Mucogingival Surgery - JIACD · IntroducI ng Less pain for your patients.1 Less chair side time for...

The Journal of Implant & Advanced Clinical Dentistry

Volume 6, No. 7 october 2014

Mucogingival Surgery

Maxillary Anterior Immediate Implant

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References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

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IntroducIng

Less pain for your patients.1

Less chair side time for you.1

Mucograft® is a pure and highly biocompatible porcine collagen matrix. The spongious nature of Mucograft® favors early vascularization and integration of the soft tissues. It degrades naturally, without device related inflammation for optimal soft tissue regeneration. Mucograft® collagen matrix provides many clinical benefits:

For your patients...

Patients treated with Mucograft® require 5x less Ibuprofen than

those treated with a connective tissue graft1

Patients treated with Mucograft® are equally satisfied with esthetic outcomes when compared to connective tissue grafts2

For you...

Surgical procedures with Mucograft® are 16 minutes shorter in duration on average when compared to those involving connective tissue grafts1

Mucograft® is an effective alternative to autologous grafts3, is ready to use and does not require several minutes of washing prior to surgery

For full prescribing information, please visit us online at www.osteohealth.com or call 1-800-874-2334

References: 1Sanz M, et. al., J Clin Periodontol 2009; 36: 868-876. 2McGuire MK, Scheyer ET, J Periodontol 2010; 81: 1108-1117. 3Herford AS., et. al., J Oral Maxillofac Surg 2010; 68: 1463-1470. Mucograft® is a registered trademark of Ed. Geistlich Söhne Ag Fur Chemische Industrie and are marketed under license by Osteohealth, a Division of Luitpold Pharmaceuticals, Inc. ©2010 Luitpold Pharmaceuticals, Inc. OHD240 Iss. 10/2010

Mucograft® is indicated for guided tissue regeneration procedures in periodontal and recession defects, alveolar ridge reconstruction for prosthetic treatment, localized ridge augmentation for later implantation and covering of implants placed in immediate or delayed extraction sockets. For full prescribing information, visit www.osteohealth.com

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The Journal of Implant & Advanced Clinical DentistryVolume 6, No. 7 • october 2014

Table of Contents

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Oralife is a single donor grafting product processed in accordance with AATB standards as well as state and federal regulations (FDA and the states of Florida, California, Maryland and New York). Oralife allografts are processed by LifeLink Tissue Bank and distributed by Exactech Inc.1. Data on file at Exactech. 2. McAllister BS, Hagnignat K. Bone augmentation techniques. J Periodontal. 2007 Mar; 78(3):377-96. 3. Blum B, Moseley J, Miller L, Richelsoph K, Haggard W. Measurement of bone morphogenetic proteins and

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11 Correction of a Defective Dento-Gingival Complex Utilizing a Combined Periodontal Plastic-Restorative Approach: A Case Report Dr. Daniel Gober, Dr. Ira Freedman

19 Multidisciplinary Approach to Maxillary Anterior Dental Implant Therapy: A Case Report Sherman Lin

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Table of Contents

27 In Vivo ImmunohistochemicalInvestegation of Bone Deposition at Amelogenin Coated Ti Implant Surface Dr. Bushra Habeeb Al-Molla, Dr. Nada Al-Ghaban, Dr. Abbas Taher

39 The Future of Implant Dentistry:An Editorial Commentary Dr. Sachin Mittal, Dr. Pankaj Kharade, Dr. Bhushan Kumar, Dr. Charu Gupta Mittal

47 6 Year Survival and EarlyFailure Rate of 2,918 Implants with Hydrophobic and Hydrophilic Enossal Surfaces Dr. Olivier Le Gac, Ueli Grunder



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Tara Aghaloo, DDS, MDFaizan Alawi, DDSMichael Apa, DDSAlan M. Atlas, DMDCharles Babbush, DMD, MSThomas Balshi, DDSBarry Bartee, DDS, MDLorin Berland, DDSPeter Bertrand, DDSMichael Block, DMDChris Bonacci, DDS, MDHugo Bonilla, DDS, MSGary F. Bouloux, MD, DDSRonald Brown, DDS, MSBobby Butler, DDSNicholas Caplanis, DMD, MSDaniele Cardaropoli, DDSGiuseppe Cardaropoli DDS, PhDJohn Cavallaro, DDSJennifer Cha, DMD, MSLeon Chen, DMD, MSStepehn Chu, DMD, MSD David Clark, DDSCharles Cobb, DDS, PhDSpyridon Condos, DDSSally Cram, DDSTomell DeBose, DDSMassimo Del Fabbro, PhDDouglas Deporter, DDS, PhDAlex Ehrlich, DDS, MSNicolas Elian, DDSPaul Fugazzotto, DDSDavid Garber, DMDArun K. Garg, DMDRonald Goldstein, DDSDavid Guichet, DDSKenneth Hamlett, DDSIstvan Hargitai, DDS, MS

Michael Herndon, DDSRobert Horowitz, DDSMichael Huber, DDSRichard Hughes, DDSMiguel Angel Iglesia, DDSMian Iqbal, DMD, MSJames Jacobs, DMDZiad N. Jalbout, DDSJohn Johnson, DDS, MSSascha Jovanovic, DDS, MSJohn Kois, DMD, MSDJack T Krauser, DMDGregori Kurtzman, DDSBurton Langer, DMDAldo Leopardi, DDS, MSEdward Lowe, DMDMiles Madison, DDSLanka Mahesh, BDSCarlo Maiorana, MD, DDSJay Malmquist, DMDLouis Mandel, DDSMichael Martin, DDS, PhDZiv Mazor, DMDDale Miles, DDS, MSRobert Miller, DDSJohn Minichetti, DMDUwe Mohr, MDTDwight Moss, DMD, MSPeter K. Moy, DMDMel Mupparapu, DMDRoss Nash, DDSGregory Naylor, DDSMarcel Noujeim, DDS, MSSammy Noumbissi, DDS, MSCharles Orth, DDSAdriano Piattelli, MD, DDSMichael Pikos, DDSGeorge Priest, DMDGiulio Rasperini, DDS

Michele Ravenel, DMD, MSTerry Rees, DDSLaurence Rifkin, DDSGeorgios E. Romanos, DDS, PhDPaul Rosen, DMD, MSJoel Rosenlicht, DMDLarry Rosenthal, DDSSteven Roser, DMD, MDSalvatore Ruggiero, DMD, MDHenry Salama, DMDMaurice Salama, DMDAnthony Sclar, DMDFrank Setzer, DDSMaurizio Silvestri, DDS, MDDennis Smiler, DDS, MScDDong-Seok Sohn, DDS, PhDMuna Soltan, DDSMichael Sonick, DMDAhmad Soolari, DMDNeil L. Starr, DDSEric Stoopler, DMDScott Synnott, DMDHaim Tal, DMD, PhDGregory Tarantola, DDSDennis Tarnow, DDSGeza Terezhalmy, DDS, MATiziano Testori, MD, DDSMichael Tischler, DDSTolga Tozum, DDS, PhDLeonardo Trombelli, DDS, PhDIlser Turkyilmaz, DDS, PhDDean Vafiadis, DDSEmil Verban, DDSHom-Lay Wang, DDS, PhDBenjamin O. Watkins, III, DDSAlan Winter, DDSGlenn Wolfinger, DDSRichard K. Yoon, DDS

Editorial Advisory Board

Founder, Co-Editor in ChiefDan Holtzclaw, DDS, MS

Co-Editor in ChiefNick Huang, MD


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Wilcko et al

An understanding of the normal anatomy of the marginal soft tissue and its rela-tionship to tooth contour is indispens-

able for the proper restoration of moderate to severe recession defects in the presence of cervical tooth lesions. Both periodontal plas-tic surgery and restorative treatment must

be coordinated so that a properly contoured dento-gingival complex can be restored. The following case report demonstrates a unique approach to restoring a healthy mucogingival complex and highlights how the neglect to fol-low up with restorative treatment in a timely manner can reverse any surgical achievements.

Correction of a Defective Dento-Gingival Complex Utilizing a Combined Periodontal

Plastic-Restorative Approach: A Case Report

Dr. Daniel Gober1 • Dr. Ira Freedman2

1. Private Practice. Cedar Hurst, NY, USA

2. Associate Clinical Professor, Nova Southeastern University College of Dental Medicine

Fort Lauderdale, Florida, USA

Abstract

KEY WORDS: Mucogingival defect, gingival graft, restoration, healing


12 • Vol. 6, No. 7 • October 2014

Gober et al

INTRODUCTIONWhen recession defects are present simultane-ously with cervical tooth lesions, both the clini-cal crown and gingival contour are defective. Attempts to correct these defects with a single discipline can prove ineffective because of the interdependent relationship between the tooth contour and gingival architecture. The gingi-val architecture shape is influenced by the cer-vical tooth contour and the ability to achieve a properly finished cervical restoration presup-poses anatomically shaped and healthy mar-ginal soft tissue. A combined surgical-restorative approach must be employed and coordinated to correct the defect. The following case report demonstrates how a unique periodontal plastic surgical approach followed by properly executed restorative treatment can successfully convert a defective dento-gingival complex to one that displays excellent esthetics and physiologic contour, provided it is done in a timely manner.

CLINICAL PRESENTATIONA 60 year old female presented to the Nova Southeastern University College of Dental Medi-cine (NSU-CDM) Postgraduate Periodontol-ogy Clinic in May 2012 with a chief complaint, “these teeth look terrible!” She pointed to the maxillary right area. Teeth #’s 4,5, and 6 pre-sented with unaesthetic, poorly contoured and defective composite restorations which she reported had been placed over 10 years ago (Figure 1). There was severe recession mea-suring 6-7 mm, clefts of the gingival margin, and minimal attached keratinized tissue. The gingi-val zeniths came to a sharp point and lacked any semblance of the scalloped gingival morphology typically seen in a normal periodontium.1 These

teeth also had cervical defects on the anatomic crown which made it difficult to identify the cemento-enamel junction. Pocket depths in this region ranged from 2-3 mm with localized bleed-ing on probing. No clinical mobility was observed. Radiographs revealed interproximal bone levels within normal limits and no periapical pathology.

