INTRODUCTION TO DENTAL IMPLANTOLOGY HISTORY OF DENTAL IMPLANTS EUGENIA PROKOPETS, DDS LSU PERIODONTICS

Thank you Dr. Simmons

BEFORE THE COMMON ERA 16TH AND 17TH CENTURIES Archeological records from China and Egypt show evidence of gold and ivory dental implants root replacement by allogenic tooth transplantation (17th Cent England and France) dentalimplantchicago.blogspot.com silverspringdentist.blogspot.com

EARLY 20TH CENTURY Metal implant devices of gold, lead, iridium, tantalum, stainless steel, and cobalt alloy were developed 1943- Germany, intramucosal button inserts Titanium blade implants were introduced in the 1960s but success was short lived www.nycdentist.com ocw.tufts.edu medical-dictionary.thefreedictionary.com ocw.tufts.edu

BLADE IMPLANTS Pictures courtesy of Dr. Simmons

1952 SWEDEN PER-INGVAR BRÅNEMARK honoriscausa.unab.cl conducted an experiment where he utilized a titanium implant chamber to study blood flow in rabbit bone At the conclusion of the experiment, when it became time to remove the titanium chambers from the bone, he discovered that the bone had integrated completely with the implant that the chamber could not be removed. Brånemark called the discovery "osseointegration" and saw the possibilities for human use. honoriscausa.unab.cl

P.I. BRÅNEMARK & CO-WORKER EARLY 60 S PUBLISHED 1977 DENTAL COMMUNITY SKEPTICAL Oral Development and Histology

SCHROEDER (SWITZERLAND)INDEPENDENT OF BRÅNEMARK MID 70 S DEVELOPED NEW TECHNIQUE TO SECTION UNDECALCIFIED BONE AND IMPLANT TOGETHER Pictures courtesy of Dr. Simmons

Osseointegration A DIRECT STRUCTURAL AND FUNCTIONAL RELATIONSHIP BETWEEN ORDERED LIVING BONE AND THE SURFACE OF A LOAD-BEARING IMPLANT AT THE MICROSCOPIC LEVEL

100 NOBELPHARMA IMPLANTS PLACED AND LOADED OVER 1-18 YEARS SWEDEN 1977 COMMITTEE OF 3 UNIVERSITY PROFESSORS REVIEWED DATA AND VERIFIED ADELL & CO-WORKERS 1981 REPORTED 91% SUCCESS IN MANDIBLE WITH 81% SUCCESS IN MAXILLA, 1,000 IMPLANTS FOR 5YRS 1982 TORONTO CONFERENCE-MAJOR DENTAL SCHOOLS (NORTH AMERICA) ACCEPTED IMPLANTS http://newsletter.nobelbiocare.com

Pictures courtesy of Dr. Simmons

WORLDWIDE NEW IMPLANT DESIGNS AND SURFACES WERE BROUGHT TO THE MARKET THAT WERE NOT PROPERLY TESTED Pictures courtesy of Dr. Simmons

Pictures courtesy of Dr. Simmons

EARLY 1980 S osseointegrated implants became the accepted mode of therapy surgical goal = placement of the implant in the available bone prosthetic positioning was not critical often edentulous patients Pictures courtesy of Dr. Simmons

ALBREKTSSON1986 at that time only 2 implant systems that met criteria 1. Brånemark osseintegrated screw 2. Small transosteal staple acceptable long term results >10yrs Pictures courtesy of Dr. Simmons encouraged meticulous evaluation of each and every inserted implant

ALBREKTSSON 1986 Successful outcome dependent on: biocompatibility of implant material macroscopic and microscopic nature of implant surface status of the implant bed in both a health (non-infected) and morphologic (bone quality) context surgical technique undisturbed healing phase prosthetic design and long-term loading phase (design, materials, location, anticipated loading, hygiene and cosmetic considerations)

ALBREKTSSON 1986 Ossteointegration is a histological definition, only partially a clinical and radiographic one (mobility and bone response can only be evaluated over time) conventional gingival indices are not included in implant success Surgical skill should be matched by the prosthodontic skill= common denominator for any implant system

RATIONALE FOR DENTAL IMPLANTS Number of dental implants increased almost 10 fold from 1983 to 2002 5 fold increase from 2000-2005 $550 million of implant products sold to North Am. dentists in 2005 compared to $10 million in 1983 (Misch 2008) 852328 www.thaimedicalvacation.com

1. aging population living longer INCREASED NEED 2. tooth loss related to age 3. consequences of fixed prosthesis failure 4. anatomical consequences of edentulism 5. poor performance of removable prostheses 6. consequences of removable partial dentures 7. psychosocial aspects of tooth loss and needs and desires of baby boomers 8. predicatable long-term results of implant supported prostheses 9. advantages of implant supported restorations

