Denis Cecchinato

Eriberto A. Bressan
Marco Toia
Mauricio G. Araujo
Birgitta Liljenberg
Jan Lindhe

Osseointegration in periodontitis
susceptible individuals

Authors affiliations:
Denis Cecchinato, Institute Franci, Padova, Italy
Eriberto A. Bressan, Department of Periodontology,
University of Padova, Padova, Italy
Marco Toia, Institute Franci, Padova, Italy
Mauricio G. Araujo, Department of Dentistry, State
University of Maringa, Maringa, Brazil
Birgitta Liljenberg, Jan Lindhe, Department of
Periodontology, Sahlgrenska Academy at University
of Gothenburg, Goteborg, Sweden

Key words: bone implant interactions, clinical research, clinical trials, morphometric analysis

Corresponding author:
M. G. Araujo
Rua Silva Jardim, 15/sala 03
87013-010
Maringa-Parana, Brazil
Tel/Fax: +55 44 3224 6444
e-mail: odomar@hotmail.com

(group NP). As part of site preparation for implant placement, a 3 mm trephine drill was used to

Abstract
Objectives: The aim of the present study was to examine tissue integration of implants placed (i)
in subjects who had lost teeth because of advanced periodontal disease or for other reasons, (ii) in
the posterior maxilla exhibiting varying amounts of mineralized bone.
Material and methods: Thirty-six subjects were enrolled; 19 had lost teeth because of advanced
periodontitis (group P) while the remaining 17 subjects had suffered tooth loss from other reasons
remove one or more 2 mm wide and 56 mm long block of hard tissue [biopsy site; Lindhe et al.
(2011). Clinical of Oral Implants Research, DOI: 10.1111/j.1600-0501.2011.02205.x]. Lateral to the
biopsy site a twist drill (diameter 2 mm) was used to prepare the hard tissue in the posterior
maxilla for the placement of a screw-shaped, self-tapping micro-implant (implant site). The
implants used were 5 mm long, had a diameter of 2.2 mm. After 3 months of healing, the microimplants with surrounding hard tissue cores were retrieved using a trephine drill. The tissue was
processed for ground sectioning. The blocks were cut parallel to the long axis of the implant and
reduced to a thickness of about 20 lm and stained in toluidine blue. The percentage of (i) implant
surface that was in contact with mineralized bone as well as (ii) the amount of bone present
within the threads of the micro-implants (percentage bone area) was determined.
Results: Healing including hard tissue formation around implants placed in the posterior maxilla
was similar in periodontitis susceptible and non-susceptible subjects. Thus, the degree of bone-toimplant contact (about 59%) as well as the amount of mineralized bone within threads of the
micro-implant (about 4550%) was similar in the two groups of subjects. Pearsons coefficient
disclosed that there was a weak negative correlation ( 0.49; P < 0.05) between volume of fibrous
tissue (biopsy sites) and the length of bone to implant contact (BIC) while there was a weak
positive correlation (0.51; P < 0.05) between the volume of bone marrow and BIC.

Date:
Accepted 3 July 2011
To cite this article:
Cecchinato D, Bressan EA, Toia M, Araujo MG, Liljenberg B,
Lindhe J. Osseointegration in periodontitis susceptible
individuals.
Clin. Oral Impl. Res. 23, 2012, 14
doi: 10.1111/j.1600-0501.2011.02293.x

2011 John Wiley & Sons A/S

Osseointegrated titanium implants are frequently used as abutments for various fixed
or removable reconstructions in prosthetic
dentistry. Although this kind of treatment is
remarkably successful, both early and late
failures occur (for review see Tomasi et al.
2008). An early failure indicates, according to
Friberg et al. (1991) that e.g. (i) surgical errors
and complications were encountered during
the placement of the implants, (ii) bone
defects with buccal or lingual concavities
were present at the recipient site or (iii) that
healing of the ridge after tooth extraction had
occurred with fibrous rather than bone tissue
formation.
Less than 3% of all implants (for review
see Berglundh et al. 2002; Tomasi et al. 2008)

fail to integrate with the host bone during

healing following surgical placement. In a
study comprising 4641 implants, it was
observed [Friberg et al. (1991)] that jaws with
advanced resorption (groups D and E; Lekholm & Zarb 1985) and with soft bone (group
4; Lekholm & Zarb 1985) of the maxillae presented the highest rates of early implant failures.
The composition of the bone tissue of the
edentulous ridge of the posterior maxilla of
human volunteers was recently described
(Lindhe et al. 2011). The harvested tissue
exhibited pronounced inter- as well as intraindividual variation but was comprised of a
mixture of lamellar bone (47%) and woven
bone (8%), osteoid (4%), bone marrow (16%)

