Bone healing pattern in surgically created circumferential defects around submerged implants: an experimental study in dog

Objective: To describe the healing of marginal defects below or above 1 mm of dimension around submerged implants in a dog model. Material and methods: In 12 Labrador dogs, all mandibular premolars and first molars were extracted bilaterally. After 3 months of healing, full-thickness flaps were elevated in the edentulous region of the right side of the mandible. Two recipient sites were prepared and the marginal 5mm were widened to such an extent to obtain, after implant installation, a marginal gap of 0.5mm at the mesial site (small defect) and of 1.25mm at the distal site (large defect). Titanium healing caps were affixed to the implants and the flaps were sutured allowing a fully submerged healing. The experimental procedures were subsequently performed in the left side of the mandible. The timing of the experiments and sacrifices were planned in such a way to obtain biopsies representing the healing after 5, 10, 20 and 30 days. Ground sections were prepared and histomorphometrically analyzed. Results: The filling of the defect with newly formed bone was incomplete after 1 month of healing in all specimens. Bone formation occurred from the base and the lateral walls of the defects. A larger volume of new bone was formed in the large compared with the small defects. Most of the new bone at the large defect was formed between the 10- and the 20-day period of healing. After 1 month of healing, the outline of the newly formed bone was, however, located at a similar distance from the implant surface (about 0.4mm) at both defect types. Only minor newly formed bone in contact with the implant, starting from the base of the defects, was seen at the large defects (about 0.8mm) while a larger amount was detected at the small defects (about 2.2 mm). Conclusion: Marginal defects around titanium implants appeared to regenerate in 20-30 days by means of a distance osteogenesis. The bone fill of the defects was, however, incomplete after 1 month.

Use of a titanium device in lateral sinus floor elevation: an experimental study in monkeys

Aim: To evaluate the effect of a space-maintaining device fixed to the lateral wall of the maxillary sinus after the elevation of the sinus mucosa on bone filling of the sinus cavity. Material and methods: Immediately after the elevation of the maxillary sinus Schneiderian membrane accomplished through lateral antrostomy in four monkeys, a titanium device was affixed to the lateral sinus wall protruding into the sinus cavity to maintain the mucosa elevated without the use of grafting material. The healing of the tissue around the implants was evaluated after 3 and 6 months. Ground sections were prepared and analyzed histologically. Results: The void under the elevated sinus membrane, originally filled with the blood clot, was reduced after 3 as well as after 6 months of healing of about 56% and 40.5%, respectively. In seven out of eight cases, the devices had perforated the sinus mucosa. The formation of mineralized bone and bone marrow amounted to about 42% and 69% after 3 and 6 months, respectively. The connective tissue represented about 53% and 23% of the newly formed tissue after 3 and 6 months, respectively. Conclusions: New bone formation was found below the devices. However, shrinkage of the newly formed tissue was observed both after 3 and 6 months of healing. Hence, the space-maintaining function of the devices used in the present study has to be questioned.

Early peri-implant endosseous healing of two implant surfaces placed in surgically created circumferential defects. A histomorphometric and fluorescence study in dogs

Objective Several implant surfaces are being developed, some in the nanoscale level. In this study, two different surfaces had their early healing properties compared in context of circumferential defects of various widths. Material and methods Six dogs had the mandibular premolars extracted. After 8weeks, four implants were placed equicrestally in each side. One acted as control, while the others were inserted into sites with circumferential defects of 1.0, 1.5 and 2.0mm wide and 5mm deep. A nano-modified surface was used on one side and a micro-rough on the other. Bone markers were administered on the third day after implant placement and then after 1, 2, 4weeks to investigate the bone formation dynamic through fluorescence analysis. Ground sections were prepared from 8-week healing biopsies and histomorphometry was performed. Results The fluorescence evaluation of the early healing showed numerically better results for the nano-modified group; however this trend was not followed by the histomorphometric evaluation. A non-significant numerical superiority of the micro-rough group was observed in terms of vertical bone apposition, defect bone fill, bone-to-implant contact and bone density. In the intra-group analysis, the wider defects showed the worse results while the control sites showed the best results for the different parameters, but without statistical relevance. Conclusion Both surfaces may lead to complete fill of circumferential defects, but the gap width has to be considered as a challenge. The nano-scale modification was beneficial in the early stages of bone healing, but the micro-rough surface showed numerical better outcomes at the 8-week final period.

