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Criteria for the evaluation of dental implant success are proposed. These criteria are applied in an assessment of the long-term efficacy of currently used dental implants including the subperiosteal implant, the vitreous carbon implant, the blade-vent implant, the single-crystal sapphire implant, the Tubingen implant, the TCP-implant, the TPS-screw, the ITI hollow-cylinder implant, the IMZ dental implant, the Core-Vent titanium alloy implant, the transosteal mandibular staple bone plate, and the Branemark osseointegrated titanium implant. An attempt has been made to standardize the basis for comments on each type of implant.
The purpose of the present study was to evaluate the influence of different surface characteristics on bone integration of titanium implants. Hollow-cylinder implants with six different surfaces were placed in the metaphyses of the tibia and femur in six miniature pigs. After 3 and 6 weeks, the implants with surrounding bone were removed and analyzed in undecalcified transverse sections. The histologic examination revealed direct bone-implant contact for all implants. However, the morphometric analyses demonstrated significant differences in the percentage of bone-implant contact, when measured in cancellous bone. Electropolished as well as the sandblasted and acid pickled (medium grit; HF/HNO3) implant surfaces had the lowest percentage of bone contact with mean values ranging between 20 and 25%. Sandblasted implants with a large grit and titanium plasma-sprayed implants demonstrated 30-40% mean bone contact. The highest extent of bone-implant interface was observed in sandblasted and acid attacked surfaces (large grit; HCl/H2SO4) with mean values of 50-60%, and hydroxylapatite (HA)-coated implants with 60-70%. However, the HA coating consistently revealed signs of resorption. It can be concluded that the extent of bone-implant interface is positively correlated with an increasing roughness of the implant surface.
A total of 2895 threaded, cylindrical titanium implants have been inserted into the mandible or the maxilla and 124 similar implants have been installed in the tibial, temporal or iliac bones in man for various bone restorative procedures. The titanium screws were implanted without the use of cement, using a meticulous technique aiming at osseointegration--a direct contact between living bone and implant. Thirty-eight stable and integrated screws were removed for various reasons from 18 patients. The interface zone between bone and implant was investigated using X-rays, SEM, TEM and histology. The SEM study showed a very close spatial relationship between titanium and bone. The pattern of the anchorage of collagen filaments to titanium appeared to be similar to that of Sharpey's fibres to bone. No wear products were seen in the bone or soft tissues in spite of implant loading times up to 90 months. The soft tissues were also closely adhered to the titanium implant, thereby forming a biological seal, preventing microorganism infiltration along the implant. The implants in many cases had been allowed to permanently penetrate the gingiva and skin. This caused no adverse tissue effects. An intact bone-implant interface was analyzed by TEM, revealing a direct bone-to-implant interface contact also at the electron microscopic level, thereby suggesting the possibility of a direct chemical bonding between bone and titanium. It is concluded that the technique of osseointegration is a reliable type of cement-free bone anchorage for permanent prosthetic tissue substitutes. At present, this technique is being tried in clinical joint reconstruction. In order to achieve and to maintain such a direct contact between living bone and implant, threaded, unalloyed titanium screws of defined finish and geometry were inserted using a delicate surgical technique and were allowed to heal in situ, without loading, for a period of at least 3--4 months.
Abstract In this study the microbiota associated with oral endosteal titanium hollow cylinder implants (ITI) was studied using microscopic, immunochemical and cultural methods. Samples from 5 edentulous patients with successfully incorporated implants serving as abutments for overdentures for more than one year were compared with samples from 7 patients with clinically failing implants. Unsuccessful sites were characterized by pocket probing depths of 6 mm or more, suppuration and visible loss of alveolar bone around the implant as visualized on radiographs. These sites harbored a complex microbiota with a large proportion of Gram‐negative anaerobic rods. Black‐pigmented Bacteroides and Fusobacterium spp. were regularly found. Spirochetes, fusiform bacteria as well as motile and curved rods were a common feature in the darkfield microscopic specimens of these sites. Control sites in the same patients harbored small amounts of bacteria. The predominant morphotype was coccoid cells. Spirochetes were not present, fusiform bacteria, motile and curved rods were found infrequently and in low numbers. The microbiota in control sites in unsuccessful patients and in site in successful patients were very similar. On the basis of these results, it is suggested that “periimplantitis” be regarded as a site specific infection which yields many features in common with chronic adult periodontitis.