Cecchinato et al
Osseointegration in periodontitis

and fibrous tissue (13%). There was no apparent difference between the tissue harvested
from periodontitis and non-periodontitis subjects.
The aim of the present study was to examine tissue integration of implants placed (i) in
subjects who had lost teeth because of
advanced periodontal disease or for other reasons, (ii) in the posterior maxilla exhibiting
varying amounts of mineralized bone.

Material and methods

The regional ethics committee at the University Hospital, Padova, Italy, approved the
study. Forty-nine partially dentate subjects
with fully healed edentulous portions (Hammerle et al. 2004) in the posterior maxilla
(position 1417 and 2427) and scheduled for
implant-supported restorations were recruited
in three different centers. The removal of the
tooth/teeth in the region had occurred at
least 46 months prior to the initiation of
the present study.
The subject sample was described in a previous publication as well as inclusion and
exclusion criteria (Lindhe et al. 2011). Thirteen of the originally recruited subjects were
for different reasons not enrolled in the
study. Of the 36 enrolled subjects, 19 had
lost teeth because of advanced periodontitis
(group P) while the remaining 17 subjects
had suffered tooth loss from other reasons
(group NP). Prior to implant surgery,
informed consent for placement and removal
of the micro-implants was obtained from
each patient.
The patients were treated under local
anaesthesia. Buccal and palatal full thickness
flaps were elevated to expose the bone of the
alveolar ridge. As part of site preparation for
implant placement, a 3 mm trephine drill
was used to remove one or more 2 mm wide
and 56 mm long block of hard tissue (biopsy
site; for details see Lindhe et al. 2011). Hard
tissue preparation was continued according
to the manual for the Astra Tech System
and one or more standard implants (Astra
Tech System; Astra Tech, Molndal, Sweden) were installed and cover screw(s) placed.
Lateral (mesial or distal) to the biopsy site,
a twist drill (diameter 2 mm) was used to
prepare the hard tissue for the placement of a
specially designed and custom-manufactured
screw shaped, self-tapping micro-implant
with an Osseospeed surface (Astra Tech)
(implant site). The micro-implants used were
5 mm long, had a diameter of 2.2 mm and
were at all sites fully submerged in the bone

2 |

Clin. Oral Impl. Res. 23, 2012 / 14

tissue of the ridge. A cover screw was placed

on the implant device. The flaps were
replaced and closed with interrupted sutures
that were removed after 10 days.
After 3 months of healing, i.e. at the time
for the second stage surgery at the standard
implants, minute full thickness flaps were
elevated. The micro-implants with surrounding hard tissue cores were retrieved using a
trephine drill (internal diameter 3.4 mm,
external diameter 4.0 mm). The flaps were
replaced and secured with interrupted sutures
that were removed after 10 days.
Abutments were placed on the standard
implants and the restorative procedure was
initiated.
The samples from the biopsy sites were
decalcified, dehydrated, and embedded in paraffin (for details see Lindhe et al. 2011). Serial
sections were prepared parallel with the long
axis and from the central portion of the harvested tissue cylinder. The microtome was
set at 5 lm. Sections were stained in haematoxylin and eosin or Movat pentachrome.
The biopsies from the implant sites were
placed in a fixative containing a 4% buffered
formalin solution and were processed for
ground sectioning according to methods
described by Donath & Breuner (1982) and
Donath (1988). The samples (blocks) were
dehydrated in increasing grades of ethanol
and infiltrated with Technovit 7200 VLCresin (Kulzer, Friedrichrsdorf, Germany),
polymerized and sectioned using a saw
microtome (Leica SP 1600; Leica, Nussloch,
Germany).
The blocks that were cut parallel to the
long axis of the implant were reduced to a
thickness of about 20 lm by microgrinding
and polishing and stained in toluidine blue.
The percentage of (i) implant surface that
was in contact with mineralized bone as well
as (ii) the amount of bone present within the
threads of the micro-implants (percentage
bone area) was determined according to Jensen & Sennerby (1998). The measurements
were performed in a Leitz DM-RBE micro-

