Vol.18 / No.

1 Jul-Aug 2009

Dental Implant Summaries

and related areas of research

18/1

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Dental Implant Summaries

1 A randomized prospective
multicenter trial evaluating the platform-switching technique for the prevention of postrestorative crestal bone loss
Int. Journal of Oral and Maxillofacial Implants June 2009. Prosper L, Radaelli S, Pasi M. Zarone F, Radaelli G, Gherlone E.

Vol. 18 / No. 1 Jul-Aug 2009

2 Agreement of quantitative

subjective evaluation of esthetic changes in implant dentistry by patients and practitioners

Int. Journal of Oral and Maxillofacial Implants June 2009. Esposito M, Grusovin M. Worthington H.

3 Load fatigue performance of

implant-ceramic abutment combinations
Int. Journal of Oral and Maxillofacial Implants August 2009. Nguyen H, Tan K, Nicholls J.

4 The possible association among

bone density values, resonance frequency measurements, tactile sense, and histomorphometric evaluations of dental implant osteotomy sites
Implant Dentistry August 2009. Aksoy U, Eratalay K, Tozum T.

5 A rough surface implant neck

with microthreads reduces the amount of marginal bone loss: A prospective study
Clinical Oral Implants Research August 2009. Bratu E. Tandlich M, Shapira L.

6 Bone strain and interfacial

sliding analyses of platform switching and implant diameter on an immediately loaded implant
Journal of Periodontology July 2009. Hsu J-T, Fuh L-J. Lin D-J, Shen Y-W, Huang H-L.

7 Biofilm on dental implants:

A review of the literature
Int. Journal of Oral and Maxillofacial Implants August 2009. Subramani K, Jung R, Molenderg A. Hmmerle C.

8 Randomized-controlled

clinical trial of customized zirconia and titanium implant abutments for single-tooth implants in canine and posterior regions
Clinical Oral Implants Research August 2009. Zembic A, Sailer I. Jung R-E, Hammerle C.

9 Is insertion torque correlated

to bone-implant contact percentage in the early healing period? A histological and histomorphometrical evaluation of 17 human-retrieved implants
Clinical Oral Implants Research August 2009. Degidi M, Perrotti V. Strocchi R, Piattelli A. Iezzi G.

10 Influence of the height of the

external hexagon and surface treatment on fatigue life of commercially pure titanium dental implants

11 Influence of early cover

Int. Journal of Oral and Maxillofacial Implants August 2009. Gil F, Aparicio C, Manero J, Padrs A.

screw exposure on crestal bone loss around implants: Intraindividual comparison of bone level at exposed and non-exposed implants
Journal of Periodontology June 2009. Kim T-H, Lee D-W. Kim C-K, Park K-H, Moon I-S.

12 Evaluation of nano-

technology-modified zirconia oral implants: A study in rabbits

Journal of Clinical Periodontology July 2009. Lee J, Sieweke J. Rodriguez N, Schpbach P. Lindstrm H, Susin C, Wikesj U.

13 Bone quality assessment

based on cone beam computed tomography imaging

Clinical Oral Implants Research August 2009. Hua Y, Nackaerts O. Duyck O, Maes F, Jacobs R.

14 Mechanical non-surgical

treatment of peri-implantitis: A double blind randomized longitudinal clinical study

Journal of Clinical Periodontology July 2009. Renvert S, Samuelsson E. Lindahl C, Persson G.

15 Extent of peri-implantitis
associated bone loss
Journal of Clinical Periodontology April 2009. Fransson F, Wennstrom J. Tomasi C, Berglundh T.

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A randomized prospective multicenter trial evaluating the platform-switching technique for the prevention of postrestorative crestal bone loss
Crestal bone loss (CBL) has been an established criterion for long-term implant success. Several etiological factors have been proposed for CBL such as: surgical trauma, abnormal occlusal loading, implant-abutment junction variations, bacterial colonization, biologic width issues and host response to changes in bacterial flora. Conventionally, implants have been restored with matching diameter abutments with studies showing CBL of up to 2mm, after the first year of function. Use of the platform switching concept has increased over the years, with some implants incorporating this in their design. Although there have been some studies showing favorable bone level changes around platform switched implants, there is still a need for prospective studies to evaluate this phenomenon more objectively. This study, therefore aimed to establish whether implants placed posteriorly with an enlarged platform (EP) results in reduced CBL when compared to standard diameter implants using the conventional submerged (CS) protocol, the conventional non-submerged (CNS) protocol and submerged implants with a platform-switched abutment design (SPS).

Prosper L. Redaelli S. Pasi M. Zarone F. Radaelli G. Gherlone E. June 2009 Int. Journal of Oral and Maxillofacial Implants Vol.24 No.2 pp299-308 Correspondence to: Prof. Loris Prosper Via San Gottardo 84 20152 Monza Milan ITALY

MaterialandMethods78 patients were enrolled in this multicenter, randomized

prospective study. Main inclusion criteria included: type 2 or 3 bone, non-smokers, good oral hygiene with no periodontal disease and no clenching or bruxing habit. Microtextured surface implants were used (Sandblasted and acid-etched, Winxix Ltd. London). Nonsubmerged implants had machined collars, whereas the submerged implants were microtextured up to and including the neck. Standard implants had diameters of 3.3, 3.8 and 4.5mm and were slightly conical with spiral coils reducing in depth towards the implant neck resulting in an almost parallel implant. The EP implants were more conical, with a similar progressive coil design and implant widths of 3.3, 3.8 and 4.5mm but the implant necks were 3.8, 4.5 and 5.2mm respectively, with a centralized abutment junction. Both types of implant were randomly assigned to each group (CS, CNS and SPS). Bone quality was assessed by 2 to 4 examiners until agreement was reached. Patients were excluded if agreement was less than 50%, or included type 4 bone. Implants were restored after 3months in the mandible and 6 months in the maxilla and were assessed at insertion and followed up annually for 2 years with standard clinical and radiographic assessments. Statistical tests were utilized to determine the influence of age, sex, treatment protocol and any confounding variables, both within and between groups. Data was grouped according to CBL values as follows: < 0mm, 0.1-0.5mm, 0.6-1.0mm, 1.1-1.5mm and > 1.6mm.

ResultsOf the 78 patients recruited, only 68 were included in the study. A further 6
patients experienced implant failures and another 2 withdrew, with their results being excluded from the analyses. Therefore, 60 patients with 360 implants were included in the data. 100% of EP implants in the CS and SPS groups exhibited no bone loss over 2 years compared with 92% in the CNS group (P=0.007). Standard diameter implants in all groups exhibited more CBL than EP implants, with significant differences for CS and CNS groups (P=.0006). However, only small increases in CBL were seen for the standard implants in the SPS group (6.7% > 0 < 1.0mm), which was not significant, but this was significantly different when compared to standard implants in the other 2 groups (p<0.0001). No other factors demonstrated any significant influence.

The control implant (3.8mm) on the left was compared to a platform enlarged implant 4.5mm/3.8mm on the right

DiscussionandConclusionThere are several factors that have been shown to maintain crestal bone, and platform switching is one such factor, and this study corroborates this view demonstrating that it plays an important role in maintenance of crestal bone particularly for standard diameter implants. It can also be concluded that the use of an enlarged platform implant had a beneficial effect on maintenance of crestal bone levels irrespective of whether a one or two stage protocol was utilized and that it further enhanced the effects of platform switching. Additional studies are needed to evaluate long term results of platform switching under various conditions.
Dental Implant Summaries, Specialist Dental Summaries www.dentalsummaries.com Vol.18/ No.1 Jul-Aug 2009

Agreement of quantitative subjective evaluation of esthetic changes in implant dentistry by patients and practitioners
The ultimate goal of implant therapy is not only to provide function but to also have the best esthetic outcome. Several techniques have been suggested to improve implant esthetics ranging from simple gingival grafting to more complex grafting involving hard tissues. Unfortunately, very few trials have evaluated the esthetic outcome of implant treatment from both a patient and dentist perspective. One objective method of assessment was the Jemt Index or Papillary Score that was modified by others and formed the basis of many studies. Newer indices (the implant crown aesthetic index, the pink esthetic score and the California Dental Association criteria) have been developed, with varying degrees of reliability and ease of use. The current study aimed to determine the reliability of a subjective quantitative method of assessing esthetic changes after implant therapy, from a patient and clinician viewpoint. It also set out to determine whether a similarity existed between the perception of esthetics between clinicians and patients.

