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Insua A, Galindo-Moreno P, Miron RJ, Wang HL, Monje A. Emerging factors affecting peri-implant bone metabolism. Periodontol 2000 2024; 94:27-78. [PMID: 37904311 DOI: 10.1111/prd.12532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/05/2023] [Accepted: 09/10/2023] [Indexed: 11/01/2023]
Abstract
Implant dentistry has evolved to the point that standard implant osseointegration is predictable. This is attributed in part to the advancements in material sciences that have led toward improvements in implant surface technology and characteristics. Nonetheless, there remain several cases where implant therapy fails (specifically at early time points), most commonly attributed to factors affecting bone metabolism. Among these patients, smokers are known to have impaired bone metabolism and thus be subject to higher risks of early implant failure and/or late complications related to the stability of the peri-implant bone and mucosal tissues. Notably, however, emerging data have unveiled other critical factors affecting osseointegration, namely, those related to the metabolism of bone tissues. The aim of this review is to shed light on the effects of implant-related factors, like implant surface or titanium particle release; surgical-related factors, like osseodensification or implanted biomaterials; various drugs, like selective serotonin reuptake inhibitors, proton pump inhibitors, anti-hypertensives, nonsteroidal anti-inflammatory medication, and statins, and host-related factors, like smoking, diet, and metabolic syndrome on bone metabolism, and aseptic peri-implant bone loss. Despite the infectious nature of peri-implant biological complications, these factors must be surveyed for the effective prevention and management of peri-implantitis.
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Affiliation(s)
- Angel Insua
- Department of Periodontology and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pablo Galindo-Moreno
- Department of Periodontology and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Oral Surgery and Implant Dentistry, University of Granada, Granada, Spain
| | - Richard J Miron
- Department of Periodontology, University of Bern, Bern, Switzerland
| | - Hom-Lay Wang
- Department of Periodontology and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alberto Monje
- Department of Periodontology and Oral Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Periodontology, University of Bern, Bern, Switzerland
- Department of Periodontology, Universitat Internacional de Catalunya, Barcelona, Spain
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Dong S, Zhao T, Wu W, Zhang Z, Wu J, Cai K, Li G, Lv J, Zhou H, Tang C. Sandblasted/Acid-Etched Titanium Surface Modified with Calcium Phytate Enhances Bone Regeneration in a High-Glucose Microenvironment by Regulating Reactive Oxygen Species and Cell Senescence. ACS Biomater Sci Eng 2023; 9:4720-4734. [PMID: 37491189 DOI: 10.1021/acsbiomaterials.3c00385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
Hyperglycemia in patients with diabetes affect osteoblast function, leading to abnormal bone metabolism and implant failure. Adequate bone volume surrounding an implant is essential for osseointegration, which can be improved by implant surface modifications. In this study, titanium surfaces were hydrothermally treated with a mixture of phytic acid (PA) and calcium hydroxide to produce a calcium-decorated surface. The control group comprised pure titanium with a sandblasted/acid-etched (SLA) surface. The elemental composition, hydrophilicity, surface roughness, and morphology of the titanium surfaces were examined. Evaluation of in vitro osteogenic differentiation ability in a high-glucose environment using alkaline phosphatase (ALP) staining, ALP activity assays, Alizarin Red S staining, quantitative reverse transcription-polymerase chain reaction (qRT-PCR), and immunofluorescence staining revealed that Ca-PA-modified SLA titanium surfaces can promote osteogenic differentiation of human bone marrow mesenchymal stem cells (hBMSCs). Evaluation of oxidative stress and aging using reactive oxygen species (ROS), malondialdehyde (MDA), superoxide dismutase (SOD), and β-galactosidase staining revealed that Ca-PA-modified SLA titanium surfaces can reduce ROS production and ameliorate oxidative stress damage in hBMSCs. In vivo assessment of osteogenesis in a diabetic rat model revealed that Ca-PA coating promotes peri-implant osseointegration. Ca-PA-modified SLA titanium surface is a candidate for improving implant osseointegration in patients with diabetes.