scope (Leica, Wetzlar, Germany) equipped

with an image system (Q-500 MC; Leica).
ANOVA was used to assess differences
between data obtained from samples representing periodontitis and non-periodontitis
subjects. The subject was used as the statistical unit. Values of P < 0.05 were accepted as
being statistically significant. Pearsons coefficient of correlation was calculated to assess
whether the amount of (i) mineralized bone,
(ii) bone marrow, (iii) fibrous tissue determined in the biopsy samples influenced the
degree of bone to implant contact (BIC) and
amount of mineralized bone within threads
(B-area) were measured in the ground sections from implant sites.

Results
The protocol used in the current clinical
study did not delay the upcoming restorative
procedure and no complications from adjacent sites harbouring the standard implant(s)
were reported.
The tissues from the biopsy sites were
comprised of a mixture of mineralized bone
(including lamellar and woven bone), osteoid,
bone marrow, and fibrous tissue. The overall
tissue build up of the biopsy sites is
presented in Table 1 (from Lindhe et al.
2011) as well as findings from periodontitis susceptible and non-susceptible subjects.
Mineralized bone (lamellar and woven
bone) made up 55.1 11.1% (group P =
54.6 11%, group NP = 55.8 11.5%) of the
tissue volume while bone marrow occupied
16.5 10.4% (group P = 17.4 11.6%, group
NP = 15.4 8.8%)
and
fibrous
tissue
12.8 8.9% (group P = 12.6 10.7, group
NP = 12.9 6.3%).
At the time of retrieval surgery all microimplants were clinically stable. Eight of the
implant site specimens were discarded for
different technical reasons. The ground sections consisted of a central region that
included the titanium screw lateral of which
varying amounts of tissue were present. The

Table 1. Percentage distribution (%) of various tissue elements in the biopsy sites (data from
Lindhe et al. 2011)
Total sample (n = 36)
Mineralized bone
(LB+WB)
Bone marrow
LB+WB+osteoid
Fibrous tissue

55.1
16.5
59.4
12.8

11.0
10.4
12.3
8.9

Group P (n = 19)
54.6
17.4
58.4
12.6

11
11.6
13.0
10.7

Group NP (n = 17)
55.8
15.4
60.6
12.9

11.5
8.8
11.5
6.3

Values are mean standard deviation.

Group P, periodontitis susceptible subjects; group NP, non-periodontitis susceptible subjects;
LB, lamellar bone; WB, woven bone.
2011 John Wiley & Sons A/S

Cecchinato et al
Osseointegration in periodontitis

bone tissue was comprised mainly of lamellar bone. The soft tissue had morphological
features characteristic of either bone marrow
or loose connective tissue (Fig. 1).
The hard tissue present within the threads
of the micro-implants and close to the rough
surface of the titanium device was comprised
of lamellar bone and at some sites a mixture
of lamellar and woven bone (Fig. 2). The mineralized tissue or bone marrow appeared in
all sections to be in direct contact with the
surface of the micro-implant.
There was no apparent difference between
the tissue surrounding implants retrieved
from patients in groups P and NP. The degree
of bone to implant contact (Table 2; BIC%)
was 58.6 12.9% (group P = 59.6 13.3%,
group NP = 57.2 13.5%). No significant difference was observed between the groups
with respect to BIC%.
The percentage of mineralized bone within
the implant threads (Table 2; B-area) was
47.5 15.2% (group P = 49.5 16.3, group
NP = 44.7 13.9%). No significant difference
was observed between implants retrieved from
periodontitis susceptible and non-susceptible
subjects with respect to B-area.
Pearsons coefficient disclosed that there
was a weak negative correlation ( 0.56;
P < 0.05) between volume of fibrous tissue

Fig. 1. A photomicrograph illustrating a micro-screw

with surrounding tissue. Most parts of the titanium
device after 3 months of healing were properly integrated in mineralized bone. Toluidine blue stain. Original magnification 92.5.

