Osseointegration Short Review PDF
Osseointegration Short Review PDF
Osseointegration Short Review PDF
DOI 10.1007/s13191-013-0252-z
REVIEW ARTICLE
Osseointegration: An Update
S. Parithimarkalaignan T. V. Padmanabhan
Received: 1 May 2012 / Accepted: 1 December 2012 / Published online: 11 January 2013
Indian Prosthodontic Society 2013
Abstract Osseointegration, defined as a direct structural alloplastic materials is achieved, and maintained, in bone
and functional connection between ordered, living bone and during functional loading (Zarb &Albrektsson,) [1, 2]. His-
the surface of a load-carrying implant, is critical for implant tologic appearance resembled a functional ankylosis with no
stability, and is considered a prerequisite for implant load- intervention of fibrous or connective tissue between bone
ing and long-term clinical success of end osseous dental and implant surface.
implants. The implanttissue interface is an extremely The successful outcome of any implant procedure is
dynamic region of interaction. This complex interaction mainly dependent on the interrelationship of the various
involves not only biomaterial and biocompatibility issues components of an equation that includes the following [3]:
but also alteration of mechanical environment. The pro-
1. Biocompatibility of the implant material
cesses of osseointegration involve an initial interlocking
2. Macroscopic and microscopic nature of the implant
between alveolar bone and the implant body, and later,
surface & designs [4]
biological fixation through continuous bone apposition and
3. The status of the implant bed in both a health and a
remodeling toward the implant. The process itself is quite
morphologic (bone quality) context
complex and there are many factors that influence the for-
4. The surgical technique per se [5, 6]
mation and maintenance of bone at the implant surface. The
5. The undisturbed healing phase [7]
aim of this present review is to analysis the current under-
6. Loading conditions
standing of clinical assessments and factors that determine
the success & failure of osseointegrated dental implants. The challenge confronting the clinician is that these
several factors must be controlled almost simultaneously, if
Keywords BoneMetal interface Endosseous implants a predictably successful outcome is to be expected.
Mechanical interlock Implant stability
Research Background
Introduction
In clinical experiences it has been demonstrated that the
Osseointegration is defined as a time dependent healing
implants were anchored in bone without intervening fibrous
process whereby clinically asymptomatic rigid fixation of
tissue, while the experimental data point to an osseointe-
gration even at the ultrastructural level. Collagen filaments
S. Parithimarkalaignan
approaching the titanium oxide surface and separated only
Department of Prosthodontics, Penang International Dental
College, Butterworth, Malaysia by a 2040 nm thick Proteoglycan layer [8] have been
e-mail: parithisiva@gmail.com observed. Studies on the importance of controlling the
surgical technique [5, 9] have demonstrated that bone tis-
T. V. Padmanabhan (&)
sue is much more sensitive to heat than previously
Department of Prosthodontics, Sri Ramachandra Dental College
&Hospital, Porur, Chennai, India believed. Eriksson and Albrektsson found that subjecting
e-mail: tvpadu@gmail.com newly inserted titanium implants to a temperature elevation
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of 47 C significantly disturbed their subsequent integra- Radiolucent zones around the implant are a clear indi-
tion in the bone bed. Haraldson has measured bite force cation of its being anchored in fibrous tissue, Whereas the
levels in patients with osseointegrated dental implants and lack of such zones is not evidence for osseointegration. The
found that these were similar to levels measured in dentate reason for this is that the optimal resolution capacity of
patients with the same extension of the dentition. Brane- radiography is in the range of 0.1 mm whereas the size of a
mark [10] and Adell et al. [11] and Lekholm et al. [12], soft tissue cell is in the range of 0.01 mm; thus a narrow
have examined soft tissue reactions to the mucosa-pene- zone of fibrous tissue may be undetectable by radiography
trating abutments and found a healthy gingival reaction
3. The use of a metal instrument to tap the implant and
with very few inflammatory cells. The bacteriological
analyze the transmitted sound may, in theory, be used
investigation revealed only about 3 % of the microflora
to indicate a proper osseointegration. However, there
contained potentially dangerous bacteria such as spiro-
is no typical sound diagram defined for the
chetes. Till date, no other dental implant system has been
osseointegrated implant in contrast to the implant
so thoroughly evaluated from both an experimental and
anchored in fibrous tissue. Therefore, clinical tests of
clinical point of view.
