ABSTRACT

PhD THESIS

BIOLOGICAL RESEARCHES IN VIVO/IN

VITRO OF DIFFERENT IMPLANT

MATERIALS

Scientific coordinator,

Univ.Prof. PhD. Norina Consuela FORNA

PhD student,

DIMA COSMIN

2019

1

CONTENT

INTRODUCTION

1

GENERAL PART

CHAPTER 1. DENTAL IMPLANTS OSSEOINTEGRATION- ACTUAL CONCEPTS

CHAPTER 2. IMPLANT PARAMETERS INFLUENCING OSSEOINTEGRATION

2.1. Implant materials

2.1.1. Impant materials classification

2.1.2. Pure titan. Titan alloys

2.1.3. Ceramics

2.1.4. Polymers

2.2. Geometry and macrodesign

2.3. Implant surfaces. Microdesign

2.4. Dimensional parameters

2.5. Dental implants bioactivity

CHAPTERS 3. FACTORS IN SUCCES/FAILURE OF IMPLANT-PROSTHETIC

THERAPY

3.1. Individual factors (systemic, local)

3.2. Implant sites quality

3.3. Functional loading protocoles

3.4. Implant surgical techniques

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8

8

8

10

12

13

14

18

24

26

32

32

33

35

37

2

PERSONAL PART

CHAPTER 4. STUDY REGARDING OSSEOINTEGRATION OF BIOACTIVE

DENTAL IMPLANTS

41

4.1. Objectives of research

41

4.2. Materials and method 41

4.3. Results 48

4.4. Discussions 59

4.5. Conclusions

64

CHAPTER 5. IN VITRO STUDY REGARDING ALTERATION DEGREE OF

DENTAL IMPLANTS SURFACES DURING THREE DENTAL

PROCEDURES

65

5.1. Objectives of research

65

5.2. Materials and method 65

5.3. Results 70

5.4. Discussions 83

5.5. Conclusions 89

CHAPTER 6. BIOMECHANICAL CONSIDERATIONS REGARDING

MATERIALS AND DESIGN OF DENTAL IMPLANTS

93

6.1. Objectives of research

93

6.2. Materials and method 93

6.3. Results 95

6.4. Discussions 108

6.5. Conclusions 115

GENERAL CONCLUSIONS

116

CHAPTER 7. ORIGINALITY AND PERSPECTIVES

117

BIBLIOGRAFIE 119

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Key words: partial edentation, dental implant, implant-prosthetic therapy, bioactive

surfaces, osseointegration

Content of PhD Thesis:

• theoretical part in 3 chapters (40 pages);

• personal part in 3 chapters (80 pages);

• 73 figures (personal part);

• 253 references.

Note: this abstract contains references, tables and images, respecting numerotation and

content of PhD Thesis.

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CHAPTER 4. OSSEOINTEGRATION OF DENTAL IMPLANTS WITH

BIOACTIVE SURFACES

4.1.MOTIVATION AND OBJECTIVES OF THE STUDY

Although the implant failure rate is extremely low, 1-2% of the implants are

associated with insufficient osseointegration within a few months of implantation

(Chrcanovic & col., 2014). Even under successful osteointegration, secondary failures,

most of them caused by peri-implantitis, may occur in 5% of patients in whom implant-

prosthetic therapy has been performed (Chrcanovic & col., 2014). The failure rate in

primary osteointegration of dental implants may be increased in patients with diabetes,

osteoporosis, in the treatment with bisphosphates, or under head and neck radiotherapy.

For this category of patients it is absolutely necessary to use implants with bioactive

surfaces, which lead to the improvement of the osseointegration rate (Gomez-de Diego &

col., 2014). The use of the dental implants with modified surfaces (bioactive implants)

leads to the increase of the bone-implant contact surface on long term and to the decrease

of the marginal post-implant resorption, allowing the use of unprocessed protocols at

shorter intervals of time from the implantation time, by accelerating the processes of

osseointegration (Smeets et al., 2016).

The study aimed to evaluate the post-operative evolution and the osseointegration

capacity of three implant systems with modified surfaces (bioactive), made of pure

titanium or Ti-6Al-4V alloy, at 12 months post-loading.

4.2. MATERIALS AND METHOD

The study was performed on 30 partially mandibular edentulous patients (15-male;

15-female; 35-48 years) scheduled for implant-prosthetic therapy through fixed implant-

supported restorations. Implant-prosthetic therapy was performed with dental implant

systems with bioactive surfaces. Each implant system was inserted into 10 molar sites and

10 premolar sites that allowed the use of implants with lengths of 10-11.5mm and

diameters 4-4.5mm. The patients were divided into three groups according to the type of

implant system used:

Lot 1 (n = 10 patients, 20 implants) - Any Ridge implant (Megagen), manufactured from

CpTi;

Lot 2 (n = 10 patients, 20 implants) -MIS Seven implant (MIS), made of Ti-6Al-4V alloy;

Lot 3 (n = 10 patients, 20 implants) - MIS C1 implant (MIS), made of Ti-6Al-4V alloy.

Functional loading was performed at 4-5 months post-implantation for all groups of

patients. At the level of the mandibular areas, it were performed CBCT sections

immediately after loading and at 12 months after loading. The peri-implant status was

monitored for 12 months post-loading (clinical, radiographic examination and CBCT

exam). The comparison of the degree of osseointegration of the three types of implants was

made by evaluating the post-implant resorption and the peri-implant density.