Esposito M. Grusovin M. Worthington H. June 2009 Int. Journal of Oral and Maxillofacial Implants Vol.24 No.2 pp309-315 Correspondence to: Prof. Marco Esposito Dept. of Oral and Maxillofacial Surgery, University of Manchester Higher Cambridge Street Manchester M15 6FH UK

MaterialandMethodsPre- and post-operative photos of 32 partially edentulous patients were selected. Although a good esthetic outcome was achieved with most patients, cases varied in the final result from poor to good, allowing discrimination between cases. Photos were standardized as much as possible and included the full smile and close up views of the treated area, giving 4 photos for each patient. Written instruction was given to 10 clinicians and 30 patients who then assessed all photos. The remaining 2 patients acted as the test sample. Photos were assessed in the same order by everyone and repeated 14 days or more later. The tasks included: 1. Identifying the pre-treatment photo, 2. Rating treatment outcome on a (VAS) visual analogue scale (from 1=poor to 10=excellent), 3. Rating the perception of esthetics on an ordinal scale (0=poor to 4=excellent), 4. Deciding whether the observer was pleased with the outcome. Data was subject to statistical analysis. ResultsFor distant smile photos, patients correctly identified preoperative photos in 83%
of cases initially but this went up to 90% at the follow up test. For the close up photos correct identification occurred for 83% at both tests. Clinicians fared better with the overall smile readings of 87-100% initially and 83-100% at the second test. Two clinicians identified all photos correctly, on both occasions. When intra-observer agreements were looked at, both on the VAS scale and categorical (kappa) scale, there was slight agreement for 3 clinicians, fair agreement for 5 clinicians, moderate for 1 clinician and substantial for 1 clinician. For close up photos, the readings were 87-97% initially and 90-100% at second test. One clinician gave slight agreement, 5 were fair, 2 were moderate and 2 were substantial. Poor patientpractitioner agreement as well as poor agreement between practitioners was observed on all levels. The overall Kappa values for comparison between clinicians were poor for magnified and distant photos. Both patients and clinicians gave very high esthetic satisfaction ratings for all before and after photos preventing a meaningful kappa statistic to be ascertained.

It was found in this study that patients and practitioners saw the esthetic qualities of their treatment quite differently

DiscussionandConclusionThis study is in agreement with previous studies which show that patients give better ratings for the esthetics than clinicians. Due to the nature of subjective analyses, it is difficult to determine which group is more accurate in their judgments. However, it is clear that the parameters that clinicians consider important (soft tissues, contralateral teeth and gingival height variations) may not be important to the patient. This suggests that the patient may be better placed to give their subjective opinion in such studies. It was also notable that using the smile images was more reliable than the close-up images, possibly due to the fact that the overall smile is what can be seen in everyday situations. Although patients were generally in agreement, they only assessed their own photos. In contrast, there was less agreement between clinicians but this may have been due to them assessing photos of all patients. In conclusion, this study showed that clinician and patient agreement was poor indicating that they perceive esthetics quite differently.
Dental Implant Summaries, Specialist Dental Summaries www.dentalsummaries.com Vol.18/ No.1 Jul-Aug 2009

Load fatigue performance of implant-ceramic abutment combinations

In pursuit of enhanced esthetic outcomes in implant therapy there has been an increase in the use of ceramic abutments to avoid grey shine-through in the peri-implant tissues. Densely sintered yttrium-stabilized zirconium dioxide (Y-TZP) abutments have the advantage of being tooth colored, biocompatible, and compared to alumina exhibit high strength and chemical resistance. Disadvantages include brittleness under tensile forces. While previous studies have shown that zirconia abutments were twice as resistant to fracture as alumina abutments, they have not been subjected to rotational load testing. This in-vitro study aimed to determine the load-fatigue performance of 4 implant systems and their respective zirconia abutments.

Nguyen H. Tan K. Nicholls J. August 2009 Int. Journal of Oral and Maxillofacial Implants Vol.24 No.4 pp636-646 Correspondence to: Dr. Keson B. Tan Department of Restorative Dentistry, Faculty of Dentistry National University of Singapore, 5 Lower Kent Ridge Road Singapore 119074 REPUBLIC OF SINGAPORE

MaterialandMethodsThe 4 implant systems with their corresponding zirconia abutments tested were: 1. Replace Select internal-connection (Nobel Biocare); 2. Brnemark Mark III external-connection (Nobel Biocare); 3. Osseotite NT external connection (3i) and 4. Osseotite NT Certain internal-connection (3i). Diameters ranged from narrow (3.3mm, 3.5mm), regular (4.0mm, 4.3mm) and wide (5.0mm) for Nobel Biocare implants and 4.1mm and 5.0mm for 3i implants. This resulted in 10 groups, with 5 samples in each. Procera Zirconia abutments (Nobel Biocare) were standardized to match those of the preformed ZiReal Osseotite (3i) abutments. Implants were secured in the test apparatus and their respective abutments secured to the recommended torque value. A customized brass crown was also cemented to each abutment (Panavia F). Fatigue testing was carried out at 45 to the long axis of the sample with a 21N load at 10Hz. All samples were checked for concentricity during cyclic loading with a limit of 5 million cycles. Light and scanning electron microscopy was used to analyze the fractured surfaces. Two way analysis of variance (ANOVA) was used, with the system and diameter being the independent variables and the number of fatigue cycles to failure the dependent variable. Significant subsets in the 10 test groups were determined by oneway ANOVA and Tukey highly significant difference (HSD) post-hoc test at p<0.05. Results58% of all samples failed with 36% exhibiting abutment fracture. No failures were recorded for any of the 5.0mm diameter 3i samples or for one 4.1mm 3i sample. Screw fracture featured in all samples except the wide diameter implants from all systems. Overall there were 7 implant fractures in narrow and regular platform Replace Select, as well as 4.1 diameter Osseotite NT implants. There were significant differences between implant diameters but not between implant systems. DiscussionandConclusionImplant fractures were seen at the thinnest part of the
internal tri-channel of 5 Replace Select implants. This concurs with other finite element analysis studies. Interestingly when abutment screw fracture occurred these were at the first thread for all samples, with scratches indicating screw loosening prior to failure. Screw loosening was also observed in the Brnemark group prior to fracture, but the most common cause of failure was abutment fracture. There were 2 gold screw fractures in the Osseotite NT group and one combined implant and screw fracture. Again implant fracture also occurred at the thinnest aspect of the internal thread. Osseotite Certain implants also exhibited abutment and screw fractures as well as separation of the titanium insert from the zirconia abutment. It was notable that there was no damage to the zirconia/abutment interface when there was a titanium insert. Three zirconia abutments failed after comparatively few cycles suggesting that there were pre-existing cracks. The failure rate in this study was 58%. Previous studies on titanium abutments using similar testing methods yielded failure rates of 20% and 30%. Data from the current study indicates that zirconia abutments are more prone to failure than their metal counterparts particularly on narrow and regular diameter implants, suggesting that their performance may be dependent on abutment dimensions and design characteristics.
Dental Implant Summaries, Specialist Dental Summaries www.dentalsummaries.com Vol.18/ No.1 Jul-Aug 2009

Four implants and their respective zirconia abutments were subjected to rotational load testing to examine comparative performance

The possible association among bone density values, resonance frequency measurements, tactile sense, and histomorphometric evaluations of dental implant osteotomy sites: A preliminary study
The ability to determine bone quality (density) in a quantitative manner, prior to, or at the time of implant placement is considered useful as a prognostic indicator for implant success. CT scans provide quantifiable bone density measurements which may relate to actual bone quality found at the time of surgery using non-invasive techniques such as tactile sense, insertion torque and resonance frequency analysis (RFA). A more specific analysis would be achieved using histology to determine the actual percentage of trabecular bone by volume (TBV) in the region where the implant is to be placed. If this measurement could be shown to correlate to CT or to other non-invasive analyses then it might be possible to predict outcome in relation to bone density. Consequently, this preliminary clinical study was carried out in order to determine if a relationship exists between CT values, histological TBV, tactile measurements, and stability measurements using RFA.