CASE ANALYSIS & TREATMENT RATIONALE

Studies have shown that when there is marginal tissue recession in the absence of interproximal tissue loss (Miller Class I and II), complete root coverage can be expected.2-6 In this case, how-ever, because these recession defects were con-tinuous with a cervical anatomic defect, a root coverage procedure by itself would not completely correct the clinical defect. A new restoration would also be required to properly restore the cer-vical third of the crown and recreate a physiologic dento-gingival interface. The patient was informed that a combined periodontal plastic-restorative approach was indicated in order to success-fully achieve a physiologic and an esthetic result.

The coronally advanced flap alone, or in com-bination with a sub-epithelial connective tissue graft, an allograft dermal matrix, or a xenograft collagen matrix has been successfully used to achieve root coverage in Miller Class I and II recession defects.7-10 They do not, however, predictably augment the zone of attached kera-tinized tissue.11 In cases which aim to achieve both root coverage and an increase in the zone of keratinized tissue, a two-step procedure has been recommended.12 This entails an initial sur-gery employing a free gingival graft followed by a coronally advanced flap after six weeks of healing. Although predictable, this procedure requires two


Gober et al

surgical procedures, increased morbidity asso-ciated with secondary healing at the free gingi-val graft donor site, and increased healing time.

We formulated an alternative approach that would allow us to achieve our surgical objectives and eliminate some of the disadvantages of the aforementioned two-step procedure. A closer look at the surrounding gingival tissues in this case revealed that there were wide zones of keratinized tissue adjacent to the recession defects. Also

noted were the “full” interproximal papilla which were indicative of a good blood supply and which could serve as excellent sites for anchoring the re-positioned tissue. We planned to utilize these wide zones of tissue by employing sliding pedicle grafts combined with a sub-epithelial connective tissue graft.13 In this manner all of our surgical objectives could be achieved in one surgery: root coverage, an increased thickness of gingival tissue and a wider zone of attached keratinized tissue.

Figure 1: Pre-operative view. Severe recession with poorly contoured and marginated composite restorations. Note how the gingival margins approach a sharp point at the zenith and the lack of attached keratinized tissue.

Figure 2: Incision design. Horizontal Incisions were made at the level of the estimated cement-enamel junctions and oblique incisions were made paralleling the direction to where the tissue would position.

Figure 3: Following flap reflection and root planing. The restorations were removed and the roots were planed to so that all convexity was reduced.

Figure 4: Harvested connective tissue graft.

14 • Vol. 6, No. 7 • October 2014

Gober et al

The patient was informed that once initial tissue healing is complete, the remaining cervical lesions would be restored with composite restorations.

SURGICAL PROCEDUREThe patient was given 2 g Amoxicillin and 800 mg of Ibuprofen prior to the procedure. A straight horizontal incision was made at the level of the estimated cemento-enamel junction just distal to #7 extending to the mesial surface of tooth #3. Oblique inci-sions were then made paralleling the direc-tion in which each pedicle was going to slide

(Figure 2). Full thickness flaps were elevated to the level of the buccal bone crest followed by partial thickness dissection apically leav-ing intact periosteum for increased blood supply and flap mobilization. The existing com-posite restorations were completely removed with a diamond bur.14 The exposed root sur-faces were then planed with a Rhodes Back-Action Periodontal Chisel in order to reduce the root prominences and bring them within the confines of the alveolar housing (Figure 3).

A sub-epithelial connective tissue graft mea-suring approximately 30 x 10 x 1.5mm was

Figure 5: Connective tissue graft secured to the papillae. Figure 6: Immediate post-op. Notice that the areas of graft intentionally left exposed inter-radicularly.

Figure 7: One month post-op demonstrating initial root coverage and tissue thickening.

Figure 8: Three month post-op. Surgical objectives achieved but scalloped gingival architecture still lacking.


Gober et al

Figure 9. Eight month post-op. Cervical defects still have not been restored. Site shows signs of regression with clefting of tissue and angular shape to the marginal gingiva.

Figure 10. Ten months post-op. Teeth have been restored and gingiva now demonstrates normal gingival architecture with no evidence of clefting

harvested from the right palate using a single-incision technique15-16 (Figure 4) and secured against the root surfaces and exposed inter-proximal bone and connective tissue by sutur-ing its coronal aspect to the undisturbed interproximal papillae with 5-0 chromic gut sutures (Figure 5). Periosteal releasing inci-sions were made to eliminate any tension of the buccal tissue. The pedicles were moved laterally and coronally to cover the graft on top of the root surfaces and were passively stabi-lized with a combination of simple interrupted and sling sutures. The portion of the connec-tive tissue graft overlying the root surfaces was covered with pedicle tissue and the portion of connective tissue in the inter-radicular areas was left exposed (Figure 6). A periodontal pack was placed over the surgical site in order to prevent trauma to or movement of the surgi-cal site during the initial stages of healing. The patient was instructed to rinse with Peridex twice a day for 2 weeks for plaque control and was prescribed Amoxicillin 500 mg q8h for 7 days and analgesic medication for pain control.

CLINICAL OUTCOMESPostoperative healing of the surgical site pro-gressed uneventfully. There were no signs of infection or delayed healing. After 1 month, the tissue was well adapted to the root surface in a coronal position but the tissue was bulky and uneven with indentations in the area where the incisions were made (Figure 7). After 3 months of healing, a dramatic increase in root coverage, tissue thickness, and attached kera-tinized tissue was evident. Despite the suc-cessful increase in tissue quantity and quality, an angular shape of the marginal gingiva was present; an anatomically normal scalloped shape of the gingival margin was still lack-ing (Figure 8). The patient was instructed to have the cervical third of her teeth restored with the expectation that with properly con-toured restorations, the marginal gingiva would adapt and acquire a scalloped architecture.

Four months later, the patient returned for a consultation regarding a different area of her dentition. She still had not gone to have her res-torations completed as previously instructed. At

16 • Vol. 6, No. 7 • October 2014

Gober et al

this time, there was an obvious change of the previously augmented gingiva. It was now com-pletely linear from the distal line angle of tooth #4 to the mesial line angle of tooth #5. The marginal gingiva of #6 was also flat. There was also a cleft of the interproximal tissue between teeth #4 and #5 (Figure 9). It appeared as if the previously grafted area was regressing.

Consideration was given to perform a gingivoplasty between teeth #4 and #5 with the intent of providing a fresh connec-tive tissue surface for new epithelial migra-tion to establish tissue continuity. Instead, we decided to delay this until after the res-torations were completed. We did not want to plasty the tissue without address-ing the underlying cause of this regression.

Shortly thereafter, composite restora-tions were completed in the NSU-CDM Pre-Doctoral Clinic. The tooth color, contour and emergence profile were restored. After receiv-ing her restorations, the patient presented back to the NSU-CDM Post-Graduate Peri-odontology Clinic for follow up and gingi-voplasty. At this time (10 months post-op), however, the previously flat and linear gingival contours and tissue cleft were no longer pres-ent. Instead, the gingival architecture was scal-loped and continuous, although the contour by #6 remained flat (Figure 10). The gingiva-plasty procedure was deemed unnecessary and the patient was satisfied with the final result.

CONCLUSIONThe above case demonstrates that there is an interdependent relationship between the cer-vical contour of the tooth and the form of the marginal gingiva. The gingiva relies heavily on

the cervical contour of the tooth for its shape and if the tooth contour is defective, the gin-giva cannot achieve its physiologic shape. A severe combined recession and cervical crown defect on teeth #4-6 was treated with slid-ing pedicles combined with a sub-epithelial connective tissue graft. This facilitated the achievement of root coverage, an increase in gingival thickness and an increase in keratin-ized tissue in one surgical visit. Despite the “surgical” success which was achieved, the gingival esthetics was lacking; the gingival mar-gins were flat and angular. As time progressed and the patient neglected to restore the cervi-cal lesions of her teeth, the previously aug-mented site exhibited signs of regression. It was only after the cervical third of the teeth were restored and proper contours were re-estab-lished that the marginal gingiva took on a more physiologic shape and esthetic appearance. ●

Correspondence:Daniel Gober, DDSSouth Island Periodontics & Implantology, PLLC657 Central AveCedarhurst, NY [email protected]


Gober et al

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Orban B. Clinical and histologic study of the surface characteristics of the

gingiva. Oral Surg Oral Med Oral Path 1948;1:827-841.

2. Miller PD. A Classification of Marginal Tissue Recession. Int J Periodontics Restorative Dent 1985;5:8-13

3. Kuis et al. Coronally Advanced Flap Alone or With Connective Tissue Graft in the treatment of Single Gingival Recession Defects: A Long-Term Randomized Clinical Trial. J Periodontol 2013; 84:1576-1585.

4. Huang L-H, Neiva R & Wang H-L. Factors Affecting The Outcomes of Coronally Advanced Flap Root Coverage Procedure. J Periodontol 2005;76:1729-1734.

5. Zucchelli G. & De Sanctis M Long-term outcome following treatment of multiple Miller Class I and II recession defects in esthetic areas of the mouth. J Periodontol 2005;76:2286-2292.

6. Langer B. & Langer L. Subepithelial Connetive Tissue Graft Technique for root coverage. J Periodontol 1985;56:715-720.

7. Woodyard JG, Greenwell H, Hill M, et al. The clinical effect of acellular dermal matrix on gingival thickness and root coverage compared to coronally positioned flap alone. J Periodontol 2004;75:44-56.

8. Barker et al. A comparative Study of root coverage using two different Acellular Dermal Matrix Products. J Periodontol 2010;81:1596-1603.

9. Tal H. Subgingival acellular dermal matrix allograft for the treatment of gingival recession. A case report. J Periodontol 1999;70:1118-1124.