Measurement of the post-implant resorption was performed by comparing the level

of the immediate post-implant marginal bone and at 12 months post-loading. The

measurements were performed by processing CBCT images in OnDemand software. The

peri-implant density measurement was performed using OnDemand software (apex,

middle third, neck) by comparing CBCT images immediately post-implantation and at 12

months post-loading. With the help of OnDemand3D software, the DICOM information

has been reconstructed into a high-resolution three-dimensional image of the jaw, and

analyzed in 3D, being divided into sections starting from 0.5 mm thick. Patients were

investigated by postoperative CBCT (Promax 3D Mid, Planmeca Oy, Finland), following

the same protocol. Stages in the bone parameters measurement protocol are as follows:

- reorienting the images according to the reference areas that received alveolar bone

addition or sinus lift;

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- selecting the regions of interest;

- setting the sectioning parameters (thickness 1mm, range 1mm);

- 2D densimetric measurements at the section level (the values obtained were

automatically expressed in Hounsfield -HU units).

The data were recorded in Microsoft Excel tables and were statistically processed

using SPSS 24.0. First it were calculated the descriptive statistics parameters, respectively

the height and density immediately psot-operative and at 12 months post-loading

(separately at the level of molars and premolars), for the three types of implants systems.

The results were presented in tables and graphs performed in Microsoft Excel. Figures

4.1.a-f, 4.2.a-f, 4.3.a-f present clinical aspects and CBCT images (preoperative, post-

implantation, post-loading) for the patients in each study group:

-figures 4.1.a-h- implant-prosthetic therapy with implants Megagen AnyRidge, IDS;

-figures 4.2.a-h- implant-prosthetic therapy with MIS Seven, MIS implants;

-figures 4.3.a-g- implant-prosthetic therapy with MIS C1, MIS implants

Fig. 4.1.a. Preoperatory clinical aspect

Fig. 4.1.b. Preoperatory radiographic aspect

Fig. 4.1.c. Intraoperative

clinical aspects

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Fig. 4.1.d-e. Postimplant radiographic aspects

Fig. 4.1.f. Postimplant clinical aspects

Fig. 4.1.g-h. Post-implant alveolar dimensional parameters (software OnDemand)

FIGURES 4.a-h. A.P., age 48, implant-prosthetic therapy with Megagen Any Ridge implant system

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Fig. 4.2.a-b. Preoperatory clinical aspects

Fig. 4.2.c. Preoperatory radiographic aspect

Fig. 4.2.d-e. Intraoperatory clinical aspects

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Fig. 4.2.f. Post-implant radiographic aspects

Fig. 4.2.g. Post-implant clinical aspects

Fig. 4.2.h. Post-implant alveolar dimensional parameters (CBCT)

FIGURES 4.2.a-h. H.L., age 45, implant-prosthetic therapy with MIS Seven implant systems

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Fig. 4.3.a. Preoperatory clinical aspects

Fig. 4.3.b. Preoperatory radiographic aspects

Fig. 4.3.c-d. Intraoperatory clinical aspects

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Fig. 4.3-e-f. Post-implant clinical and radiographic aspects

Fig. 4.3.g. Post-implant alveolar dimensional parameters (CBCT)

FIGURES 4.3.a-g. M.N., age 54, implant-prosthetic therapy with MIS C1 implant system

4.3. RESULTS

The levels of peri-implant marginal bone resorption at 12 months post-loading, for the

three implant systems investigated, were as follows (fig.4.7.a):

- AnyRidge implant system (Megagen): 0.32 mm for implants located at the molar level,

0.33 mm for implants located at the premolar level;

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- MIS C1 implant system (MIS): 0.30 mm for implants located at the molar level, 0.32 mm

for implants located at the premolar level;

- MIS Seven implant system (MIS): 0.33mm for implants located at the molar level,

0.35mm for implants located at the premolar level.

For all the three implant systems investigated, there were statistically significant

differences between the values of the height of the implant sites immediately after loading

and those recorded at 12 months after loading. There were no statistically significant

differences between the values of the post-loading resorption (12 months interval) between

the three implant systems investigated. The values of the peri-implant bone density

increased at 12 months post-loading; the mean values were as follows (fig. 4.7.b):

- AnyRidge implant system (Megagen): 604 HU for implants located at the molar level,

669 HU for implants located at the premolar level;

- MIS C1 implant system (MIS): 616 HU for implants located at the molar level, 690 HU

for implants located at the premolar level;

- MIS Seven implant system (MIS): 586 HU for implants located at the molar level, 663

HU for implants located at the premolar level.

Fig.4.4.a. Immediately post-loading height of the implant sites- Megagen implant system

Fig.4.4.b. Immediately post-loading density of the implant- Megagen implant system

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Fig.4.5.a. Immediately post-loading height of implant sites- MIS Seven implant system

Fig.4.5.b. Immediately post-loading density of implant sites- MIS Seven implant system

Fig.4.6.a. Immediately post-loading height of implant sites - MIS C1 implant system

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Fig.4.6.b. Immediately post-loading density of implant sites- MIS Seven implant systems

Fig.4.7.a. Post-loading resorption degree (12 months post-loading)

Fig.4.7.b. The increase of bone density (12 months post-loading)

For all the three implant systems investigated, there were statistically significant

differences between the mean values of the peri-implant bone density immediately after

loading and mean values recorded at 12 months after loading.

There were no statistically significant differences between the mean values of the

density gain at 12 months post-loading, between the three investigated implant systems.

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4.4. DISCUSSIONS

Given the low number of clinical studies that confirmed the data obtained in vitro,

our study demonstrates the advantages of implants with bioactive surfaces by 100%

success rate at 6 months intervals (with secondary stability in all investigated patients), the

reduced level of post-implant marginal bone resorption (below 1mm for all three brands of

implant systems with bioactive surfaces) and high values of peri-implant density.

