Dr.

Rajendra Kumar

 Bone

healing is certainly a fascinating biological accomplishment of the skeletal tissues and one of the rare examples in which regenerative processes fully restore the original structure and function.
is achieved by a sequence of cellular activities that closely resemble the development and growth of bone during embryonic and postnatal life. Bone regeneration follows two pathways
Periodontology 2000, Vol. 17, 1998

This

1. Direct (or primary) healing: a scaffold of woven bone, closely associated with an expanding vascular net, invades the granulation tissue that organizes the initially formed blood clot.

2. Secondary (or indirect) healing: connective tissue and/ or fibrocartilage differentiates within the fracture gaps and is replaced by bone as in endochondral ossification.

Periodontology 2000, Vol. 17, 1998

 In

the late 1950s, Branemark predictably achieved an intimate bone-to-implant apposition that offered sufficient strength to cope with load transfer. from Switzerland in mid 1970s was first to illustrate histologically that a direct bone to implant contact occurs.

Schroder

Wiess

1987, came with a concept of fibro-osseous retention and stated that there is no direct bone to implant contact and there is presence of collagen fibres between implant surface and bone. Periodontology 2000, Vol. 17 1998

 But

this concept was later on discarded by Meffert et al 1992 with a view that there is formation of fibrous tissue if premature loading of implant is done which causes apical migration of junctional epithelium into the bone and implant interface followed by connective tissue elements and if there is no close approximation of bone and implant, i.e. tight fit

 Osseointegration

clearly belongs to the category of direct or primary healing. Originally, it was defined as direct bone deposition on the implant surfaces , a fact also called "functional ankylosis" (Branemark 1977). a more comprehensive way, osseointegration is characterized as "a direct structural connection between ordered, living bone and the surface of a loaded "implant (Listgarten 1991).
Periodontology 2000, Vol. 17,1998

In

 Osseointegration

can be compared with direct fracture healing, in which the fragment ends become united by bone, without intermediate fibrous tissue or fibrocartilage formation.
difference, however, exists: osseointegration unites bone not to bone, but to an implant surface: a foreign material. Thus the material plays a decisive role for the achievement of union.
Periodontology 2000, Vol. 17 1998

A fundamental

1) Bioinert or Bioactive Materials Osseointegration requires a bioinert or bioactive material and surface configurations that are attractive for bone deposition (osteophilic). Bioinert materials do not release any harmful sub- stances and therefore do not elicit adverse tissue reactions. Titanium, either commercially pure or in certain alloys, is generally recognized as being bioinert and used extensively in both dental and orthopedic surgery. A bioactive material is thought to cause a favorable tissue reaction. either by establishing chemical bonds with tissue components (hydroxyapatite) or by promoting cellular activities involved in bone matrix formation.
Periodontology 2000, Vol. 171998

2) Surface Configuration a) Surface free energy or wettability-is an important parameter for interaction between bone and implant.
b)

Rough Surface - The notion that surface properties might influence the elaboration of boneimplant contact is relatively new. It could be anticipated material rough surfaces will improve adhesive strength compared with smooth ones.

The observation that a rough surfaces speed up the bone apposition; More prostaglandin E2 (PGE2)and transforming growth factor beta (TGF-1) are produced on roughened than smooth surfaces Gradually increases the extent of the boneimplant interface

Roughened surfaces also show some disadvantages, such as increased ion leakage and increased adherence of macrophages and subsequent bone resorption.

Fig. Roughened surf aces are achieved by plasma spraying, by acid etching or as shown here by oxidizing

Fig. Even turned , or machined, implant surfaces are not smooth

c) Microporosity : Adhesion, however, requires either a chemical bond or a microporosity (microprotrusions and microundercuts of 20 50 micrometer) that leads to a microindentation between bone and metal Macroporosity(pore size 100-500 micrometer) favors bony ingrowth and is widely used as porous coatings.