Aksoy U. Eratalay K. Tozum T. August 2009 Implant Dentistry Vol.18 No.4 pp316-21 Reprint requests to: Dr. T. Tozum Dept. of Periodontology Faculty of Dentistry Hacettepe University Sihhiye, TR-06100 Ankara TURKEY

MaterialandMethods10 healthy, non-smoking patients received a total of 11 posterior mandibular and 12 posterior maxillary implants. All patients had a basic clinical and conventional radiographic examination followed by a CT scan for pre-operative planning. A measurement in Hounsfield units (HU) was made to give a value of bone density at each of the proposed implant sites as indicated by markers placed into custom scanning guides. The implants (SwissPlus, Zimmer Dental, Carlsbad, CA) were inserted via a crestal incision. At the time of placement an initial trephine bur 2mm x 5mm was used to remove a core biopsy. At the same time a measurement of tactile sensation was made according to the Misch classification for bone quality (D1 to D4). After implant insertion RFA was performed (Osstell Mentor, probe version 2, Sweden) to evaluate the implant stability quotient (ISQ) for each of the 23 implants. Thereafter, a healing abutment was placed and flaps sutured. Patients were reviewed at 7-10 days and restorations placed after 6 months. Biopsies were prepared for histomorphometric evaluation of TBV, which represented the percentage of trabecular bone present in the area of the specimen. Statistical analysis was carried out to assess the presence or absence of a correlation between CT values (HU), RFA values, tactile sense and TBV using the Spearmans correlation coefficient. ResultsAll implants were restored successfully. The average bone density from all the sites was 554.87302.045 HU. The mean RFA and TBV were 72.286.194 ISQ and 41.017 12.552% respectively. While males had a higher mean CT value than females this was not significant. Females had significantly higher RFA values (P=0.011) than males but significantly lower TBV values (P=0.008). Maxillary sites yielded significantly lower CT values (P=0.046) compared with mandibular sites, and although not significant, the TBV values in the mandible were higher than those in the maxilla. Yet RFA values were lower in the mandible compared to the maxilla. The only significant correlation found for all implants in all patients was between tactile sensation and CT values (r=-0.52, P=0.009). Analysis by gender revealed that male subjects showed correlation between RFA and tactile sensation (r=-0.53, P=0.042), while females showed correlation between CT values and TBV (r=0.810, P=0.015), and between RFA (r=0.807, P=0.015) and tactile sense (r=-0.756, r=0.030). DiscussionandConclusionBone quality classifications have given practitioners the ability to make assessments at the time of surgery. However, the use of CT measurements has been proposed as providing a pre-operative evaluation which is directly related to histological values for bone density and non-invasive tactile measurements. While some correlations were evident, this study, as with previous studies, was unable to demonstrate a correlation between ISQ and CT values. As the surgeon in the present study was experienced a correlation was shown between tactile sensation and CT values. However, a correlation between CT and TBV was only apparent in females. An important limitation which may affect the significance was the small sample making it clear that further studies with larger sample sizes are required.
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A rough surface implant neck with microthreads reduces the amount of marginal bone loss: A prospective study
All implants display some degree of marginal bone remodeling (MBR) after insertion. This tends to occur in 2 phases, early (after uncovery and abutment connection) and late (during the rest of the life of the implant). The latter is regarded as having an inflammatory and possibly overloading etiology. Early MBR is attributed to re-establishment of the biologic width apical to the implant / abutment connection and can be influenced to a certain extent by implant design. Machined implant necks tend to exacerbate MBR whereas roughened and micro-threaded necks tend to retain more bone over time. The objective of this study was to compare MBR in two similarly designed tapered implant systems and compare MBR and the initial stability of the implants due to the thread design and the influence this may have on MBR during early implant function.

Bratu E. Tandlich M. Shapira L. August 2009 Clinical Oral Implants Research Vol.20 No.8 pp827-832 Reprint requests to: Dr. L. Shapira Dept. of Periodontology Faculty of Dental Medicine Hadassah Medical Centre PO Box 12272 Jerusalem ISRAEL

MaterialandMethodsTwo tapered, threaded implant designs from the same company

(MIS-Implants Inc., Israel) were used. One had a 1mm polished collar (P) and one a microthreaded moderately rough collar (M). Implant dimensions were identical though threads patterns varied. One of each implant matched for identical size (10 or 11.5mm length and 3.75 or 4.2mm ) was inserted as a pair (P mesially and M distally) utilizing a two-stage standardized protocol in to the posterior mandibles of 48 patients (ages 23 - 65) seeking replacement of missing posterior teeth. Thus 48 pairs of implants were inserted with 8 patients receiving bilateral pairs but only having one side analyzed. All implants were inserted to depth such that the necks of the implants were placed at the bone crest. A PerioTest (Medizintechnik Gulden) reading (PTR) was used to assess stability at implant insertion and at prosthetic connection after 4 months. MBR was measured on dental panoramic tomograms at baseline (prosthesis connection), and after 6 and 12 months of functional loading, using the shoulder of the implant as a reference and a baseline value of zero since the shoulder was leveled with the bone crest. Any occurrence of premature dehiscence during healing was noted but not treated further. All prosthetic treatment was carried out after the same time period (4 months) using a cemented crown over a standard milled abutment. MBR was evaluated as the primary variable, while PTR values, incidence of premature exposure and associated bone loss were secondary variables. MBR around each implant at each time point and PTR results were subjected to statistical analysis with significance set at P=0.05.

Results2 patients were lost to follow up and thus only 46 pairs of implants in 46 patients were analyzed. Dehiscences during healing occurred in both groups (P: n=8, M: n=4) but all implants osseointegrated. All implants lost statistically significant amounts of marginal The implant on the left had bone (P<0.05) with more loss evident in the first 6 months of function. The comparative a 1mm polished collar and values of MBR (mm SD) for P and M groups were 0.77 (0.46) and 0.21 (0.19) at 4 months, no micro-grooves. This was compared to an implant on the 1.2 (0.44) and 0.56 (0.23) at 6 months and 1.47 (0.4) and 0.69 (0.25) at 1 year respectively. right with the same surface The P group lost significantly more bone than the M group (p<0.05). Dehiscence led to a treatment but with microgrooves and no polished collar statistically significantly increase in MBR in the P group (P<0.05) but had no impact on the M group of implants at any time in the study. PTR values improved for both groups between insertion and final readings (P<0.001) but were significantly better (more negative) in the M group. There was no correlation between size of implant and PTR value. DiscussionandConclusionIn the current study, implants that varied in their neck design and surface topography exhibited statistically significant differences in the degree of marginal bone remodeling after abutment connection and up to one year in function. Since the chemical composition and neck dimensions of the implant pairs in each site were identical, this study supports previous investigations that show that polished implant collars are less successful at retaining marginal bone than roughened collars. However, this study could not determine whether the surface roughness or the microthread design enabled better bone retention in the M group, and this warrants further investigation.
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Bone strain and interfacial sliding analyses of platform switching and implant diameter on an immediately loaded implant: Experimental and 3-D finite element analyses
The effect of platform switching and varying implant diameter on the stresses transmitted to bone during immediate loading are largely uninvestigated. This study uses a combination of load testing on standardized lithographic models and 3-D finite element analysis (FEA) to compare effects on bone strain at the implant-bone interface (IBI) of varing implant diameters and platform switching (PS).