The maximum success rate in the case of delayed implantation in healed extraction

sites, highlighted in our study for the three investigated implant systems, supports the data

reported by similar researches (Antetomaso & col., 2018; Coelho & col., 2015; Wenneberg

& col., 2015 ).

The results regarding the vertical peri-implant resorption and survival rate are

similar to those reported by a few research groups (Wenneberg & al., 2011; Esposito & al.,

2013; Streckbein & al., 2014), or even superior when compared with studies, investigating

bioactive implant systems, performed by Mendonca & col. (2008) and Ostman & col.

(2013).

In this context, the use of bioactive dental implants is recommended both in clinical

situations without special risks, and for patients with high risk of implant failure, due to

systemic disorders, lack of compliance with oral hygiene recommendations, or smokers

affected by periodontal disease (Gomez-de Diego & al., 2014).

4.5. CONCLUSIONS

• The use of bioactivated implant systems Any Ridge (Megagen), MIS Seven and

MIS C1 is associated with reduced levels of vertical marginal bone resorption,

increased peri-implant bone density and 100% implant survival rate at 12 months

post-loading;

• The level of post-implant resorption at 12 months after implants insertion, varies

between 0.32-0.33mm for AnyRidge implant system (Megagen), 0.30-0.32 mm for

MIS C1 implant system (MIS) and 0.33-0.35mm for MIS Seven implant system

(MIS);

• For all the three implant systems investigated, there were statistically significant

differences between the values of the height of the implant sites immediately after

loading and those recorded at 12 months after loading.

• There are no statistically significant differences between the dental implant systems

regarding peri-implant bone resorption at 12 months post-loading;

• The level of peri-implant bone density gain at 12 months post-implantation varies

between 604-669 HU for AnyRidge implant system (Megagen), 586-663 HU for

MIS C1 implant system (MIS) and 616-650 HU for MIS Seven implant system

(MIS), with absence of statistically significant differences between the investigated

implant systems;

• For all the three implant systems, there were statistically significant differences

between the values of the peri-implant bone density immediately after loading and

those recorded at 12 months after loading;

• There are no statistically significant differences between the investigated implant

systems regarding the values of the peri-implant bone density gain at 12 months

post-loading.

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CHAPTER 5. IN VITRO STUDY ON THE DEGREE OF ALTERING THE

SURFACE IMPLANTS DURING VARIOUS DENTAL PROCEDURES

5.1. MOTIVATION AND OBJECTIVES OF THE STUDY

Altered implant surfaces during air-flow dental procedures, ultrasound debridement

or laser decontamination, lead to bacterial attachment and bacterial biofilm formation as a

result of the increased surface roughness (DiSalle & col., 2018). The degree of bacterial

plaque contamination is dependent on alteration degree of the surfaces, topography of the

surface, microdesign, the degree of bioactivity and the macrodesign of the dental implant

(Subramani & col., 2009). Under these conditions, the purpose of any implant

decontamination procedure should be the efficiency of decontamination with minimal

alteration of implant surfaces (Wei & col., 2017).

The study investigated the degree of alteration of the dental implant surfaces during

the simulation of dental procedures commonly used in oral cavity cleaning and treatment

of peri-implantitis (air-flow, ultrasound, laser-assisted decontamination).

5.2. MATERIAL AND METHOD

The study was conducted on 32 pure titanium (Grade 4) discs with smooth (Ra =

0.014 µm) and rough (Ra = 0.92 µm) surfaces, 2mm thick, 15mm in diameter, and 8 dental

implants made of different materials (4 MIS V3 implants from Ti-6Al-4V alloy, 4

NobelActive implants from Ti-15Zr alloy, 8 Sky zirconia implants). The samples were

divided into three groups according to the type of dental procedure simulated for the

evaluation of the alteration degree:

-Study group 1- Air-flow technique (group 1.A- action time 30 seconds / T1; group 1.B-

action time 60 seconds / T2); Pearl Flash calcium carbonate powder (Nakanishi, Japan), 5

bar pressure, 5 mm distance, 900 angle with respect to the surface of the dental disc or

implant, under water flow 20mL / min; after the completion of the procedure, the samples

were cleaned by continuing air-flow procedure at a pressure of 1 bar.

-Study group 2 - Ultrasonic debridement (group 2.A- action time 30 seconds / T1; group

2.B- action time 60 seconds / T2): Woodpecker device, metal handle (lateral surface in

contact with the surface of the disc or dental implant in a manner similar to clinical

conditions), power 70% equivalent to the power used in subgingival debridement, under

water cooling of 50mL / min (group 1.A- 30 seconds; group 1.B- 60 seconds); after

completion of the procedure, the samples were cleaned by ultrasonic immersion in pure

water for 5 minutes.

-Study group 3- Diode laser decontamination: (group 3.A- action time 10 seconds / T1;

group 3.B- action time 20 seconds / T2): 810nm laser (Claros Nano, Elexxion), 2.5W,

continuous mode, diameter of the fiber optic tip 600 µm, applied at an angle of 900 to the

surface of the disc or dental implant.

-Study group 4- Erbium laser decontamination (group 4.A- action time 10 seconds / T1;

group 4.B- action time 20 seconds / T2): 2780nm laser (WaterLase, BioLase), 4W, pulsed

mode (10Hz), diameter of the fiber optic tip 600 µm, applied at an angle of 900 to the

surface of the disc or dental implant, under water irrigation.