Fig. 2. Higher magnification of the area outlined in

Fig. 1.The tissue present within the threads of the
micro-implants was mainly comprised of lamellar bone.
Toluidine blue stain. Original magnification 910.

2011 John Wiley & Sons A/S

Table 2. Amount of bone to implant contact (BIC%) as well as amount of mineralized bone within
threads (B-area%)

BIC
B-area

Total sample (n = 28)

Group P (n = 16)

Group NP (n = 12)

58.6 13.2%
47.5 15.2%

59.6 13.3%
49.5 16.3%

57.2 13.5%
44.7 13.9%

Values are mean standard deviation.

BIC, bone to implant contact%, B-area, mineralized bone within threads; Group P, periodontitis
susceptible subjects; group NP, non-periodontitis susceptible subjects.

(biopsy sites) and the length of bone to

implant contact (BIC) while there was a corresponding weak positive correlation (0.57;
P < 0.05) between the volume of bone marrow and BIC. There was no significant correlation between amount of mineralized bone
(lamellar + woven bone) present in the
biopsy sites and the degree of BIC or B-area
determined in the implant sites.

Discussion
In this clinical-histological study it was
observed that the placement and retrieval of
micro-implants in the posterior maxilla of
human volunteers could be performed without jeopardizing healing of standard screwtype implants. This is an agreement with
conclusions previously presented (e.g. Jensen
& Sennerby 1998; Ivanoff et al. 2001; Hallman et al. 2002; Lindgren et al. 2009) from
similar studies.
In the current sample close to 60% of the
surface of the micro-implants was found to
be in contact with mineralized bone (BIC).
This indicates that the micro-implants at
the time of implant retrieval were properly
osseointegrated. This high percentage of BIC
that had been established already after
3 months of healing furthermore documents
that the surface of the micro-implants had
excellent osteoconductive properties. This
conclusion is in agreement with observations from experiments using various animal
and in vitro models (e.g. Ellingsen 1995;
Berglundh et al. 2007; Isa et al. 2006; Thor
et al. 2007).
The main finding of the present study was
that healing including hard tissue formation
around implants placed in the posterior maxilla apparently was similar in periodontitis
susceptible and non-susceptible subjects.
Thus, after 3 months of submerged healing,
neither the degree of bone-to-implant contact
(BIC) nor the amount of mineralized bone

within threads (B-area) of the micro-implant

differed between the two groups of subjects.
It is well known that cells that repopulate
post-extraction sockets determine the quality
of the tissue formed (Amler 1969; Melcher
1976; Cardaropoli et al. 2003). Thus, provided
cells with a bone forming potential (e.g. periodontal ligament fibroblasts, pericytes, osteoblasts) become established in the provisional
matrix, woven bone will form and fill the
socket void. This immature bone will during
remodelling be replaced with lamellar bone
and marrow (Cardaropoli et al. 2003). However, if during the early phase of healing,
mesenchymal cells originating from the
gingiva or oral mucosa migrate into the
socket (the wound), a fibrous connective
tissue will be established and hard tissue
formation becomes compromised. In the
current biopsy sample fibrous connective
tissue made up about 13% of the total tissue
volume; in six sites >20% of the volume was
made up of a fibroblast and collagen rich connective tissue. The statistical analysis (Pearsons correlation coefficient) disclosed that
there was a negative correlation between
amount of fibrous tissue and degree of bone
to implant contact. This means that site
preparation and implant placement in an
alveolar ridge in which large amounts of
fibrous connective tissue are present may
retard (prevent) osseointegration during healing. In a previous publication (Lindhe et al.
2011) it was reported that the amount of
mineralized bone (lamellar bone and woven
bone) that was present in biopsies sampled
from the posterior maxilla varied considerably; from about 80% to 35%. In the current
analysis it was observed that the amount of
mineralized bone as assessed in the paraffin
sections did not correlate with the degree of
BIC or B-area. This indicates that wound
healing (and associated osseointegration) following site preparation and implant installation are unrelated to the amount of hard
tissue present at the recipient site.

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2011 John Wiley & Sons A/S