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Osseointegration in Implants: A Review

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Review Article
___________________________________________________ ____________________
J Res Adv Dent 2014; 3:3:67-72.

Osseointegration in Implants: A Review

Durgaraju Macha1 Pradeep Koppolu2* Lingam A Swapna3 Chandrahas Bathini4

1Reader,Department of Prosthodontics, Guru Gobind Singh College of Dental Sciences & Research Center, Burhanpur, Madhya Pradesh, India.
2Senior Lecturer, Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India.
3Senior Lecturer, Department of Oral Medicine and Radiology, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India.
4Reader, Department of Periodontics, Guru Gobind Singh College of Dental Sciences & Research Center, Burhanpur, Madhya Pradesh, India.

ABSTRACT

Background: Osseointegration of dental implants refers to direct structural and functional link between living
bone and the surface of a non-natural implant. It follows bonding up of an implant into the jaw bone when bone
cells fasten themselves directly onto the titanium surface.It is the most investigated area in implantology in
recent times. Evidence based data reveals that osseointegrated implants are predictable and highly successful.
This process is relatively complex and is influenced by various factors in formation of bone neighbouring implant
surface. The present review provides the understanding of various features of osseointegrated implants.

Keywords: Osseointegration, Implants, Bone.

INTRODUCTION implant without any intervening layer of fibrous

It is the direct structural and functional link
between living bone and the surface of a non-
natural implant. It is a direct bone anchorage to an
implant body, which can provide a foundation to
support prosthesis; it has the ability to transmit
occlusal forces directly to bone.1
Definition
Osseointegration was first defined as a direct
contact between living bone and the surface of a
load-carrying implant at the histological level.2
“It is a process whereby clinically asymptomatic
rigid fixation of alloplastic material is achieved and
maintained in bone during functional loading” −
“Functional ankylosis”.3
“It is the direct anchorage of an implant by the
formation of bone directly on the surface of an
_______________________________________________________________________________________
tissue.”4
HISTORY
An investigational work was carried out in
Sweden by Professor Per-Ingvar Branemark and his
colleaguesfrom 1950to 1960. It was in 1952Dr. Per-
Ingvar Branemark discovered that titanium glued
well with bone; a spectacle which was later termed
as osseointegration.5In 1965, Dr.Branemark and his
associates started clinical trials with titanium dental
implants with great success.Dr. Per–Ingvar
Branemark, had studied the theory of tissue united
prosthesis at the Laboratory of Vital Microscopy at
the University of Lund, and consequently at the
Laboratory for Experimental Biology at the
University of Gothenburg.2In the early 1960s,
Branemark and co-workers at the University of
Goteborg started developing a unique implant that
for clinical function depended on direct bone
anchoragetermed osseointegration.He discovered a

Copyright ©2014
strong and direct bone anchorage of a titanium
chamber while reviewing microcirculation in bone
repair mechanisms.
Bone
Osseointegration is a constant procedure
representing process of formation and adaptation to
function and repair, which isdue toOsteoblastic and
Osteoclastic activity of bone, also known as
coupling.7-9
2. Osseointegration supported by Branemark
(1985.)10
Stages of Osseointegration:
In bone defects, principal fractures and in
Osseointegration the healing is stimulated by any
lesion of the pre-existing bone matrix. When the
matrix is open to extracellular fluid, noncollagenous
proteins and growth factors are released and
activate bone repair takes place.

Bone density classification Osseointegration follows a common, biologically

determined program that is subdivided in to 3
In 1988 Misch10classified bone density stages:
groups independent of regions of jaw based on
macroscopic cortical and trabecular bone. Dense or 1. Incorporation by woven bone
porous cortical bone is found on the external formation.
surface of the bone and comprises of the crest of
edentulous ridge. Granular and fine trabecular bone 2. Adaptation of bone mass to load
are found surrounded by the outer shell of cortical (lamellar and parallel-fibered bone
bone. deposition)