To evaluate the effect of the air-flow technique (Lots 1.A- 30 seconds, 1.B- 60

seconds) on implant surfaces, it were used 8 pure titanium disks and 2 Sky (Bredent)

dental implants made of zirconia.

Group 1.A (30 seconds) included 4 pure titanium disks and 1 Sky implant

(Bredent). Group 1.B (60 seconds) included 4 pure titanium disks and 1 Sky implant

(Bredent). At each level of the disc, both on the smooth surface and on the rough surface, 3

circular areas (2mm2) were made; these areas were subjected to the action of the abrasive

powder jet (30 seconds – group 1.A; 60 seconds – group 1.B ) at 25psi pressure. The data

regarding the degree of roughness at the level of the pure titanium disc surfaces were

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collected from the level of 10 circular areas. At the cervical surface of Sky (Bredent)

zirconium implants, 10 circular areas (1 mm2) were made, each subjected to the action of

the abrasive powder jet at 25psi pressure (30 seconds – group 1.A; 60 seconds – group

1 .B).

To evaluate the effect of ultrasound debridement (group 2.A- 30 seconds, group

2.B- 60 seconds), it were used 8 pure titanium disks and 2 Sky (Bredent) dental implants

made of zirconia.

Lot 2.A (30 seconds) included 4 pure titanium disks and 1 Sky implant (Bredent).

Group 2.B (60 seconds) included 4 pure titanium disks and 1 Sky implant (Bredent). At the

level of each disk, both on the smooth surface and on the rough surface, were made 3

circular areas (2mm2) which were subjected to the ultrasound action (30 seconds – group

2.A; 60 seconds – group 2.B). The roughness of the pure titanium disk surfaces was

measured at the level of 10 circular areas. At the cervical surface of the Sky (Bredent)

zirconium implants, 10 circular areas (1 mm2) were performed, each subjected to the action

of the ultrasonic device (30 seconds – group 2.A; 60 seconds – group 2.B).

To evaluate the effect of the laser diode (810nm) at 2.5W power (10Hz),

continuously (group 3.A-10 seconds, group 3.B- 20 seconds), it were used 8 pure titanium

disks and 2 dental implants from each of the following categories:

- Sky dental implant (Bredent) - made of zirconium;

- MIS V3 dental implant (MIS) - made of Ti-6Al-4V alloy;

-NobleActive dental implant (Noble Biocare) - made of Ti-15Zr.

At the level disc surfaces, both on the smooth surface and on the rough surface, it

were made 3 circular areas (2mm2) which were subjected to the action of laser energy (10

seconds – group 3.A; 20 seconds – group 2.B). The surface roughness of the disks was

measured at 10 circular areas. At the level of the smooth surfaces of the Sky implants of

zirconium and of the excavated (concave) areas of the MIS V3 (MIS) and NobleActive

(Noble Biocare) implants, 10 circular areas (1 mm2) were made, which were subjected to

the action of laser energy (10 seconds – group 3.A; 20 seconds – group 3.B).

To evaluate the effect of the Er, Cr: YSGG (2780nm) laser at 4W power, pulsatile

mode, 10Hz frequency (group 4.A- 10 seconds, group 4.B- 20 seconds) 8 pure titanium

disks and 2 dental implants were used from each of the following categories:

- Sky dental implant (Bredent) - made of zirconium;

- MIS V3 dental implant (MIS) - made of Ti-6Al-4V alloy;

-NobleActive dental implant (Noble Biocare) - made of Ti-15Zr.

At the level of each disk, both on the smooth surface and on the rough surface,

were made 3 circular areas (2mm2) that were subjected to the action of laser energy (10

seconds – group 4.A; 20 seconds – group 4.B). The roughness of the pure titanium disk

surfaces was measured at the level of 10 circular areas. At the level of the smooth surfaces

of the Sky zirconium implants and to the excavated (concave) areas of the MIS V3 (MIS)

and NobleActive (Noble Biocare) implants, 10 circular areas (1 mm2) were delimited.

These areas were subjected to the action of laser energy (10 seconds – group 4.A; 20

seconds – group 4.B)

It was used optical microscopy (Zeiss Axio Imager A1m microscope, Germany;

magnification x 50, in bright field and dark field) and SEM microscopy (VEGA LSH

microscope, Czech Republic), at magnification x 2000, to detect changes in smooth and

rough surfaces of the titanium disks. The SEM microscope, fully computer controlled, has

a tungsten filament electron gun, which can achieve a resolution of 3nm at 30KV, with

magnification power between 30 and 1,000,000 X in resolution mode, acceleration voltage

between 200 V at 30 kV, scan speed between 200 ns and 10 ms per pixel. Working

pressure is less than 1x10-2 Pa. One disc from each study group was used.

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The optical microscopy and SEM investigations were carried out within the

Laboratory of Scientific Investigation and Conservation of Cultural Heritage,

ARHEOINVEST Interdisciplinary Platform, «Al.I.Cuza» University, Iasi.

The evaluation of the roughness of the surfaces of the samples subjected to the

dental procedures was carried out with the help of the Surface Roughness Measuring

Tester SJ-210, Mitutoyo (Japan) within the Tolerance and Measurement Laboratory of the

Faculty of Machines Construction and Industrial Management (“Gh.Asachi” Technical

University, Iasi). Regarding the roughness standards, the evaluation was based on the

standards applicable to ISO1997. For each assessed area, 10 traces were recorded in

different areas subjected to the physical agents used with a load of 0.75 mN, using a peak

with a diameter of 2 µm, a scan speed of 0.5 mm / s and the threshold of length (λc) 0.25

µm. The roughness parameters were calculated, the parameter Ra being used for each

roughness profile.