AGE RELATED TOOTH LOSS life expectancy has increased older individuals living more social life, dating, dining, traveling in past, geriatric dentistry was typically inexpensive with nonsurgical approaches dental services for elderly are a growing demand

ADVANTAGES OF SINGLE TOOTH IMPLANTS High success rate decreased risk of caries of adj teeth decreased risk of endodontic problems of adjacent teeth improved ability to clean the proximal surfaces of adjacent teeth improved esthetics of adjacent teeth improved maintainance of bone in the edentulous site psychological advantage decreased abutment tooth loss Lindhe

ADVANTAGES OF IMPLANT SUPPORTED PROSTHESES maintain bone restore and maintain occlusal vertical dimension maintain facial esthetics improve phonetics improve occlusion improve/regain oral proprioception (occlusal awareness) www.pvsmile.com.mx increase prosthetic success improve masticatory performance improve stability and retention of removable prosthesis improve psychological health

SUCCESS AND SURVIVAL

STABILITY A PROCESS WHEREBY CLINICALLY ASYMPTOMATIC RIDGID FIXATION OF ALLOPLASTIC MATERIALS IS ACHIEVED AND MAINTAINED IN BONE DURING FUNCTIONAL LOADING (ZARB & ALBREKTSSON 1991)

THE PRIMARY FUNCTION OF A DENTAL IMPLANT IS TO ACT AS AN ABUTMENT FOR A PROSTHETIC DEVICE, SIMILAR TO A NATURAL TOOTH ROOT AND CROWN. ANY SUCCESS CRITERIA, THEREFORE, MUST INCLUDE FIRST AND FOREMOST SUPPORT OF A FUNCTIONAL PROSTHESIS CARL E. MISCH

What is implant success?

Success is used to describe ideal clinical conditions, or lack of problems. The implant success rate should also include the associated prosthetic survival rate. -C. MISCH, 2008-ICOI PISA CONSENSUS CONFERENCE

What is implant survival?

Whether or not the implant is still in the mouth or has been removed. -C. MISCH, 2008-ICOI PISA CONSENSUS CONFERENCE

PERIODONTAL (CLINICAL) INDICES- MISCH 2008 ICOI used to evaluate implants do not define the success or failure

PERIODONTAL (CLINICAL) INDICES- MISCH 2008 ICOI the term implant success describes ideal clinical conditions time period of approximately 12 months for implants serving as prosthetic abutments early success: 1-3 yrs intermediate success: 3-7 yrs long-term success: 7+ yrs

PERIODONTAL (CLINICAL) INDICES- MISCH 2008 ICOI Pain pressure from restorative component usually does not occur unless mobile and surrounded my inflammatory tissue Mobility healthy implant moves less than 75ųm, zero clinical mobility clinically mobile implant represents CT between implant and bone

PERIODONTAL (CLINICAL) INDICES- MISCH 2008 ICOI Radiographic Crestal Bone Loss 0.1-0.2mm in first year Probing Depths little diagnostic value unless accompanied by signs (PaRL, purulence, BOP) and/or symptoms (discomfort, pain) Deep pockets not always associated with accelerated marginal bone loss (Lekholm et al) Beneficial to probe to establish baseline of tissue and to monitor over time

PERIODONTAL (CLINICAL) INDICES- MISCH 2008 ICOI Peri-Implant Disease Inflammatory process- bacteria is primary factor (anaerobic) Stress induced- overloading of implant, bacteria is secondary factor Any exudate persisting for more than 1-2 weeks usually warrants surgical revision of peri-implant area

ICOI PISA IMPLANT QUALITY OF HEALTH SCALE

How successful have we been? What does the longitudinal data show?

LONG TERM SUCCESS/SURVIVAL Jemt et al. followed 876 Branemark implants placed in partially edentulous jaws of 244 patients, between 1968-1988 only 4 of the 293 prostheses were removed prosthesis stability rate 98.7%

LONG TERM SUCCESS/SURVIVAL Nevins, Lang 1995; 309 implants placed in 59 recalcitrant perio patients 4 Mand, 3 Max failed, success rate 98%

LONG TERM SUCCESS/SURVIVAL Simonis et al. 2010 55 patients, 131 implants, 10-16yr data 12 implants were lost during observation period Implant survival 89.23% at 10 yrs 82.94% at 16 yrs pts with history of periodontitis are more prone to peri-implantitis (OR=5.1)

LONG TERM SUCCESS/SURVIVAL Mandibular Implants Ueda 2011, JOMI 314 implants eval for 10-24 years cumulative survival rate 85.9% reasons for removal: peri implantitis and mobility

LONG TERM SUCCESS/SURVIVAL Buser et al 2012 CIDRR: 10 year survival and success rate (SLA) Survival: 98.8% Success: 97% Charyeva et al 2012 Swed Dent: Survival: 96% Success: 94.3% Peri-implantitis and mucositis: bad OH, not frequent visits, multiple units 3

