Running head: OSSEOINTEGRATION 1

Factors Aiding in Osseointegration

Marisa Martin & Haleigh Turley

Lamar Institute of Technology Dental Hygiene Program

IMPLANT SUCCESS 2

Abstract

Dental implants have become the modern solution for tooth loss compared to the former solution

of dentures, partials, and fixed bridges. Implants offer a more hassle free aesthetic solution to

missing teeth. Although the success rate for dental implants is quite respectable, there are still

instances where implant failure does occur. As oral health professionals, we should strive to

achieve the best for our patients. In this research paper, you will find ways to merge the gap

between implant failure and unsurpassed implant success. Aspects such as care for implants,

screw shape, material makeup, and texture of the implant are presented in this research. These

factors are significant in implantology because they each support osseointegration. Implant

failure will occur if there is little or no osseointegration, which makes these dynamics so

significant. The key objectives discussed will aid dental professionals in providing the best

experience for patients with dental implants.

IMPLANT SUCCESS 3

Factors Aiding in Osseointegration

At some point in their life most individuals will face the hassle and embarrassment of

tooth loss. Not only is this aesthetically problematic, but can also impair this persons overall

health.why? Over time, there have been modifications to help resolve the issue of tooth loss.

Today, the most advanced way to correct a missing tooth or teeth is by placing implants. Per

Baggi, Di Girolamo, Vairo, and Sannino, (2013) a dental implant is a biocompatible device,

surgically placed into mandibular or maxillary bone for supporting a prosthetic tooth crown, and

thus allowing the replace of the teeth lost due to caries, periodontal disease, injuries, or other

reasons (p.1). After the missing tooth is replaced, the success of the implant is the single most

important factor in treatment. In this essay the reader will better understand osseointegration and

why it is a key factor in implant success. It will also discuss contributing factors that aid

osseointegration and the adverse effects if the implants are not properly maintained.

The need for implants can depend on many factors and every case is different. Factors

that call for implant replacement include: an unsalvageable cariogenic tooth, wanting to only

replace one tooth, and aiding in denture and partial retention. There are several reasons to choose

to place an implant over traditional alternatives. By placing an implant you are only replacing

one tooth, this means you will not be drilling on what could be virgin teeth that are next to the

tooth you need to replace. Implants are also a wise alternative to patients who would not do well

wearing a partial. Placing one or two implants in place of partial benefits the patient because the

implants will be non-removable and the patient will be able to care for the implants just like their

natural teeth instead of having a foreign object. Implants can also be placed below a denture or

partial denture for stabilization and bone retention.

IMPLANT SUCCESS 4

Dental implants have a long history and have evolved throughout the years. Materials

used to make implants include cobalt and chromium, aluminum, stainless steel, and titanium.

Factors such as availability, biocompatibility, and the ability to osseointegrate are considered

when electing the proper implant material. Smeets et al. (2016) states the core of the vast

majority of dental implants is composed of titanium or titanium alloy due to the high

biocompatibility and corrosion resistance as well as the favorable mechanical properties (p. 2).

Titanium can be easily modified in order to facilitate osseointegration to form a better link

between the implant and bone. The core of the vast majority of dental implants is composed of

titanium or titanium alloy due to the high biocompatibility and corrosion resistance as well as the

favorable mechanical properties [5].11 Titanium can be easily modified in order to facilitate

osseointegration to form a better link between the implant and bone. Zirconium has become an

important non-metal material in the recent years when it comes to implants. This is due to the

increase in demand for aesthetic implants and more tooth-colored resolution compared to

titanium. Another important factor along with different types of material makeup, are the

variations of screw shapes and lengths. Smeets et al. (2016) shares the common implant shapes

are cylindrical or tapered (p. 1). Mangano et al. (2017) explains the macrotopography (implant

design) represents a very important element: it is believed that it can contribute significantly to

the primary implant stabilization (p. 2). Cylindrical implants provide a better outcome when in

comparison to other shapes of implants. Zheng, Yang, Hu, and Luo (2014) concluded in their

study results also revealed that among implants of the three shapes: cylindrical, tapered, stepped

implant, cylindrical implant showed the lowest peak stress of surrounding bone (p. 27). Less

stress on the bone promotes a higher likelihood of proper osseointegration, leading to a more

effective implant in the long run.

IMPLANT SUCCESS 5

Osseointegration is a structural and functional union of healthy bone and the implant.

Successful implants are based on the direct bone anchorage with the implant body. This means

that the bone and the implant make direct contact with no intervening connective tissues.

Osseointegration is best achieved when the surface texture of the implant has been modified to a

more porous state. Smeets et al. (2016) revealed surface characteristics like topography,

wettability, and coatings contribute to the biological processes during osseointegration by

mediating the direct interaction to host osteoblasts in bone formation (p. 1). Smeets (2016) also

stated until the 1990s, dental implants had primarily machined surfaces which implies a turned,

milled, or polished manufacturing process. Imperfections along these machined surfaces enable

osteogenic cells to attach and to deposit bone, thus generating a bone-to-implant interface (p. 2).