The data collected by profilometry were analyzed using statistical tests t and

Wilcoxon. In the first stage, a descriptive statistic was obtained for the data collected for

each type of dental procedure investigated (air-flow debridement, ultrasonic debridement,

diode laser therapy, erbium laser therapy) (tables 5.I.a-d). In the second stage we aimed to

compare the Ra parameter at the initial time and at times T1 and T2, for each of the dental

simulated procedures. We checked, with the help of the Kolmogorov-Smirnov test,

whether or not the values of the coefficients comply with the normal distribution law, to

determine whether, for comparisons between study groups, we will use paired, parametric

(t-test) or nonparametric (Wilcoxon test) tests. The results of the paired sample comparison

tests for each batch are presented in tables 5.II.a-d. In the third stage we aimed to

determine whether there are statistically significant differences between the degree of

change of the roughness of the investigated surfaces between moments C and T1, C and

T2, T1 and T2, for each of the dental procedures investigated (tables 5.III.a-d). In the

graphs shown in Figures 5.3 (air-flow), 5.4 (ultrasound), 5.5 (laser diode), 5.6. (laser Er,

Cr: YSGG) these values are presented for each of the types of samples investigated.

5.3. RESULTS

The examination in optical microscopy (x 50) shows the existence of alterations of

the surfaces of the pure titanium disks, both at the level of the smooth surfaces and at the

level of the rough surfaces, for all the three assessed dental procedures (figures 5.1.a-h). In

the case of smooth surfaces treated by air-flow technique or by ultrasonic action, the rough

aspect was highlighted. For rough surfaces treated by air-flow technique or by ultrasonic

action, the decrease of the degree of roughness was highlighted. .

On rough surfaces the alteration was less visible. SEM (x 2000) microscopy images

(Fig. 5.2.ah), for smooth surfaces treated by air-flow or ultrasonic action, showed the

increase of roughness in the form of ridges and craters (in air-flow technique), or micro-

pits ( in US technique).

For rough surfaces, the decrease of roughness was noted, the surfaces having a

smoother appearance. In the case of smooth surfaces subjected to the action of the 810nm

(2.5W) diode laser or Er, Cr: YSGG 2780nm (4W), grooves with widths between 1-5 µm

were highlighted.

Ti disks- Smooth surfaces Ti disks- Rough surfaces

CONTROL

18

AIR-FLOW

(30 sec)

AIR-FLOW

(60 sec)

US

(30 sec)

US

(60 sec)

DIODE

LASER

810nm

2.5W

(10 sec)

DIODE

LASER

810nm

2.5W

(20 sec)

LASER

Er,Cr:YSGG

2780nm

4W

(10 sec)

LASER

Er,Cr:YSGG

2780nm

4W

(20 sec)

Figures 5.1.a-h. Optic microscopy (x 50)- Ti disks

Discuri Ti pur- Suprafeţe netede Discuri Ti pur- Suprafeţe rugoase

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CONTROL

AIR-FLOW

(30 sec)

AIR-FLOW

(60 sec)

US

(30 sec)

US

(60 sec)

20

DIODE

LASER

810nm

2.5W

(10 sec)

DIODE

LASER

810nm

2.5W

(20 sec)

LASER

Er,Cr:YSGG

2780nm

4W

(10 sec)

LASER

Er,Cr:YSGG

2780nm

4W

(20 sec)

Fig. 5.2.a-h. SEM aspects (x 2000)- Ti disks surfaces

In tables 5.I.a-d. are presented the descriptive statistics of Ra parameter values for

the samples surfaces. Statistically significant differences were found for most of the values

recorded at the three investigated time points, for all dental procedures used and for all

types of samples, with exception of the following situations:

- There are no statistically significant differences between Ra values of the smooth and

rough surfaces of pure Ti disks after 10 seconds and 20 seconds of air-flow technique

action;

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- There are no statistically significant differences between Ra values of the smooth surface

of pure Ti disks after 10 seconds and 20 seconds of ultrasonic technique action;

- There are no statistically significant differences between Ra values of the smooth and

rough surfaces of pure Ti disks after 10 seconds and 20 seconds of diode laser action;

- There are no statistically significant differences between Ra values after 10 seconds and

20 seconds of action of the diode laser at the implant surface of the Ti-6Al-4V;

- There are no statistically significant differences between Ra values after 10 seconds and

20 seconds of diode laser action on the surface of the zirconium implant;

- There are no statistically significant differences between Ra values after 10 seconds and

20 seconds of erbium laser action on the surface of the zirconium implant.

In the graphs shown in Figures 5.3 (air-flow), 5.4 (ultrasound), 5.5 (laser diode),

5.6. (laser Er, Cr: YSGG) these values are presented for each of the investigated dental

procedures.

Fig.5.3. Changes of mean Ra values recorded at different times

for surfaces submitted to Air-Flow technique

Fig.5.4. Changes of mean Ra values recorded at different times

for surfaces submitted to US technique

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Fig.5.5. Changes of mean Ra values recorded at different times

for surfaces submitted to diode laser action (810nm)

Fig.5.6. Changes of mean Ra values recorded at different times

for surfaces submitted to Er,Cr :YSGG laser (2780nm)

5.4. DISCUSSIONS

The results show that the roughness of the smooth surfaces samples (equivalent to

the surfaces of the implants with unmodified surfaces) increased in all the investigated

study groups after the action of the physical agents associated to the simulated dental

procedures.