LONG TERM SUCCESS/SURVIVAL Tioblast implants Gotfredsen et al CIDRR 2012 10 yrs - 100% survival (single, anterior maxilla) Mertens et al CIDRR 2012 11 yrs - 96.8% survival, 92.6% success (fixed, edentulous maxilla) TiUnite Implants Degidi et al : COIR 2012 10 yrs - 97.3% survival (8.2% p-i) Ostman et al :CIDRR 2012 10 yrs - 99.2% survival

A CHANGED PHILOSOPHY AND PRACTICE OF PERIODONTICS

A CHANGED PHILOSOPHY AND PRACTICE OF PERIODONTICS prior to current predictability of dental implants, the goal was to preserve the natural teeth to avoid a removable prosthesis surgical perio therapy -> beneficial but can compromise form, function and esthetics maintenance of periodontally compromised teeth to avoid tooth loss is no longer necessary Klokkevold 2000

DENTAL/PERIODONTAL CONDITION CONVENTIONAL TREATMENT COMMENTS IMPLANT ALTERNATIVE COMMENTS SINGLE MISSING TOOTH 3 UNIT FIXED MARYLAND BRIDGE REMOVABLE PROSTHESIS PREP OF ADJ TEETH PTS DISLIKE REMOVABLE PROSTHESIS SINGLE IMPLANT MAY NEED BONE OR SOFT TISSUE NO PREPERATION OF NATURAL TEETH LONG TERM SUCCESS PERIODONTALLY COMPROMISED TOOTH MOD/SEV BONE & ATTACHMENT LOSS PERIO SURGERY REGENERATIVE SURGERY CAN BE MAINTAINED REGENERATIVE SUCCCESS DEPENDS ON DEFECT EXTRACTION BONE AUGMENTATION IMPLANT AFTER HEALING BONE LOSS IS MINIMAL LONG TERM SUCCESS MOD-SEVERE FURCATION PERIO SURGERY REGENERATIVE SURGERY PROGNOSIS DIMINISHED EXTRACTION BONE REGENERATION IMPLANT ELIMINATE FURCATION BONE LOSS MINIMAL LONG TERM SUCCESS MULTIPLE MISSING TEETH REMOVABLE PARTIAL DENTURE PARTIAL HAS MOVEMENT MULTI UNIT FIXED IMPLANT SUPPORTED MAY NEED BONE OR SOFT TISSUE NO PREPARATION OF NATURAL TEETH LONG TERM SUCCESS NATURAL LOOK EDENTULOUS ARCH Klokkevold 2000 COMPLETE DENTURE REMOVABLE, BONE RESORPTION AND TISSUE CHANGES CONTINUE IMPLANT SUPPORTED OVER DENTURE PATIENTS MORE CONFIDENT BONE AND TISSUE CHANGES MINIMIZED LONG TERM SUCCESS

REFERENCES Albrektsson T et al: The long term efficacy of currently used dental implants: A review and proposed criteria of success. Int J Oral Max Implants 1:11-26, 1986 Boioli L et al: A meta-analytic, quatitative assessment of osseointegration establishment and evolution of submerged and non-submerged endosseous titanium oral implants. Clin Oral Implants Res. 12: 579-88, 2001 Block, Michael S., and John N. Kent. "Dental Implants: A Historical Perspective." Endosseous Imlplants for Maxillofacial Reconstruction. Philadelphia: W. B. Saunders Company, 1995. 1. Print. Klokkevold P et al: Current status of dental implants: A periodontal perspective. Int J Oral Maxillofac Implants 15: 56-65, 2000 Lang and Salvi. Implants in Restorative Dentistry (CH 52). Clinical Periodontology and Implant Dentistry, Lindhe, J.; Lang, K. 5th Edition, 2008, Blackwell Munksgaard (Volume 2). Misch. Rational for Dental Implants. (CH 1). pp 3-25. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book. Misch CE, Perel ML, Wang HL, et al. Implant success, survival, and failure: the International Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant Dent. 2008 Mar;17(1):5-15. Salinas TJ, Eckert SE. In patients requiring single-tooth replacement, what are the outcomes of implant- as compared to tooth-supported restorations? Int J Oral Maxillofac Implants. 2008 Jan-Feb;23(1):56. Simonis P, Dufour T, Tenenbaum H. Long-term implant survival and success: a 10-16-year follow-up of non-submerged dental implants. Clin Oral Implants Res. 2010 Jul;21(7):772-7. Ueda T, Kremer U, Katsoulis J, Mericske-Stern R. Long-term results of mandibular implants supporting an overdenture: implant survival, failures, and crestal bone level changes. Int J Oral Maxillofac Implants. 2011 Mar-Apr;26(2):365-72.

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