Hsu J-T. Fuh L-J. Lin D-J. Shen Y-W. Huang H-L. July 2009 Journal of Periodontology Vol.80 No.7 pp1125-1132 Reprint requests to: Dr. Heng-Li Huang School of Dentistry China Medical University 91 Hsueh-Shih Road 404 Taichung TAIWAN

MaterialandMethodsData from a CT scan of an edentulous mandible from a dried

skull was used to construct 5 standardized resin impregnated powder models of the premolar and molar regions using rapid prototyping stereolithographic techniques. The models and implants were tested to determine mechanical properties for FEA. One implant (13mm long, external hex ICE, 3i Biomet) was inserted into each model. The implants were either 3.75mm or 5mm diameter and were passively screwed into the models (SC) or cemented with cynoacrylate (CA) to represent either an immediately placed implant or an osseointegrated implant respectively. An abutment of either 4mm or 5mm was then attached to each implant to give 5 samples with (PS) or without a platform switch (NPS): A: 3.75/SC/NPS; B: 5.0/SC/PS; C: 5 /SC/NPS; D: 5/CA/PS and E: 5/CA/NPS. A custom jig in a universal testing machine (JSU-H1000, Japan Instrumentation Systems) was used to vertically and obliquely (45 buccal to lingual) load each abutment with 130N at 1mm/min. Peak tensile and compressive bone strains were recorded with rosette strain gauges cemented to the buccal and lingual aspects of each sample. Each reading was taken 3 times and analyzed using standardized software. A frictional coefficient of 0.6 was used to simulate sticking and sliding friction between implant and bone in the immediate loading scenario. Implant and bone nodes were merged to simulate osseointegration in the integrated implant scenario. The lingual and lower borders of the mandible were regarded as fixed.

ResultsThere were no significant differences (p>0.05) noted in bone strain values

between models with and without PS. Bone strains were higher in A, B and C compared to D and E and these were concentrated mainly on the lingual aspect of each implant. Peak compressive strain values exceeded peak tensile strain values in magnitude. Peak compressive strain values under vertical and oblique loads were 7% and 8.3% lower respectively in B when compared to A. C exhibited a 90% increase in bone strain under vertical load when compared to A but a 48.3% reduction under lateral loading. FEA showed that C had 28.5% and 30.8% higher compressive and tensile strains under vertical loading when compared to D and E respectively, and a 54% higher compressive strain under oblique loading. PS did not influence peak bone strains under vertical loading. Compressive strains for B & D (PS samples) were 9% and 5% lower than those for C and E (NPS samples). Bone strain under vertical and oblique loading for B and C (5mm implant) was 26.1% and 28.4% lower respectively when compared to A (3.75mm implant). Sliding and gap distances varied by less than 3m between A, B and C. PS led to concentration of stress in the abutment/external hex interface but bone strain distribution did not differ significantly between PS samples and NPS samples.

Vertical and lateral loading forces were examined on FE models in order to compare standard and wide body implants with platform switching on the latter as shown above

DiscussionandConclusionWithin the constraints of this study (static load and relatively homogeneous materials), the data suggest that a wider diameter implant reduces crestal bone strain. Most strain in the immediate loading model is seen where implant to bone contact occurs directly and is minimal in areas of no contact. It is speculated that this may lead to overload or atrophic resorption respectively though more clinical data is required. Micromovement of <3m is well below the 50-150m of movement traditionally quoted as being necessary for prevention of integration. PS leads to a small but insignificant reduction of <10% in crestal bone strain. Peak compressive and tensile strains in bone are higher in immediately loaded implants than in integrated implants. However, PS does not significantly influence crestal bone strain or micromovement.
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Biofilm on dental implants: A review of the literature

Subramani K. Jung R. Molenderg A. Hmmerle C. August 2009 Int. Journal of Oral and Maxillofacial Implants Vol.24. No.4 pp616-626 Correspondence to: Dr. K. Subramani Department of Fixed and Removable Prosthodontics, Dental Material Science Center for Dental and Oral Medicine and CranioMaxillofacial Surgery, University of Zurich Zurich SWITZERLAND

Oral biofilms that form on transmucosal implant components are composed of a complex microbial flora that is supported by an extracellular matrix of bacterial and salivary origin. Their presence can lead to inflammation of the marginal tissues that may ultimately result in peri-implantitis and bone loss. The purpose of the present review article was to discuss biofilm formation on dental implant surfaces and the influence of surface characteristics, material, and design of implants and abutments on biofilm formation and its sequelae.

MaterialandMethodsA MEDLINE literature search was performed of studies published over a 40 year period up to 2007. Fifty three in vitro and in vivo articles were identified. These included studies on biofilm formation on teeth and implants, as well as the effect of implant and abutment design, and the influence of implant surface characteristics on biofilm formation. Since these articles were mostly descriptive it was not possible to perform a comprehensive meta-analysis on this topic. ResultsBiofilm formation on teeth and implants follows the same initiation and maturation
process, the difference being that the surface properties of implants have an impact on early microbial adhesion. The early bacterial colonizers, namely streptococci give way to a diverse flora of gram-ve anaerobes and filamentous species which form over a 24 week period. Hence, the initial colonizers provide a favorable environment for the growth of periodontopathic microorganisms that can lead to periodontitis and peri-implantitis. A number of in vitro and in vivo studies have confirmed that surface roughness of the implant encourages bacterial attachment. It has been reported that titanium with a low roughness average of (Ra)0.088m strongly inhibits plaque accumulation and maturation after 24 hours. By contrast titanium surfaces that are hydrophobic, due to the adhesion of impurities following repeated dry sterilization, are more readily colonized. Hard coating implants with titanium or zirconium nitride can reduce bacterial adhesion. Furthermore, an increase in surface free energy of implants and abutments together with surface physicochemical characteristics of the colonizing bacteria also affects the rate of biofilm formation. In addition to the above, rough abutments and over contoured restorations can lead to increased plaque accumulation. In fact rough abutments have been reported to harbour 25 times more sub-gingival bacteria than pristine abutments. However, reducing roughness below a threshold Ra of 0.2m has not been shown to have an impact on biofilm formation in the long-term. Furthermore it has been reported that a higher prevalence of anaerobic bacteria is associated with cement-retained prostheses compared with screw-retained prostheses. The presence of a microgap at the implant-abutment junction is also known to be associated with bacterial colonization and has been implicated as a risk factor for bone loss. There are conflicting data regarding the bacteriostatic effect of titanium on oral microflora, however, some data has been presented supporting the antimicrobial properties of titanium oxide which forms on implant surfaces in vivo. This has been shown to lead to reduced staphylococcal colonization and increased osteoblast adhesion. Silver-coated titanium surfaces have also been examined showing antimicrobial activity without any adverse effects on osteoblast and epithelial cells, as has a vancomycin-modified titanium surface, which has been shown to limit bacterial colonization in vitro and to be stable.