implant interfacial arrangements are only capable of
Branemark and Albrektsson [13] evaluated the outcome
roughly indicating the true tissue responses
of all implants inserted during 1 year and then followed up
for 5 years and found an implant success rate of 96.5 % in the Osseointegration is also a measure of implant stability,
mandible. This improved success rate compared to the data which can occur at 2 different stages: primary and secondary.
published by Adell et al. [14] reflects a true improvement in Primary stability of an implant mainly comes from mechan-
the outcome, attributed to meticulous surgical and prosth- ical engagement with compact bone. Secondary stability, on
odontic techniques. other hand, offer biological stability through bone regener-
ation and remodeling. The former is a requirement for sec-
ondary stability. The latter, however dictates the time of
functional loading.
Materials and Methods
Implant stability, an indirect indication of osseointegra-
tion, is a measure of the clinical immobility of an implant.
Stages of Osseointegration
Currently; various diagnostic analyses have been suggested
to define implant stability standardized radiographs, cutting
Direct bone healing, as it occurs in defects, primary fracture
torque resistance test, modal analysis and, Resonance fre-
healing and in Osseointegration is activated by any lesion of
quency analysis (RFA).
the pre-existing bone matrix. When the matrix is exposed to
Presently, clinical application of RFA [17] includes
extra cellular fluid, noncollagenous proteins and growth
establishing (1) a relationship between exposed implant
factors are set free and activate bone repair [15]. Once
length and resonance values or ISQ values [18]; (2) differ-
activated; osseointegration follows a common, biologically
ential inter and intra arch ISQ values for implants in various
determined program that is subdivided into 3 stages:
location; (3) prognostic criteria for long term implant suc-
Incorporation by woven bone formation; cess; (4) diagnostic criteria for implant stability [19].
Adaptation of bone mass to load (lamellar and parallel- The evaluation of implant stability using RFA machines
fibered bone deposition); such as Osstell and Implomates still has some uncertain
Adaptation of bone structure to load (bone remodeling). issues.
It is clinically being used without much conclusive data
on the bone metal interface & resonance frequency val-
Clinical Assessments for Osseointegration
ues. Further research is needed to establish higher reli-
ability of these diagnostic devices.
Many methods have been tried to clinically demonstrate
osseointegration of an implanted alloplastic material.
These are [16]:
Factors That Determine Success and Failure
1. Performing a clinical mobility test and finding that the of Osseointegrated Implants
implant is mobile is definite evidence that it is nonin-
tegrated. The presence of clinical stability cannot be Osseointegration is the basis of a successful endosseous
taken as conclusive evidence of osseointegration implant. The process itself is quite complex and there are
2. Radiographs demonstrating a apparently direct contact many factors that influence the formation and maintenance
between bone and implant have been cited as evidence of bone at the implant surface. To fully understand what
of osseointegration influences osseointegration, it is important first to examine
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more closely the interface, the traits of a surface that allow plasma spraying is the risk of scaling and cracking due to
for biocompatibility, and the common surfaces used and the high processing temperatures. Also, there is a risk of
studied such as titanium oxide and hydroxyapatite. abraded material being implanted into the bone-implant
interface. The amount of melting of the plasma sprayed
Bone-Implant Interface [20] titanium contributes to this abrasion. That is, the more the
melting, the more abrasion resistant the surface.
