|Year : 2023 | Volume
| Issue : 1 | Page : 24
Strategic implants and bone morphogenic changes: Survival and clinical success in long-term
B Gangadhar1, Anbu Ila2, Randhir Kumar3, Beautlin Ruban4, Kurian Punnoose5, Shilpa Dandekeri6, J Suresh Babu7, C Swarnalatha7, Abhishek S Nayyar8
1 Department of Oral and Maxillofacial Surgery, PMNM Dental College and Hospital, Bagalkot, Karnataka, India
2 Department of Dentistry, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
3 Department of Periodontology, Patna Dental College and Hospital, Patna, Bihar, India
4 Consultant Oral and Maxillofacial Surgeon, Nagercoil, Tamil Nadu, India
5 Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
6 Department of Prosthodontics and Crown and Bridge, Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India
7 Division of Periodontology, Department of Preventive Dental Sciences, College of Dentistry, University of Ha'il, Ha'il, Kingdom of Saudi Arabia
8 Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India
|Date of Submission||15-May-2022|
|Date of Decision||19-Jul-2022|
|Date of Acceptance||08-Sep-2022|
|Date of Web Publication||18-Mar-2023|
Department of Prosthodontics and Crown and Bridge, Nitte (Deemed to be University), AB Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka
Source of Support: None, Conflict of Interest: None
Dental implants are one of the established treatment protocols to replace/restore lost tooth/teeth structures. Ihde and Ihde redefined concept of strategic implantology based on immediate loading. The aim of present case series was to evaluate efficacy of strategic implants regarding primary stability, quality of bone, survival, and clinical success in long-term. The present case series included a total of 26 patients aged 40 to 70 years restored with strategic implants after an immediate loading protocol. On follow-up visits, clinical assessment of implant stability was done by absence of implant mobility and absence of pain and dysesthesia while radiographically, immediate postoperative crestal bone level was compared with that observed on follow-up visits. Also, integration of apical and/or crestal threads of implants were assessed radiographically for any signs of radiolucency along with healing of sockets and crestal bone levels in relation to abutment margins.
Keywords: Immediate loading, primary stability, quality of bone, strategic implants
|How to cite this article:|
Gangadhar B, Ila A, Kumar R, Ruban B, Punnoose K, Dandekeri S, Babu J S, Swarnalatha C, Nayyar AS. Strategic implants and bone morphogenic changes: Survival and clinical success in long-term. J Orthodont Sci 2023;12:24
|How to cite this URL:|
Gangadhar B, Ila A, Kumar R, Ruban B, Punnoose K, Dandekeri S, Babu J S, Swarnalatha C, Nayyar AS. Strategic implants and bone morphogenic changes: Survival and clinical success in long-term. J Orthodont Sci [serial online] 2023 [cited 2023 Oct 3];12:24. Available from: https://www.jorthodsci.org/text.asp?2023/12/1/24/371966
| Introduction|| |
Strategic implants are important because teeth bare quintessential components of stomatognathic system are considered as a disability when lost or damaged. The inadvertent absence of teeth not only affects mastication but also speech and facial profile in the affected individual. The replacement/restoration of lost teeth can be done by removable or fixed means. Dental implants are one of such methods to replace/restore lost tooth/teeth structures.,, A plethora of researchers from across the world including Pasqualini et al., Garbaccio D, Scortecci G, and Ihde and Ihde have published their work on immediate loading implant designs. Sufficient studies, references, and articles are also easily available in the literature that support the use and successful clinical outcomes with immediate, functional loading implants within conventional and basal implantology including the works of Albrektsson et al.,, Chrcanovic et al.,,,Misch et al.,,,,,,,, Szmukler-Moncler et al., Degidi et al.,,,,, Vantaggiato et al., Felice et al., Tarnow et al., Romanos et al., and especially Adell et al. and Brånemark et al.,
In conventional/alveolar implantology, “All on Four” is the most preferred method for immediate, functional loading dental implants, especially in case of atrophied jaws wherein implants are placed between the intermental foramina of lower jaw and in premaxilla region having cantilever extensions., Szmukler-Moncler et al. proposed prerequisites for immediate, functional loading implants emphasizing avoidance or reduction of cantilever in designs, high density bone at selected implant site, implant design that increases mechanical retention, rough implant surface to increase primary stability, bicortical implant placements for increased stability, avoidance or reduction of distal cantilevers, and protected occlusal scheme against overloading. Chen et al. also proposed requisites for immediate functional loading strategic dental implants, wherein the implant-supported restoration is placed within 48 hours of implant insertion and a distinction is made between immediate restoration for an aesthetic purpose and true immediate loading.
