The Biology of Dental Implants

1. The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota

3. Concepts of Connective Tissue Healing Around Implants • Osseous Integration / Osseointegration • Fibrous Integration • Fibro-osseous Integration

5. Bone Healing • Phase I: Inflammatory Phase • Phase II: Proliferative Phase • Phase III: Maturation Phase

6. Phase I Bone Healing: Day 1-10 • Absorption of plasma proteins • Platelet aggregation and activation • Clotting cascade activation • Cytokine release

7. Phase I Bone Healing: Day 1-10 • Nonspecific cellular inflammatory response • Specific cellular inflammatory response • Macrophage mediated inflammation

9. Phase II Bone Healing: Day 3-42 • Neovascularization • Differentiation, proliferation and activation of cells • Production of immature connective tissue matrix

10. Phase III Bone Healing: After Day 28 • Remodeling of the immature connective tissue matrix with coupled resorption/ deposition of bone • Bone remodeling in response to implant loading • Physiologic bone recession

11. Mucoperiosteal Healing • Phase I: Inflammatory Phase • Phase II: Proliferative Phase • Phase III: Maturation Phase

12. Phase I Mucoperiosteal Healing Inflammatory Phase: Day 1-10 • Platelet aggregation and activation • Clotting cascade activation • Cytokine release • Nonspecific cellular inflammatory response • Macrophage mediated inflammation

13. Phase II Mucoperiosteal Healing Proliferative Phase: Day 2-42 • Neovascularization • Differentiation, proliferation and activation of cells • Deposition of immature collagen, elastin, and ground substance

14. Phase III Mucoperiosteal Healing Maturation Phase: After Day 21 • Connective Tissue Remodeling

15. Bone Implant Interface • Dependent on implant material • Calcified bone, unmineralized osteoid matrix, and connective tissue • Zone of amorphous material • Proteoglycans and glycosaminoglycans • 100-3000 angstroms • Collagen filaments

17. Chemical Bonds Between Bone and Implants • van der Waals • Local direct chemical bonds (ionic, covalent) • Chemical bonding well described with calcium phosphate ceramics • Some materials have no chemical bond but have excellent bone contact • (CP titanium vs. HA)

23. Factors Affecting Healing • Surgical technique • Premature loading • Surgical fit • Extraction sites

24. Factors Affecting Healing • Peri-implantitis • Bone quality • Staged healing

26. Logic CONTROL

27. STUDY DESIGN 3 Healing Groups Experiment Control 12 Pigs 6 Pigs Healing Healing 1 Month 1 Month 2 Month 2 Month (4) (4) 4 Month 4 Month (4) (4) (4) (4) 5 Months Non-Loading 5 Months Controlled Loading

28. Radio-Subtraction (S3D, MDRCBB) One Month Healing Four Months Healing

29. Micro-CT Images Four Months Two Months One Month

30. Stevenel’s Blue and Van Gieson’s Picro-Fuchsin Stain Four Months Two Months One Month

31. Issues Relating to Physical Status of Recipient • Nutritional status • Age • Hematologic issues

32. Issues Relating to Physical Status of Recipient • Diabetes • Corticosteroids • Radiation

33. 51 year old man • CC- “I ‘ve been referred for evaluation and treatment for a growth in my jaw” • HPI • 2 month duration • mobile teeth • facial swelling

34. 51 year old man • PMH • Hypertension-well controlled • PDH • Imaging findings • 4 cm x 2 cm radiolucent lesion left mandibular body causing tooth displacement

39. 51 year old man • Problem list • Radiolucent lesion • Teeth vital • Buccal plate perforation • No paresthesias • Differential diagnosis • ameloblastoma • central giant cell lesion • odontogenic myxoma

43. 51 year old man • Treatment plan • Incisional biopsy for histologic typing • Prosthodontic consultation • Definitive imaging (CT scan) • Biopsy results • Acanthomatous ameloblastoma

44. 51 year old man • Treatment • Arch bars/surgical stent construction • Transcervical approach for exposure and lateralization of IAN/Mental nerve • Transoral marginal resection preserving inferior border • Reconstruction plate applied for stabiliation