implant failure will be rare
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