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Chapter 8

Implant Application

8.1. General 217

8.2. Clinical Reports 222

8.3. Surface and Interface Characterization 227

8.4. Reactions in Chemical and Mechanical Environments 230

8.5. Reaction in Biological Environment 235

References 246

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Chapter 8

Implant Application

In the past, a metallic post was either cemented or screwed into the canals of teeth

that had lost their crowns, but still had their roots. Such teeth are “root-treated” to

remove their nerves and blood supplies, and onto the posts ceramic or ceramic

metal crowns are themselves cemented. Although many attempts have been made

to replace missing roots with all sorts on metallic implants, the satisfactory use of

a screwed in implant was found only in the mid-1980s. In practice the gum is slit,

and a hole is cut slowly in the bone, and then a CpTi screw is slowly inserted and

covered with gum tissue for 6 months. During this time, the bone grows into inti-

mate contact with the passive oxide layer on the titanium and it is said to be

osseointegrated. The gum tissue is cut once more, and a titanium sleeve is screwed

onto the implant. This will ultimately pass through the healed gum. Onto these

sleeves a metallic superstructure can be screwed, and this can support, for exam-

ple, a polymeric denture base and artificial teeth. For many years, these super-

structures have been cast in gold alloys, and getting them to sit perfectly on the

titanium sleeves has been a challenge of the highest order. However, titanium

frameworks are currently being investigated, particularly those constructed by

alternative routes to casting, and considerable promise is being shown by those

made by superplastic forming. Titanium implants, for example, have had their sur-

faces coated with hydroxyapatite to promote the osseointegration [8-1].

The service conditions in the mouth are hostile, both corrosively and mechani-

cally. All parts are continuously bathed in saliva, an aerated aqueous solution of

about 0.1 N chloride, with varying amounts of Na, K, Ca, PO

, CO

, sulfur com-

pounds and mucin. The pH value is normally in the range of 5.5–7.5, but under

plaque deposits it can be as low as 2. Temperatures can vary ±36.5

C, and a vari-

ety of food and drink concentrations apply for short periods. Loads may be up to

1000 N, sometimes at impact speeds. Trapped food debris may decompose, and

sulfuric compounds discolor [8-2].

8.1. GENERAL

Direct bony interface promised more predictability and longevity than previously

used systems; hence, oral implantology gained significant additional momentum.

A carefully planned full rehabilitation of the mouth using “state of the art” meth-

ods can free the patient of dental problems for decades. However, this can only be

217

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achieved with the complete cooperation of the patient, accompanied by regular

supervision and care on the part of the dental surgeon and his assistants (e.g., the

dental hygienist). Accordingly, there are four major factors which should be met

to accomplish the successful implant: (1) correct indication and favorable

anatomic conditions (bone and mucosa), (2) good operative technique, (3) patient

cooperation (oral hygiene), and (4) adequate superstructure. According to Binon

[8-3], there are approximately 25 dental implants manufacturing companies, pro-

ducing about 100 different dental-implant systems with a variety of diameters,

lengths, surfaces, platforms, interfaces, and body designs. The most logical differ-

entiation and distinctions are based on the implant/abutment interface, the body

shape, and the implant-to-bone surface.

There are two ways to retain the implant restorations: cementation or screw-

tightening. Implant superstructures are usually made by the lost-wax casting

method, and are normally gold alloy beams that fit directly onto metallic compo-

nents called abutments that protrude through the soft tissues of the mouth, and

which are themselves attached to machined titanium components known as dental

implants. The dental implants are sited in the hard bone tissues where intimate con-

tact occurs between the metallic component and the natural tissues. The super-

structure is screwed or cemented to the abutments, and teeth are then placed along

the beam in an aesthetic fashion. Patients prefer this form of fixed bridgework as it

is more reminiscent of their natural teeth than a denture. For the whole prosthesis

to have the optimal chance of success there must be no misfit between the beam

and the abutments. Mainstream philosophy in the design and restoration of implant

prostheses from the 1980s through the early 1990s reflected a strong preference for

screw-retained over cement-retained restorations. This preference most likely was

the result of how osseointegrated implants and their restoration were introduced.

Although retrievability remains the primary advantage of a screw-retained

approach, cemented implant restorations are attractive for several reasons. First, the

preclusion of the interference of screw access holes with esthetic results or with the

occlusion of the restoration. Second, cement-retained approaches substantially

reduce restoration costs. With some systems, screw-retained restoration involves

nearly four times the component cost of cemented restoration. Third, if no occlusal

screw is present, its loosening is not a possible complication of implant prostho-

dontics. Fourth, a cemented restoration is more likely to achieve passive fit than a

screw-retained restoration. The argument for increased passivity rests on the

assumption that tightening a screw-retained restoration may create substantial

strain within the restoration, implant, and investing bone complex. The use of

cemented restorations also avoids the clamping effect of multiple screws drawing

an ill-fitting prosthesis into place against the support. Fifth, the implant industry’s

desire to extend routine implant use into the general dental practices has stimulated

218 Bioscience and Bioengineering of Titanium Materials

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interest in simplifying implant restorative procedures. Cementation of fixed-

implant restorations more closely follow the procedures routinely performed on

natural teeth [8-4, 8-5].

The implantation of devices for the maintenance or restoration of a body func-

tion imposes extraordinary requirements on the materials of construction.

Foremost among these is an issue of biocompatibility, as we had discussed in pre-

vious Chapters 6 and 7. There are interactions between the material and the sur-

rounding living tissue, fluid, and blood elements. Some of these are simply

adaptive. Others constitute a hazard, both short and long term, to the survival of

the living system [8-3, 8-6–8-9]. There are mechanical and physical properties

which the material must provide. Some of these govern the ability of the device to

provide its intended function from a purely engineering viewpoint. Others, such

as, tribology including wear and friction, corrosion and mechanical compliance

relate significantly to the biocompatibility issue. Human implantation applications

impose more stringent requirements on reliability than any other engineering task.

In most applications an implanted device is expected to function for the life of the

patient. It is necessary to think in terms of reliability of performance of thousands

of devices for the lifetime of a patient and a tolerable expectation of failure of per-

haps not more than one in a thousand. Most available data in handbooks, publica-

tions, and product brochures represent mean values and supplementary statistical

information, and, therefore, comparable reliability is also in question [8-7–8-9].

However, it is surprising to note that there is no safety factor concept in the den-

tal and medical area, whereas it is a very important concept in engineering, par-

ticularly designing crucial structures and structural components.

As for orthopedic implants, natural synovial joints, e.g., hip, knee, or shoulder

joints, are complex and delicate structures capable of functioning under critical

conditions. Unfortunately, human joints are prone to degenerative and inflamma-

tory diseases that result in pain and joint stiffness. Primary or secondary

osteoarthritis (osteoarthrosis), and to a lesser extent rheumatoid arthritis (inflam-

mation of the synovial membrane) and chondromalacia (softening of cartilage),

are, apart from normal aging of articular cartilage, the most common degenerative

processes affecting synovial joints. In fact, 90% of the population over the age of

40 suffers from some degree of degenerative joint disease. Premature joint degen-

eration may arise from deficiencies in joint biomaterial properties, from excessive

loading conditions, or from failure of normal repair processes, where the explicit

degenerative processes are not yet completely understood [8-10, 8-11].

The use of Ti materials for medical and dental-implant applications has

increased tremendously over the past few decades. One of the prime reasons for

this increased use is the design of implants around its unique properties. In the

case of high load bearing and fatigues, for devices such as hip prostheses,

Implant Application 219

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