D1: Compact cortical bone 3. Adaptation of bone structure to load

(bone remodelling).
D2: Thick compact to porous cortical bone on the
crest and coarse trabecular bone within. Key factors responsible for successful
Osseointegration:
D3: Thin porous cortical bone on the crest fine
trabecular bone within. There are several reasons for primary as
well as secondary failure of osseointegration. These
D4: Fine trabecular bone. failures may be attributed to an inadequate control
of the six different factors known to be important
D5: Immature, non-mineralized bone. for the establishment of a reliable, long-term
osseous anchorage of an implanted device. These
To preserve a persistent level of bone
factors are:13
remodelling, there should be appropriate local
stimulation as well as crucial levels of thyroid Implant material biocompatibility.
hormone, calcitonin, and vitamin D within the
system. Occlusion or occlusal force stimulus, and 1. Implant design characteristics.
general health management are both important
forperfect bone remodelling at the fixture 2. Implant surface characteristics.
locations.11
3. Bone density quality.
There are two basic theories regarding the
4. Surgical considerations.
bone-implant interface and retention of an
endosteal implants in function. They are: 5. Loading conditions.

1. Fibro-osseous integration supported by

Linkow (1970), James (1975), and Weiss
(1986.)12

68
Table 1: Implant material biocompatibility.14

Biological Chemical composition

biocompatibility Metals Ceramics Polymers
Biotolerant Gold Polyethylene
Cobalt-chromium Polyamide
alloys Poly-methyl
Stainless steel methacrylate
Zirconium Poly-tetrafluoro
Niobium ethylene
Tantalum Poly-urethane
Bioinert Commercially pure Aluminum oxide
titanium( CPTi) Zirconium oxide
Titanium alloy
(Ti-6Al-4V)
Bioactive Hydroxyapatite
Tricalcium phosphate
Tricalciumpyrophosphate
Fluorapatite
Carbon: vitreous,
Bioglass

Implant design characteristic:  Modification in the design, size and pitch of

Implant design refers to the 3Dorganization
of the implant i.e., form, configuration, geometry,
contour, surface macro irregularities and macro
structure. Exactitude fit in the vital bone leads to
osseointegration. At present, satisfactory long-term
documentation solitary on threaded types of oral
implants that have been established to function for
decades devoid of clinical problems.
Various implant designs are cylindrical, screw
shaped implants, Threaded and Non threaded
the threads can affect the long term
osseointegration.
Advantages of threaded implants:
 Load distribution for stress is better as the
functional area is more than the cylindrical
implants.
 Threads enhance the primary implant
stability and evade micro movement of the
implants till osseointegration is reached.

Cylindrical implants / press fit implants:
They lead to stark bone resorption due to
micro movement of the implant in the bone.
Alberktsson in 1993 reported that enduring bone
saucerization of 1mm – first year, 0.5 mm annually
and there after cumulative rate of resorption up to 5
year follow up.
Threaded implants:
 Documentation for long term clinical
function.
The various forms of threads are: Standard V –
thread, Square thread, Buttress thread.
The threaded portion of a screw-shaped
implant has three typical regions: the top, the flank
and the valley region. Of the three different sites,
the top region frequently has the roughest surface.15
If we assume that all parts of an implant are
equally important with respect to osseointegration,
a proper characterization of the implant surface
must include measurements made in all
3areas.Alignment of irregularities may give isotopic
surface & anisotropic surface.