10. Cardaropoli et al. Treatment of Gingival Recession Defects Using Coronally Advanced Flap With a Porcine Collagen Matrix Compared to Coronally Advanced Flap With Connective Tissue Graft: A Randomized Controlled Clinical Trial. J Periodontol 2012;83:321-328.

11. American Academy of Periodontology. Oral Reconstructive and Corrective Considerations in Periodontal Therapy. J Periodontol 2005; 76:1588-1600.

12. Bernimoulin JP, Luscher B, & Muhlemann HR. Coronally repositioned periodontal flap. Clinical evaluation after 1 year. J Clin Periodontol 1975;2:1-13.

13. Harris RJ. The connective tissue and partial thickness double pedicle. A predictable method of obtaining root coverage. J Periodontol 1992;63:477-486.

14. Goldstein et al. Coverage of previously carious roots is as predictable a procedure as coverage of intact roots. J Periodontol 2002;73:1419-1426.

15. Hurzeler M & Weng D. A single-incision technique to harvest subepithelial connective tissue grafts from the palate. Int J Peridontics Restorative Dent 1999;19:279-287.

16. Lorenzana E & Allen E. The single-incision palatal harvest technique: A strategy for esthetics and patient comfort. Int J Periodontics Restorative Dent 2000;20:297-305.

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Lin

The following case report demonstrates a multidisciplinary approach to restore a maxillary anterior dental implant. A com-

bination of restorative and orthodontic treat-ments were used to prepare the maxillary anterior site for dental implant placement. Fol-

lowing placement of the dental implant, peri-odontal crown lengthening was performed prior to final prosthetic restoration of the dental implant to achieve a harmonious and esthetic final result that has remained stable for 7 years.

Multidisciplinary Approach to Maxillary Anterior Dental Implant Therapy: A Case Report

Sherman Lin, DDS1

1. Private practice San Diego, California, USA

Abstract

KEY WORDS: Dental implants, maxilla, prosthetics, orthodontics


20 • Vol. 6, No. 7 • October 2014

Lin

CASE REPORTA 44 year old male in good physical condition was admitted to the clinic for a loose crown on left maxillary central incisor (#9). The patient also wished to have a better alignment and esthetics of his anterior teeth. Clinical and radiographic evaluation revealed a fractured tooth that was endodonticaly treated many years ago (Fig.1). The tooth was deemed non-restorable without undergoing crown lengthen-ing to expose more tooth structure. In doing so, however, the esthetic result would have been severely compromised. The patient agreed and chose to do other available options. Limited orthodontic therapy to better align the anterior teeth followed by extraction, immediate implan-tation and temporization of tooth #9 was pro-posed to the patient. The patient concurred and wished to proceed with the treatment plan.

The crown of tooth #9 was removed, an endodontic post was placed (Fig.2), and a tem-porary composite crown was fabricated on top of the post (Fig.3). Orthodontic brackets with a straight arch wire were placed from tooth #6 to tooth #11 to better align the anterior teeth (Fig.4). After 6 months of limited orthodontic treatment, the patient was satisfied with the alignment of his anterior teeth (Fig.5). Occlu-sion was checked and remained uneventful. The patient was then prepped for extraction of tooth #9 with immediate implantation. The orthodontic wire was removed and tooth num-ber #9 was carefully elevated out of the socket with minimal trauma by using periosteal instru-ments and piezoelectric unit. No gingival flap was raised. The socket was left well intact, with a slight buccal dehiscence detected. A tita-nium dental implant fixture (Dentium Company)

of 4.3mm body, 4.5 mm platform, and 10mm in length was inserted into the socket. Excellent primary stability was achieved. The surround-ing socket space around the fixture was filled with allograft bone graft material (Oragraft by Salvin Dental) that consists of 50/50 mixture of cortical and cancellous particles of 250 to 500 microns. A collagen membrane was sutured in place with 5-0 chromic gut resorbable suture to cover the socket opening and contain the graft within. Orthodontic arch wire was placed back on the anterior teeth with a temporary crown attached to the wire on the #9 position. A radiograph was taken following surgery (Fig.6),

Figure 1: Pre-surgical radiograph of tooth #9.


Lin

and the patient was dismissed with post-operative instructions and antibiotic regiment.

A ten day post-surgical check revealed uneventful healing for the patient. At 5 months after the initial placement of implant, the patient was recalled for restorative procedure of implant #9. The orthodontic archwire was removed and a round tissue punch of 4.5 mm in diameter was used to uncover the implant. A final impression was taken at implant level with a transfer post. Gingival depth was measured, and an appropriate shade was selected. The case was sent to a laboratory for fabrication of the final crown. The patient was dismissed with a temporary abutment and a composite tem-porary crown. The orthodontic arch wire was reattached to the anterior teeth. Ten days later patient was readmitted for final cementation of the crown. A 4.5mm diameter dual abutment (Dentium) and gingival height of 2.5mm was screw retained on to the fixture and the final

crown was cemented on to the abutment (Fig7). Gingival recontouring of teeth #’s 7, 8, and 10 was accomplished with an electrosurgical unit for more esthetic gingival architecture (Fig.8). All orthodontic apparatus were removed and the teeth were polished. A radiograph was taken for evaluation prior to cementing to check the fit. The patient was dismissed with a prefab-ricated orthodontic retainer and instructions for care. Patient was scheduled to be checked at every 6 month interval during the hygiene recall visits. A 3year (Fig.9), and a 7 year post- op radiograph and photograph was taken and shown on record (Fig.10, 11). The patient was very pleased with the final treatment result. The recovery phase of implant therapy was unevent-ful. Radiographic analysis of subsequent years showed well preserved crestal bone level. Dense cortical formation of the crestal bone surrounding the implant was also evident ●

Figure 2: Endodontic post insertion on tooth #9. Figure 3: Temporization of tooth #9 after post insertion.

22 • Vol. 6, No. 7 • October 2014

Lin

Figure 4: Radiograph of orthodontic archwire placement.

Figure 5: Anterior tooth alignment after 6 months of orthodontic treatment.

Figure 6: Radiograph following dental implant and bone allograft placement at site #9.


Lin

Figure 7: Radiograph immediately following delivery of abutment and permanent crown.

Figure 8: Gingivectomy of teeth 7, 8, and 10.

Figure 9: Radiograph at 3 years after treatment.

24 • Vol. 6, No. 7 • October 2014

Lin

Figure 10: Radiograph at 7 years after treatment.

Figure 11: Clinical presentation at 7 years after treatment.

DisclosureThe author reports no conflicts of interest with anything mentioned in this article.

Correspondence:Dr. Sherman Lin12925 El Camino Real J-28San Diego, California, USA 92130Tel: 818-995-7971

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Wilcko et al

Background: A dental implant is an artificial tooth root fixed into the jaws to hold a replacement tooth or bridge. Functional surface modifications by organic material such as amelogenin coating seem to enhance early peri-implant bone formation. The aim of the study was to study the expression of osteocalcin and collagen I as bone forma-tion markers in amelogenin coated and uncoated implant in interval periods ( 1,2,4 and 6 weeks).

Materials and Methods: Commercially pure Titanium (cpTi) implants, coated with amelogenin protein, were placed in the tibias of 40 New Zea-land white rabbits, histological and immunohis-tochemical tests for detection of expression of osteocalcin and collagen I were performed on all the implants of both control and experimental groups for (1,2,4 and 6 weeks) healing intervals.

Results: Histological finding for coated titanium implant with amelogenin illustrated an early bone formation, mineralization and maturation in com-parison to control. Immunohistochemical finding showed that positive reaction for osteocalcin and collagen I was expressed by osteoblast cells (OB)at implants coated with amelogenin, indicating that bone formation &maturation was accelerated by adding biological materials as a modification modality of implant surface.

Conclusion: the present study con-cludes that coating of implants with amelogenin showed increment in osseo-integration in a short interval period.

In Vivo Immunohistochemical Investegation of Bone Deposition at Amelogenin

Coated Ti Implant Surface

Dr. Bushra Habeeb Al-Molla1 • Dr. Nada Al-Ghaban2 • Dr. Abbas Taher3

1. Lecturer Oral Histology& Biology, College of Dentistry, Kufa University, Iraq

2. Assistant Professor Oral Histology& Biology, College of Dentistry, Baghdad University, Iraq

3. Professor & Dean of College of Dentistry Kufa University, Kufa Iraq

Abstract

KEY WORDS: Amelogenin, dental implant, biochemical bone markers, osteocalcin, collagen I, osseointegration.


28 • Vol. 6, No. 7 • October 2014

INTRODUCTIONDental implant is an artificial tooth root fixed into the jaws to hold a replacement tooth or bridge.1 Titanium is widely used for dental implants because of its biocompatibility, mechanical strength and plasticity for prosthetic design. When titanium is implanted into live bone tis-sue, it actually integrates with the bone.2 Bone healing around implants involves the activa-tion of a sequence of osteogenetic, vascular and immunological events that are similar to those occurring during bone healing.3 Osseo-integration refers to the growth of bone as it incorporates surgically implanted materials.4 In order to enhance bone formation, implants have been coated with bone specific biomol-ecules.5 Many kinds of bioactive materials used to coat the surfaces of dental implants.6

Amelogenins are the major organic compo-nent in the enamel matrix of developing teeth and plays an important role in enamel biomin-eralization.7 Amelogenins are hydrophobic enamel proteins secreted by ectodermal cells, ameloblasts, during enamel. Osteoblasts, odon-toblasts and bone marrow stromal cells also express the amelogenin gene, suggesting that osteoblasts and odontoblasts come into con-tact with full-length amelogenin and amelogenin cleavage products.8 Cells treated with tyrosine-rich amelogenin peptide (TRAP) were evaluated for cell proliferation, gene expression for osteo-calcin. Low molecular mass amelogenin-related polypeptides extracted from mineralized dentin have the ability to affect the differentiation path-way of embryonic muscle fibroblasts in culture and lead to the formation of mineralized matrix in vivo implants.9 Amelogenins self-assemble to form a non-soluble protein scaffold in the

form of nanospheres which are thought to play a central role in controlling crystal growth and tissue architecture during enamel formation.10

