Clinical and histological evaluation of immediate-loaded posterior implants in nonhuman primates

PURPOSE: To evaluate a square-thread design implant and compare the bone-implant contact percentage between immediate-loaded and nonloaded implants (controls) in nonhuman primates. MATERIALS: Five nonhuman primates each received 3 implants, with a total of 5 control implants and 10 immediate-loaded implants in posterior regions of the mouth. Ninety days after surgery (and function was appropriate), block sections of the implants were removed and sectioned in 200-mum thick pieces. The block sections were stained with modified Masson for evaluation of the bone-implant contact percentage. RESULTS: One of the immediate-loaded implants failed. The bone-implant contact percentage of control implants ranged from 50.34% to 64.13% and averaged 56.3%. The bone-implant contact percentage of immediate-loaded implants ranged from 43.23% to 75.72%, with an average of 62.4%. Two implants had lower bone-implant contact percentage than the others, and when these are not included in the evaluation, the bone-implant contact percentage average increased to 67.6%. CONCLUSIONS: Immediate-loaded implants in the nonhuman primates often have a higher bone-implant contact percentage at 90 days than unloaded implants. The bone remodeling is different for loaded implant-bone interfaces than for unloaded conditions. However, 1 immediate-loaded implant failed, and 2 implants had lower bone-implant contact percentage than controls. Therefore, although there are benefits of immediate loading, there appear to also be some risks.     

Bone response to plasma-cleaned titanium implants

Glow-discharged titanium implants, with a presumed high surface energy, and conventionally prepared and sterilized titanium implants were inserted in the rabbit tibia and femur. The removal torque and histology were compared after 6 weeks in situ. No qualitative or quantitative differences were detected for implants with different preoperative preparation. The results indicate that the conventional implant treatment described is sufficient to give a surface condition with similar early healing responses as those observed with glow-discharge-treated implants.     

Bone response to immediate loading through titanium implants with different surface roughness in rats

Because of its high predictability of success, implant therapy is a reliable treatment for replacement of missing teeth. The concept of immediate implant loading has been widely accepted in terms of early esthetic and functional recovery. However, there is little biological evidence to support this concept. The objective of this study was to examine the interactive effects of mechanical loading and surface roughness of immediately loaded titanium implants on bone formation in rats. Screw-shaped anodized titanium implants were either untreated (smooth) or acid-etched. Two implants were inserted parallel to each other in the tibiae of rats, and a closed coil spring (2.0 N) was immediately applied. Trabecular and cortical bone around both implants was analyzed using microtomographic images, and a removal torque test was performed at weeks 1, 2, and 4. Immediate loading of acid-etched implants resulted in significant decreases in bone mineral density, contact surface area, and cortical bone thickness. These effects were not observed after immediate loading of smooth implants. Conversely, loading did not influence acid-etched implant fixation; however, smooth implant fixation at week 1 was significantly reduced. These results imply that surface roughness regulates bone response to mechanical stress and that immediate loading might not inhibit osseointegration for smooth and rough implants in the late healing stages.     

Bone response to titanium alloy implants placed in diabetic rats

Although dental implants continue to provide consistent and predictable treatment options for most patients, some people with uncontrolled systemic disease may be denied implant treatment. Diabetes is one such disease. According to the U.S. Centers for Disease Control and Prevention, diabetes is a leading cause of blindness, kidney failure, and amputations of the lower extremities. These complications result from microvascular disturbances associated with diabetes. The effect of diabetes on the healing of titanium implants has not been well established. In this study of 32 rats, diabetes was induced in 16 animals by injection of streptozotocin (65 mg/kg); the remaining 16 animals served as controls. Titanium alloy implants were placed in the tibiae of all 32 rats using standard surgical techniques. Implants healed for 14 days. Blood samples were obtained for serum glucose, osteocalcin, and alkaline phosphatase analyses. Implants were retrieved and processed for histomorphometric analyses. Three quantities were measured using light microscopy, video capture, and computer analysis: percent osseointegration (i.e., linear bone interface), associated bone volume percent, and contact frequency. Diabetic animals demonstrated significantly less osseointegration than controls. However, bone volume percent in diabetic animals was about 4 times greater than controls. Biochemical analyses were mixed; diabetic animals demonstrated increased serum osteocalcin levels compared to controls but decreased alkaline phosphatase. Based on the results of this study, it was concluded that the bone response associated with titanium alloy implants in the tibiae of diabetic rats is uniquely different from controls.     