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Affiliation(s)
- Shuo Dong
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Tong Zhao
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Wei Wu
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Zhewei Zhang
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Jin Wu
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Kunzhan Cai
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Guoqing Li
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Jiaxin Lv
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Heyang Zhou
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
| | - Chunbo Tang
- Department of Dental Implantology, The Affiliated Stomatological Hospital of Nanjing Medical University, Nanjing 210029, China
- Jiangsu Province Key Laboratory of Oral Diseases, Nanjing 210029, China
- Jiangsu Province Engineering Research Center of Stomatological Translational Medicine, Nanjing 210000, China
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Provisional Matrix Formation at Implant Surfaces—The Bridging Role of Calcium Ions. Cells 2022; 11:cells11193048. [PMID: 36231011 PMCID: PMC9563433 DOI: 10.3390/cells11193048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
The success of dental implants lies in their strong and lasting integration into the patient’s receiving bone. The first biological interactions at the implant surface determine the subsequent evolution of the integration process. In this study we set our objective to analyze the mechanistic interaction of the early regenerative matrix at implant surfaces modified with calcium ions (Ca) as compared to standard implant surfaces (NoCa). We put the surfaces in a Quartz Crystal Microbalance with Dissipation (QCM-D) to monitor the frequency shift (f) and the viscoelastic properties of the adsorbed biofilms and used Scanning Electron Microscopy (SEM) to visualize the resulting interfaces. Upon the addition of human blood plasma, Ca surfaces formed an adsorbed three-dimensional film attached to the surface (∆f = −40 Hz), while with NoCa, the biofilm formed but was not attached to the surface (∆f = 0 Hz). After 20 min in blood, two representative commercial implants with Ca and NoCa surfaces showed also distinct interfaces: Ca implants formed a visible clot attached to the implant which was composed mainly of platelets (Surface Coverage: 40 ± 20%) and some red blood cells (SC: 9 ± 3%) entrapped within a fibrin network (SC: 93 ± 5%). The NoCa implants were largely populated by red blood cells (SC: 67 ± 12%) with scarce fibrin remnants (SC: 3 ± 2%), and the implants showed no clot on their surfaces macroscopically. The pre-clinical and clinical results discussed in this work encourage the modification of titanium implant surfaces with calcium ions to improve the bone regenerative process. Taken together, these results add more information about the roles of Ca ions in bridging the formation of the provisional matrix at implant surfaces and their effects on implant osseointegration.
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Dias Corpa Tardelli J, Cândido dos Reis A. Influence of surface electric charge of Ti implants on osteoblastic interaction: A systematic review. Saudi Dent J 2022; 34:335-345. [PMID: 35814840 PMCID: PMC9263760 DOI: 10.1016/j.sdentj.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/13/2022] [Indexed: 11/25/2022] Open
Abstract
Objective A critical analysis of the existing literature to answer “What is the influence of electrical charge of titanium alloys in the electrical interaction with osteoblastic cells for osseointegration?”. Design This systematic review followed PRISMA. The personalized search strategy was applied in PubMed, Science Direct, Embase, and Scopus databases, furthermore, in the grey literature in the Google Scholar and ProQuest. The selection process was carried out in two stages independently by two reviewers according to the eligibility criteria. The risk of bias was also analyzed. Results When applying the search strategy, 306 articles were found, after removing duplicates 277 were analyzed by title and abstract, of which 33 were selected for full reading, of which 10 met the eligibility criteria. And one was included from the additional literature search. Of these, all had a low risk of bias. Conclusions 1. The phenomenon of osseointegration is complex and, independent of the superficial electrical charge of the implant, it may occur. To understand osseointegration, attention must be paid to the synergistic action of the electrical potential; chemical composition, intrinsic to the alloy and from surface treatment; and topography, which will determine the speed of adhesion, proliferation, and osteoblast differentiation. 2. The presence of Ca2+ deposited on the surface acts as a driving force for biomineralization that induces osteoblastic attraction and differentiation; 3. For a better understanding of the current literature, more studies are needed to describe the osteogenic regulation process through protein mediation; 4. Topography and chemical composition act as decisive parameters for cell viability independent of the attractive electrical charge.