Osteocalcin, the γ-carboxyglutamic acid-containing protein, which in most species is the predominant noncollagenous protein of bone and dentin, has been postulated to play roles in bone formation and remodel-ing.11 Osteocalcin is secreted solely by osteo-blasts and is pro-osteoblastic, or bone building, by nature. It is also implicated in bone min-eralization and calcium ion homeostasis.12

Type I collagen (COL1) is the major organic component of the mineralized bone matrix. By immunohistochemical staining they could detected its expression in bone matrix.13 Type I collagen fibers are the most abundant organic constituent and they may be involved in aligning the mineral crystals.14

MATERIAL & METHODSMaterials

1. 80 screw shaped implants, 3.5mm in diameter & a total length of 8mm ( threaded part is 5mm & smooth part is 3mm)

2. Amelx (amelogenin) protein (His tag) (ab139212) Abcam UK.

3. Anti-Osteocalcin antibody (ab13418) Abcam UK

4. Anti-collagen-I antibody(ab90395) Abcam UK

5. Detection Kits System (ab 94740) Abcam UK

6. Protein Block 15 Enhancer 7. Naphthol Phosphate 8. Fast Red Chromogen 9. AP-Conjugate 10. Co-factor Enhancer

Al-Molla et al


MethodsForty New Zealand rabbits aged 10-12 months were used in this study, they were divided into four groups for (1, 2, 4 and 6 weeks) healing intervals,10 animals for each period. Animals were generally anaesthetized & atraumatic sur-gical technique was performed to prepare two holes in the tibia, amelogenin coated implant was inserted in one hole &uncoated implant

(control) placed in the second one. All tis-sue specimens, samples and controls, were fixed in 10% neutral formalin and processed in a routine paraffin blocks. Each formalin-fixed paraffin-embedded specimen had serial sec-tions were prepared as follows: 5μm thick-ness sections were mounted on clean glass slides for routine Haematoxylin and Eosin staining (H&E), from each block of the stud-

Figure 1: Thread show bone trabeculae in A –implant at 1w interval, H&E X 20.

Figure 2: Thread show no bone trabeculae in uncoated implant at 1w interval, H&E X 20.

Figure 3: Thread show thick bone trabeculae in A – coated implant at 2w interval, H&E X 20.

Figure 4: Thread show bone trabeculae in uncoated implant at 2w interval, H&E X 20.

Al-Molla et al

30 • Vol. 6, No. 7 • October 2014

ied sample and the control group for histo-pathological re-examination. Other 4 sections of 5μm thickness were mounted on positively charged microscopic slides to obtain a greater tissue adherence for immunohistochemistry. The procedure of the IHC assay adapted by this study was carried out in accordance with the manufacturer instructions (Abcam UK).

RESULTS A: Histological examination1 week postoperativelyIn the amelogenin coated implant, In the thread area bone trabeculae appeared and the osteo-blast cells arranged in a single raw at the edges of these trabeculae, osteocytes were occupying their large lacunae and they were more in number in the newly formed bone (figure1), in uncoated

Figure 5: Thread show mature bone in A –coated implant at 4w interval, H&E X 20.


Figure 7: Thread mature bone in A -coated implant at 6w interval, H&E X 20.

Figure 8: Thread show thick bone trabeculae in uncoated implant at 6w interval, H&E X 20.

Al-Molla et al


implants the marrow space showed large number of fatty tissue with granulation tissue with large blood vessels, no woven bone shown (figure2).

2 weeks postoperativelyIn amelogenin coated implants histological find-ing showed threads represented the screw shape with thick bone trabeculae and reticulo-fiber tissue in between them, large number of

osteocytes and osteoblasts appeared in (fig-ure 3), in control group, a number of active osteoblast and progenitor cells scattered within woven bone, with few thin bone trabeculae involve preosteocytes and osteocytes (figure 4).

4 weeks postoperativelyAmelogenin coated implants show Calci-fied bone tissue was viewed at implant site

Figure 5: Thread show mature bone in A –coated implant at 4w interval, H&E X 20.


Figure 7: Thread mature bone in A -coated implant at 6w interval, H&E X 20.

Figure 8: Thread show thick bone trabeculae in uncoated implant at 6w interval, H&E X 20.

Al-Molla et al

32 • Vol. 6, No. 7 • October 2014

Figure 9: Strong positive expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes, progenitor cells and extracellular matrix in A-coated implant, red stain with counter stain hematoxylin, X 40.

Figure 10: Negative expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes, progenitor cells and extracellular matrix in uncoated implant, red stain with counter stain hematoxylin, X 40.

Figure 11: Weak positive expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes, A-coated implant, red stain with counter stain hematoxylin, X 40.

Figure 12: Strong positive expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes, progenitor cells and extracellular matrix in uncoated implant, red stain with counter stain hematoxylin, X 40.

after 2 weeks of implantation, few osteo-blasts lined the small cavities presented with large number of osteocytes (figure 5), con-trol one show threads formed at the site of the implant with thin bone trabeculae and reticulofiber tissue in between them (figure 6).

6 weeks postoperativelyMature bone thread at the site of the implant coated with amelogenin appeared (figure 7), bone deposit around uncoated implant (control) in a form of thread with thick bone trabeculae in control group (figure 8).

Al-Molla et al


Figure 13: Negative expression AP- conjugate red stain for localization of OC in A-coated implant, red stain with counter stain hematoxylin, X 40.

Figure 14: Moderate positive expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes in uncoated implant, red stain with counter stain hematoxylin, X 40.

Figure 15: Negative expression AP- conjugate red stain for localization of OC in A-coated implant, red stain with counter stain hematoxylin, X 40.

Figure 16: Weak positive expression AP- conjugate red stain for localization of OC in osteoblasts, osteocytes in uncoated implant, red stain with counter stain hematoxylin, X 40.

B: Immuno-histochemical examination for: - osteocalcin(OC)expression1week postoperativelyThe OC expression was strong positive in the osteoblasts, osteoclasts, osteocytes, progenitor cells and extracellular matrix in A-coated implants

(figure 9). Negative expression of OC monoclo-nal antibody on uncoated implant in progeni-tor, fatty cells and extracellular matrix (figure 10).

Al-Molla et al

34 • Vol. 6, No. 7 • October 2014

Figure 17: View for strong positive AP- conjugate red stain for localization of COLL1 in thread site of A-coated implant, red stain with counter stain hematoxylin, X 20.

Figure 18: View for weak positive AP- conjugate red stain for localization of COLL1 in thread site of uncoated implant, red stain with counter stain hematoxylin, X 20.

Figure 19: View for weak positive AP- conjugate red stain for localization of COLL1 in thread site of A-coated implant, red stain with counter stain hematoxylin, X 20.

Figure 20: View for strong positive AP- conjugate red stain for localization of COLL1 in thread site of uncoated implant, red stain with counter stain hematoxylin, X 20.

2 weeks postoperativelyThe OC expression was negative in them, while still weak positive in some osteoblasts cells and extracellular matrix in marrow space in A-coated implants (figure 11). That OC expression was strong positive in the osteoblasts, osteo-clasts, osteocytes in control group (figure 12).

4 weeks postoperativelyOC localization was negative expression in osteoblasts and osteocytes in A-coated (fig-ure 13) while in control group the OC local-ization was moderate positive expression in osteoblasts and osteocytes, progeni-tor cell and extracellular matrix (figure 14).

Al-Molla et al


Figure 21: View for negative expression AP- conjugate red stain for localization of COLL1 at 4 weeks interval of A-coated implant, red stain with counter stain hematoxylin, X 20.

Figure 22: View for moderate positive AP- conjugate red stain for localization of COLL1 in thread site of uncoated implant, red stain with counter stain hematoxylin, X 2.0.

Figure 23: View for weak positive AP- conjugate red stain for localization of COLL1 in thread site of uncoated implant, red stain with counter stain hematoxylin, X 20.

6 weeks postoperativelyOC localization was negative expres-sion in osteoblasts and osteocytes in coated (figure 15) and OC localization was negative expression in osteoblasts and osteocytes in the uncoated (figure 16).

C: Collagen I expression1 week postoperativelyImmunohistochemical staining with COLL1 showed was strong positive expression in the osteoblasts, osteoclasts , osteocytes, progenitor cells and extracellular matrix in A-coated implant (figure 17) while the uncoated implant showed weak positive expression of COLL1 (figure 18).

2 weeks postoperativelyAt 2 weeks of healing periods and when there was increased in osteocytes and osteoblasts, the COLL1 expression was weak positive in them, and strong positive expression in extra-cellular matrix with progenitor cells in marrow space in A group (figure 19). Uncoated implant, the COLL1expression was strong positive in the osteoblastes, osteoclasts, osteocytes, pro-genitor cells and extracellular matrix (figure 20).

4 & 6 weeks postoperativelyNegative expression in A group in 4 and 6

Al-Molla et al

36 • Vol. 6, No. 7 • October 2014

Al-Molla et al

weeks intervals (figure 21). For uncoated implants, COLL1 localization was moder-ate positive expression in osteoblasts at 4 weeks interval and weakly positive expres-sion at last interval period (figures 22, 23).