Biofilm formation on different implant surfaces and implant designs was compared in this literature review

DiscussionandConclusionThis literature review suggests that rough implant and abutment surfaces increase bacterial adhesion and speed of biofilm formation as well as sheltering bacteria against shear forces in the oral environment. In addition the presence of a microgap and over contouring of restorations aids biofilm formation. Therefore optimizing implant abutment design as well as provision of easily cleansable restorations would reduce the likelihood of plaque accumulation. Although some data on silver and vancomycinmodified surfaces in available, the effects of these in vivo on osteoblasts and cells from the periodontium is unclear and requires further investigation.
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Randomized-controlled clinical trial of customized zirconia and titanium implant abutments for single-tooth implants in canine and posterior regions: 3-year results
Titanium and ceramic abutments are commonly used today. Titanium (Ti) is resistant to distortion and works well in all areas of the mouth. Despite titaniums colour, which can cause a greyish discoloration of the gingival tissues, it is generally considered to be the goldstandard for implant-borne reconstructions. More recently high strength ceramics such as alumina and zirconia have been used in the esthetic zone but there remains concern over their brittleness. The aim of this study was to assess the survival and complication rates between CAD/CAM customized zirconia (Zr) and titanium abutments (Procera, Nobel Biocare) in the canine and posterior regions of the mouth.

Zembic A. Sailer I. Jung R-E. Hammerle C. August 2009 Clinical Oral Implants Research Vol.20 No.8 pp802-808 Correspondence to: Dr. Irina Sailer Department of Fixed and Removable Prosthodontics, Dental Materials Science Center for Dental and Oral Medicine, University of Zurich Plattenstr. 11 8032 Zurich SWITZERLAND

MaterialandMethods22 patients treated with 40 implants (Brnemark RP, Nobel

Biocare) for replacement of missing canines, premolars and molars, were randomly assigned to either a test group (TG: zirconia abutments + Procera All-Ceramic Crowns, ACC) or control group (CG: titanium abutments + Metal Ceramic Crowns, MCC). Implants were placed using a 2-stage protocol with abutments connected 4-6 months after surgery and torqued to 32Ncm. The test group (n=20) consisted of 17 ACC and 1 MCC cemented onto the Zr abutments, and 2 screw-retained ACC crowns. The control group consisted of 20 Ti abutments with cemented MCC crowns. Resin (Panavia 21, Kuraray; Rely X, 3M ESPE) and glass ionomer (Ketac Cem, 3M ESPE) cements were used. Clinical and radiographic examinations were carried out at crown insertion and at 6, 12, and 36 months post-loading. Clinical examination involved assessment for material fractures of abutments or crowns, abutment screw loosening/fracture, break of cement seal, or chipping of ceramic; in addition a biological examination to assess probing depths (PD), plaque retention (PR) and bleeding on probing (BOP) at 4 points around each implant and control teeth was undertaken. Mesial and distal marginal bone levels (MBL) were also recorded from digitized radiographs by 2 independent examiners. Finally an esthetic examination was performed using a spectrometer (Spectroshade, MHT, Switzerland) to assess the colour of gingiva 1 mm below the gingival margin. Soft-tissue thickness (using a size 20 endodontic file with a stopper) and the height of the papilla (mesially and distally) were also recorded. The data was analyzed using Student unpaired t-tests and Mann Whitney rank tests at 95% confidence levels.

Results18 patients with 18 test and 10 control abutments were followed up to 36 months.
There were no cases of de-cementation, screw loosening, or fractured abutments, however, 2 MCCs in the control group exhibited minor chipping. Clinical parameters for both groups were very similar to each other and also to natural teeth, although the PD values were higher at the implants. There was little change in MBLs over the 3-year period for either group and the color evaluation revealed no significant difference between the test and control groups (EZr=9; ETi=7), although both materials induced a visible colour change compared to The clinical performance natural teeth. Furthermore, no significant differences were found between soft-tissue of single-tooth CAD/CAM designed zirconia and titanium thickness or papilla height between groups, although the soft-tissue thickness around the abutments was compared over implants (~1.80.7mm) was greater than at teeth (~1.50.9mm).
a 3-year period

DiscussionandConclusionResults demonstrate that there were no complications for either Zr or Ti abutments, over a 3-year period. Only minor chipping of the MCCs was found on Ti abutments. This study exhibited excellent results for Zr abutments (68% premolars, 18% molars), which is similar to previous studies. However, one must be cautious as it has been shown that Zr can decrease its fracture toughness by 50% over longer periods of time in a humid environment. The slightly worse value recorded for visible discoloration of the gingiva with Zr abutments was surprising. Screw loosening was not observed in the present study probably due to the exceptional fit of both CAD/CAM abutments and the comparable biological parameters and esthetic evaluation reinforce the absence of clear differences between these two abutment materials over a 3-yerar period. More randomized studies are required.
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Is insertion torque correlated to bone-implant contact percentage in the early healing period? A histological and histomorphometrical evaluation of 17 human-retrieved implants
In areas of good bone quality and quantity, dental implants can expect to achieve high primary stability. The primary stability of a dental implant has been proposed as a good indicator for long term success and is related to bone structure and biomechanics, bone density, percentage of bone to implant contact (%BIC), implant geometry, and surgical technique. A stable implant in dense bone allows optimal distribution of any loads placed upon the implant during the healing phase. Accurate histomorphometric assessment can be used to assess the bone-implant interface and primary stability of implants, but requires destructive, invasive implant removal and therefore cannot be used in clinical practice. An established alternative method of assessing the primary stability of an implant is the peak insertion torque (PIT). This study aimed to compare the values for PIT and the %BIC in humans to determine the presence or absence of correlation.

Degidi M. Perrotti V. Strocchi R. Piattelli A. Iezzi G. August 2009 Clinical Oral Implants Research Vol.20 No.8 pp778-781 Correspondence to: Prof. Adriano Piattelli Via F. Sciucchi 63 66100 Chieti ITALY

MaterialandMethodsA retrospective evaluation of implants which had been placed and retrieved from the posterior mandible for various reasons was undertaken. Reasons for retrieval included psychoses, nerve damage, restorative complications and hygiene. All implants (N=17) had a sand-blasted, acid etched surface, were self tapping and had been placed according to the manufacturers instructions (Ankylos Plus and Xive, DentsplyFriadent; NanoTite, 3i; SLActive, Straumann). Various placement protocols were utilized depending on the case requirements at the time of surgery and 7 of the implants had been immediately loaded. The PIT value had been recorded for each implant and the value recorded in the patients records. The implants were removed within an 8-week period of placement using a 5mm trephine bur. Specimens were dehydrated, fixed, and sectioned longitudinally to a thickness of 30m. Sections were stained with von Kossa and acid fuchsin and one section stained with silver nitrate and basic fuchsin. Histomorphometric analysis of %BIC was carried out under light microscopy using three slides for each implant and the results assessed using a histomorphometry software package. Results were subject to statistical analysis using the Friedman test at a level of p < 0.05 to assess correlation between %BIC and PIT. ResultsAll of the implants were osseointegrated and stable at the time of removal, with no radiographic bone loss. Histological evaluation highlighted numerous cellular and structural markers of bone repair, healing and turnover with no evidence of inflammatory cell infiltrate, apical epithelial migration or dense connective tissue at the bone-implant interface. Many marrow spaces were observed on the implant surface, where osteoid matrix was evident. There was no statistically significant correlation between PIT and %BIC for any of the implants, regardless of the time of implant retrieval. DiscussionandConclusionThe benefits of high initial implant stability are well documented, but the exact level of insertion torque necessary to effect an adequate degree of primary stability remains undetermined and the principle mechanism of this early stability is as yet unclear, but likely to be multifactorial. Despite numerous studies investigating the factors thought to be responsible and recording these parameters using a variety of techniques, a significant relationship between PIT and %BIC has yet to be determined. Whilst the precise relationship between PIT and primary stability is as yet undetermined, it is known that increasing PIT values correlate to increasing bone density and quality; however, cadaver studies have demonstrated that the torque required for implant insertion and removal may vary irrespective of bone mass or density. Considering the likely multifactorial relationship between PIT and %BIC, the present study has many limitations with respect to sample size, implant uniformity and removal time. Given the importance of primary implant stability further controlled studies may be useful in understanding the precise relationship between primary implant stability, PIT and %BIC.
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Influence of the height of the external hexagon and surface treatment on fatigue life of commercially pure titanium dental implants
Dental implant fracture is a rare occurrence but can be catastrophic. The factors predisposing to fracture can be classified into geometric design and the material properties of the implant, where the goal will be to increase its fatigue resistance to prevent fracture in the implant body and the external hexagon (HEX). Poor prosthesis fit, peri-implant bone loss and too few implants for the required clinical situation are all factors that will contribute to increased stress along the body of an implant, potentially leading to fracture, with the size of the HEX having been shown to influence the mechanical stability of the restoration. In addition the micro-geometry of the implant can also affect its fatigue resistance in that a rough surface topography would seem more prone to generate small cracks at centers of stress concentration, which could propagate through the implant leading to fracture. Logically it would seem that rougher surfaces would induce more surface cracks, and the potential dilemma arises because it has been established that these surfaces increase bone to implant contact and enhance osseointegration. Therefore the aim of this study was to compare different HEX heights and surface topographies of titanium implants on their fatigue resistance.