The increase of the roughness parameters was dependent on the action time for all

the dental procedures (air-flow, ultrasonic scanning, diode laser therapy, erbium laser

therapy), but there were no statistically significant differences between Ra values recorded

at 30 seconds and 60 seconds for air-flow and US techniques, respectively between Ra

values recorded at 10 seconds, respectively 20 seconds of diode or erbium laser action.

The results confirm the data reported in the literature regarding the possibilities of

altering the implant surfaces in the dental prophylaxis procedures, in the periodontal

therapy or peri-implant therapy, by using air-flow technique (Di Salle & col., 2018; Wei &

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col., 2017; Louropoulou & col. 2015, Bennani & col., 2015; Cochis & col., 2013, Tastepe

& col., 2012), US technique (Nakazawa & col., 2018; Louropoulou & col. 2015, Park &

col., 2012; Seol & Col., 2012; Vigolo & Col., 2010), diode laser (Rios & col., 2016;

Kushima & col., 2016; Gianelli & col., 2015; Geminiani & col., 2012), erbium laser (Alagl

& col., 2019; Saffarpour & col., 2018; AL-Hashedi & col., 2017; Eick & col., 2017;

Strever & col., 2017; Soares & col., 2016; Ayobian-Markazi et al., 2015; Miranda et al.,

2015; Park et al., 2012).

In interpretation of these results we must consider the fact that they were obtained

in vitro conditions, where there were no interferences from factors that are found in the

oral cavity (pH, temperature, etc.).

5.5. CONCLUSIONS

• The air-flow technique leads to a significant alteration of the dental implant

surfaces, after of 30 seconds action; the increase of Ra parameter values when the

laser action is prolonged from 30 seconds to 60 seconds is not statistically

significant both for smooth and rough surfaces of pure titanium discs as well as for

zirconium dental implant;

• The ultrasound technique leads to a significant alteration of the implant surfaces, at

an action time of 30 seconds; the increase of Ra parameter values when US action

is prolonged from 30 seconds to 60 seconds is not statistically significant both for

smooth and rough surfaces of pure titanium discs as well as for zirconium implant;

• The use of diode laser (810nm) at a power of 2.5W (specific to the peri-implant

decontamination procedures) leads to the alteration of the implant surfaces,

demonstrated by the significant increase of the roughness of the smooth surfaces,

both for an action time of 20 seconds and for an action time of 10 seconds;

increasing the action time from 10 seconds to 20 seconds does not lead to

statistically significant differences between the Ra values both for smooth and

rough surfaces of pure titanium discs as well as for the surfaces of the dental

implants manufactured from titanium alloys (Ti-6Al-4V, Ti-15Zr);

• The use of erbium laser (2790nm) at a power of 4W (specific for the peri-implant

decontamination procedures) leads to the alteration of the implant surfaces,

demonstrated by the significant increase of the roughness of the smooth surfaces,

both for an action time of 20 seconds and action time of 10 seconds; increasing the

action time from 10 seconds to 20 seconds does not lead to statistically significant

differences between the Ra values both for the smooth and rough surfaces of pure

titanium discs as well as for the surfaces of the dental implants manufactured from

titanium alloys (Ti-6Al-4V, Ti-15Zr).

24

CHAPTER 6. BIOMECHANICAL CONSIDERATIONS REGARDING THE

MATERIALS AND DESIGN OF DENTAL IMPLANTS

6.1. PURPOSE OF THE STUDY

In order to evaluate the influence of the dental implant material on the tensions in

the peri-implant tissue, three types of materials used for 4 commercial models of implants

were considered, in simulated situation of unilateral edentation of premolar 34:

a. Cp-Ti Grade 4;

b. Ti-6Al-4V (TAV);

c. Ti-15Zr;

Implant models used in the study are similar to the commercial types AlphaBio

Neo, Nobel Biocare NobelActive Internal RP, Megagen AnyRidge XPEED, and MIS V3.

The aim of study is to evaluate the distribution of tensions in the peri-implant

tissue, as well as the maximum values of tensions in the cortical and trabecular bone tissue,

considering the material characteristics of the dental implant and bone tissue complex as

well as the physiological load, through finite element analysis (FEA).

The objectives pursued in this chapter are:

1. Modeling the study structure and imposing the parameters for finite element analysis;

2. Evaluation of the state of tension at the level of peri-implant tissue in case of material

type variation;

3. Assessment of the state of tension in the level of peri-implant tissue in case of variation

of implant design.

6.2. MATERIALS AND METHOD

To assess the tension at the peri-implant level, the method of finite element analysis

(FEA) was used. This method allows to simulate the behavior of the implant complex in

the mandibular bone tissue by means of virtual 3D models and a software in which the

conditions of the simulation are imposed, conditions that approximate the real clinical

situation. The method is particularly advantageous because it allows the exploration of

some parameters through easily repeatable and modifiable analyzes, without ethical

implications, which in clinical conditions would be difficult or even impossible to achieve

(Huempfner-Hierl & col., 2014).

To perform these finite element analyzes, 3D models of the study elements were

made using the Autodesk Inventor Professional version 2017 (Autodesk, Inc., San Rafael,

CA, USA).

Four 3D implant assemblies have been modeled, consisting of implant, prosthetic

abutment, prosthetic abutment, cement layer and ceramic crown. Implants have been

modeled with different macrostructure designs. All four implants were of conical type with

different geometries at the level of the threads: triangular, rectangular shape, respectively

triangular plates of plateau type and with different angles of the threads as can be seen in

Figures 6.1, 6.2, 6.3 and 6.4.