In Brief Objective The aim of the present experiment was to assess the consequences of cochlear implantation at different ages on the development of the human central auditory system. Design Our measure of the maturity of central auditory pathways was the latency of the P1 cortical auditory evoked potential. Because P1 latencies vary as a function of chronological age, they can be used to infer the maturational status of auditory pathways in congenitally deafened children who regain hearing after being fit with a cochlear implant. We examined the development of P1 response latencies in 104 congenitally deaf children who had been fit with cochlear implants at ages ranging from 1.3 yr to 17.5 yr and three congenitally deaf adults. The independent variable was the duration of deafness before cochlear implantation. The dependent variable was the latency of the P1 cortical auditory evoked potential. Results A comparison of P1 latencies in implanted children with those of age-matched normal-hearing peers revealed that implanted children with the longest period of auditory deprivation before implantation—7 or more yr—had abnormal cortical response latencies to speech. Implanted children with the shortest period of auditory deprivation—approximately 3.5 yr or less—evidenced age-appropriate latency responses within 6 mo after the onset of electrical stimulation. Conclusions Our data suggest that in the absence of normal stimulation there is a sensitive period of about 3.5 yr during which the human central auditory system remains maximally plastic. Plasticity remains in some, but not all children until approximately age 7. After age 7, plasticity is greatly reduced. These data may be relevant to the issue of when best to place a cochlear implant in a congenitally deaf child. Because P1 latencies of the cortical auditory evoked potential vary as a function of chronological age, they can be used to infer the maturational status of auditory pathways and the human central auditory system. This measure was used to assess the consequences of deafness and of cochlear implantation at different ages on auditory development. The development of P1 response latencies was measured in 104 congenitally deaf people who had been fitted with cochlear implants at ages ranging from 1.3 years to adulthood. A comparison of P1 latencies in implanted children with those of age-matched normal-hearing peers revealed that implanted children with the longest period of auditory deprivation before implantation-7 or more years-had abnormal cortical response latencies to speech. Implanted children with no more than 3.5 years of auditory deprivation evidenced age-appropriate latency responses within 6 months after the onset of electrical stimulation. These data suggest that in the absence of normal stimulation there is a sensitive period of about 3.5 years during which the human central auditory system remains maximally plastic.
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About half of all nosocomial infections are associated with indwelling devices. Infections associated with implanted surgical devices are particularly difficult to deal with because they can require prolonged antibiotic treatment and repeated surgical procedures. This review summarizes the diagnostic challenges and explains the approaches to managing infections that are associated with various devices, including prosthetic heart valves, vascular grafts, pacemakers and defibrillators, and joint prostheses.
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BACKGROUND: The biologic width around implants has been well documented in the literature. Once an implant is uncovered, vertical bone loss of 1.5 to 2 mm is evidenced apical to the newly established implant-abutment interface. The purpose of this study was to evaluate the lateral dimension of the bone loss at the implant-abutment interface and to determine if this lateral dimension has an effect on the height of the crest of bone between adjacent implants separated by different distances. METHODS: Radiographic measurements were taken in 36 patients who had 2 adjacent implants present. Lateral bone loss was measured from the crest of bone to the implant surface. In addition, the crestal bone loss was also measured from a line drawn between the tops of the adjacent implants. The data were divided into 2 groups, based on the inter-implant distance at the implant shoulder. RESULTS: The results demonstrated that the lateral bone loss was 1.34 mm from the mesial implant shoulder and 1.40 mm from the distal implant shoulder between the adjacent implants. In addition, the crestal bone loss for implants with a greater than 3 mm distance between them was 0.45 mm, while the implants that had a distance of 3 mm or less between them had a crestal bone loss of 1.04 mm. CONCLUSIONS: This study demonstrates that there is a lateral component to the bone loss around implants in addition to the more commonly discussed vertical component. The clinical significance of this phenomenon is that the increased crestal bone loss would result in an increase in the distance between the base of the contact point of the adjacent crowns and the crest of bone. This could determine whether the papilla was present or absent between 2 implants as has previously been reported between 2 teeth. Selective utilization of implants with a smaller diameter at the implant-abutment interface may be beneficial when multiple implants are to be placed in the esthetic zone so that a minimum of 3 mm of bone can be retained between them at the implant-abutment level.
A classification for peri-implant diseases and conditions was presented. Focused questions on the characteristics of peri-implant health, peri-implant mucositis, peri-implantitis, and soft- and hard-tissue deficiencies were addressed. Peri-implant health is characterized by the absence of erythema, bleeding on probing, swelling, and suppuration. It is not possible to define a range of probing depths compatible with health; Peri-implant health can exist around implants with reduced bone support. The main clinical characteristic of peri-implant mucositis is bleeding on gentle probing. Erythema, swelling, and/or suppuration may also be present. An increase in probing depth is often observed in the presence of peri-implant mucositis due to swelling or decrease in probing resistance. There is strong evidence from animal and human experimental studies that plaque is the etiological factor for peri-implant mucositis. Peri-implantitis is a plaque-associated pathological condition occurring in tissues around dental implants, characterized by inflammation in the peri-implant mucosa and subsequent progressive loss of supporting bone. Peri-implantitis sites exhibit clinical signs of inflammation, bleeding on probing, and/or suppuration, increased probing depths and/or recession of the mucosal margin in addition to radiographic bone loss. The evidence is equivocal regarding the effect of keratinized mucosa on the long-term health of the peri-implant tissue. It appears, however, that keratinized mucosa may have advantages regarding patient comfort and ease of plaque removal. Case definitions in day-to-day clinical practice and in epidemiological or disease-surveillance studies for peri-implant health, peri-implant mucositis, and peri-implantitis were introduced. The proposed case definitions should be viewed within the context that there is no generic implant and that there are numerous implant designs with different surface characteristics, surgical and loading protocols. It is recommended that the clinician obtain baseline radiographic and probing measurements following the completion of the implant-supported prosthesis.