Bone response to submerged, unloaded implants inserted in poor bone sites: a histological and histomorphometrical study of 8 titanium implants retrieved from man

An important parameter that influences the long-term success of oral implants is the bone quality of the implant bed. Posterior areas of the jaws have been avoided in implant dentistry because of their poor bone quality, higher chewing forces, and presumed higher implant failure rates. Several researchers have deemed soft bone implant sites to be a great potential risk situation, and most failures have been found in sites where the bone density was already low. The inferior success rates in the posterior maxilla have been attributed to a lower bone density and a lesser bone-implant interface. The aim of the present study was a histological and histomorphometrical analysis of the bone response to submerged implants inserted in posterior areas of the human jaws and retrieved, for different causes, after healing periods varying from 6 weeks to 12 months. Eight submerged implants that had been retrieved for different causes after different healing periods were evaluated in the present study. All implants were submerged and unloaded. Three implants had been removed for inadequate patient adaptation, 2 for inability of the implant to meet changed prosthetic needs, 1 for not optimal position from esthetic and hygiene aspects, and the last 2 for pain and dysesthesia. All the implants were retrieved with a 5-mm trephine bur. Newly formed peri-implant bone was found in all implants even after shorter healing periods. The bone-implant contact percentage varied from 30% to 96%. In conclusion, some surfaces have an improved characteristic of contact osteogenesis in soft bone, with coverage of the implant surface with a bone layer as a base for intensive bone formation and remodeling. We documented osseointegration of implants with a rough surface even after an insertion period of less than 2 months, both in the mandible and in the maxilla. From these results, we tentatively extrapolate that these implants might be carefully loaded after 2 months of healing, even when inserted in soft bone. A higher removal torque value might lead to a more predictable use of shorter implants, to a support of a prosthesis with fewer implants, or to shorter healing periods.     

Bone contact around acid-etched implants: a histological and histomorphometrical evaluation of two human-retrieved implants

The surface characteristics of dental implants play an important role in their clinical success. One of the most important surface characteristics of implants is their surface topography or roughness. Many techniques for preparing dental implant surfaces are in clinical use: turning, plasma spraying, coating, abrasive blasting, acid etching, and electropolishing. The Osseotite surface is prepared by a process of thermal dual etching with hydrochloric and sulfuric acid, which results in a clean, highly detailed surface texture devoid of entrapped foreign material and impurities. This seems to enhance fibrin attachment to the implant surface during the clotting process. The authors retrieved 2 Osseotite implants after 6 months to repair damage to the inferior alveolar nerve. Histologically, both implants appeared to be surrounded by newly formed bone. No gaps or fibrous tissues were present at the interface. The mean bone-implant contact percentage was 61.3% (+/- 3.8%).     

Bone response to alteration of surface topography and surface composition of sandblasted and acid etched (SLA) implants

The titanium surface obtained by sandblasting and etching (SLA) is an easily alterable surface that smears and loose its typical texture. In addition, the etching process modifies the surface composition of commercially pure titanium; the latter contains titanium and an added 20-40% of titanium hydride. Therefore, the influence of a heavy surface alteration and the influence of the composition at the SLA surface, i.e. with and without titanium hydride, were investigated in vivo. Three implant groups were inserted in the mandible of Land Race pigs and left to heal during 10 weeks in a submerged way: (1). a standard SLA control group (SLAstd) with the SLA surface containing titanium hydride; (2). a test group with the SLA surface heavily altered at the thread level (SLAalt); (3). a test group with an SLA surface devoid of titanium hydride (SLAT). Sample size was n = 8. Histomorphometry analysis did not show a statistically significant difference between the control group (SLAstd: 82.12 + 6.1%), the altered surface test group (SLAalt: 86.25 + 7.4%) and the SLA without titanium hydride test group (SLAT: 75.12 + 7.6%). The data suggest that alteration of the SLA surface, if it occurs, should not be detrimental to bone response. The soft and easy smearable SLA surface might even be an advantage when surface maintenance is required. Surface composition did not play a significant role in the bone response to the SLA surface and it can therefore be concluded that the osteophilic properties of the SLA surface are due to its surface topography and not to its specific surface composition.     