The implant models used in the study are similar to the commercial types AlphaBio

Neo, Nobel Biocare NobelActive Internal RP, Megagen AnyRidge XPEED respectively

MIS V3. These commercial designs were used as models because it was considered

important to use implant models that are similar to frequently used dental implant systems.

Considering this principle, the analyzes performed can really approximate the simulated clinical situation. The correspondence between the design of the four commercial models

and the type of material is as follows:

25

• Cp-Ti Grade 4 (used in the manufacture of the Megagen AnyRidge XPEED

implant;

• Ti-6Al-4V (used in the manufacture of AlphaBio Neo and MIS V3 implants);

• Ti-15Zr (used in the manufacture of the Nobel Biocare NobelActive Internal RP

implant).

This correspondence was also preserved in a series of simulations of 3D models in our

study in order to maintain the accuracy of the analyzes.

Regarding the design of the implant models, microspirators were modeled at the

implant package level, in two different models (Figure 6.2). Also, microthreads were also

modeled at the implant body. Macro-design details for each modeled implant are shown in

Figure 6.2. Because the modeled implants were similar to those used in clinical conditions,

small variations in diameter and length are present, which are shown in detail in the

following description of each unit.

The simulations were performed in Simulation Mechanical version 2017 (Autodesk,

Inc., San Rafael, CA, USA). A static analysis with linear, elastic, isotropic material

properties was selected for all simulated cases.

Two material characteristics were used, namely Young's modulus (modulus of

elasticity) and Poisson's coefficient (Table 6.I). The mechanical properties of the materials

are presented for each element of analysis in Table 6.I. Patterns were applied to the end

surfaces of the mandibular section. In Figure 6.3. are presented the selected networks for

the simulation of all models. In Autodesk Simulation Mechanical 2017, this type of

support is represented by triangles (Figure 6.6).

The type of contact between the bone and the implant was defined as perfectly tight.

From a clinical perspective, this type of contact would translate into perfect

osteointegration. Studies have shown that introducing a coefficient of friction between the

implant and the peri-implant bone leads to an artificial reduction of tensions in the peri-

implant bone tissue (Lee & col.2008).

A number of tensions were applied to the surfaces of the ceramic crown. The loads

applied simulate the masticatory forces and were based on previous studies by Himmlova

and her colleagues (Himmlova & col. 2004): 114.6 N in axial direction, 17.1 N in lingual

direction and 23.4 N in distal direction. Subsequently, the mesh stage was completed. This

consists in discretizing the FEA model, dividing it into a very large number of elements

and nodes. Example of mesh result for 3D complex implant assembly - mandibular section

is illustrated in Figure 6.6.

Tabel 6.I. Materials properties for 3D models

Material Young modulus

(MPa)

Poisson

coefficient

Ceramic crown (Vaillancourt&col.1995) 140 000 0.28

Ti-6Al-4V (Grandin&col.2012) 110 000 0.35

Ti-15Zr (Brizuela-Velasco&col.2017) 103 700 0.334

Cp-Ti Grade 4 (Gurgel-Juarez&col.2012, Saetra

CP-TitaniumGrade4 data sheet) 103 421.35 0.35

Cortical bone (Bozkaya&col.2004, Van

Oosterwyck&col.1998, Chun&col.2005) 13700 0.3

Trabecular bone (Chun&col.2005,

Tolidis&col.2012) 1370 0.3

Cement (Prendergast&col.1996) 10760 0.35

26

6.3. RESULTS

In the simulations performed with finite element analysis, a series of differences

were recorded regarding the maximum tension values both at the level of cortical bone

tissue and at the level of spongious bone tissue in the case of the material Ti-6Al-4V, Ti-

15Zr and Cp-Ti4 for all simulated assemblies.

The influence of the material corresponding to each modeled assembly was first

analyzed. The results revealed notable differences between the 4 implant systems

regarding the value of tensions in cortical and spongious bone tissue, as can be seen in

Figure 6.7.

Thus, the maximum tension at the level of cortical bone was recorded to assembly

A manufactured from Ti-6Al-4V and the minimum tension was recorded to assembly B

manufactured from Cp-Ti4. At the level of the spongious bone, the maximum value was

obtained for D-assembly manufactured from Ti-6Al-4V and the minimum value was

recorded to B-assembly.

The influence of each implant material was investigated, by associating the three

materials to each assessed implant system.

The peri-implant stress values were assessed for the dental implant systems

manufactured from the three evaluated materials.

Fig.7.8. Maximum values of von Mises peri-implant tensions for assembly A

(dental implants manufactured from Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

27

Fig.7.9. Maximum values of von Mises peri-implant tensions for assembly B

(dental implants manufactured from Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Fig.7.10. von Mises peri-implant tensions for assembly C

(dental implants manufactured from Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Fig.7.11. von Mises peri-implant tensions for assembly D

(dental implants manufactured from Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

28

Fig. 18. Peri-implant tensions distribution for assembly A

(Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Fig. 19. Peri-implant tensions distribution for assembly B

(Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Fig. 20. Peri-implant tensions distribution for assembly C

(Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Ti-6Al-4V

Ti-15Zr Cp-Ti4

Ti-6Al-

4V

Ti-15Zr Cp-Ti4

Ti-6Al-

4V

Ti-15Zr Cp-Ti4

29

Fig. 21. Peri-implant tensions distribution for assembly D

(Ti-6Al-4V, Ti-15Zr, Cp-Ti4)

Fig. 22. Peri-implant tensions distribution in spongious bone for

all threads designs (Assemblies A-D) for dental implants manufactured from Ti-6Al-4V

Ti-6Al-

4V

Ti-15Zr Cp-Ti4

Filet cu spire triunghiulare cu

mifrofilet alăturat (ansamblu

A)

Filet cu spire de tip platou

(ansamblu B)

Filet cu spire dreptunghiulare

cu microfilet alăturat

(ansamblu C)

Filet simplu cu spire

triunghiulare (ansamblu D)

30

6.4.DISCUSSIONS

The present study focused on the influence of materials in the context of a complex

geometry of dental implants.