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Antiua E, Escuer V, Alkhraisat MH. Short Narrow Dental Implants versus Long Narrow Dental Implants in Fixed Prostheses: A Prospective Clinical Study. Dent J (Basel) 2022; 10:dj10030039. [PMID: 35323241 PMCID: PMC8947067 DOI: 10.3390/dj10030039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/17/2022] [Accepted: 03/01/2022] [Indexed: 12/10/2022] Open
Abstract
There is a paucity of studies that assess short and narrow dental implants. This prospective study aimed to evaluate the performance of both short (≤8 mm) and narrow (≤3.5 mm width) dental implants supporting fixed prostheses in the atrophic maxilla or mandible. Towards that aim, patients with short implants were included in the study. The control group was those with long and narrow dental implants (length > 8 mm and diameter ≤ 3.5 mm). Clinical and demographic variables were extracted from clinical records. During the follow-up, implant survival and marginal bone loss were evaluated and statistically analysed. Forty-one implants were included (18 and 23 implants in the test and control groups, respectively). The median follow-up time was 26 months since insertion in both groups. The results revealed that there was no implant failure and no statistically significant differences in terms of marginal bone loss. Only one screw-loosening effect occurred in the short implants group. Short, narrow dental implants could be an alternative for the restoration of severely resorbed jaws.
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Affiliation(s)
- Eduardo Antiua
- Clínica Eduardo Anitua, 01007 Vitoria, Spain;
- University Institute for Regenerative Medicine and Oral Implantology—UIRMI (UPV/EHU—Fundación Eduardo Anitua), 01007 Vitoria, Spain
- BTI Biotechnology Institute, 01005 Vitoria, Spain
- Correspondence: (E.A.); (M.H.A.)
| | - Virginia Escuer
- Clínica Eduardo Anitua, 01007 Vitoria, Spain;
- University Institute for Regenerative Medicine and Oral Implantology—UIRMI (UPV/EHU—Fundación Eduardo Anitua), 01007 Vitoria, Spain
| | - Mohammad H. Alkhraisat
- University Institute for Regenerative Medicine and Oral Implantology—UIRMI (UPV/EHU—Fundación Eduardo Anitua), 01007 Vitoria, Spain
- BTI Biotechnology Institute, 01005 Vitoria, Spain
- Correspondence: (E.A.); (M.H.A.)
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Mozzati M, Gallesio G, Menicucci G, Manzella C, Tumedei M, Del Fabbro M. Dental Implants with a Calcium Ions-Modified Surface and Platelet Concentrates for the Rehabilitation of Medically Compromised Patients: A Retrospective Study with 5-Year Follow-Up. MATERIALS 2021; 14:ma14112718. [PMID: 34064086 PMCID: PMC8196782 DOI: 10.3390/ma14112718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/07/2023]
Abstract
Background: Platelet concentrates are biological, autologous products obtained from the patient’s whole blood, consisting of a supraphysiological concentration of platelets and growth factors, that have proved beneficial in different applications in the medical and dental fields. They are used in several medical and dental applications to enhance tissue healing. Previous evidence shows that platelet concentrates may be beneficial in patients with compromised systemic conditions, in which the healing process is impaired. Aim: To evaluate the 5-year clinical outcome of implant treatment using acid-etched implants with calcium ions-modified surface in association with plasma rich in growth factors, in patients with systemic diseases of a different nature. Methods: Charts of 99 medically compromised patients, who had received a total of 224 dental implants from January 2013 to June 2013, were retrospectively evaluated. Patients were divided into four groups, according to their condition: diabetes (n = 39 patients), osteoporosis (n = 36), lupus erythematosus systemic (n = 5), rheumatoid arthritis (n = 19). The main outcomes were implant survival, marginal bone level (MBL) change and complications throughout follow-up. Results: Mean follow-up was 63.06 ± 1.90 months (range 60.1 to 66.4 months). In total, eight implants failed in 6 diabetic patients and 4 in 3 patients with rheumatoid arthritis. Overall 5-year implant survival was 94.6%. In total, 30 complications occurred in 24 patients, mostly transient, and no severe adverse event occurred. Overall MBL change was 0.45 ± 0.12 mm, with no significant differences among groups. Conclusions: In the present sample of medically compromised patients, rehabilitation with calcium ions-modified surface implants associated with plasma rich in growth factors proved to be a safe and effective treatment. The satisfactory results achieved after 5-year follow-up are comparable to those historically reported for healthy patients.