Osseointegration is a striking phenomenon in which bone HA coatings have the advantage of increasing surface
directly opposes the implant surface without any inter- area, decreasing corrosion rates, and accelerating bone
posing collagen or fibroblastic matrix. Numerous studies formation via faster osteoblast differentiation. Also, due to
have all concluded that the strength of an osseointegrated the enhanced biomechanics HA coated implants are better
implant is far greater than that of a fibrous encapsulated able to withstand loads. Other advantages of HA include
implant. Also, the strength of the interface between bone the more organized bone pattern and higher degree of
and implant increases soon after implant placement mineralization at the interface, as well as increased bone
(012 weeks). This strength may in fact be related to the penetration (which improves fixation). The bone bonding
amount of bone surrounding the implant surfaces. Other capabilities of HA make it a very desirable surface and
factor that may affect the strength of the interface is bio- probably the most reliable surface up to date.
physical stimulation and time allowed for healing. Studies
have shown that measurable increases in bone implant Implant Surface Characteristics
interactions take place for at least 3 years.
The Surface Quality will determine tissue reaction to an
Implant Biocompatibility [21] oral implant. Surface quality may be dived into three cat-
egories: (1) Mechanical properties, (2) Topographic prop-
Commercially pure titanium is widely used as an implant erties [26] (3) physiochemical properties.
material as it is highly biocompatible, it has good resis-
tance to corrosion, and no toxicity on macrophages or Mechanical Properties
fibroblasts, lack of inflammatory response in peri-implant
tissues and its composed of an oxide layer and has the Mechanical properties of implant surfaces relate to poten-
ability to repair itself by reoxidation when damaged. tial stresses in the surface that may result in increased
Another material used for implants, Titanium -6 Alumi- corrosion rate and wear relating to the hardness of the
num-4 Vanadium (TI-6AL-4 V) alloy exhibits soft tissue material. Wear is related to the strength of the material, but
reactions very similar to those reported to cp Ti [22, 23]. also to the surface roughness. One technique to minimize
the wear is ion implantation.
Titanium Oxide
Topographic Properties
When Ti (Titanium) or Ti alloys are exposed to air or
normal physiologic environments, there is a reaction with The surface topography relates to the degree of roughness
the oxygen that causes and oxide layer to be formed. Usu- of the surface and the orientation of the surface irregular-
ally the oxide is in the form of TiO2. The oxide layer pro- ities. The chemical composition of the implant interface on
tects against corrosion. Calcium and phosphate ions have the implant surface was shown to affect initial cell
been found in the oxide layers, which suggest that there is attachment. This has stimulate great interest on implant
an active exchange of ions at the bone implant interface. surface modification as a way to accelerate the rate of
In addition, porous surfaces have been shown to enhance osseointegration.
ionic interactions, initiate a double physical and chemical
anchor system and augment load bearing capacity. Also,
Surface Roughness
porous surfaces can increase the tensile strength via growth
of bone three dimensionally as well as increased healing
Depending on the scale of the features and based on the
rates. The majority of commercially available implants are
proposal of Wennerberg and Albrektsson, surface rough-
covered via plasma spraying. Titanium plasma spraying
ness can be divided into four categories:
[24, 25] involves molten droplets being sprayed in a
powder form onto the implant surface at high temperatures. Smooth surfaces: Sa value \0.5 lm (e.g. polished
Thus, an increased surface area is obtained, increased bone abutment surface).
contact is achieved and the ability to form a 3 dimensional Minimally rough surfaces: Sa value 0.5 to \1.0 lm
interconnection is enhanced. The disadvantage of Titanium (e.g. turned implants).
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moderately rough surfaces: Sa value 1.0 to \2.0 lm this lowered success is unknown, but vasoconstriction may
(e.g. most commonly used types). play a role.