Gil F. Aparicio C. Manero J. Padrs A. August 2009 Int. Journal of Oral and Maxillofacial Implants Vol.24 No.4 pp583-590 Correspondence to: Dr. Francesco Gil Department of Materials Science and Metallurgical Engineering, ETSEIB Technical University of Catalonia, Av. Diagonal 647 08028 Barcelona SPAIN

MaterialandMethods5 groups with 7 implants in each group were created. The first three groups had an electropolished surface with HEX heights of 0.6mm, 1.2mm and 1.8mm (EP1, EP2 and EP3 respectively), group 4 had the larger HEX height but with an acid etched surface (AE3) and group 5 had a grit-blasted surface (GB3). Each implant was clamped at a level of 3mm below the HEX, simulating the bone level with a degree of bone remodeling, and an abutment connected at 25Ncm, immersed in artificial saliva and a cyclical force applied at 10Hz between 10 and 225N at 30 to its long axis. The deformed/fractured implants were examined by both scanning and transmission electron microscopy and an analysis of variance with the multiple comparison Fisher test used to compare the groups with regard to fatigue life and fracture resistance. ResultsMean implant surface roughness measured 0.20m for EP<2.1m for AE<4.29m for GB. The number of force cycles necessary to cause implant deformation/fracture differed between the groups to a statistically significant degree with fatigue life ordered as follows: EP1<EP2<AE3<EP3<GB3. The mode of failure also differed with the 0.6mm HEX causing internal abutment screw fracture and shearing of the HEX, with the remaining groups demonstrating fracture within the implant body. Appearance and propagation of cracks was also of interest as the cracks were generally initiated on the surface of all the groups except the GB3 surface, where the cracks were initiated 20m sub-surface. DiscussionandConclusionThe tolerance of fit at the implant/abutment interface was
consistent amongst the groups in this study which necessitates the identification of other factors that might impact upon fatigue life. The fatigue life of the shorter HEX sizes was less than half that for the 1.8mm HEX (p<.02), this being explained by the area of contact between the implant and abutment which is proportional to the resistance to bending. The grit blasted implants showed the longest fatigue life of all (p<0.0001). This is the opposite of what was hypothesized. The explanation lies in the analysis of the surface cracks, where all the groups, except GB3, had the cracks initiate at the surface, whereas cracks in the GB3 group were at a depth of 20m. This is explained by the method of blasting where the particles contact the surface and compress the metal. Cracks can only propagate from a tensile state and therefore this compressive area increases the resistance to cracking. The favorable osseointegration of acid etched implants as compared with smoother surfaces has been well established, but this study showed that they would be more prone to fractures under fatigue. It was shown that hydrogen from the acid solutions can diffuse into the surface and form metal hydrides, which can also cause a greater degree of brittleness within commercially pure titanium. In summary, greater HEX sizes will increase fracture resistance of implants, especially when combined with a grit blasted surface.
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Various HEX heights were tested under 30 deg loading conditions until failure

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Influence of early cover screw exposure on crestal bone loss around implants: Intraindividual comparison of bone level at exposed and non-exposed implants
Conventional placement of dental implants using a submerged (2-stage) or non-submerged (1-stage) protocol creates an ideal environment for the development of osseointegration and the maintenance of marginal bone tissues. In the submerged protocol oral hygiene measures are unnecessary as the implant should not normally be exposed the oral environment and in the case of non-submerged protocols the design of the permucosal abutment allows a strict oral hygiene regimen to be implemented. However, where a previously submerged implant becomes exposed spontaneously to the oral environment strict hygiene measures may not be in place creating the risk of marginal bone loss through plaque mediated infection and inflammation. Authors such as Adell et al. (1981), Toljanic et al. (1999) and Tal (1999) have reported spontaneous exposure rates of between 5 and 15% for submerged implants. The aim of this study was to evaluate the influence of spontaneous early exposure of cover screws on crestal bone loss around dental implants.

Kim T-H. Lee D-W. Kim C-K. Park K-H. Moon I-S. June 2009 Journal of Periodontology Vol.80 No.6 pp933-939 Correspondence to: Dr. Ik-Sang Moon Dept. of Periodontology Gangam Severance Dental Hospital, College of Dentistry Yonsei University Seoul KOREA

MaterialandMethodsA total of 781 implants were placed in 355 medically healthy patients between 2000 and 2007. From this group it was found that 24 of them had developed spontaneous exposure for 28 of their implants. In a sub-set of this group, 19 patients (14 male, 5 female; mean age 54, range 34 to 82) it was also possible to compare on an intraindividual basis comparative bone loss between their exposed and their other nonexposed implants. All implants had been placed more than 3 months after tooth extraction. Initial placement was at or below the bone crest and no augmentation materials were used. No brushing was permitted post-surgery and all patients rinsed 2x daily with an antiseptic mouth rinse until suture removal 10 days later. Mandibular implants were scheduled for exposure 3 months post-placement and after 6 months for maxillary implants. All patients were reviewed at 1, 3 and 7 weeks post-placement. Any implant that became spontaneously exposed was immediately provided with a healing abutment. In all cases healing abutments were placed without raising a flap via a mini crestal incision and patients were asked to implement thorough hygiene maintenance. Final prostheses were placed 3 to 4 weeks after the planned healing periods of 3 and 6 months. Mean marginal bone levels were calculated from mesial and distal values collected from digitized radiographs to an accuracy of 0.10mm. These measurements were made by a single investigator whose results were subjected to calibration by an independant supervisor. All data was subjected to statistical analysis with P value significance set at 0.05. ResultsMean crestal bone loss for spontaneous/early exposed implants was 0.40
0.53mm (range -0.15 to 2.15mm) and for the non-exposed group was 0.180.26mm (range -0.03-0.85mm). The difference between the groups was statistically significant (P=0.02).