The effect of implant design on insertion torque and immediate micromotion

Objectives: To evaluate the effect of insertion torque on micromotion to a lateral force in three different implant designs. Material and methods: Thirty-six implants with identical thread design, but different cutting groove design were divided in three groups: (1) non-fluted (no cutting groove, solid screw-form); (2) fluted (901 cut at the apex, tap design); and (3) Blossomt (Patent pending) (non-fluted with engineered trimmed thread design). The implants were screwed into polyurethane foam blocks and the insertion torque was recorded after each turn of 901 by a digital torque gauge. Controlled lateral loads of 10N followed by increments of 5 up to 100N were sequentially applied by a digital force gauge on a titanium abutment. Statistical comparison was performed with two-way mixed model ANOVA that evaluated implant design group, linear effects of turns and displacement loads, and their interaction. Results: While insertion torque increased as a function of number of turns for each design, the slope and final values increased (Po0.001) progressively from the Blossomt to the fluted to the non-fluted design (M +/- standard deviation [SD] = 64.1 +/- 26.8, 139.4 +/- 17.2, and 205.23 +/- 24.3 Ncm, respectively). While a linear relationship between horizontal displacement and lateral force was observed for each design, the slope and maximal displacement increased (Po0.001) progressively from the Blossomt to the fluted to the non-fluted design (M +/- SD 530 +/- 57.7, 585.9 +/- 82.4, and 782.33 +/- 269.4 mm, respectively). There was negligible to moderate levels of association between insertion torque and lateral displacement in the Blossomt, fluted and non-fluted design groups, respectively. Conclusion: Insertion torque was reduced in implant macrodesigns that incorporated cutting edges, and lesser insertion torque was generally associated with decreased micromovement. However, insertion torque and micromotion were unrelated within implant designs, particularly for those designs showing the least insertion torque.

Biomechanical and histologic evaluation of non-washed resorbable blasting media and alumina-blasted/acid-etched surfaces

Objectives: To compare the biomechanical fixation and histomorphometric parameters between two implant surfaces: non-washed resorbable blasting media (NWRBM) and alumina-blasted/acid-etched (AB/AE), in a dog model. Material and methods: The surface topography was assessed by scanning electron microscopy, optical interferometry and chemistry by X-ray photoelectron spectroscopy (XPS). Six beagle dogs of similar to 1.5 years of age were utilized and each animal received one implant of each surface per limb (distal radii sites). After a healing period of 3 weeks, the animals were euthanized and half of the implants were biomechanically tested (removal torque) and the other half was referred to nondecalcified histology processing. Histomorphometric analysis considered bone-to-implant contact (BIC) and bone area fraction occupancy (BAFO). Following data normality check with the Kolmogorov-Smirnov test, statistical analysis was performed by paired t-tests at 95% level of significance. Results: Surface roughness parameters Sa (average surface roughness) and Sq (mean root square of the surface) were significantly lower for the NWRBM compared with AB/ AE. The XPS spectra revealed the presence of Ca and P in the NWRBM. While no significant differences were observed for both BIC and BAFO parameters (P>0.35 and P>0.11, respectively), a significantly higher level of torque was observed for the NWRBM group (P = 0.01). Bone morphology was similar between groups, which presented newly formed woven bone in proximity with the implant surfaces. Conclusion: A significant increase in early biomechanical fixation was observed for implants presenting the NWRBM surface.