Peri-implant tissue response to TiO2 surface modified implants

Objectives: The objective of this study was to evaluate peri‐implant soft tissue attachment and alveolar bone height on nanoporous TiO₂ thin film on commercial titanium dental implants compared with unmodified standard implants. Material and methods: In six adult beagle dogs, the mandibular premolars P2–P4 were extracted bilaterally. Sol–gel‐derived nanoporous TiO₂ thin film was produced on smooth coronal part of standard ITI^® Straumann implants (4.1 mm × 8.0 mm) by dip coating method. After 3 months healing period of the extraction sockets modified (n=24) and unmodified (n=11) control implants were placed bilaterally. The animals were killed after 8 weeks and the samples were retrieved and processed for histologic/histomorfometric and TEM/SEM evaluations. Results: Histological examination showed mild or absent inflammatory reaction in peri‐implant connective tissues around the surface modified implants. Further, junctional epithelium (JE)/connective tissue (CT) appeared to be in immediate contact with the experimental implants. Of the experimental implants, 22% were judged to be detached from the implant surface while 45% of the untreated control implants were detached. Dense plaques of hemidesmosomes were found in TEM evaluation of the JE cell membrane facing the surface‐treated implants. In the histomorfometric analysis, the distance between the implant margin and alveolar bone crest was significantly shorter in surface‐treated implants than in the control implants (P<0.02). Conclusion: Nanoporous sol–gel‐derived TiO₂ thin film on ITI^® Straumann dental implants improved soft tissue attachment in vivo.     

Bone response to machined and resorbable blast material titanium implants: an experimental study in rabbits

The aim of the present study was a comparison of implants' responses to a machined surface and to a surface sandblasted with hydroxyapatite (HA) particles (resorbable blast material [RBM]). Threaded machined and RBM, grade 3, commercially pure, titanium, screw-shaped inplants were used in this study. Twenty-four New Zealand white mature male rabbits were used. The inplants were inserted into the articular femoral knee joint according to a previously described technique. Each rabbit received 2 inplants, 1 test (RBM) and 1 control (machined). A total of 48 implants (24 control and 24 test) were inserted. The rabbits were anesthetized with intramuscular injections of fluanisone (0.7 mg/ kg body weight) and diazepam (1.5 mg/kg b.wt.), and local anesthesia was given using 1 mL of 2% lidocaine/adrenalin solution. Two rabbits died in the postoperative course. Four animals were euthanatized with an overdose of intravenous pentobarbital after 1, 2, 3, and 4 weeks; 6 rabbits were euthanatized after 8 weeks. A total of 44 implants were retrieved. The specimens were processed with the Precise 1 Automated System to obtain thin ground sections. A total of 3 slides were obtained for each implant. The slides were stained with acid and basic fuchsin and toluidine blue. The slides were observed in normal transmitted light under a Leitz Laborlux microscope, and histomorphometric analysis was performed. With the machined implants, it was possible to observe the presence of bone trabeculae near the implant surface at low magnification. At higher magnification many actively secreting alkaline phosphatasepositive (ALP+) osteoblasts were observed. In many areas, a not yet mineralized matrix was present. After 4 to 8 weeks, mature bone appeared in direct contact with the implant surface, but in many areas a not yet mineralized osteoid matrix was interposed between the mineralized bone and implant surface. In the RBM implants, many ALP+ osteoblasts were present and in direct contact with the implant surface. In other areas of the implant perimeter it was possible to observe the formation of an osteoid matrix directly on the implant surface. Mature bone with few marrow spaces was present after 4 to 8 weeks. Beginning in the third week, a statistically significant difference (P < .001) was found in the bone-implant contact percentages in machined and RBM implants. It must be stressed that these results have been obtained in a passive, nonloaded situation.     