Finally the macro-design or shape of an implant has an important bearing on protruding surface of implant elements of implant surface such as ridges, crests, teeth, ribs or the edge of the threads that apparently act as stress risers when the load is transferred.

3. Primary stability and adequate load:

tissue response to a freshly installed implant greatly depends on the mechanical situation. in direct fracture healing, it requires perfect stability if bone is expected to be formed. In a fracture, a stable fixation is obtained by exact adaptation and compression of the fragments. depends on the bone quality and available volume, the relation between drill and implant diameter, and the implant geometry and precise press fitting at surgery.

The

As

It

 It

must counteract all forces that create micromotion between the implant and the surrounding tissues. Or, in other words, it should build up enough preload to compensate for functional load. thus determines not only the size but also the direction of the forces that are considered to remain adequate.

It

 All

these parameters must be specified, and this makes it understandable why immediate functional loading may be adequate for such systems as barconnected screws, whereas others require a prolonged, unloaded healing period before a prosthesis can be installed.

 Cell
The

kinetics and tissue remodeling:

osseointegration process observed after implant insertion can be compared to bone fracture healing. site osteotomy preparation (bone wounding) initiates a sequence of events, including an inflammatory reaction, bone resorption, release of growth factors, and attraction by chemotaxis of osteoprogenitor cells to the site.

Implant

 Differentiation

of osteoprogenitor cells into osteoblasts leads to bone formation at the implant surface. Extracellular matrix proteins, such as osteocalcin, modulate apatite crystal growth.

Specific

conditions, optimal for bone formation, must be maintained at the healing site to achieve osseointegration.

Immobility of the implant relative to the bone must be maintained for bone formation at the surface. A mild inflammatory response enhances the bone healing, but moderate inflammation or movement above a certain threshold is detrimental. When micromovements at the interface exceed 150 m, the movement will impair differentiation of osteoblasts and fibrous scar tissue will form between the bone and implant surface.

 Therefore

it is important to avoid excessive forces, such as occlusal loading, during the early healing period. tissue damage and debris created by the osteotomy site preparation must be cleared up by osteoclasts for normal bone healing.
multinuclear cells, originating from the blood, can resorb bone at a pace of 50 to 100 m per day.

Bone

These

There

is a coupling between bone apposition and bone resorption.

Fig. The basic multicellular unit is the basic remodeling process for bone renewal. Osteoclasts are imported by the vascular supply , and the resorption lacunae are soon filled by the lining osteoblasts.

Fig. After insertion of an implant , slight tissue necrosis may result from surgical trauma. This tissue or interposed blood clot is removed by the multinucleated osteoclast and is replaced by osteoid (poorly mineralized ) bone.

 Osseointegration

follows a common biologically determined program that is subdivided into 3 stages:-

1) Incorporation by woven bone formation; 2) Adaptation of bone mass to load (lamellar and. parallel -fibered bone deposition) 3) And adaptation of bone structure to load (bone remodeling).

 Woven

bone is quickly formed in the gap between the implant and the bone; it grows fast, up to 100 m per day, and in all directions.
is characterized by a random orientation of its collagen fibrils, high cellularity, and limited degree of mineralization, the biomechanical capacity of woven bone is poor and thus any occlusal load should be well controlled or avoided in the early phase of healing.

It

 After

several months, woven bone is progressively replaced by lamellar bone with organized, parallel layers of collagen fibrils and dense mineralization.
bone is certainly the most elaborate type of bone tissue. Packing of the collagen fibrils into parallel layers within alternating course (Comparable to plywood) gives it the heighest ultimate strength.

Lameller

 Contrary

to the fast-growing woven bone, lamellar bone formation occurs at a slow pace (only a few microns per day).
after 18 months of healing, a steady state is reached where lamellar bone is continuously resorbed and replaced

Ultimately,

Fig. A, After initial healing, woven bone, as characterized by its irregular pattern, is laid down. B, After weeks or months, progressively a lamellar bone is laid down, with regular concentric lamellae

 At

the light microscopic level, an intimate bone-toimplant contact has been extensively reported. Once the bone-to-implant interface has reached a steady state, it can maintain itself over decades, as ascertained by human histology from implants retrieved because of hardware fractures
Fig. Once a steady state has been achieved at the bone-to-implant interface, an intimate contact can be observed, with some marrow spaces seen in between at the light microscopic level.