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Affiliation(s)
- Marco Mozzati
- Private Practitioner, SIOM Oral Surgery and Implantology Center, 10126 Turin, Italy; (M.M.); (G.G.)
| | - Giorgia Gallesio
- Private Practitioner, SIOM Oral Surgery and Implantology Center, 10126 Turin, Italy; (M.M.); (G.G.)
| | - Giulio Menicucci
- Prosthodontic Department, School of Dentistry, University of Turin, 10124 Turin, Italy; (G.M.); (C.M.)
| | - Carlo Manzella
- Prosthodontic Department, School of Dentistry, University of Turin, 10124 Turin, Italy; (G.M.); (C.M.)
| | - Margherita Tumedei
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti, 66100 Chieti, Italy;
| | - Massimo Del Fabbro
- Department of Biomedical, Surgical and Dental Sciences, University of Milano, 20122 Milan, Italy
- IRCCS Orthopedic Institute Galeazzi, Dental Clinic, 20161 Milan, Italy
- Correspondence: ; Tel.: +39-02-50319950
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Yin S, Zhang W, Tang Y, Yang G, Wu X, Lin S, Liu X, Cao H, Jiang X. Preservation of alveolar ridge height through mechanical memory: A novel dental implant design. Bioact Mater 2021; 6:75-83. [PMID: 32817915 PMCID: PMC7419257 DOI: 10.1016/j.bioactmat.2020.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/26/2022] Open
Abstract
Irreversible marginal bone loss can hinder recovery around dental implants. Insufficient alveolar osteogenesis and stress concentration during chewing contribute to marginal bone resorption and can result in implant failure. A biomaterial with a micropore-channel structure was developed using 3D printing technology. This design facilitated bony ingrowth and provided similar mechanical stimulation at the implant neck during mastication to a natural tooth. The micropore channels provided a guiding structure for bone mesenchymal stem cell proliferation and differentiation without the need for growth factors. Specifically, this was achieved through mechanical transduction by F-actin remodeling and the activation of Yes-associated protein (YAP). The implants were verified in a canine dental implant surgery model, which demonstrated the promising use of biomaterial-based dental implants in future clinical applications.
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Affiliation(s)
- Shi Yin
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Wenjie Zhang
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Yanmei Tang
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Guangzheng Yang
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Xiaolin Wu
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Sihan Lin
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
| | - Xuanyong Liu
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics, Chinese Academy of Sciences, Shanghai, 200050, China
- Center of Materials Science and Optoelectronics Engineering, University of Chinese Academy of Science, Beijing, 100049, China
| | - Huiliang Cao
- State Key Laboratory of High Performance Ceramics and Superfine Microstructure, Shanghai Institute of Ceramics, Chinese Academy of Sciences, Shanghai, 200050, China
| | - Xinquan Jiang
- Department of Prosthodontics, Shanghai Engineering Research Center of Advanced Dental Technology and Materials, Shanghai Key Laboratory of Stomatology, Shanghai Research Institute of Stomatology, National Clinical Research Center for Oral Diseases, Shanghai Ninth People's Hospital, College of Stomatology, Shanghai Jiao Tong University School of Medicine, No. 639 Zhizaoju Road, Shanghai, 200011, China
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Abstract
Adequate bone remodeling may be a primary parameter for long-term successful complication-free dental implant treatment. A 1.8-mm osseous thickness around dental implants is thought to be the minimum thickness for adequate vasculature for osteocyte nutrition and function. A dental implant does not provide progenitor cells or angiogenic or osteogenic factors. Thus, the surrounding bone may need to have a 1.8-mm thickness to accommodate the vasculature necessary for nutrients for appropriate remodeling. Additionally, the 1.8-mm dimension may provide for mechanical load resistance. There is no evidence to illustrate the physiologic need for the 1.8-mm dimension. This dimension requirement is based on clinical outcome observations. Basic science research for bone survival around dental implants is needed.
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Kulakov AA, Kasparov AS, Porfenchuk DA. [Factors affecting osteointegration and the use of early functional load to reduce the duration of treatment in dental implantation]. STOMATOLOGIIA 2019; 98:107-115. [PMID: 31513161 DOI: 10.17116/stomat201998041107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The article presents literature data on the impact of the surface and shape of dental implants and early functional load with aesthetic and functional rehabilitation on osteointegration and stability of implants at various implantation terms.
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Affiliation(s)
- A A Kulakov
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
| | - A S Kasparov
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
| | - D A Porfenchuk
- Central Research Institute of Dentistry and Maxillofacial Surgery, Moscow, Russia
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