Images showing a typical example of a spontaneous exposure before placement of a healing abutment

DiscussionandConclusionThe additional crestal bone loss observed at spontaneously exposed implants, it is suggested, was mainly due to continuous plaque and food debris accumulation during the phase between occurrence and surgical placement of a cleansible healing abutment. It was assumed in this study that there would be no differences in marginal bone levels, however, it was found there was a considerable elapse of time before the exposure was found and then treated with the placement of a healing abutment. During this interval there was considerable potential for bone damage. Van Assche et al. (2008) reported bone loss of 1.96mm compared to 0.49mm when early exposure of implants was recorded. However, in their study unlike this one, no attempt was made to place the healing abutments ahead of the planned healing interval. A limitation of this study was that the exact period of time the cover screw was exposed for was not known and in any case it would be unethical to deliberately leave such exposures untreated. Animal studies with deliberate untreated exposure may shed light on the rate of bone loss, however, on the basis of this study the authors recommend regular post-surgical checks in order to minimise any deleterious impact of spontaneous exposure.
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Evaluation of nano-technology-modified zirconia oral implants: A study in rabbits

The macro and micro-geometrical modifications of an implant surface are known to enhance its osteoconductivity, important for early loading strategies. Recently, the application of nanotechnology has been claimed to enhance these surface properties further. One problem with the metallic implant materials currently used is that they can cause a grey hue in the cervical gingival tissue, and this has led workers to begin looking at alternative base materials to titanium, with the strength and bio-compatibility of zirconia being at the forefront. The aim of this study was to combine nanotechnology with a zirconia implant, to test osteoconductivity potential in the rabbit model.

Lee J. Sieweke J. Rodriguez N. Schpbach P. Lindstrm H. Susin C. Wikesj U. July 2009 Journal of Clinical Periodontology Vol.36 No.7 pp610-617 Correspondence to: Dr. Jaebum Lee Laboratory for Periodontal and Facial Regeneration, Department of Periodontics and Oral Biology, Medical College of Georgia School of Dentistry 1120 15th Street AD 1432 Augusta Georgia 30912 USA

MaterialandMethodsForty male adult New Zealand white rabbits received one implant
in each femoral condyle of their hind leg. Two test groups received a zirconia implant with one of two surface modifications using nanotechnology. The control groups consisted of a regular zirconia surface (ZiUnite, Nobel Biocare) and a titanium implant (TiUnite, Nobel Biocare). The nanosurfaces were prepared with a calcium phosphate (CaP) coating, using two differing methods (Zi/CaP1 and Zi/CaP2), while the zirconia control implant had a pore-forming sintered surface (ZiC) and the titanium control implant had an anodized microtextured surface (TiC). The animals were anesthetized and implants placed in a standardized technique with 20 animals receiving Zi/CaP1 and Zi/CaP2, half of which were sacrificed at 3 weeks with the remainder at 6 weeks. The control animals, receiving ZiC and TiC were also split into two groups of ten, and were subject to the same healing times. The implants were all removed, sectioned, stained and prepared for histometric analysis, with photomicrographs produced using scanning electron microscopy. Statistical analysis of variance at a level of p<0.05, was used to evaluate the bone density remote from the threads (BDRT), bone density inside the threads (BDIT) and the percentage bone to implant contact (%BIC).

ResultsFour animals were excluded from the study and replaced for various reasons.
The %BIC of control group TiC (77%) was significantly better than both test groups Zi/ CaP1 (65%) and Zi/CaP2 (62%) at 3 weeks (p<0.05) but not significantly different to the ZiC group (70%). There was no statistical difference between the ZiC and the two test nano surfaces for %BIC but there were significant differences for both BDRT, BDIT (p<0.05). No such differences were noted between the ZiC and TiC control groups. At 6 weeks, there were no differences in %BIC, BDRT, BDIT, between any of the test or control groups.

DiscussionandConclusionFrom a histometric viewpoint, all surfaces used in this

study demonstrated high levels of osseointegration in a rabbit model, where the 3 and 6-week healing times would correlate to early and conventional loading in humans. The test Zirconia implants used Due to the difficulty in sectioning and preparing zirconia, backscatter scanning electron in this study were prepared microscopy has been shown to be an effective alternative to histometric analysis and hence with a CaP nano-layer coating a combination of both was used in this study. CaP nanotechnology has been shown to accelerate bone healing and it is hypothesized that the CaP nano-coating used on the test implants in this study has not significantly altered the surface texture, but just changed the composition of the zirconium surface, leading to a lower risk of the problems previously observed with CaP on titanium implants, where detachment from the implant surface led to failure. Zirconia as an implant surface, shows good osteoconductive properties, is biocompatible, mechanically strong and shows reduced microbial colonization. It shows a high level of osseointegration. However, the current study shows that the addition of CaP nanotechnology does not seem to enhance the osteoconductivity of the test zirconia surfaces over conventional zirconia or titanium surfaces.

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Bone quality assessment based on cone beam computed tomography imaging

Low bone quality has been identified as one of the potential factors related to biological failure of implants. Osteoporosis can be an etiological factor in low or reduced bone quality. From a clinical viewpoint, spiral 3D CT scans can be used to provide Hounsfield units (HU) for regions of interest as a way of assessing bone mineral density. Fractal analysis, an approach using texture, can be used to determine fractal dimension (FD) and this has been shown to be useful in comparing normal and osteoporotic bone. Currently, the use of cone beam computed tomography (CBCT) has increased with widespread use in dentomaxillofacial radiology. CBCT does however, have certain limitations that can affect bone quality assessment. Technical constraints of image datasets exist and CBCT data can be associated with larger amounts of scattered x-rays that can increase the noise in reconstructed images. It is also know that beam hardening in CBCT is a phenomenon that can affect the relative HU values for soft and hard tissues. As a result, measuring HU may not be an ideal method to assess bone mineral density when CBCT is used. The aim of the current study was to assess the validity of other parameters such as fractal analysis or morphometry as indicators of bone quality assessment.

Hua Y. Nackaerts O. Duyck O. Maes F. Jacobs R. August 2009 Clinical Oral Implants Research Vol.20 No.8 pp767-771 Correspondence to: Dr. Reinhilde Jacobs Oral Imaging Center School of Dentistry, Oral Pathology and Maxillofacial Surgery, Faculty of Medicine Universiteit Leuven Kapucijnenvoer 7,3000 Leuven BELGIUM

MaterialandMethods19 human mandibular dry bone specimens were divided into three groups. A control group (CG) consisting of two samples, Group 1 (n=5) had artificial bone lesions of approximately 11.5mm created with a spoon excavator. In Group 2 (n=12), decalcification in order to simulate the osteoporotic condition was effected using a HCl solution. CBCT images were obtained using an i-CAT scanner by placing the samples into a polystyrene container containing water in order to simulate soft tissue. Bone mineral density (BMD) was determined using dual-energy X-ray absorptiometry (DXA). Surface roughness (FD) was quantified using 2D fractal analysis (FD). Regions of interest were divided into both cortico-cancellous samples or restricted to the trabecular bone. 3D fractal analysis was carried out using similar methods. Standard morphometric techniques were used to determine mean density value (MDV) using gray values and area of bone structure (ABS) based on image pixellation. Statistical analysis using Spearmans was applied to calculations of FD, BMD and MDV. Changes in FD and MDV were subjected to descriptive statistics. ResultsAll test specimens showed a reduction in weight after modification. Calculations
of the mean FD for 2D fractal analysis showed that values decreased for Groups 1 and 2 after sample modification. With 3D fractal analysis, a reduction in FD was noted for corticocancellous samples but increases in FD observed for trabecular bone samples. Reductions after modification were noted for ABS with increases in MDV. A statistically significant correlation existed between FD and BMD (p<0.05) as well as BMD and ABS (p<0.05). However, correlation between BMD and MDV was not statistically significant (p>0.5).

DiscussionandConclusionThe current study used in vitro methods to attempt to

Image showing the i-CAT cone validate and assess the accuracy of CBCT scans in determining the quality of bone and in beam CT scanner used to aquire particular osteoporotic bone. The study found that 2D fractal analysis significantly related the data in this study

to BMD with 3D fractal analysis allowing decalcification or the presence of bone lesions to be quantified. The fact that FD increased for trabecular bone is contrary to expectations but has been shown before. The significance of this is as yet unknown. Nonetheless morphometric measurements confirmed decreases in bone area. The absence of correlation between density, based on gray values and BMD (using DXA) would appear to be due to intensity inhomogeneity and may affect the ability for CBCT images to be used for such measurements. Based on the results of this in vitro study, there is some doubt as to the validity of density measurements using CBCT. In contrast, fractal analysis and bone area measurements would appear to demonstrate potential as parameters for bone quality assessment. Further studies are required to verify these findings.