69
 Wennerberg 2000 reported that improved
bone fixation (osseointegration) will be attained
with implants with an enlarged isotropic surface as
matched to implant with turned anisotropic surface
structure.16
Different machining process results in different
surface topographies:
1. Turned surface / machined surface.
2. Hydroxyapatite coated surface
3. Acid etch surface – Hydrogen Chloride
(Hcl)&Sulfuric acid(H2 SO4).
4. Blasted surface – Titanium dioxide
(Tio2) /Aluminium oxide (Al2 -
O3)particles.
5. Blasted + Acid etch surface(SLA surface
) ; AL2O3 Particles, Hcl, H2SO4
Tri calcium phosphate, Hydrogen
fluoride&Nitrate
6. Titanium plasma sprayed surface
7. Nano sized hydroxyapatite coated
surfaces.
With respect to the deceptive topography
there is strong documentation that most plane
surfaces don’t result in antolerable bone cell
adhesion. Such implants do consequentlyget
anchored in soft tissue even with the best material
used.
Carlsson et al published evidence of
dominance of the threaded design in
osseointegration compared with plates and several
irregular implant shapes.17
Kasemo and Lausmaahave summarizedstandpoints
on the implant surface and made 3 important
conclusions: 18
(1) It is not possible to predict how surface
change status affects the long-term
function of an implant.
(2) The surface status of a particular
implant material may vary widely
depending on its preparation and
handling.
(3) The surface status of implants is crucial
for in vivo function and should
therefore be specific and standardized.
Osteo promotion:
It is the procedure to enhance the
formation of bone approximating the implant
surface using bone regeneration techniques (using
Polytetrafluoroethylene membrane).Bone growth
factors like Platelet-derived growth factor
(PDGF),Insulin-like growth factor (IGF), Platelet-
rich plasma,transforming growth factor (TGF –
B1)stimulates osteoprogenitor cells, enhance the
bone growth.
Stefini CM et al (2000) recommend
applying PDGF and IGF on the implant surfaces
afore placing in to cervical bed. This technique
showed improved wound healing and prompt
osseointegration.19
Indications:
1. Localized ridge augmentation preceding to
placement.
2. Situations with deficient alveolar bone
volume.
3. Treatment of peri implant bone defect.
Hyperbaric oxygen therapy (HBO):
HBO uplifts the partial pressure of oxygenin the
tissues. Granstrom G (1998) reported that HBO can
counteract some of the negative effect from
irradiation and act as a stimulator for
osseointegration.20
Role of HBO in Osseo integration:
1. Bone cell metabolism
2. Bone turnover
3. Implant border and the capillary network
in the implant bed (angiogenesis)
Osseointegration from the perspective of inter
molecular forces:
According to Albrektsson et al. Calcified
tissue extents within 50 A0 of the implant surface.
The metal surface is atremendously polarizable
titanium oxide coatingaltered by auxiliaryfilths
from the majority metal phase.21,22
With time the titanium oxide surface blends
with material from contiguous tissue, and a thin
70
layer of ground substance of cellular origin is
engaged on the implant so as to reinforce bone
tissue and titanium. The interactions are
electrostatic rather than hydrophobic or Van Der
Waals interactions. To a charged body the highly
polar oxide coatingdelivers a sturdily attractive
substitute to water. The numerous configurations of
titanium and oxygen possibly occur on such a
surface andoffer a widespread variety of adsorbent
locations to attract innumerableranges of charges
that possibly reside on the water – soluble ground
substance. V. Adrian Parsegian even expected spots
of strong interaction involving charge assemblages
such as those seen betweendimerizing proteins.23
Patient Selection and Preparation
The surgeon with judgement should carefully
evaluate the patient prior to recommending
implants. Evaluation should include:24,21
 Consultation.
 Oral examination
 Radiographic assessment.
 Diagnostic casts mounted on an
appropriate articulator.
Several matters merit attention during
evaluation stage:
 Age
 Medical status
 Patient motivation
 Concurrent drug therapy
 Informed consent
All patients are recalled at least annually for
examinations, which include the following:
 Patient’s opinion of the treatment result
 Bone characteristics
 State of bridge occlusion and stability
 State of oral hygiene
 Mechanical component conditions
CONCLUSION
The tooth is attached to its adjacent bone
by soft tissue, an extremely differentiated
periodontal membrane. It seems natural;
consequently, that early investigators of oral
implants appealed that the soft tissue seen around
their devices was a duplication of nature and