Retrospective Clinical Study of 988 Dual Acid-Etched Implants Placed in Grafted and Native Bone for Single-Tooth Replacement

Purpose: To evaluate the influence of sex, implant characteristics, and bone grafting on the survival rate of dual acid-etched (DAE) implants. Materials and Methods: Patients treated with internal-hex DAE implants for single-tooth replacement in a military dental clinic between January 2005 and December 2010 were included in this study. Clinical data related to implant characteristics, implant location, presence of grafted bone, and implant failures were collected. The primary outcome was implant loss. The survival rate was analyzed using the Kaplan-Meier method. Cox regression modeling was used to determine which factors would predict implant failure. Results: DAE implants were evaluated in a total of 988 patients (80.3% men). Twenty-four (2.4%) implants failed, most were cylindric (54.2%) with regular platforms (70.8%) and were 10 mm long (58.3%). The failure rate was 2.4% for the anterior maxilla, 3.3% for the posterior maxilla, 1.6% for the anterior mandible, and 2.0% for posterior mandible. The cumulative survival rate was 97.6%. The failure rate was 8.8% in implants placed after sinus augmentation, 7.3% in bone block-grafted areas, and 1.6% in native bone. Based on multivariable analysis (Cox regression), sinus augmentation and bone block grafting had a statistically significant effect on implant failure; the hazard ratios were 5.5 and 4.6, respectively. Conclusion: The results revealed that DAE implants had high survival rates, and no influence of sex, location, shape, diameter, or length on failure rates could be observed. However, a significant association was observed between failure and presence of bone graft in the implant area. Int J Oral Maxillofac Implants 2012;27:1243-1248

In vitro analysis of the influence of surface treatment of dental implants on primary stability

Surface treatment interferes with the primary stability of dental implants because it promotes a chemical and micromorphological change on the surface and thus stimulates osseointegration. This study aimed to evaluate the effects of different surface treatments on primary stability by analyzing insertion torque (IT) and pullout force (PF). Eight samples of implants with different surface treatments (TS - external hexagon with acid surface treatment; and MS - external hexagon, machined surface), all 3.75 mm in diameter x 11.5 mm in length, were inserted into segments of artificial bones. The IT of each sample was measured by an electronic torquemeter, and then the pullout test was done with a universal testing machine. The results were subjected to ANOVA (p < 0.05), followed by Tukey's test (p < 0.05). The IT results showed no statistically significant difference, since the sizes of the implants used were very similar, and the bone used was not highly resistant. The PF values (N) were, respectively, TS = 403.75 +/- 189.80 and MS = 276.38 +/- 110.05. The implants were shown to be different in terms of the variables of maximum force (F = 4.401, p = 0.0120), elasticity in maximum flexion (F = 3.672, p = 0.024), and relative stiffness (F = 4.60, p = 0.01). In this study, external hexagonal implants with acid surface treatment showed the highest values of pullout strength and better stability, which provide greater indication for their use.

Long-term rabbits bone response to titanium implants in the presence of inorganic bovine-derived graft

This study evaluated bone responses to titanium implants in the presence of an inorganic graft material. The bilateral mandible incisors of 24 rabbits were surgically extracted and one of the exposed sockets, chosen at random, was filled with an inorganic xenogenic bone graft (Gen-ox (R)), whereas the remaining socket was left to heal naturally and served as a control. After 60 days, titanium implants were inserted in the specific areas, and on days 0, 30, 60, and 180 after the implant insertions, six animals of each group were killed. Digital periapical radiography of implant region was obtained and vertical bone height (VBH) and bone density (BD) were evaluated by digital analysis system. In the undecalcified tissue cuts, bone-to-implant contact (BIC) and bone area (BA) within the limits of the implant threads were evaluated and compared statistically by means of two-way ANOVA and Tukey's test (rho < 0.05). No significant differences were detected in VBH and BA, either between groups or between different experimental intervals. The BD was significantly higher in the experimental group than in the control group in all the intervals tested, but there were no significant differences by interval. The BIC was statistically lower in the control group on day 0; however, a significant increase was observed on days 60 and 180 (rho < 0.05). The use of an inorganic xenograft prior to insertion of a titanium implant did not interfere with the course of osseointegration.