Rough surfaces: Sa value C2.0 lm (e.g. plasma sprayed Other common clinical host bed problems involve
surfaces). osteoporosis and resorbed alveolar ridges. Such clinical
states may constitute an indication for ridge augmentation
Moderate roughness and roughness is associated with
with bone grafts.
implant geometry, such as screw structure, and macropo-
In jaws with insufficient bone volume for implant
rous surface treatments. Previous studies demonstrated that
installation, a grafting technique has been recommended in
this typeof roughness [27] allowed for bone ingrowth and
order to increase the amount of hard tissues. To create
provided mechanical interlocking shortly after implant
more alveolar bone without grafting, a new surgical tech-
placement. Higher Bone implant contact [28] (BIC) and
nique was tested, relying on the biologic principle of gui-
removal torque force suggested enhanced secondary sta-
ded tissue regeneration. It is of great value in situations
bility compared to smooth and minimally rough implants.
with insufficient alveolar bone volume.
There are two main theories regarding the influence of
implant surface microtopography on peri-implant tissue
Surgical Technique
formation(1) the surface energy and (2) the distortional
strain. The smaller grain size on the surface results in higher
Minimal tissue violence at surgery is essential for osseo-
surface energy, which is more favorable for cell adherence.
integration. This objective depends on continuous and
Furthermore, potential drawbacks of roughening the
careful cooling while surgical drilling is performed at low
implant surface include problems with periimplantitis and a
speed.
greater risk of ionic leakage.
If too violent a surgical technique is used, frictional heat
will cause a temperature rise in the bone and the cells that
Physical Characteristics
should be responsible for bone repair will be destroyed.
However, the critical time/temperature relationship for
Refer to factors such as surface energy and charge. A
bone tissue necrosis is around 47 C applied for 1 min.
surface with a high energy has a affinity for adsorption. In
other words, an oral implant with high surface energy may
Loading Conditions
show stronger osseointegration.
Glow discharge treatment results in high surface energy
The primary factor for success at the time of placement is
as well as implant sterilization.
achieving primary stability. Any micromotion during initial
A practical way to measure the surface energy is contact
phases of bone healing will cause a lack of integration.
angle measurements, a method also determine whether a
Failure is most often caused by overloading due to trans-
surface is hydrophobic or hydrophilic (wettability of the
mucosal forces of removable appliance over the implant site.
surface).
Any attempt to keep a patient functioning with fixed
provisional restoration during the healing phases of treat-
Implant Bed ment, will allow for easier patient management.
If immediate loading at the time of final definitive
A healthy implant host site is required. However, in the implant placement is to be considered, not only should the
clinical reality; the host bed may have suffered from pre- initial stability be extremely tight, but control of the
vious irradiation and osteoporosis, to mention some unde- occlusion on the provisional interim restoration must be
sirable states for implantation. Previous irradiation need adjusted and monitored carefully through the initial healing
not be an absolute contraindication for the insertion of oral period.
implants. However, it is preferable that some delay is
allowed before an implant is inserted into a previously Recent Innovations in Dental Implant Technology
irradiated bed. Furthermore, some 1015 % poorer clinical to Enhance Osseointegration
results must be anticipated after a therapeutical dose of
irradiation. Because of vascular damage, at least in part. 1. Use of computer aided radiographic treatment planning
One attempt to increase the healing conditions in a previ- & surgical guide fabrication using advanced computer
ously irradiated bed is by using hyperbaric oxygen, as a aided design/computer aided manufacturing software
low oxygen tension definitely has negative effects on tissue 2. Implant surfaces with hydrophilic properties that
repair. promote osteoconduction of new bone growth
Smoking has been reported to yield significantly lower 3. Use of recombinant human growth factors on the
success rates with oral implants. The mechanism behind implant surface or as a part of the placement
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6 J Indian Prosthodont Soc (Jan-Mar 2013) 13(1):26
4. Surface chemistry modifications to accelerate bone 8. Small IA, Misiek DJ (1986) A sixteen-year evaluation of the
mandibular staple bone plate. J Oral Maxillofacial Surg 44:6066
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with osseointegrated implant bridges. In:van Steenberghe D,
Albrektsson T, Branemark P-I, Henry P, Holt R, Lide G (eds).
Excerpta Medica, Amsterdam, p 320325
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