Hard tissue reaction to dual acid-etched titanium implants: influence of plaque accumulation. A histological study in humans

OBJECTIVES: The aim of this investigation was to evaluate histologically, histometrically, and histomorphometrically the influence of plaque accumulation on the peri-implant hard tissues. MATERIAL AND METHODS: Twelve fully edentulous subjects were selected for this investigation. Four to five standard titanium screw implants were placed interforaminally. Two small custom-made screw implants were incorporated in the region of the former first molar, one in each lower quadrant. One month after abutment connection, plaque control was terminated randomly at one of the custom-made implants and continued at the other implant. The custom-made implants and the surrounding tissue were harvested after different time points of plaque accumulation (7, 21, or 90 days). Thus, according to the plaque control program and implant removal time, there were six groups each with four implants for investigation. After histologic processing of the biopsies, histologic, histometric, and histomorphometric analyses were performed. RESULTS: Four of the 24 implants were unavailable for analysis. One implant was mobile at abutment connection and another implant was mobile 2 weeks after abutment connection; both implants had to be removed. The bone around two implants was destroyed during the removal with the trephine bur; therefore, these two implants could not be evaluated histologically either. No differences in the histologic appearance of the peri-implant bone between the different groups could be observed. Histomorphometrically, the implant surface in contact with mineralized bone as a fraction of the implant surface (measured from the buccal to the lingual implant shoulder) varied between 59% and 73%. The implant surface in contact with mineralized bone from the first bone-to-implant contact buccally to the first bone-to-implant contact lingually varied between 80.6% and 91.5%. The values for the distance from the implant shoulder to the first bone-to-implant contact, i.e. peri-implant bone loss, varied from 1.1 to 2.2 mm. No statistically significant differences could be found between any of the evaluated variables. CONCLUSIONS: This clinical investigation is the first to evaluate the hard tissue reactions to different plaque accumulation periods. Within the limits of this experiment, it can be concluded that the bone reaction toward the different plaque accumulation periods and in the different plaque control/accumulation groups were similar. It can be further concluded that the observed bone loss is rather attributed to the establishment of the biologic width than to plaque accumulation.     

Bone regeneration in dehiscence-type defects at chemically modified (SLActive) and conventional SLA titanium implants: a pilot study in dogs

OBJECTIVES: The aim of the present study was to evaluate bone regeneration in dehiscence-type defects at titanium implants with chemically modified (mod) and conventional sand-blasted/acid-etched (SLA) surfaces. MATERIAL AND METHODS: Standardized buccal dehiscence defects (height: 3 mm, width: 3 mm) were surgically created following implant site preparation in both the upper and lower jaws of four beagle dogs. modSLA and SLA implants were inserted bilaterally according to a split-mouth design. The animals were sacrificed after 2 and 12 weeks (n=2 animals each). Dissected blocks were processed for histomorphometrical analysis: defect length, new bone height (NBH), percent linear fill (PLF), percent of bone-to-implant contact (BIC-D) and area of new bone fill (BF). RESULTS: Wound healing at SLA implants was predominantly characterized by the formation of a dense connective tissue at 2 and 12 weeks, without significant increases in mean NBH, PLF, BIC-D or BF values. In contrast, modSLA implants exhibited a complete defect fill at 12 weeks following implant placement. In particular, histomorphometrical analysis revealed the following mean values at 12 weeks: NBH (3.2+/-0.3 mm), PLF (98%), BIC-D (82%) and BF (2.3+/-0.4 mm(2)). CONCLUSION: Within the limits of the present study, it was concluded that modSLA titanium surfaces may promote bone regeneration in acute-type buccal dehiscence defects at submerged implants.     

A histological investigation on early tissue response to titanium implants in a rat intramedullary model

Miniature grade 1 titanium screws were inserted in the tibias of 12 mature Wistar rats. Animals were sacrificed at 4, 7, and 21 days postimplantation. A combination of two morphological approaches was used to examine the tissue response to implants. One part of the prepared tissue specimens was routinely embedded in paraffin after a weak decalcification in EDTA. In this case, the implant was mechanically removed before embedding. The remainder of the specimens were embedded in polymethylmethacrylate resin, and ground sections were realized according to Donath's method. New bone formation occurred soon after implantation. Initially, on the fourth day, the presence of osteoid could be observed near the implant surface. On the seventh day, well-mineralized bone tissue was apposed directly on the implant surface. On the 21st day, the bone tissue became a highly organized lamellar bone.     