 Bone

remodeling characterizes the last stage of ossseointegration. It starts around the third month and after several weeks of increasingly high activity, slows down again, but continues for the rest of life. In cortical as well as in cancellous bone, remodeling occurs in discrete units, often called a bone multicellular unit, as proposed by Frost (1963). Remodeling starts with osteoclastic resorption, followed by lamellar bone deposition. Resorption and formation are coupled in space and time

 Remodeling

in the third stage of osseointegration contributes to an adaptation of bone structure to load in two ways: 1. It improves bone quality by replacing pre-existing, necrotic 'bone and/or initially formed, more primitive woven bone with mature, viable lamellar bone. 2. It leads to a functional adaptation of the bone structure to load by changing the dimension and orientation of the supporting elements.

 Once

osseointegration is achieved, implants can resist and function under the forces of occlusion for many years. Longitudinal biomechanical assessments seem to indicate that during the first weeks after placement of one-stage implants, decreased rigidity is observed. may be indicative of bone resorption during the initial phase of healing Subsequently, rigidity increases and continues to increase for years.

This

 Thus,

when a prosthesis is installed immediately (in 1 day) or early (in 1 to 2 weeks), care must be taken to control against overload. It is important to recognize that sites with limited primary stability or less boneto-implant contact (e.g., posterior maxilla) will likely go through a period of even less bone support in the early stages of bone healing due to the initial phase of bone resorption.

Histologically, osseointegration is defined as the direct structural and functional connection between ordered, living bone and the surface of a load-bearing implant without intervening soft tissues. 1. Areas of cortical bone 2. Areas of cancellous bone 3. In retrieved human implants

Periodontology 2000, Vol. 17, 1998

 Primary

stability is obtained by press-fitting, which leads to direct bone-implant contact. Press fitting often causes local overload, with plastic deformation of the lamellae and even fissures and microcracks. local blood supply is disturbed by rupture and compression of vessels. The bone becomes avascular and necrotic but still provides stability.

The

Periodontology 2000, Vol. 17, 1998

D.Primary contact with cortical bone. Press-fitting led to local overload and plastic deformation of the lamellae. Some fissures originate from the edge of the thread. Remodeling in the otherwise devitalized bone has started at the lower margin of the micrograph. Sandblasted and acid-etched surface, 3 months unloaded,

b. osseointegration in cortical bone, Periodontology 2000, Vol. 17, 1998

When screw-type implants are inserted into cortical bone a bur is recommended with a diameter that is somewhat larger then the core of the thread.
The wall of the bore-hole is then often detectable in the sections and are separated from the screw thread by a 50to 100-micro meter -wide gap . At 3 months, it is partially or completely filled by lamellar bone, formed in the second stage of osseointegration.

Bone remodeling, as the dominant mechanism in stage three, finally replaces the avascular areas by mature living bone. Cortical remodeling substantially contributes to the increase in interface between implant and living Periodontology 2000, Vol. 17, 1998 bone.

Fig. e. Secondary bone-implant contact by bone apposition. A straight cement line delineates the wall of the former drill hole from the bony filling in the thread. Two large vascular spaces are lined by osteoblasts and osteoid, indicating ongoing bone deposition. Titanium plasma-sprayed surface, 3 months unloaded, x 75 f. Secondary bone-implant contact achieved by cortical bone remodeling. Three cortical bone remodeling units have evolved in direct contact with the implant surface. At 3 months, they are in an early stage of bone formation. Sandblasted and acid etched surface, 3 months unloaded,x 8 0 Periodontology 2000, Vol. 17, 1998