accordingly would lead to enduring function.
Conversely, certain histologic differences between
the proper ligament and the soft tissue were
observed in nearby metallic devices, this led to the
formulation of new nomenclature named
osseointegration. Even though implantologyis the
prime areas of the present research, a
comprehensive and thorough understanding of
bone–implant interface interactions is important for
the dental surgeon to give the patient finest
promising clinical care after understanding patients
bone characteristics’, thus enabling a treatment
plan which follows the principles and gives better
clinical expectedness.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this
article was reported.
REFERENCES
1. Albrektsson T, Jacobsson M: Bone-metal
interface in osseointegration. J Prosthet Dent
1987; 57:597.
2. Branemark, P.I. Osseointegration and its
the
experimental background. J Prosthet Dent
1983; 50(3):399-410
3. Zarb CA, Albrektsson T. Nature of implant
attachments. In: Branemark P-I, Zarb C,
Albrektsson T, editors. Tissue-integrated
prostheses osseointegration in clinical
dentistry. Chicago: Quintessence Publishing
Co.; 1985. pp. 88–98
4. Albrektsson, T, Johansson C. Osteoinduction,
osteoconduction and osseointegration. Eur
Spine J 2001;10(2): 96-101
5. Branemark R, Branemark PI, Rydevik B, Myers
RR. Osseointegration in skeletal reconstruction
and rehabilitation. A review. J Rehabil Res Dev
2001; 38(2):175–181
6. Albrektsson T, Berglundh T, Lindhe
J. Osseointegration: historic background and
current concepts. Clinical periodontology and
implant dentistry. 4. Copenhagen: Blackwell
Munksgaard, Oxford; 2003. pp. 809–820
71
7. Muhonen, Virpi. Bone–Biomaterial Interface.
The effects of surface modified NiTi shape
memory alloy on bone cells and tissue.
ActaUnivOul D 974, 2008
8. Rodan GA, Martin TJ. Role of Osteoblasts in
Hormonal Control of Bone Resorption – a
hypothesis. Calcif Tissue Int 1981 33:349-351
9. Lacey DL, Timms E, Tan HL, Kelley MJ, Dunstan
CR, BurgessT, Elliott R, Colombero A, Elliott G,
Scully S, Hsu H, Sullivan J, Hawkins N, Davy E,
Capparelli C, Eli A, Qian YX, Kaufman S, Sarosi I,
Shalhoub V, Senaldi G, Guo J, Delaney J & Boyle
WJ (1998) Osteoprotegerin ligand is a cytokine
that regulates osteoclast differentiation and
activation. Cell 93: 165-176
10. Misch CE. Contemporary Implant
Dentistry. 2nd ed. USA: Mosby
publication; 1999: 239-250
11. Albrektsson T, Brånemark PI, Hansson HA,
Kasemo B, Larsson K,Lundström I, McQueen D,
Skalak R: The interface zone of inorganic
implants in vivo: titanium implants in bone.
Ann Biomed Eng1983;11:1-27
12. Linkow LI. Implant dentistry today: a
multidisciplinary approach, Volume III. Italy:
Piccin Padua; 1990: 1513-18
13. FawadJaved,Hameeda Bashir Ahmed,
RobertoCrespi,Georgios E. Romanos. Role of
primary stability for successful
osseointegration of dental implants: Factors of
influence and evaluation. Interv Med Appl Sci.
2013; 5(4): 162–167
14. Muddugangadhar BC, Amarnath GS, Tripathi S,
Dikshit S, Divya MS. Biomaterials for dental
implants: An overview. Int J Oral
ImplantologyClin Res 2011;2(1):13-24.
15. Albrektsson T, Wennerberg A. Oral implant
surfaces: part 1 - review focusing on
View publication stats
topographic and chemical properties of
different surfaces and in vivo responses to
them. Int J Prosthodont. 2004;17:536-43.
16. Wennerberg A, Albrektsson T. Suggested
guidelines for the topographic evaluation of
implant surfaces. Int J Oral Maxillofac Implants
2000;15:331-344.
17. Carlsson L, R stlund T, Albrektsson B,
Albrektsson T. Removal torques for polished
and rough titanium implants. Int J Oral
Maxillofac Implants 1988; 3(1):21-24
18. BengtKasemo and JukkaLausmaa Material-
tissue Interfaces: The Role of Surface
Properties and Processes. Environ Health
Perspect. 1994; 102(5): 41–45
19. Stefani CM, Machado MA, Sallum EA, Sallum
AW, Toledo S, Nociti H Jr. Platelet-derived
growth factor/insulin-like growth factor-1
combination and bone regeneration around
implants placed into extraction sockets: a
histometric study in dogs. Implant Dent. 2000;
9(2):126-31.
20. GostaGranstromPlacement of Dental Implants
in Irradiated Bone: The Case for Using
Hyperbaric Oxygen. J Oral MaxillofacSurg
64:812-818, 2006
21. Albrektsson T and Lekholum U:
Osseointegration, Current state of the art –
Dent Clin North Am. 1987; 33: 537 – 557
22. Albrektsson T, Sennerby L. State of the art in
oral implants, J ClinPeriodontol 1991;18:478-
481.
23. Parsegian A V. Molecular forces governing tight
contact between cellular surfaces and
substrates. J Prosthet Dent 49:838-842, 1983.
24. Beyron H: Occlusion: Point of Significance in
planning restorative procedures. J Prosthet
Dent 1973; 30:641-649.
72