Development of an optimal interface between bone and orthopaedic and dental implants has taken place for many years. In order to determine whether a newly developed implant material conforms to the requirements of biocompatibility, mechanical stability and safety, it must undergo rigorous testing both in vitro and in vivo. Results from in vitro studies can be difficult to extrapolate to the in vivo situation. For this reason the use of animal models is often an essential step in the testing of orthopaedic and dental implants prior to clinical use in humans. This review discusses some of the more commonly available and frequently used animal models such as the dog, sheep, goat, pig and rabbit models for the evaluation of bone-implant interactions. Factors for consideration when choosing an animal model and implant design are discussed. Various bone specific features are discussed including the usage of the species, bone macrostructure and microstructure and bone composition and remodelling, with emphasis being placed on the similarity between the animal model and the human clinical situation. While the rabbit was the most commonly used of the species discussed in this review, it is clear that this species showed the least similarities to human bone. There were only minor differences in bone composition between the various species and humans. The pig demonstrated a good likeness with human bone however difficulties may be encountered in relation to their size and ease of handling. In this respect the dog and sheep/goat show more promise as animal models for the testing of bone implant materials. While no species fulfils all of the requirements of an ideal model, an understanding of the differences in bone architecture and remodelling between the species is likely to assist in the selection of a suitable species for a defined research question.
If dental implantology is an increasingly successful treatment modality, why should we still need to understand the mechanisms of peri-implant bone healing? Are there differences in cortical and trabecular healing? What does "poor quality" bone mean? What stages of healing are most important? How do calcium phosphate-coated implants accelerate healing? What is the mechanism of bone bonding? While there are still many aspects of peri-implant healing that need to be elucidated, it is now possible to deconvolute this biological reaction cascade, both phenomenologically and experimentally, into three distinct phases that mirror the evolution of bone into an exquisite tissue capable of regeneration. The first and most important healing phase, osteoconduction, relies on the recruitment and migration of osteogenic cells to the implant surface, through the residue of the peri-implant blood clot. Among the most important aspects of osteoconduction are the knock-on effects generated at the implant surface, by the initiation of platelet activation, which result in directed osteogenic cell migration. The second healing phase, de novo bone formation, results in a mineralized interfacial matrix equivalent to that seen in the cement line in natural bone tissue. These two healing phases, osteoconduction and de novo bone formation, result in contact osteogenesis and, given an appropriate implant surface, bone bonding. The third healing phase, bone remodeling, relies on slower processes and is not considered here. This discussion paper argues that it is the very success of dental implants that is driving their increased use in ever more challenging clinical situations and that many of the most important steps in the peri-implant healing cascade are profoundly influenced by implant surface microtopography. By understanding what is important in peri-implant bone healing, we are now able to answer all the questions listed above.
Issues related to peri-implant disease were discussed. It was observed that the most common lesions that occur, i.e. peri-implant mucositis and peri-implantitis are caused by bacteria. While the lesion of peri-implant mucositis resides in the soft tissues, peri-implantitis also affects the supporting bone. Peri-implant mucositis occurs in about 80% of subjects (50% of sites) restored with implants, and peri-implantitis in between 28% and 56% of subjects (12-40% of sites). A number of risk indicators were identified including (i) poor oral hygiene, (ii) a history of periodontitis, (iii) diabetes and (iv) smoking. It was concluded that the treatment of peri-implant disease must include anti-infective measures. With respect to peri-implant mucositis, it appeared that non-surgical mechanical therapy caused the reduction in inflammation (bleeding on probing) but also that the adjunctive use of antimicrobial mouthrinses had a positive effect. It was agreed that the outcome of non-surgical treatment of peri-implantitis was unpredictable. The primary objective of surgical treatment in peri-implantitis is to get access to the implant surface for debridement and decontamination in order to achieve resolution of the inflammatory lesion. There was limited evidence that such treatment with the adjunctive use of systemic antibiotics could resolve a number of peri-implantitis lesions. There was no evidence that so-called regenerative procedures had additional beneficial effects on treatment outcome.