DISCUSSIONThe results of this study showed that osseoin-tegration can be obtained when implants are inserted in a living bone and when a suitable biological environment for bone formation is cre-ated. The strength of the bond between osseo-integrated implant and the bone increases with time since during healing and remodeling, an increase in the degree f bone implant contact and maturation of bone occurs, this result coincides with finding of Wennerberg and Albrektsson.15

Successful attachment on artificial surface is prerequisite for inducing new bone formation locally at the site of implantation. Protein-coated surfaces may influence the biocompatibility of implant materials by initiating and supporting osteogenesis.16 Januario et al,17 observed a pro-cess of cortical thickening which they called corticalization. In studied groups of the pres-ent study, following insertion of a biocompat-ible cpTi implant into cortical bone the implants were not submitted to any load, in most of the implants the presence of such thicken-ing (corticalization” process) was observed, in agreement with the finding of Hammad et al.18

The uncoated implants, at one week dura-tion, showed embryonic connective tissue with active collagen fiber deposition were showed around implant this result agreement with find-ing of Jamel,19 who reported that within one week, embryonic connective tissue with active collagen fiber around the implant which rep-

resent organic constitution of bone would be formed. Uncoated Ti implant in rabbit tibia after two weeks of implantation shows a number of active osteoblast and progenitor cells scattered within woven bone, with few thin bone trabecu-lae. These finding supported by the result of Nie-haus,20 who found more osteons had uptake of bone marker on day 14 than at any other time during the study new bone was visible within the area between the threads of the control screws. At four weeks duration, according to the study conducted by Yoshinari,21 the micrographs of the implant–bone interfaces at 4 weeks after implan-tation show that bone tissue has grown on the implant surface., while after six weeks duration thick bone trabeculae and large number of bone forming cells on the border of bone trabeculae and this agree with Depprich,22 who found that when the healing period was near the 6 weeks,

The amelogenin (A) coated implants at one and two weeks duration, the histological view illustrates woven bone in the thread area which was followed the screw shape with bone tra-beculae appeared and the osteoblast cells arranged at the periphery of these trabeculae, osteocytes were embedded within the newly formed bone. These result were indicated that the amelogenin has good biocompatibility that enhances osteoblast precursor cell in bone mar-row to activate and to differentiate to a special-ized cell. This result agreement with Nakayama23 and Shimizu,24 who showed that the Recombinant amelogenin (1μg/ml) increased bone sialopro-tein mRNA levels which is an early phenotypic marker of osteoblast differentiation. At four and six weeks duration, amelogenin expression in osteocytes, osteoblasts, osteoclasts, bone mar-row cells, and cartilage cells, together with the

Al-Molla et al


Al-Molla et al

accumulating data indicating amelogenin induc-tion of osteogenesis and inhibition of osteo-clastogenesis. Hatakeyama et al.,25 suggest that amelogenin has a crucial role in the pro-cesses of bone development and remodeling.

Osteocalcin(OC) expression was strong posi-tive in the active mitotic osteoblast, and progenitor cells in all experimental groups at 1 week interval. OC seems to have a role in the early stages of bone formation and some studies by Al-Ghani et al.,26 suggest that is a chemotactic for osteoclast and regulate osteoblast activity too. Our results shows a greater number of positive cells indicate a more rapid tissue reaction on implant surface. Novaes et al.,27 who reported that osteocalcin, as one of the important indicators of osteogenic dif-ferentiation and bone tissue formation, have been shown to express at higher levels on modified titanium surfaces. In vitro studies demonstrated that mRNA of collagen type I is expressed during the initial period of proliferation and extracellular-matrix biosynthesis, since it is hypothesized that enhanced expression of osteogenic markers in vitro leads to more and more expeditious bone for-mation at the bone–biomaterial interface in vivo(28). Once differentiated, osteoblasts produce several proteins, such as type I collagen, osteocalcin, and alkaline phosphatase, which will generate newly formed bone,29 and then undergo differentiation under an osteocyte phenotype Therefore, Coll1 is a bone marker associated with the differentiation of osteocyte,30 and this agree with the results in this study where the osteocyte express Coll1. ●

Correspondence:Dr. Abbas [email protected]

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.References 1. Alghamdi H, Cuijpers V, Wolke J, Beucken J and Jansen J. Calcium-phosphate-

coated Oral Implants Promote Osseointegration in Osteoporosis. J Dental Research,2013.

2. Naitoh M, Nabeshima H, Hayashi H, Nakayama T, Kurita K and Ariji E. Postoperative Assessment of Incisor Dental Implants Using Cone-Beam Computed Tomography. J Oral Implantology, 2010; 36(5): 377-384.

3. Dimitriou R, Babis GC, Biomaterial osseointegration Enhancement with biophysical stimulation. J Musculoskelet Neuronal Interact, 2007; 7(3):253-65.

4. Bougas K, Jimbo R, Xue Y, Mustafa K and Wennerberg A. Implant Coating Agent Promotes Gene Expression of Osteogenic Markers in Rats during Early Osseointegration. International Journal of Biomaterials,2012; 9

5. Geng-Sheng C, Yu C, Kun W, Fang-Rong D and Ning L. Repressive but not activating epigenetic modifications are aberrant on the inactive X chromosome in live cloned cattle.Develop. Growth Differ, 2009; 51, 585–594.

6. Oida, Nagano T, Yamakoshi Y, Ando H, Yamada M and Fukae M. Amelogenin gene expression in porcine odontoblasts. J Den Res, 2002; 81(2): 103–108.

7. Haze A, Taylor A, Blumenfeld A, Rosenfeld E, Leiser Y, Dafni L, Shay B, Gruenbaum-Cohen Y, Fermon E, Haegewald S, Bernimoulin J and Deutsch D. Amelogenin expression in long bone and cartilage cells and in bone marrow progenitor cells. Anat Rec,2007; 290: 455–460

8. Veis A, Tompkins K, Alvares K, Wei K, Wang L, Wang X, Brownell A, Jengh S and Healy K. Specific Amelogenin Gene Splice Products Have Signaling Effects on Cells in Culture and in Implants in Vivo. J Bio Chem, 2000; 275, 41263-41272.

9. Du C, Falini G, Fermani S, Abbotat C and Moradian-Oldak J. Supramolecular assembly of amelogenin nanospheres into birefringent microribbons. Science, 2005; 307: 1450–1454.

10. Oida, Nagano T, Yamakoshi Y, Ando H, Yamada M and Fukae M. Amelogenin gene expression in porcine odontoblasts. J Den Res, 2002; 81(2): 103–108.

11. Lee N, Sowa H, Hinoi E, Ferron M, Ahn J, Confavreux C, Patrick J, McKee M, Jung D, Zhang Z, Kim J, Mauvais-Jarvis F, Patricia P and Karsenty G. Endocrine regulation of energy metabolism by the skeleton. Cell, 2007;130(3):456-469.

12. AL-Zubaydi T, Al-Hijazi, and Al-Ghani B. In vivo study of the effect of collagen protein coated implant as compared with implants coated with a mixture of partially stabilized zirconia and collagen on Osseointegration. J Bagh College Dentistry,2011; 23(special issue).

13. Sun P, Wang J, Zheng Y, Fan Y and Gu Z. BMP2/7 heterodimer is a stronger inducer of bone regeneration in peri-implant bone defects model than BMP2 or BMP7 homodimer. Dental Materials J, 2012; 31(2): 239–248

14. Ogata Y. Adverse host tissue response in loosening of dental implants proteolytic enzymes and peri-implant destruction. Periodontal Research,2008;43(2):127-135.

15. Wennerberg A and Albrektsson T. On implant surfaces: a review of current knowledge and opinions. Int J Oral Maxillofac Implants, 2010;25:63-74.

16. Sodek J and Cheifitz S. Molecular regulation of osteogenesis. In: Davies JE, editor. Bone engineering. Toronto, Canada: em squared In, 2000; 31–43.

17. Januario A, Sallum E, Toledo S, Sallum A and Nociti F. Effect of Calcitonin on Bone Formation Around Titanium Implant. A Histometric Study in Rabbits. Braz Dent J, 2001; 12(3): 158-62.

18. Hammad TI, Al-Ameer SS, Al-Zubaydi TL. Histological and mechanical evaluation of eletrophoretic bioceramic deposition Ti-6Al-7Nb dental implants College of dentistry, Univ. of Baghdad 2007.

19. Jamil B. Role of biomaterial collagen coated titanium implants surface on expression of bone protein markers and osseointegratin reaction, in comparison to titanium implant coated with zirconia. PhD thesis, collage of Dentistry, University of Baghdad, 2011.

20. Niehaus A, Anderson D, Samii V, Weisbrode S, Johnson J, Noon M, Tomasko D and Lannutti J. Effects of orthopedic implants with a polycaprolactone polymer coating containing bone morphogenetic protein-2 on osseointegration in bones of sheep. Am J Vet Res,2009; 70:1416–1425.

21. Yoshinari M, Oda Y, Inoue T, Matsuzaka K and Shimono M. Bone response to calcium phosphate-coated and bisphosphonate immobilized titanium implants.Biomaterials, 2003; 23 :2879–2885.

22. Depprich R, Zipprich H, Ommerborn M, Naujoks C, Wiesmann H, Kiattavorncharoen S, Lauer H, Meyer U, Kübler N and Handschel J. Osseointegration of zirconia implants compared with titanium: an in vivo study. Head & Face Medicine, 2008; 4:30

23. Nakayama Y, Yang L, Mezawa M, Araki S, Li Z, Wang Z, Sasaki Y, Takai H, Nakao

S, Fukae M and Ogata Y. Effects of porcine 25 kDa amelogenin and its proteolytic derivatives on bone sialoprotein expression. J Perio Res,2010;45(5):602-611.

24. Shimizu E, Nakajima Y, Kato N, Nakayama Y, Samoto H and Ogata Y. Regulation of Rat Bone Sialoprotein (BSP) gene transcription by enamel matrix derivative. J Periodontol, 2004;75:260–267.

25. Hatakeyama J, Sreenath T and Hatakeyama Y. The receptor activator of nuclear factor-kappa B ligand-mediated osteoclastgenic pathway is elevated in amelogenin null mice. J Biol Chem, 2003;278:35743–35749.

26. Al-Ghani B, Al-Hijazi A and AL-Zubaydi T. In vivo immunohistochemical investegation of bone deposition at collagen coated Ti implant surface. J Bagh College Dentistry, 2011; 23.

27. Novaes A, Souza S, Barros R, Pereira K, Iezzi G and Piattelli A. Influence of Implant Surfaces on Osseointegration. Braz Dent J,2010; 21(6): 471-481

28. Wilmowsky V, Bauer S, Roedl S, Neukam F, Schmuki P and Schlegel K. Effect of diameter of anodic TiO2 nanotubes on bone formation. Clin. Oral Impl. Res, 2012; 23: 359–336

29. Katagiri T and Takahashi N. Regulatory mechanisms of osteoblast and osteoclast differentiation. Oral Dis, 2002; 8:147-159.