Surface characteristics contribute such an immense part in osseointegration, it is the most

important property in a dental implant in my opinion. Duraccio, Mussano, and Faga (2015)

explained various methods have been developed in order to create a rough surface and improve

the osseointegration of Titanium dental implants. The most common used are: Titanium plasma

spraying, blasting with ceramic particles, acid etching, and anodization (p. 4782).

Osseointegration is an important factor in implant survival, without osseointegration it can lead

to peri-implantitis and ultimately implant failure.

Other factors to help aid osseointegration are titanium plasma spraying, sandblasting the

implant, acid etching, and fluoride solutions. Titanium plasma spraying (TPS) is a method that

uses Titanium powder projected through a high temperature plasma torch to create Titanium

particles. These particles condense and fuse to form a uniform film surrounding the implant.

Duraccio, Mussano, and Faga (2015) claims the resulting coating has an average roughness of

around 7 lm, which increases the surface area of the implant (p. 4783). The increase in surface
IMPLANT SUCCESS 6

area provides additional area for bone to integrate with the implant surface, thus improving the

likelihood of successful osseointegration. Duraccio, Mussano, and Faga (2015) disclosed

however, particles of Titanium have sometimes been found in the bone adjacent to implants.

The presence of metallic wear particles from endosseous implants in the liver, spleen, small

aggregates of macrophages, and even in the para-aortic lymph nodes has also been reported (p.

4783). These metals are a possible artifact from wear or other factors and could become a

concern if ever found to produce adverse effects. Duraccio, Mussano, and Faga (2015) reveal

another approach for roughening the Titanium surface consists in blasting (also called grit-

blasting or sandblasting) the implants with hard ceramic particles (p. 4783). The ceramic

particles are checked for chemical stability and biocompatibility before being shot out against the

implant surface at high pressure. This technique produces a highly-roughened implant surface

which delivers a sturdier mechanical anchorage and fixation to the bone. Duraccio, Mussano, and

Faga (2015) explain the desired roughness can be set up by the particle size (p. 4783).

Particles of the blasting material often embed themselves into the implant and remain even after

ultrasonic cleaning, acid passivation, and sterilization. This is a possible hindrance for

ossification of the implant and the main downfall of this type of texturizing. One of the best and

most highly recommended techniques to alter the texture of an implant is by chemicals.

Duraccio, Mussano, and Faga (2015) states acid etching produces micro-pits on Titanium

surfaces with sizes ranging from 0.5 to 2 lm diameter (p. 4784). This nano-porous surface is

preferred over a highly roughened surface and promotes healing rate of bone tissue around the

implant. Duraccio, Mussano, and Faga (2015) reveal acid etching has been shown to greatly

enhance osseointegration (p. 4784). This acid etch produces a favorable micro-rough surface

that permits bone formation directly onto the implant surface. Duraccio, Mussano, and Faga
IMPLANT SUCCESS 7

(2015) also explain another approach involves treating Titanium dental implants in uoride

solutions (p. 4784). The fluoride ion creates a soluble TiF4 species when reacted with Titanium

to create a chemical surface treatment. Duraccio, Mussano, and Faga (2015) state this chemical

treatment of Titanium created both a surface roughness and uoride incorporation favorable to

the osseointegration of dental implants (p.4784). These acid etched and fluoride treated

implants have shown to establish a better quality bond between bone and implant. The only

downfall is that the chemicals may hinder the mechanical properties of the Titanium implant.

Duraccio, Mussano, and Faga (2015) disclosed for instance, acid etching can lead to hydrogen

embrittlement of the Titanium, creating micro cracks on its surface that could reduce the fatigue

resistance of the implants (p. 4784). All of these methods help with osseointegration although

there are a few downfalls. These methods need to be considered when the benefit for the patient

outweighs the risk to aid in successful implantation.

Some cases are ideal and the implant can be inserted straight into the bone where the

tooth/teeth are missing while others require bone grafting. Bone grafting is the use of cadaver

bone or artificial bone to fill a tooth socket. The reason for this is to aid in osseointegration and

increase the bone level in which the implant sits. In modern dentistry bone grafting is known as

the Gold Standard when it comes to regenerating bone in a socket. Recent studies have found a

new way to improve bone grafting by using bone marrow straight from the patients themselves. .