Bone tissue, cellular, and molecular responses to titanium implants treated by anodic spark deposition

A myriad of titanium (Ti) surface modifications has been proposed to hasten the osseointegration. In this context, the aim of this study was to perform histomorphometric, cellular, and molecular analyses of the bone tissue grown in close contact with Ti implants treated by anodic spark deposition (ASD-AK). Acid-etched (AE) Ti implants either untreated or submitted to ASD-AK were placed into dog mandibles and retrieved at 3 and 8 weeks. It was noticed that both implants, AE and ASD-AK, were osseointegrated at 3 and 8 weeks. Histomorphometric analysis showed differences between treatments only for bone-to-implant contact, being higher on AE implants. Although not backed by histomorphometric results, gene expression of key bone markers was higher for bone grown in close contact with ASD-AK and for cells harvested from these fragments and cultured until subconfluence. Cell proliferation at days 7 and 10 and alkaline phosphatase activity at day 10 was higher on AE surfaces. No statistical significant difference was noticed for extracellular matrix mineralization at 17 days. Our results have shown that the Ti fixtures treated by ASD-AK allowed in vivo osseointegration and induced higher expression of key markers of osteoblast phenotype, suggesting that this surface treatment could be considered to produce implants for clinical applications. (c) 2012 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 100A:30923098, 2012.

The impact of healing time before loading on orthodontic mini-implant stability: a histomophometric study in minipigs

Objective: To evaluate healing time before loading, areas compression and tension and location of insertion on mini-implant stability. Design: Six minipigs were used. Each animal received 3 mini-implants in each quadrant: 1 mini-implant was used as an unloaded control (G1, n = 24); the other 2 were loaded with 150 g-force at three time intervals (G2: immediate loading, G3: after 15 days and G4: after 30 days), with 16 mini-implant in each experimental group. After 120 days, tissue blocks of the areas of interest were harvested. Clinical analysis (exact Fisher test) determined the survival rate. Histological analysis (Kontron KS 300TM, Zeiss) quantified the fractional bone-toimplant contact (%BIC) and bone area (%BA) at each healing time point, areas of interest, and insertion site (ANOVA and t tests for dependent and independent samples). Results: The mini-implant survival rates were G1: 71%, G2: 50%, G3: 75% and G4: 63%, with no statistical differences between them. The groups presented similar %BIC and %BA. There were no differences between the compression and tension sides or maxillary and mandibular insertion sites. Conclusions: These results suggest that low-intensity immediate or early orthodontic loading does not affect mini-implant stability, because similar histomorphometric results were observed for all the groups, with partial osseointegration of the mini-implants present.

Acesso pela artéria subclávia para implante por cateter da bioprótese valvar aórtica CoreValve®: dados do registro brasileiro

