Optimum osseointegration – Kate Scheer
Featured Products Promotional FeaturesPosted by: Dental Design 7th June 2018
Britain’s population is living longer, and the growing number of edentulous patients is fuelling the popularity of restorative solutions such as dental implants. Teeth that may have been lost to trauma, disease, or simply failed to form, can be replaced in ways that were not possible before. As restorative dentistry aims to restore form, function and appearance of teeth, dental implants can offer a permanent alternative to tooth loss, and are particularly sought after as a result. Although the design and application of dental implants has vastly improved in recent years, patients have developed a greater expectation of their success. Therefore, it is important that the profession continues to research new ways in which to enhance the final outcome of implant treatment.
One of the factors that can influence the long-term clinical success of dental implants is osseointegration. Defined as the direct structural and functional connection between ordered, living bone and the surface of a load-carrying implant, the high-predictability of osseointegration allows the implant to be used for its intended restorative purpose, free from disease. As practitioners are also aware, osseointegration is also a measure of implant stability, which can occur at two different stages; primary stability of an implant mainly comes from mechanical engagement with compact bone, and is widely acknowledged as the prerequisite to the survival of an implant. Secondary stability, on the other hand, offers biological support through bone regeneration and remodelling around the implant after the healing period.
In order to ensure primary stability, practitioners must first determine that there is an adequate quantity of bone in the region of the planned implant, and that it is of sufficient quality. Poor bone quantity and quality have been indicated as two of the main risk factors for implant failure, and may be associated with excessive bone resorption and impairment of the healing process.[i]In the posterior maxilla, there is commonly thinner cortical bone combined with thicker trabecular bone.[ii]This hard cortical bone with a low blood supply, and the trabecular bone with low density, does not provide favourable host conditions for good prognosis of dental implants.[iii]This demonstrates how crucial it is to evaluate the condition of a patient’s bone before an implant is placed.
The design of an implant is also a key element in determining primary stability. Implants can be engineered by using different materials, surfaces, and thread designs in order to maximise strength, interfacial stability, and load transfer.[iv]Commercially, pure titanium is widely used as an implant material because it is strong, highly biocompatible, and generally resistant to corrosion. Titanium implants spontaneously form a coating of titanium dioxide, which is stable, biologically inert and promotes the deposition of a mineralised bone matrix on its surface.[v]Studies have also shown that the surface typography and roughness of an implant positively influences the healing process by promoting favourable cellular responses and cell surface interactions.[vi]
Besides the quantity and quality of bone, and morphology of the implant, the surgical technique adopted to place the implant also influences primary stability. Once the practitioner has drilled a pilot hole into the bone where the implant is to ultimately be placed, it is essential that they treat the bone with care. The practitioner must not overheat the bone during the drilling process, or else this can result in bone cell death, which in turn will prevent successful osseointegration. To avoid this complication, practitioners should ensure that the drills they employ are sharp, and are not used with excessive drilling speed or pressure. They should also continuously flush the tooth implant site with water or a saline solution as a way of minimising the amount of bone-damaging heat that is generated.[vii]
Subsequently, it is of upmost importance that practitioners take the time to consider what equipment will best aid them as they carry out the procedure to place the implant. The Piezomed system from W&H, for instance, can detect the instrument during insertion, and automatically set the correct power mode for extremely high cutting performance whilst also simultaneously cooling the operating site. This facilitates an effective surgical technique and increases patient safety. There’s also the Implantmed, which offers the facility to monitor osseointegration utilising the Osstell ISQ alongside automatic torque control and simultaneous cooling of the operating site.
Dental implants have become a scientifically accepted and predictable treatment for many edentulous patients. Osseointegration is a complex process that is a prerequisite to the ultimate functionality of a dental implant, influenced by many factors, including the condition of the bone, implant design, and surgical technique. It is vital that practitioners understand the importance of recognising conditions that place the patient at a higher risk of implant failure, so that they are better able to make informed decisions, and refine the treatment plan and the equipment they use to optimise the outcomes.
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[i]Chrcanovic, B. R., Albrektsson, T. and Wennerberg, A. (2017) Bone Quality and Quantity and Dental Implant Failure: A Systematic Review and Meta-analysis. Link: https://www.researchgate.net/profile/Bruno_Chrcanovic/publication/315463684_Bone_Quality_and_Quantity_and_Dental_Implant_Failure_A_Systematic_Review_and_Meta-analysis/links/58d246f692851cf4f8f5117f/Bone-Quality-and-Quantity-and-Dental-Implant-Failure-A-Systematic-Review-and-Meta-analysis.pdf. [Last accessed: 05.01.18].
[ii]Jacobs, R. (2003) Preoperative radiologic planning of implant surgery in compromised patients. Periodontol 2000. 33:12-25.
[iii]Todisco, M. and Trisi, P. (2005) Bone mineral density and bone histomorphometry are statistically related. Int J Oral Maxillofac Implants. 20:898-904
[iv]Steigenga, J. T., al-Shammari, K.F., Nociti, F. H., Misch, C. E. and Wang, H. L. (2003) Dental implant design and it relationship to long-term implant success. Implant Dent. 12(4):306-17.
[v]Ditcher, D. (2016) The Biologic Fundamentals of Osseointegration. Link: http://www.speareducation.com/spear-review/2016/01/the-biologic-fundamentals-of-osseointegration. [Last accessed: 05.01.18].
[vi]Javed, F., Ahmed, H. B., Crespi, R. and Romanos, G. E. (2013) Role of primary stability for successful osseointegration of dental implants: Factors of influence and evaluation. Interventional Medicine and Applied Science. 5(4):162-167.
[vii]Animated-teeth.com. (2017) The steps of the dental implant procedure. Link: https://www.animated-teeth.com/tooth-implants/b1-dental-implants-procedure.htm. [Last accessed: 05.01.18].