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Mechanical non-surgical treatment of peri-implantitis: A double blind randomized longitudinal clinical study 1: Clinical results
The prevalence of implant mucositis has been reported as >60% with the potential for periimplantitis cited between 28-56%. Peri-implantitis appears to be related to the presence of biofilms and the management of these would seem to be important in the control of periimplant infections. Treatment protocols have developed from those relating to periodontitis with implant surface debridement seen as the prerequisite for treatment. The need therefore exists to have specific knowledge of adequate intervention methods for the treatment of these conditions around dental implants. The aim of the current study was to compare the efficacy of two methods for mechanical debridement in the treatment of peri-implantitis.

Renvert S. Samuelsson E. Lindahl C. Persson G. July 2009 Journal of Clinical Periodontology Vol.36 No.7 pp604-609 Correspondence to: Prof. S. Renvert Dept. of Health Sciences Kristianstad University SE-29188 Kristianstad SWEDEN

MaterialandMethodsIn total 37 patients were enrolled into this double blind

randomized longitudinal study. The inclusion criteria were based on radiographic evidence of bone loss <2.5mm and a periodontal probing depth (PPD) of 4mm around one dental implant with bleeding and or pus on probing. Patients with bone loss in excess of 2.5mm, poorly controlled diabetes mellitus, on anti-inflammatory medication or antibiotic administration in the previous three months were excluded. Any existing periodontal lesions were treated and the subjects were subsequently randomly divided into two treatment groups. Group 1 (n=19), including 3 smokers, was treated with mechanical debridement using titanium curettes, while in Group 2 (n=18), with 2 smokers, ultrasonic debridement was undertaken using the Vector System equipped with an implant specific ultrasonic tip (LM Instruments, Finland). In both groups, the implants were subsequently polished with rubber cups and polishing paste. Oral hygiene instructions and clinical measurements were carried out at baseline, 1, 3 and 6 months post-operatively. Measurements included presence of hyperplasia, bleeding on probing graded on extent (BOP), PPDs and full mouth plaque scores. Sterile paper points were used to gain microbiological samples at relevant intervals to calculate a total bacterial load. Data was subject to appropriate statistical analysis.

ResultsData was obtained for 17 subjects in Group 1 and 14 in Group 2. Mean bone loss
around the implants at the commencement of the study was 1.5mm1.2mm. During the course of the study mean PPD varied from 2.8 - 5.5mm. No statistically significant differences (p>0.05) were noted between the two groups with relation to the study parameters. Merged data for the two groups comparing baseline with six month data showed a significant improvement in oral hygiene measures from a mean plaque index (PI) of 73% down to 53%. Reductions in peri-implantitis were also recorded with a mean difference of 27.2%7.9% as well as with a reduction in the mean BOP score (p<0.05). No significant differences were noted for PPDs between baseline and six months for either group. Microbiological analysis revealed a significantly lower total bacterial count for Group 1 (p<0.01), but only at week 1.

DiscussionandConclusionThe findings of this study would seem to confirm that no

differences exist between hand and ultrasonic mechanical debridement of peri-implantitis sites. In addition, neither treatment modality appeared to have an affect on the bacterial counts associated with diseased implant sites. It is possible that the nature of implant design and surface, together with the morphology of the superstructure can hamper efforts to disturb and remove the biofilm. It was also observed that although improvements in oral hygiene were noted, overall oral hygiene remained poor and this may have accounted for the results obtained. One possible explanation for the differences for bacterial counts at week 1 could be that hand instrumentation may be more aggressive, inducing a host response of limited duration. The results of this study demonstrate that no differences exist between hand and ultrasonic debridement methods. They would also seem to suggest that mechanical debridement in early cases of peri-implantitis may not be clinically relevant. Further studies using surgical intervention with or without adjunctive antimicrobial and/or antiinflammatory drugs would be of interest.
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Extent of peri-implantitis associated bone loss

Fransson F. Wennstrom J. Tomasi C. Berglundh T. April 2009 Journal of Clinical Periodontology Vol.36 No.4 pp357-363 Correspondence to: Dr. Christer Fransson Dept. of Periodontology The Sahlgrenska Academy Gteburg University Box 450 S-405 30 Gteburg SWEDEN

Peri-implantitis has been defined as an inflammatory process affecting the tissues around a functioning implant that results in the loss of supporting bone. In contrast peri-implant mucositis has been defined as reversible inflammatory changes of the peri-implant soft tissues without accompanying bone loss. The purpose of this retrospective study was to assess the amount of peri-implantitis induced bone loss relative to implant position for a given patient population.

MaterialandMethods182 patients (previously treated, identified, and reported upon by Fransson 2005, 2008) with a total of 1070 implants of which 39% (419 implants) exhibited peri-implantitis induced bone loss were analyzed in this study. Patient radiographs were analysed 1 year post-operatively (or 2 year post-op when the 1 year radiographs were absent) and at the end point (5 - 23 years) using a magnifying glass (x7) and a 0.1mm graded scale. The implant positions were noted relative to jaw position (upper posterior (UP), upper anterior (UA), lower posterior (LP), lower anterior (LA)) and also relative to their position within a fixed prosthesis (end implants (E) and those in between mid (M) positions), which was classified as either a full arch prosthesis (FAP) or partial prosthesis (PP). The mean bone loss was calculated for each patient and was divided into 2 categories: a)<2mm; b)2mm. Statistical analyses included Fishers exact test (95% confidence levels) for the amount of bone loss between the different implant positions (within the jaw and the prostheses) as well as the distribution of affected and non-affected implants. Using a multilevel model (MLwiN2.1, London, UK) the influence of implant position and risk of peri-implantitis associated bone loss was evaluated. ResultsThe most popular site for implant placement was the first premolar region followed by the incisors, canines and the molars, of which only a few were placed. Approximately 2 implants (42%) per patient were affected by peri-implantitis. 88% of patients had 1 affected implant in the LA region and this was the most frequent area for peri-implantitis, with 52% of implants being classified as affected compared with UA (39%), LP (35%), and UP (30%) respectively. The LA area was statistically more associated with the condition compared to the other areas, p < 0.05. In addition the highest frequency of 2mm bone loss was found in the LA region (37%) followed by UA (33%), UP (29%) and LP (25%). However, this result was not statistically significant. The number of M implants affected (44% where n=619) was significantly higher than for the E implants (32%; n=451), although this may be due to the larger number of FAP where the majority of implants were in the M position. However, the results were similar when comparing within the 2 types of prostheses (FAP: 43% vs 31% and PP:49 vs 35%). DiscussionandConclusionIn the present study there was an even spread of anterior and posterior implants of which 42% exhibited bone loss due to peri-implantitis. The range of implants presenting with bone loss varied from 30-52%, the highest prevalence being in the LA region, which is similar to findings published in other studies. On examination of the different prostheses the M positioned implants appeared to experience greater bone loss and could be deemed to be at a higher risk than implants placed as distal abutments (E). Previous studies have stated that poor oral hygiene and smoking are major factors in peri-implantitis induced bone loss, whereas occlusal load, tooth cleansing and the length of the cantilever are of minor importance. The data collated in this study concurs with many previous studies and confirms that it is possible to suffer peri-implantitis at all locations in the oral cavity, but that perhaps the anatomy of the anterior mandible and a middle abutment position within a fixed prosthesis renders an implant more susceptible to peri-implant bone loss.

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