Bone reactions to titanium screw implants in ovariectomized animals

OBJECTIVE: The purpose of this study was to investigate the reactions of bone tissue after the placement of implants into the tibiae of osteopenic model rats. STUDY DESIGN: Commercially pure titanium screw implants were placed in the bilateral proximal tibial metaphyses 168 days after ovariectomy had been performed on 12-week-old female Wistar rats. For control purposes, implants were similarly placed in sham-ovariectomy rats. The healing process was examined histologically by means of undecalcified sections at various intervals from 7 to 168 days after implantation. Through use of an automated imaging analytic system, changes in relative bone mass and implant-bone contact were histomorphometrically evaluated. RESULTS: In the cortical bone area, only a slight difference in bone contact was noted with the implant until 28 days after implantation. However, ovariectomy significantly affected bone contact at 56 days after implantation. The rate of bone contact in the cancellous bone area and the relative bone mass around the implant were significantly lower in the test group than in the control group. CONCLUSIONS: It is considered that a decrease in bone mass causes a reduction in the contact area between implant and bone and may also cause a reduction in the supporting ability of the implant because of thinning of the surrounding bone tissue.     

Bone remodeling in immediately loaded and unloaded titanium dental implants: a histologic and histomorphometric study in humans

Remodeling is thought to prevent microdamage accumulation caused by repetitive loading and to increase the fatigue life of bone. The bone remodeling rate (BRR) is the period of time needed for new bone to replace the existing bone and to allow for the adaptation of bone to its environment. BRR is expressed as a percentage or volume of new bone within a specific time period. The aim of the present study was to evaluate bone remodeling events on submerged and immediately loaded dental implants. Twelve patients with edentulous mandibles participated in this study. All patients were rehabilitated with fixed mandibular prostheses, with 10 dental implants per patient. An additional implant was inserted in the most distal posterior mandibular jaw region. In 6 patients, these additional implants were loaded with a fixed provisional prosthesis the same day of the implant surgery and loaded. In the other 6 patients, the additional implants were left submerged and not loaded. After 6 months, all the additional implants were retrieved with a trephine. The percentage of woven and lamellar bone, number of osteoclasts and osteoblasts, and percentage of bone labeled by tetracycline at 0.5 mm and 2 mm from the implant surface were evaluated. The percentage of lamellar bone, number of osteoblasts, and percentage of bone tetracycline labeling was significantly higher in the loaded implants than in the unloaded implants (P =.0001). Also in the loaded implants, the percentage of woven and lamellar bone, number of osteoclasts and osteoblasts, and percentage of bone tetracycline labeling was significantly higher at 0.5 mm than at 2 mm from the implant surface (P =.0001). No such differences were found in unloaded implants (P =.377). In conclusion, we found that (1) loading appeared to stimulate bone remodeling at the interface, (2) a higher percentage of lamellar bone was found in loaded implants, (3) the percentage of bone labeling was higher at the interface of loaded implants, (4) no differences were found in the BRRs between immediately loaded and unloaded implants, and (5) immediate loading had not interfered on the lamellar bone formation at the interface and had not produced formation of woven bone at the interface.     

Bone response to a Ca- and P-enriched titanium surface obtained by anodization

This study evaluated bone response to a Ca- and P- enriched titanium (Ti) surface treated by a multiphase anodic spark deposition coating (BSP-AK). Two mongrel dogs received bilateral implantation of 3 Ti cylinders (4.1 x 12 mm) in the humerus, being either BSP-AK treated or untreated (machined - control). At 8 weeks postimplantation, bone fragments containing the implants were harvested and processed for histologic and histomorphometric analyses. Bone formation was observed in cortical area and towards the medullary canal associated to approximately 1/3 of implant extension. In most cases, in the medullary area, collagen fiber bundles were detected adjacent and oriented parallel to Ti surfaces. Such connective tissue formation exhibited focal areas of mineralized matrix lined by active osteoblasts. The mean percentages of bone-to-implant contact were 2.3 (0.0-7.2 range) for BSP-AK and 0.4 (0.0-1.3 range) for control. Although the Mann-Whitney test did not detect statistically significant differences between groups, these results indicate a trend of BSP-AK treated surfaces to support contact osteogenesis in an experimental model that produces low bone-to-implant contact values.     