30. Bonewald L. Osteocytes as dynamic multifunctional cells of growth factors and cytokines on osteoblast differentiation. Periodontol, 2006; 41: 48-72.

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Mittal et al

Many think of dental implant procedures as an advanced futuristic development in dentistry but conventional dental implants

are not the ideal solution for replacing missing teeth as the healing process extends from 3-9 months and there is an additional failure rate varying from 5 to 10%, depending on patients’ general health as well as the quantity and quality of the bone at the

recipient site. Moreover, some dental implants are estimated to last for about 15-20 years in general. Despite much advancement in implant technol-ogy conventional titanium implants do not provide a long-lasting solution for a missing tooth. In this article different futuristic aspects of dental implan-tology are discussed which will completely change this most advanced aspect of dental treatment.

The Future of Implant Dentistry: An Editorial Commentary

Dr. Sachin Mittal1 • Dr. Pankaj Kharade2 Dr. Bhushan Kumar3 • Dr. Charu Gupta Mittal4

1. Oral and Maxillofacial Surgeon & Implantologist, Hisar, Haryana, India.

2. Prosthodontist and Fellow, Dept of Dental & Prosthetic Surgery & Oncology, Tata Memorial Hospital, Mumbai, India.

3. Graded specialist (prosthodontist) in Indian army corp.

4. Dental Surgeon with Haryana Government, India.

Abstract

KEY WORDS: Dental implants, surface modifications, metal free dental implants, stem cells


*Disclaimer: The following is an editorial commentary. The opinions expressed in this article are those of the Authors and DO NOT reflect the views of the Journal of Implant & Advanced Clinical Dentistry, its Edi-tors, or advertisers.

40 • Vol. 6, No. 7 • October 2014

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FUTURE CONSIDERATIONS FOR IMPLANT DENTISTRY

Surface ModificationsSurface modification6 is the new frontier in implant dentistry research. Bioengineer-ing, tissue engineering and nanotechnology are expected to revolutionize implant den-tistry in a dramatic way over the next two decades. The primary focus of these emerg-ing research frontiers will be aimed at explor-ing innovative ways of enhancing bone regeneration and osseointegration, modulation of the host immune response, reducing heal-ing time and preventing peri-implant disease.

Bioengineering is clearly setting the tone in innovative research.7 The arrival of nanotechnol-ogy has opened up new opportunities for the development and manipulation of implant sur-face topography. Bio mimicking the nano pat-terned surface topography of the extracellular matrix components of bone tissue could pro-mote cell attachment, proliferation and differenti-ation, thereby significantly enhancing new bone formation and attachment to implant surfaces.

Tissue engineering, and in particular mes-enchymal stem cell therapy, has the potential to offer enormous opportunities in the areas of alveolar bone and soft tissue regeneration and repair to deliver predictable implant site development and implant therapy to compro-mised patients.8 In addition, stem cell therapy could reduce donor site morbidity because it would replace autogenous tissue harvesting.

Nanotechnology will have an impact across the entire practice of implant dentistry.8 A new generation of ‘bio-active’ implants is capable of modulating cellular responses at the molecular level. Beside the advances to

implant surface topography itself, nanotech-nology offers useful possibilities with regard to diagnostic imaging methodologies, implant site preparation, restoration and aesthetics, wound healing, delivery of modulating thera-peutic molecules and drugs, management of peri-implant disease and surgical and restor-ative techniques. As nanotechnologies mature, they will become more customized, allowing them to be guided towards specific patients, treatment sites or clinical indications.

Implant Surface CoatingsVarious coatings have been developed to improve an implant’s ability to bond to living tis-sues, particularly bone. The idea is to apply a thin ceramic layer9-13 that will bond both to the implant and to the surrounding tissue while promoting bone apposition. Candidate coat-ing materials are bioactive compounds able to promote cell attachment, differentiation, and bone formation. The most prevalent bioac-tive materials are calcium phosphates, such as hydroxyapatite or tricalcium phosphate and bio-active glasses. When implanted, these bioac-tive ceramics form a carbonated apatite layer on their surfaces through dissolution and precipi-tation. This phase is equivalent in composition and structure to the mineral phase of osseous tissue. At the same time, collagen fibrils can be incorporated into the apatite agglomerates. The sequence of events is poorly understood but appears to be: adsorption of biological moieties and action of macrophages, attach-ment of stem cells and differentiation, formation of matrix, and, finally, complete mineralization.

Coating/implant adherence: Most reports indicate that currently available coating tech-


Mittal et al

niques provide inadequate adherence of CP coatings to Ti alloys. Quoted bond Strengths, 15–30 MPa, are very low.14 Systematic stud-ies of the chemical and microstructural factors that control the interfacial strength and tough-ness are needed to optimize the mechani-cal stability of the coatings. Key principles for bonding ceramics to metals, elucidated over the past decade,15 can guide such an inves-tigation but we still need to develop stan-dard procedures to test adhesion, and a clear understanding of the mechanisms of interfacial failure in the body environment.

Fixation to bone: Knowledge of biological processes occurring at the biomaterial-tissue interface is of utmost importance in predicting implant integration and host response. Two primary modes of attachment are: (1) mechani-cal, in which the implant has a rough, porous surface into which bone grows (often supple-mented by use of a bone cement); and (2) chemical, in which bone “bonds” to the implant material. Here it is difficult to decouple the effect of coating chemistry and topography. Dissolution of calcium and phosphorus from the

coating may promote mineralization and bone formation but it is not clear how much coating solubility contributes to the best fixation, and excessive resorption can limit implant lifetimes.16

Programmed dissolution rates: A criti-cal goal in the design of noble coatings is the programming of their dissolution (bioresorp-tion) rates. The role of solubility of coatings in the body is poorly understood.17 The presence of highly soluble phases markedly decreases the mechanical stability of the coating in vivo, but some solubility of coating material expe-dites fixation. These results suggest that graded coatings designed with a soluble sur-face to facilitate bonding to bone and an insol-uble layer in contact with the metal to provide adhesion, corrosion resistance, and long-term mechanical stability could offer a significant improvement over current materials. Both the composition and thickness of the graded coat-ing layers can be controlled to manipulate the resorption rates. Their resorption can be programmed to match healing rates and to expose different micro architectures, chemi-cal patterns, and porosities at different times to optimize the biomaterial coating surface for different periods of the healing-in phase.

Drug delivery: Inflammatory responses to implants are a significant problem in the health care industry. Typically, medications are given to a patient following surgery to suppress

Figure 1: Surface of dental implants.

Figure 2: Nanodentistry and dental implants.

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inflammation and to enable the intended per-formance of the implanted medical device. Although generally helpful, in many cases this approach is insufficient or entirely inef-fective.18,19,20 A different approach is to pro-vide a local dose of anti-inflammatory agents gradually released from a coating on the sur-face of the implanted device. The main advan-tage of this approach over traditional means of administering the drug is that the drug can be directly released at the implant site with-out having to go through the bloodstream. This lowers the amount of drug needed, reducing the overall toxicity and side effects. In addi-tion, growth factors that are known to encour-age tissue-implant integration, such as TGF-β may be delivered locally using this platform. These chemicals could be incorporated into the porosity of micro- and nano-porous coatings or could be dispersed in biodegradable poly-mers, and combined with the bioactive glass/CP coatings. Developing the right platform to control the release rate is the key, and closely

related to the control of the degradation rates.

Metal-Free Dental ImplantsFor decades, dentists and oral surgeons have searched for a way to replace missing teeth in a way that is sustainable, comfortable, aes-thetically pleasing and conducive to general oral health. Finally, metal-free dental implants give patients everything they need in a replacement tooth without compromise. Whereas traditional titanium dental implants can leave an unsightly dark ring around the edge of the crown, metal-free implants look healthy and natural because of the high-grade zirconium with which they are crafted. Additional benefits associated with metal-free dental implants include: 1) Bio-compatibility with surrounding gum tissue; 2) Improved resistance to the buildup of plaque and tartar, primary culprits of gum disease; 3) Preferable alternative for patients who are sen-sitive to titanium; 4) Better choice for patients who prefer a holistic approach to oral health.

Figure 3: Customized dental implants.Figure 4: Metal free dental implants.


Mittal et al

Stem Cell Dental ImplantsThe recent discovery that stem cells exist in teeth has the potential to transform dentistry and the future of medical treatments. Researchers use stem cells to create living dental implants. Fur-ther technological advancements could possibly become more common worldwide, perhaps in few years’ time, Titanium implants could be a thing of the past and stem cell dental implants may become the most prominent tooth replacement option. It is likely that this knowledge will enable all cosmetic dentists to regenerate missing teeth within the patients’ mouth as an alternative to Conventional dental implants that have involved placing a screw in the jaw, which is attached to a ”post” with a porcelain replacement tooth.

Stem Cell grafting is the latest technology in helping bone to grow in deficient parts of the jaw. The stem cells used are derived from tissues originating from the tip of the removed tooth root,

called root apical papilla. These stem cells have the capability to reproduce and develop other tissue such as bone, cartilage and skin. Stem cells are collected by needle aspiration from the hipbone and placed against the receiving site in the jawbone. This technology means peo-ple previously unable to have implants, or who could have them only after lengthy surgeries, can now be given “new” teeth in less than nine weeks from initial implantation. Unlike current dental implants, these teeth adapt to changes that occur to the jaw bone over time, limiting the need for costly and time consuming adjustments or replacement implants. New developments in stem cell research are presented almost every day, just as new ground is being made with dental implant procedures in dentistry, and using these advances researchers are able to extract stem cells from wisdom teeth which are then banked and used to preserve and protect patient’s teeth and smile in a special cryogenic storage facility.