The results of our study showed a number of differences between dental implants

made of Ti-6Al-4V (TAV), Ti-Zr and Cp-Ti4.

Research regarding tensions levels and the distribution of peri-implant stresses

demonstrates the benefits of implants manufactured from Cp-Ti4 compared to implants

manufactured from TAV or Ti-15Zr alloys.

Implant design, with reference to macrodesign and microdesign, is one of the main

factors that influence the primary stability of the implant, the values and the distribution of

peri-implant tensions (Misch & col., 2001; Abuhussein & col., 2010).

Surface treatments influence micro -design and have a direct impact on the quality

of osseointegration processes.

Macro-design is determined by implant geometry, including implant shape, spiral

shape, spiral pitch, helical angle, and has a crucial influence on achieving optimal primary

stability (Afeseh Ngwa & Col., 2009; Ho & Col., 2008).

The results of the study suggest that there are no major differences between TAV,

Ti-15Zr and Cp-Ti4 in terms of the material's ability to decrease tensions in peri-implant

bone tissue. Therefore, the benefit of one material to the other should target

biocompatibility and osseointegration.

As reported in clinical trials, Ti-15Zr is more favorable option, as it revealed a

significantly higher percentage of bone implant contact compared with TAV after 6 weeks

of osseointegration (Brizuela-Velasco & col., 2017 ).

6.5. CONCLUSIONS

• The design and simulation of dental implants assemblies and prosthetic elements by

FEA method are useful steps in analyzis of the biomechanical behavior of the peri-

implant tissues.

• The results of the study suggest the absence of significant differences between

TAV, Ti-15Zr and Cp-Ti4 regarding the ability of the material to decrease the

tensions in the peri-implant bone tissues.

• Within the same material there were differences between the tensions values when

for small changes in the geometry of dental implants.

• Fine variations in implant design have led to a signidficant difference in the peri-

implant tensions values and its distribution in both cortical and spongious bone

tissue.

• The microspheres present on the body of the implant led to a decrease in tensions in

the perimplant bone.

• The thread design with platelet-type has proved to be the most favorable of the

analyzed implant geometries, regarding the tensions values in the spongious bone.

• The design of the thread with rectangular coils and microthreads led to lower

tensions values in the spongious bone compared to the simple thread with

triangular coils.

31

GENERAL CONCLUSIONS

• The use of bioactivated implant systems Any Ridge (Megagen), MIS Seven and

MIS C1 is associated with reduced levels of vertical marginal bone resorption,

increased peri-implant bone density and 100% implant survival rate at 12 months

post-loading;

• For all the three implant systems investigated, there were statistically significant

differences between the values of the height of the implant sites immediately after

loading and those recorded at 12 months after loading.

• There are no statistically significant differences between the dental implant systems

regarding peri-implant bone resorption at 12 months post-loading;

• For all the three implant systems, there were statistically significant differences

between the values of the peri-implant bone density immediately after loading and

those recorded at 12 months after loading;

• There are no statistically significant differences between the investigated implant

systems regarding the values of the peri-implant bone density gain at 12 months

post-loading.

• The air-flow technique leads to a significant alteration of the dental implant

surfaces, after of 30 seconds action; the increase of Ra parameter values when the

laser action is prolonged from 30 seconds to 60 seconds is not statistically

significant both for smooth and rough surfaces of pure titanium discs as well as for

zirconium dental implant;

• The ultrasound technique leads to a significant alteration of the implant surfaces, at

an action time of 30 seconds; the increase of Ra parameter values when US action

is prolonged from 30 seconds to 60 seconds is not statistically significant both for

smooth and rough surfaces of pure titanium discs as well as for zirconium implant;

• The use of diode laser (810nm) demonstrated by the significant increase of the

roughness of the smooth surfaces, both for an action time of 20 seconds and for an

action time of 10 seconds; The use of erbium laser (2790nm) leads to the alteration

of the implant surfaces, demonstrated by the significant increase of the roughness

of the smooth surfaces, both for an action time of 20 seconds and action time of 10

seconds;

• The design and simulation of dental implants assemblies and prosthetic elements by

FEA method are useful steps in analyzis of the biomechanical behavior of the peri-

implant tissues.

• The results of the study suggest the absence of significant differences between

TAV, Ti-15Zr and Cp-Ti4 regarding the ability of the material to decrease the

tensions in the peri-implant bone tissues.

• Within the same material there were differences between the tensions values when

for small changes in the geometry of dental implants.

• Fine variations in implant design have led to a signidficant difference in the peri-

implant tensions values and its distribution in both cortical and spongious bone

tissue.

• The microspheres present on the body of the implant led to a decrease in tensions in

the perimplant bone.

• The thread design with platelet-type has proved to be the most favorable of the

analyzed implant geometries, regarding the tensions values in the spongious bone.

• The design of the thread with rectangular coils and microthreads led to lower

tensions values in the spongious bone compared to the simple thread with

triangular coils.

32

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39.www.idsimplants.com/implant-systems/anyridge/