Narayan, Sumidha, Pankaj, and Sarita, (2015) declare these changes have been possible though

evolution of knowledge in different fields such as surgical procedures related to implants,

implant surface and design characteristics, and the concepts and mechanisms of periimplant bone

healing (p. 40-47).Implant therapy and bone grafting are important in dentistry because they are

more stable, last just as long if not longer than their alternatives, and cannot decay.
IMPLANT SUCCESS 8

Periodontitis is the leading cause for tooth loss across the nation. Cho et al. states

periodontitis, a common periodontal disease, is an inflammatory disease that damages soft

tissue and induces periodontium destruction (p. 1). This diminishes the quality of life that this

person experiences due to things such as impaired eating habits, impaired speech, and reduced

confidence. Peri-implantitis is equivalent to periodontitis in its destruction of the periodontium

but it is located around an implant. Saini, Giri, Saini, and Saini, (2014) discovered peri-

implantitis, like periodontitis, occurs primarily as a result of an overwhelming bacterial insult

and subsequent host immune response (p. 10). This can raise the risk of implant failure and

bone loss in the region. Peri-implantitis can be easily avoided by exercising proper oral care and

maintaining adequate plaque control. The patient with an implant should be taught how to

properly remove plaque and debris from around the implant as well as indicators that might

signal an infection near or around the implant. Removing the bacteria located around an implant

should be the patients first line of defense against potential implant failure. Peri-implant

mucosistis is the equivalent of gingivitis. If the peri-implant mucosistis is not halted and the

disease progresses it can lead to peri-implantitis and ultimately failure of the implant. This is the

same relation as gingivitis leads to periodontitis if the disease is not halted or controlled.

A large amount of implant failure derives from little to no incorporation of bone onto the

implant surface. This diminishes the lock designed to hold the implant in place inside of the

bone. Duraccio, Mussano, and Faga (2015) state the establishment of a strong biomechanical

bond between implant and jawbone is called osseointegration (p. 4780). Osseointegration is the

core of implant achievement. Duraccio, Mussano, and Faga (2015) discovered the success of

osseointegration depends on many factors including mainly medical status of the patient,

smoking habits, bone quality, bacterial contamination, immediate loading, and implant surface
IMPLANT SUCCESS 9

characteristics (p. 4781). Research over time has presented alternatives to aid in

osseointegration such as special construction, diverse screw shapes, and various methods to

produce a texture on the implant surface.

Dental implants have become an important treatment for the replacement of missing

teeth. Implants are a good solution to tooth replacement because they are stable and can last a

long time without too many problems. Implants have improved overall oral health over the past

30 years. Before implants, dentures were the go-to for patients who had experienced tooth loss.

Implants can not only be treated as your own teeth on an everyday basis but can also provide the

benefit of decreasing bone loss in the area compared to dentures. Implants are exceptionally

durable and have a very high success rate, although there are some instances where

osseointegration is not accomplished and implant failure occurs. In recent years implants have

increased in popularity and have become more successful and less time consuming to place.
IMPLANT SUCCESS 10

Resources

Saini, R., Giri, P. A., Saini, S., & Saini, S. R. (2014). Peri-Implantitis: A Review. Pravara
Medical Review, 6(4), 10-13.
Duraccio, D., Mussano, F., & Faga, M. (2015). Biomaterials for dental implants: current and
future trends. Journal Of Materials Science, 50(14), 4779-4812. doi:10.1007/s10853-
015-9056-3.
Cho, Y., Seol, Y., Lee, Y., Rhyu, I., Ryoo, H., & Ku, Y. (2017). An Overview of Biomaterials in
Periodontology and Implant Dentistry. Advances In Materials Science & Engineering, 1-
7. doi:10.1155/2017/1948241
Smeets, R., Stadlinger, B., Schwarz, F., Beck-Broichsitter, B., Jung, O., Precht, C., & ... Ebker, T.
(2016). Impact of Dental Implant Surface Modifications on Osseointegration. Biomed
Research International, 20161-16. doi:10.1155/2016/6285620
Baggi, L., Di Girolamo, M., Vairo, G., & Sannino, G. (2013). Comparative evaluation of
osseointegrated dental implants based on platform-switching concept: influence of
diameter, length, thread shape, and in-bone positioning depth on stress-based
performance. Computational And Mathematical Methods In Medicine, 2013250929.
doi:10.1155/2013/250929
Mangano, C., Shibli, J. A., Pires, J. T., Luongo, G., Piattelli, A., & Iezzi, G. (2017). Early Bone
Formation around Immediately Loaded Transitional Implants Inserted in the Human
Posterior Maxilla: The Effects of Fixture Design and Surface. Biomed Research
International, 1-8. doi:10.1155/2017/4152506
ZHENG, L., YANG, J., HU, X., & LUO, J. (2014). Three dimensional finite element analysis of
a novel osteointegrated dental implant designed to reduce stress peak of cortical
bone. Acta Of Bioengineering & Biomechanics, 16(3), 21-28. doi:10.5277/abb140303
Narayan, V., Sumidha, B., Pankaj, B., & Sarita, N. (2015). Dynamics of bone graft healing
around implants. Journal Of International Clinical Dental Research Organization, Vol 7,
Iss 3, Pp 40-47 (2015), (3), 40. doi:10.4103/2231-0754.172930