CONCLUSIONThe ultimate goal of future research initia-tives is to produce biomaterials and therapies that will improve current standards of care, customized to patient’s preferences and spe-cific needs and improve quality of life. This will require greater integrated and interdisciplin-ary team work between the fields of bioengi-neering, tissue engineering, material sciences, biology and clinical sciences. Research in implant dentistry is not without problems and challenges. Studies in dental implantology are expensive to conduct, difficult to blind, require prolonged follow-up and frequently impos-sible to undertake owing to ethical constraints. Funding for research will increasingly become

Figure 5: Stem cell and dental implants.

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Correspondence:Dr. Sachin MittalC/o Sarvodaya multispecialty hospital, below dabra bridge, hisar-125001 Haryana (India) Mob. No. : 9996468881E-mail: [email protected]: 01662-231010

DisclosureThe authors report no conflicts of interest with anything mentioned in this article.

References1. Stillman N, Douglass CW (1993) Developing markets for dental implants. J

Am Dent Assoc 124: 51-56.

2. Worthington, P. Introduction: history of implants. In: WPLBR; RJE, editors. Osseointegration in dentistry: an overview. Quintessence Publishing; Il-linois: 2003. p.2.

3. Branemark PI, Adell R, Breine U, Hansson BO, Lindstrom J, Ohlsson A. In-traosseous anchorage of dental prostheses. I. Experimental studies. Scand J PlastReconstr Surg.1969; 3:81–100.

4. Linder L, Albrektsson T, Branemark PI, Hansson HA, Ivarsson B, Jonsson U, Lundstrom I. Electron-Microscopic Analysis of the Bone Titanium Interface. Acta Orthopaedica Scandinavica.1983; 54(1):45–52.

5. Hobo, S.; Ichida, E.; Garcia, L. Osseointegration and occlusal rehabilita-tion. Quintessence Publishing; Tokyo: 1990. Osseointegration Implant Systems; p. 3-4.

7. The Academy of Osseointegration. Impact of biological and technologi-cal advances on implant dentistry. Int J Oral Maxillofac Implants. 2011; 26(Suppl):7–10.

8. Hujoel P. Endpoints in periodontal trials: the need for an evidence-based research approach. Periodontology. 2000. 2004; 36:196–204.

9. Boyan BD, Lohmann CH, Dean DD, Sylvia VL, Cochran DL, Schwartz Z. Mechanisms involved in osteoblast response to implant surface morphol-ogy. Annual Review of Materials Research. 2001; 31:357–371.

10. Kasemo B. Biological surface science. Surface Science. 2002; 500:656–677.

11. Hench LL. Bioceramics. Journal of the American Ceramic Society. 1998; 81(7):1705–1728.

12. Hench, LL.; Andersson, O. Bioactive Glasses. In: Hench, LL.; Wilson, J., editors. An Introduction to Bioceramics. World Scientific; Singapore: 1993. p. 41-62.

13. Hench LL, Xynos ID, Polak JM. Bioactive glasses for in situ tissue regen-eration. Journal of Biomaterials Science (Polymer). 2004; 15(4):543–562.

14. Whitehead RY, Lucas LC, Lacefield WR. The effect of dissolution on plasma sprayed hydroxylapatite coatings on titanium. Clin Mater. 1993; 12(1):31–9.

15. Hong T, Smith JR, Srolovitz DJ. Theory of metal-ceramic adhesion. Acta Metallurgica Et Materialia. 1995; 43(7):2721–30.

16. Porter AE, Botelho CM, Lopes MA, Santos JD, Best SM, Bonfield W. Ultrastructural comparison of dissolution and apatite precipitation on hydroxyapatite and silicon-substituted hydroxyapatite in vitro and in vivo. Journal of Biomedical Materials Research Part A. 2004; 69A (4):670–679.

17. Hench LL. Biomaterials: a forecast for the future. Biomaterials. 1998; 19(16):1419–1423.

18. Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappinscott HM. Microbial Biofilms. Annual Review of Microbiology. 1995; 49:711–745.

19. Lincoff AM, Topol EJ, Ellis SG. Local drug delivery for the prevention of restenosis -fact, fancy, and future. Circulation. 1994; 90(4):2070–2084.

20. Riessen R, Isner JM. Prospectsfor site-specific delivery of pharmacologic and molecular therapies. Journal of the American College of Cardiology. 1994; 23(5):1234–1244.

a major challenge for researchers. Pooling resources through multicentre trials and col-laborative efforts are some of the innova-tive methods of addressing this challenge. ●

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Wilcko et al

Background: The aim of this paper was to obtain an objective, quantitative assessment of the clini-cal performance achieved with a specific implant line that was extensively used in an implantologi-cal office setting. A retrospective chart review was conducted with the aim to clarify whether the subjective good experience with the used Tita-nium implant line is supported by clinical results.

Methods: The clinical performance of implants with hydrophilic (INICELL) and hydrophobic (TST) enossal surfaces was compared. The cumulative implant survival rate was calculated.

Results: The data of 1063 patients that received 2918 implants (1337 Inicell, 1581 TST) has been included in the chart review. The average

follow up time was 2.1 (1,1 - 5.4) years for INI-CELL and 4.5 (1.3 - 5.9) years for TST implants. In the reported period 7 implants with INICELL (0.5 %) and 23 TST implants (1.5 %) have failed. This difference is statistically highly significant.

Conclusions: The analysis of cases treated in a single implantological office for almost 6 years confirmed the very good clinical outcome that was achieved with both used implant lines. Within the limitations of this retrospective analy-sis, the overall early failure rate of the hydro-philic implants was significantly lower than that of hydrophobic implants. The use of hydrophilic implants allows the clinician to obtain less early failures, hence the interest of an up-to-date sur-face for the daily work of an implant practice.

6 Year Survival and Early Failure Rate of 2,918 Implants with Hydrophobic and

Hydrophilic Enossal Surfaces

Dr. Olivier Le Gac1, Ueli Grunder1

1. Private practice, France

Abstract

KEY WORDS: Dental implants, failure rate, case series, enossal surface, hydrophilic, hydrophobic


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BACKGROUNDThe reconstruction of missing teeth by Tita-nium dental implants is currently the gold stan-dard in dental rehabilitation.1,2 Their clinical performance has been documented for certain brands but currently there is a wide variety of dental implants with limited, or even no clini-cal documentation. Ever since the first stud-ies showing the clinical interest of the peculiar affinity of bone tissue for titanium industry has invested a lot in order to improve the implant surfaces.3 This is why, in the course of time, clinicians had at their disposal implants sim-ply machined, then in the 80s rough implants through plasma spray, which resulted in an improved rate of osseointegration. Later on, the microstructured, or moderately rough, surfaces realized through sand-blasting and etching have become the gold standard with failure rates as low as 1%.1 Recent developments should even improve osseointegration, especially by rendering the surfaces to become hydrophilic. Such is the case of INICELL which is created immediately before implantation by expos-ing the standard surface TST to the condition-ing liquid and thus raising the surface energy. This modification has no influence on surface roughness. The advantage of hydrophilic enos-sal surfaces is in the earlier osseointegration.4 The performance of the surfaces was evalu-ated first mechanically (removal torques) his-tomorphometric analyses allowed to determine the rate of contact between bone and implant (BIC) assuring a good quality of osseointegra-tion.4 Last but not least clinical studies observe the behavior of these implants loaded earlier and earlier, for instance at 3 weeks.5 The cli-nician may wonder about the interest for his

patient to use implants that can be loaded at 3 weeks whereas those at 2 months work perfectly, unless the failure rate can be dimin-ished and the marginal bone loss reduced.

The aim of this paper was to obtain an objective, quantitative assessment of the clinical performance achieved with a specific implant line. A retrospective chart review was con-ducted with the aim to clarify whether the sub-jective good experience with the used Titanium implant line is supported by clinical results. Implants with hydrophilic (INICELL) and hydro-phobic (TST) enossal surfaces was compared.

METHODSIn 2007, the author started using titanium ELE-MENT RC implants (cylindrical enossal shape, self-cutting threads, 1 mm polished collar for optimal esthetic results; Thommen Medical AG, Grenchen, Switzerland). At that time the implants had a state-of-the-art moderately rough enossal surface (sand-blasted-acid etched; TST). In 2010 the author “switched” to use the same implant line with a super-hydrophilic (INICELL®) surface (Thommen Medical, Grenchen, Switzerland).

Due to the retrospective data analysis the patients have not been exposed to any additional risk, therefore an Ethical Commit-tee approval was not sought for. All measures have been taken in order not to disclose any patient personal data. Included are all patients that have received implants, no exclusion from the analysis was done e.g. for known risk fac-tors, such as smoking, findings in medical his-tory, etc. The retrospective results represent the review of all consecutively placed implants in a specialized center for oral implantol-ogy. As for the surgical implant bed prepara-


Le Gac et al

tion technique, the manufacturer instructions have been followed. Patients that received both INICELL and TST implants under-went the following treatment protocols:

1) immediate loading; 2) immediate tempo-rization with bone grafting, mainly for simulta-neous and two-stage sinus lifting using DBBM (Bio-Oss, Geistlich, Switzerland) or β calcium triphosphate (TCP, CEROS, Thommen Medical AG. Waldenburg, Switzerland); 3) guided bone regeneration using either autogenous bone from the retromolar area or autologous bone (TBF, France). Augmentation surgery has been performed prior to the implant place-ment. The bone healing time was 4 months when autogenous bone was used, 5 months when patients received allogeneic bone,

and 6 months or more with the bovine bone.Based on the recorded implant survival, the

cumulative implant survival rate was calculated. The differences in (early) implant failure rate were statistically tested (Fisher’s exact test).

RESULTSThe follow up data of 1063 patients that received 2918 implants has been included in the chart review. The patients have been treated i. e. implants inserted between Octo-ber 2007 and July 2012. 1337 (45.8%) of the reported implants had INICELL and 1581 (54.2 %) TST enossal surfaces. As mentioned above, the hydrophilicity / hydro-phobicity of the enossal surface was the only difference between both implant types.

Figure 1: Number of implants / patient.