INTRODUÇÃO: A via de acesso transfemoral é preferencial para o implante por cateter de bioprótese valvar aórtica. Entretanto, algumas situações, como a presença de doença vascular periférica, impossibilitam a utilização desse acesso. Nesses casos, o acesso por dissecção da artéria subclávia é uma alternativa para a realização do procedimento. Nosso objetivo foi avaliar a experiência brasileira com a utilização da artéria subclávia como via de acesso para o implante por cateter da bioprótese CoreValve®. MÉTODOS: Foram requisitos para o procedimento área valvar aórtica < 1 cm², ânulo valvar aórtico ≥ 20 mm e ≤ 27 mm (CoreValve® de 26 mm e 29 mm), aorta ascendente ≤ 43 mm e artéria subclávia com diâmetro ≥ 6 mm, isenta de lesões obstrutivas significativas, tortuosidade acentuada e calcificação excessiva. O acesso pela artéria subclávia foi obtido por dissecção cirúrgica e, sob visão direta, punção da artéria subclávia. Obtido o acesso arterial, empregou-se a técnica padrão. RESULTADOS: Entre janeiro de 2008 e abril de 2012, 8 pacientes com doença vascular periférica foram submetidos a implante de prótese CoreValve® pela artéria subclávia em 4 instituições. O procedimento foi realizado com sucesso em todos os casos, com redução do gradiente transvalvar aórtico médio de 46,4 ± 17,5 mmHg para 9,3 ± 3,6 mmHg (P = 0,0018) e melhora dos sintomas. Aos 30 dias e no seguimento de 275 ± 231 dias, 87,5% e 62,5% dos pacientes, respectivamente, apresentavam-se livres de complicações maiores (óbito, infarto do miocárdio, acidente vascular cerebral e cirurgia cardíaca de urgência). CONCLUSÕES: Na experiência brasileira, o acesso pela artéria subclávia mostrou-se seguro e eficaz como via alternativa para o implante por cateter da bioprótese CoreValve®.

Development of newly conceived biomimetic nano-structured biomaterials as scaffolds for bone and osteochondral regeneration

The present research thesis was focused on the development of new biomaterials and devices for application in regenerative medicine, particularly in the repair/regeneration of bone and osteochondral regions affected by degenerative diseases such as Osteoarthritis and Osteoporosis or serious traumas. More specifically, the work was focused on the synthesis and physico-chemical-morphological characterization of: i) a new superparamagnetic apatite phase; ii) new biomimetic superparamagnetic bone and osteochondral scaffolds; iii) new bioactive bone cements for regenerative vertebroplasty. The new bio-devices were designed to exhibit high biomimicry with hard human tissues and with functionality promoting faster tissue repair and improved texturing. In particular, recent trends in tissue regeneration indicate magnetism as a new tool to stimulate cells towards tissue formation and organization; in this perspective a new superparamagnetic apatite was synthesized by doping apatite lattice with di-and trivalent iron ions during synthesis. This finding was the pin to synthesize newly conceived superparamagnetic bone and osteochondral scaffolds by reproducing in laboratory the biological processes yielding the formation of new bone, i.e. the self-assembly/organization of collagen fibrils and heterogeneous nucleation of nanosized, ionically substituted apatite mimicking the mineral part of bone. The new scaffolds can be magnetically switched on/off and function as workstations guiding fast tissue regeneration by minimally invasive and more efficient approaches. Moreover, in the view of specific treatments for patients affected by osteoporosis or traumas involving vertebrae weakening or fracture, the present work was also dedicated to the development of new self-setting injectable pastes based on strontium-substituted calcium phosphates, able to harden in vivo and transform into strontium-substituted hydroxyapatite. The addition of strontium may provide an anti-osteoporotic effect, aiding to restore the physiologic bone turnover. The ceramic-based paste was also added with bio-polymers, able to be progressively resorbed thus creating additional porosity in the cement body that favour cell colonization and osseointegration.

Studio della superficie degli impianti dentali in titanio: La nanotecnologia nella valutazione delle nuove superfici implantari in rapporto all'osteointegrazione dei mascellari

Il presente lavoro parte dalla descrizione dei processi di rimodellamento osseo mascellare a seguito della perdita di elementi dentari e la successiva riabilitazione mediante impianto dentale osteointegrato. Approfondiremo proprio i complessi aspetti dell’osteointegrazione su superfici implantari in titanio sia a livello micro che macroscopico. Nel campo dell’implantologia, infatti, il titanio risulta essere il materiale maggiormente impiegato in virtù della sua eccellente biocompatibilità e resistenza. Successivamente prenderemo in analisi i trattamenti di superficie implantare ad oggi più diffusi, lavorati prevalentemente a livello microscopico e infine confronteremo una sistematica trattata tradizionalmente con una innovativa trattata superficialmente a livello nanometrico. Il confronto avverrà in vivo, paragonando i risultati ottenuti clinicamente e radiograficamente tra le 2 sistematiche implantari, utilizzate per ripristinare la funzione masticatoria nei pazienti arruolati.