 The

volume density of bone matrix in cortical bone is about 80-90%, in cancellous bone only 20-25%. Cancellous bone, therefore, contributes much less to the primary stability. Sites where direct contact between implant and trabeculae was forced by compression are rather rare. On the other hand, a large compartment of implant surface is exposed to bone marrow, with its ample vascularity and abundance of precursor cells for osteoblasts.
Periodontology 2000, Vol. 17,1998

Fig c. bone anchorage in the cancellous bone part g. Formation of bony anchors in the cancellous part of the implant site. The apical and the middle thread are connected to pre-existing trabeculae (brighter) by newly formed bone bridges. The coronal thread is shown at higher magnification in H. Sandblasted and acid-etched surface, 3 months unloaded,x 25 h. The middle thread exhibits primary, punctate contact with pre-existing bone. Lamellar bone apposition has completed the bony anchor that resembles a pair of pliers. Sandblasted and acid etched surface, 3 months unloaded, x 50

Secondary bone-implant contact is achieved by bridging the intertrabecular marrow space. In the first stage, scaffolds of woven bone accomplish this goal. Prominent structures on either side, that is, free ends of trabeculae, or edges and threads of the implant, serve as a sort of bridgehead and narrow the span to be covered. Once established, these bony anchors are reinforced by lamellar bone and finally subjected to continuous remodeling, which improves bone quality as well as the orientation and dimension of the supporting elements.
Periodontology 2000, Vol. 17, 1998

In-between the bony anchors a large surface remains exposed to bone marrow only. Bone ongrowth also spreads out from neighboring anchors along this surface and covers it with a bony coating often less than 50 micro meter wide This is seen in later stages of osseointegration, when the structure of the bone marrow has matured to the red and/or fatty type
Fig. i.The groovebetween the coronal and the middle thread is covered by a less than 50-micro meter-thin bony coat, deposited by the red bone marrow on the sandblasted and acid-etched surface. 3 months unloaded, x80. Periodontology 2000, Vol. 17, 1998

 Lederman

in 1998 in histologic study of titanium implants plasma sprayed screws which were functioning for 12 years reported direct contact of bone to implant as 73.4%, 82.9%, 68.7%, 80.4%, the average being 76.4%.

Periodontology 2000, Vol. 17, 1998

The part of implant adjacent to cortical bone was filled with compact bone and vascular canals with the evidence of cortical remodeling.
Adjacent to cancellous bone the implant surface was covered by 100 to 200 micrometer wide lamellar bone with few parts of bone marrow lined with thin bony coatings. The bone marrow was thick vascularized with no signs of inflammation.

In two of the four implants, the tip of the screws were firmly anchored in the inferior cortex of the mandible. The other two screw tips ended in the medullary spongiosa. In later case the screw ends are sheathed by bone that is continuous with the surrounding trabeculae that finally merge with the cortical bone.
Fig. d. The tip of the self-tapping screw protrudes into the marrow cavity. It is covered by a bone plate and supported by trabeculae that are connected to the cortical layer. e. Cortical bone remodeling is shown by a secondary osteon (darker staining) in direct contact with the titanium plasmasprayed surface,

In few areas the screw thread covered by cancellous bone remodeling was seen as osteoclasts digging out erosion cavity which is then filled up by osteoblasts was seen.

Fig. Cancellous bone remodeling resulted in a lamellar packet (darker staining) inserted into the bone plate previously deposited on the titanium plasma-sprayed surface. It is delineated by cement lines from the bone deposited earlier on the thread. Periodontology 2000, Vol. 17, 1998

 In

past 20 years osseointegrated dental implants have become a significantly accepted treatment modality of fully and partially edentulous patients by the fact that dental implants can be anchored in the jaw bone with direct bone implant contact As outlined earlier osseointegration is achieved and maintained after insertion with a cascade of three different maturation steps starting with incorporation of implant by woven bone formation, followed by adaptation of bone to load by lamellar bone, and finally on going structural adaptation of bone to load by bone remodeling.