Bone reactions adjacent to titanium implants with different surface characteristics subjected to static load. A study in the dog (II)

The purpose of the present study was to compare bone reactions adjacent to titanium implants with either a titanium plasma-sprayed (TPS) or a machined surface subjected to lateral static loading induced by an expansion force. In 3 labrador dogs, the 2nd, 3rd and 4th mandibular premolars were extracted bilaterally. 12 weeks later, 2 implants with a TPS surface were placed in one side and 2 implants with a machined surface were placed in the contralateral side. Twelve weeks after implant installation, crowns, connected in pairs with orthodontic expansion screws, were fitted to the implants and a 0.6 mm wide expansion was initiated. Clinical registrations, standardized radiographs and fluorochrome labeling were carried out during a 24-week period of loading. Biopsies with the implants in situ were harvested and processed for ground sectioning. The sections were subjected to histologic and histometric examination. A higher marginal bone level was observed around implants with a TPS surface compared to machined implants. Furthermore, the values describing the amount of bone-to-implant contact at the bone/implant interface as well as the density of the peri-implant bone were lower at the machined than at the TPS implants.     

Bone changes around hydroxyapatite and titanium implants after abutment placement in rabbits-observations using histological and three-dimensional examinations

We have previously developed a computer-aided system for examination of the three-dimensional bone structure around implants and observed the bone changes in the healing period after implant placement. This paper describes the bone changes around hydroxyapatite (HA) and titanium (Ti) implants after abutment placement using histological and three-dimensional examinations. Twenty-four HA and Ti implants were embedded in the tibias of adult male New Zealand white rabbits. After 8 weeks, the abutment had passed through periosteum and was placed under the skin. Rabbits were sacrificed 4 and 8 weeks following abutment placement. In conclusion, histological examination showed that, at 4 weeks after abutment placement, bone resorption around the implant neck was seen in both HA and Ti implants, and at 8 weeks, excessive bone formation was seen around the implant neck. Three-dimensional bone examination showed that abutment placement may affect bone formation and cause additional bone hypertrophy in the bone marrow area.     

Bone regeneration in dehiscence-type defects at non-submerged and submerged chemically modified (SLActive) and conventional SLA titanium implants: an immunohistochemical study in dogs

Objectives: The aim of the present study was to evaluate bone regeneration in dehiscence‐type defects at non‐submerged and submerged titanium implants with chemically modified (mod) and conventional sandblasted/acid‐etched (SLA) surfaces. Material and Methods: Standardized buccal dehiscence defects were surgically created following implant site preparation in both the upper and lower jaws of 12 beagle dogs. Both types of implants were randomly assigned to either a non‐submerged or a submerged healing procedure. After 1, 2, 4, and 8 weeks, dissected blocks were processed for histomorphometrical [e.g. new bone height (NBH), per cent linear fill (PLF), percentage of bone to implant contact (BIC‐D), area of new bone fill (BF)] and immunohistochemical analysis. Results: At 8 weeks, non‐submerged and submerged SLA implants revealed significantly lower mean NBH (1.1±0.8–1.9±1.2 mm), PLF (27.7±20.3–46.0±28.5%), BIC‐D (26.8±10.4–46.2±16.2%), and BF (1.3±0.9–3.4±2.8 mm²) values than respective modSLA implants [NBH (2.6±0.8–4.3±0.1 mm), PLF (64.2±19.4–107.2±4.7%), BIC‐D (67.5±18.8–82.1±14.8%), BF (2.9±1.0–6.7±1.1 mm²)]. Within modSLA groups, significantly highest BF values were observed at submerged implants. Conclusion: It was concluded that (i) modSLA titanium surfaces promoted bone regeneration in acute‐type buccal dehiscence defects and (ii) a submerged healing procedure improved the outcome of healing additionally.