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34% of the patients have received 1 implant, 29% two, 13% three and 24% of patients received 3 - 15 (1 patient) implants (Fig. 1) i. e. most frequently placed were 1 - 2 implants per patient. Of the INICELL implants, 56% were inserted in the maxilla and 44% in the mandible. Similarly, 57% TST were placed in the upper and 43% in the lower jaw (Fig. 2). The placement pattern between the INICELL and TST groups was quite simi-lar, thereby validating the homogeneity of the presented sample. The replacement of

individual tooth positions was balanced (Fig. 2). Both INICELL and TST implants had platform diameters (PF Ø) 3.5 - 6.0mm and they were 6.5 - 14.0mm long (Fig. 3).

Immediate loading was the case in 75 (7.1%) edentulous patients that have received 493 (16.9) implants (267 (20%) INICELL and 226 (14.3%) TST). Immediate temporiza-tion was done in 74 (7.0%) patients. These patients received 35 (2.6%) INICELL and 39 (2.5%) TST implants. Bone grafting material was used with 258 (8.8 %; INICELL and TST)

Figure 2: Number of INICELL and TST implants split by position in both jaws.


Le Gac et al

implants. β calcium triphosphate (TCP, CEROS) was used in 122 (11.5%), whereas Bio-Oss in 136 (12.8%) cases. Both bone grafting materials were used mainly for simultaneous and two-stage sinus lifting (29 (2.7%) and 53 (5.4%) cases respectively), sinus lift accord-ing to Summers5 (158 cases i. e. 14.9%) and guided bone regeneration (92 cases i. e. 8.7%). Autogenous bone was used in 36 (3.4%) cases, from the retromolar area and autolo-gous bone (TBF, France) in 6 (0.6%) cases.

In 56 (5.3%) cases an augmentation surgery has been performed prior to the implant place-ment. The bone healing time was 4 months when autogenous bone was used, 5 months when patients received allogeneic bone, and 6 months or more with the bovine bone.

The implant healing time recommendations of the manufacturer were also followed. Typi-cally, it was 3 and 8 weeks for INICELL and 6 or 12 weeks for TST implants that were restored as single crowns. In edentulous patients, imme-

Figure 3: Overview of used implants by diameter and length.

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Table 1: Cumulative Survival Rate *The difference is statistically significant (< 0.016; Fisher’s exact test)

(

Failed Implants CSR Observation period

Total 30 99 4.0 (1.1—5.9) years

Inicell 7* 99.5 2.1 (1.1—5.4) years

TST 23* 98.5 4.5 (1.3-5.9) years

diate loading was done whenever possible, or temporary (non-occlusal) crown was attached immediately after implantation (see above).

The average follow up time was 2.1 (1.1 - 5.4) years for INICELL and 4.5 (1.3 - 5.9) years for TST implants. In the reported period 7 (0.5%) implants with INICELL and 23 (1.5%) TST implants have failed. This difference is statistically highly significant (Table 1, Fish-er’s exact test). All implant failures occurred early i.e. before functional implant loading at the radiological check of the osseointegra-tion at 2 months after implant placement. As implants have been loaded immediately, the check of integration was done at 2 months later by X-ray and clinically after removing the provisional crown. Among the 7 failed INI-CELL implants, 3 were with reduced diameter (PFØ 3.5mm), 2 were immediately loaded, 1 was provisionally loaded and 1 implant failed in an edentulous patient with immediate load-ing. Of the 23 failed TST implants 5 were with reduced diameter (PFØ 3.5mm), 6 were lost in 4 immediately loaded, edentulous patients, 3 implants were lost in 2 patients with sinus lift. 9 implants have been lost in patients with immedi-ate temporization. The reported implant failures resulted in an overall cumulative survival rate

of 99.0%. This is quite satisfactory consider-ing the mean observation period of 4 (1.1-5.9) years. For INICELL the cumulative survival rate was 99.5%, for TST implants it was 98.5%. The apparently lower CSR of the TST implants (Table 1) was not attributable to the longer observation time of TST 4.5 (1.3 - 5.9) years as compared to INICELL implants 2.1 (1.1-5.4) years, as all of the failures occurred before implant loading. The lower early survival rate of INICELL implants was also mirrored in the survival rate recorded for individual indications:

Standard cases: within the reported popu-lation 640 patients received 968 INICELL and 1064 TST implants. In standard cases implants have been placed after perform-ing a full thickness flap and preparation of the implant bed by using the drilling sequence (recommended by the manufacturer). Most of the time a healing screw was placed and sutures done. 6 weeks later the permanent crown was fabricated and screw-attached with the torque recommended by the manu-facturer (25 N for platforms between 4 and 6 mm and 15N for the 3,5mm). Early failures have occurred with only 1 INICELL and 9 TST implants. This difference was also statisti-cally significant (p < 0.05; Fisher’s exact test).


Le Gac et al

Edentulous cases: 75 edentulous patients received 493 immediately loaded implants (267 INICELL and 226 TST). Of these 2 INI-CELL and 6 TST implants have failed early. In some of these patients the implants have been placed with the help of navigated surgery.7

Immediate loading: immediate non-occlusal loading of single tooth was done in 74 patients with 35 INICELL and 39 TST implants. Only 1 INICELL implant failed early.

Sinus floor elevation: Consecutive and simultaneous sinus lift was done in 240 patients that have received 86 INICELL and 141 TST implants. Only 3 TST implants failed early.

Reduced diameter implants: from the 228 INICELL and 203 TST inserted reduced diam-eter (PFØ 3.5mm) implants early failures occurred with 5 TST and 3 INICELL implants (this difference is not statistically significant).

DISCUSSIONMost recent studies suggested a low early fail-ure rate of < 1% and a success rate of > 95% at 10 years for non-smokers.8 Garcia-Bellostá et al.9 reported the long term survival of 980 implants that were inserted in 323 patients a periodontal practice. After 5 years follow up the CSR was 96.2%. The authors were not able to detect any significant influence of smok-ing on implant survival. The reported CSR is also comparable with the results obtained in a similar retrospective evaluation of the TST implants.10 The authors have compared the sur-vival of TST implants with reduced and standard diameters. Their report comprised 332 patients which received 736 TST implants in three prac-tices in Switzerland. The main finding was that

the CSR of TST implants with reduced diame-ter (99.5%) was no different from the CSR of standard diameter implants (99.7%). The aver-age follow up time was 20 months. Olate et al.11 demonstrated that implant length and posi-tion in frontal regions correlated significantly with early failure rate. This finding was not con-firmed in the presented study as the overall number of failed implants was quite low. The overall as well as individual INICELL and TST (early) failure rates reported in the presented retrospective analysis are therefore very well comparable with that of other implant systems.

The analysis of cases treated in a single implantological office for almost 6 years con-firmed the very good clinical outcome that was achieved with both used implant lines (ELE-MENT® RC INICELL or TST). Only early fail-ures have been observed with 7 INICELL and 23 TST implants. As a result of careful case evaluation, diagnosis and planning, a high over-all survival rate of 99.0% was achieved after an average follow up period of 4 years. This com-pares well to other implant systems for which the survival rate was investigated in prospec-tive clinical trials that usually exclude complex cases. The optimal interplay of all components of the used implant line very likely contributed to the outstanding survival rate. INICELL, the newly introduced hydrophilic enossal surface is very well suited for early loading.12 It has also lead to significantly improved early fail-ure rate. In spite of the limitations of this chart review analysis, the paper has achieved its goal i.e. the results of this quantitative long term assessment help to objectively assess the success rate of the implant treatment.

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CONCLUSIONSWithin the limitations of this retrospective anal-ysis, the overall early failure rate of the hydro-philic implants was significantly lower than that of hydrophobic implants. A large number of patients and implants has been followed long-term. The monitored implants had identi-cal geometry, they differed only in the physico - chemical properties of their enossal sur-faces i. e. hydrophilic (INICELL) and hydro-phobic (TST) enossal surfaces have been compared. The use of hydrophilic implants

allows the clinician to obtain less early failures, hence the interest of an up-to-date surface for the daily work of an implant office setting ●

Correspondence:Dr. Olivier Le Gac968, Avenue du Gl. LeclercF-47000 Agen, France+33 5 53 48 24 76+33 5 53 47 93 [email protected]

DisclosureThe author reports no conflicts of interest with any-thing mentioned in this article.

References1. Buser D. Janner SFM, Wittneben J-G, Brägger

U, Ramseier ChA, Salvi GE. 10-Year Survival and Success Rates of 511 Titanium Implants with a Sandblasted and Acid-Etched Surface: A Retrospective Study in 303 Partially Edentu-lous Patients. Clin Impl Dentistry Rel Res 2012; 14(6): 839-851

2. Östman P-O, Hellman M, Sennerby L. Ten Years Later. Results from a Prospective Single-Centre Clinical study on 121 Oxidized (TiUniteTM) Brånemark Implants in 46 Patients. Clin Impl Dentistry Relat Res 2012; 14(6): 852-860)

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5. Bornstein MM, Wittneben JG, Brägger U, Buser D. Early loading at 21 days of non-submerged titanium implants with a chemically modified sandblasted and acid-etched surface: 3-year re-sults of a prospective study in the posterior man-dible. J Periodontol. 2010 Jun;81(6):809-818

6. Summers RB. Sinus floor elevation with osteo-tomes. J. Esthet Dent 1998; 10: 164-171

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8. Bornstein MM, Halbritter S, Harnisch H, Weber HP, Buser D. A retrospective analysis of patients referred for implant placement to a specialty clinic regarding indications, surgical procedures and early failures. Int J Oral Maxillofac Implants 2008; 23: 1109-1116

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12. Stadlinger B, Ferguson SJ, Eckelt U, Mai R, Lode AT, Loukota R, Schlottig F. Biomechanical evaluation of a titanium implant surface condi-tioned by a hydroxide ion solution. Brit J Oral Maxillofac Surg 2012; 50(1): 74-79.

24 JIACDThe Journal of Implant & Advanced Clinical Dentistry

October 2008 Review | Oral Implications of Cancer Cheomotherapy October 2008October 2008

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