VEGF incorporated into calcium phosphate ceramics promotes vascularisation and bone formation in vivo

Bone formation and osseointegration of biomaterials are dependent on angiogenesis and vascularization. Angiogenic growth factors such as vascular endothelial growth factor (VEGF) were shown to promote biomaterial vascularization and enhance bone formation. However, high local concentrations of VEGF induce the formation of malformed, nonfunctional vessels. We hypothesized that a continuous delivery of low concentrations of VEGF from calcium phosphate ceramics may increase the efficacy of VEGF administration.VEGF was co-precipitated onto biphasic calcium phosphate (BCP) ceramics to achieve a sustained release of the growth factor. The co-precipitation efficacy and the release kinetics of the protein were investigated in vitro. For in vivo investigations BCP ceramics were implanted into critical size cranial defects in Balb/c mice. Angiogenesis and microvascularization were investigated over 28 days by means of intravital microscopy. The formation of new bone was determined histomorphometrically. Co-precipitation reduced the burst release of VEGF. Furthermore, a sustained, cell-mediated release of low concentrations of VEGF from BCP ceramics was mediated by resorbing osteoclasts. In vivo, sustained delivery of VEGF achieved by protein co-precipitation promoted biomaterial vascularization, osseointegration, and bone formation. Short-term release of VEGF following superficial adsorption resulted in a temporally restricted promotion of angiogenesis and did not enhance bone formation. The release kinetics of VEGF appears to be an important factor in the promotion of biomaterial vascularization and bone formation. Sustained release of VEGF increased the efficacy of VEGF delivery demonstrating that a prolonged bioavailability of low concentrations of VEGF is beneficial for bone regeneration.

Identification of a fibronectin interaction site in the extracellular matrix protein ameloblastin

Mammalian teeth are composed of hydroxyapatite crystals that are embedded in a rich extracellular matrix. This matrix is produced by only two cell types, the mesenchymal odontoblasts and the ectodermal ameloblasts. Ameloblasts secrete the enamel proteins amelogenin, ameloblastin, enamelin and amelotin. Odontoblasts secrete collagen type I and several calcium-binding phosphoproteins including dentin sialophosphoprotein, dentin matrix protein, bone sialoprotein and osteopontin. The latter four proteins have recently been grouped in the family of the SIBLINGs (small integrin-binding ligand, N-linked glycoproteins) because they display similar gene structures and because they contain an RGD tripeptide sequence that binds to integrin receptors and thus mediates cell adhesion. We have prepared all the other tooth-specific proteins in recombinant form and examined whether they might also promote cell adhesion similar to the SIBLINGs. We found that only ameloblastin consistently mediated adhesion of osteoblastic and fibroblastic cells to plastic or titanium surfaces. The activity was dependent on the intact three-dimensional structure of ameloblastin and required de novo protein synthesis of the adhering cells. By deletion analysis and in vitro mutagenesis, the active site could be narrowed down to a sequence of 13 amino acid residues (VPIMDFADPQFPT) derived from exon 7 of the rat ameloblastin gene or exons 7-9 of the human gene. Kinetic studies and RNA interference experiments further demonstrated that this sequence does not directly bind to a cell surface receptor but that it interacts with cellular fibronectin, which in turn binds to integrin receptors. The identification of a fibronectin-binding domain in ameloblastin might permit interesting applications for dental implantology. Implants could be coated with peptides containing the active sequence, which in turn would recruit fibronectin from the patient's blood. The recruited fibronectin should then promote cell adhesion on the implant surface, thereby accelerating osseointegration of the implant.