The concept of strategic implantology is based on the principles of orthopedics and traumatology. As per this concept, if implants are initially stable but have not yet undergone biological osseointegration, this clinical situation is like surgical stabilization of mobile bone fragments by osteosynthesis plates in orthopedic surgery. The concept of strategic implantology was, indeed, redefined by Ihde and Ihde, wherein smooth-surface screws are used, whereas bicortical anchorage is achieved. Also, nonparallel screws are used to enhance macro-anchorage while rigid splinting is done by fracture plates similar to the prosthesis/bridge in dental implants. The principle guidelines for strategic implantology include stable anchorage areas for cortical engagement with infection-free cortical bone, whereas other significant considerations include resorption-free bone areas like buttresses being low in metabolism, thin mucosal penetration, smooth surface, thus, virtually with no or decreased probability of peri-implantitis, an abutment, preferably, single piece, bending zone, avoidance of cantilever, and cross-arch splinting and splinting, preferably, within 72 hours of the procedure before bone remodeling starts. It is, also, significant to note that the more the atrophy, quick one must be the splinting.,
Strategic implants are nonhomogenously designed implants which are smooth or polished like osteosynthesis plates used in traumatology are self-tapping with self-cutting threads for maximum bone to implant contact and with high insertional torques. For retrievability, single-piece, multiunit, monoimplants are used. Also, the body of implant is thin but strong enough to sustain occlusal loading while it is bendable so as to bring the abutment to the desired prosthetic plane after engaging the buttress and desired cortical bone to sustain the occlusal function. Furthermore, these implants are designed to be placed flapless minimizing so-recognized “regional acceleratory phenomenon” and are least traumatic to patients with force transmission at apical threads engaged at the intended corticals and buttresses with negligible influence on relatively unstable crestal corticals on which all of the conventional implantology is based. The aim of the present case series was to evaluate efficacy of strategic implants regarding primary stability, quality of bone, and their survival and clinical success in long-term following immediate loading protocol.
| Case Series|| |
The present case series included patients reporting to the Outpatient Department for implant placement, wherein a total of 26 patients from both genders including 19 males and seven females in an age range of 40 to 70 years were restored with strategic implants after an immediate loading protocol as per feasibility of the case. In most of the cases, eight to 10 strategic implants were placed in each jaw which was, later, restored with prosthesis within 72 hours. The prominent inclusion criteria were people with partial or complete edentulism in upper or lower jaw with atrophied ridges, whereas patients excluded were those with a history of radiotherapy and/or chemotherapy in head and neck region for malignancies within 1 year of the procedure desired, those with uncontrolled diabetes or hypertension or any systemic conditions which contradicted the conduct of surgical procedures and also, pregnant female patients.
| Clinical Procedure|| |
At first visit, a detailed case history elicitation was followed by a thorough clinical and radiographic examination including an orthopantomograph of the patient [Figure 1] while the patient was explained in detail about the protocol including procedure required and the need for postoperative follow-up visits. In the second visit, a surgical template was used for assessment of implant angulations and labiopalatal/labiolingual and buccopalatal/buccolingual width of the dentulous/edentulous ridges. In the third visit, curettage and/or extraction followed by implant placement and impression were completed [Figure 2] and [Figure 3]. In the fourth visit on the very next day of implant placement, metal framework try-in was done [Figure 4] and [Figure 5], whereas in the fifth visit on the very next day of metal try-in, prosthesis was delivered. This was followed by repeated assessment of soft and hard tissues at implant site and corrections made, if any, clinically, from the sixth visit to till the 11th postoperative day while the same protocol was repeated on the 40th postoperative day and then, after 6 months and 1 year of postoperative follow-up visits of patients. Also, any change of the semi-permanent prosthesis to be done was completed at this time.
|Figure 5: Cobalt-chromium (Co-Cr) alloy framework on mandibular implants|
Click here to view
| Technique and Protocol|| |
Depending upon the various classifications of jaw ridges regarding the available cortical and cancellous bone like the Atwood DA,, Cawood and Howell, Lekholm et al., Seibert JS, and Paraskevich VL, different designs of strategic implants were chosen. With the available crestal bone width and height, strategic implant designs like BECES EX, KOC MICRO, KOC PLUS, or BECES implants were selected while in case of highly atrophied ridges, BECES and ZDI were the only options available. The procedure of implant placement was completed under local anesthesia while implants were placed at strategic sites fixated with other corticals like second or third corticals., The purchase points used for strategic implants at the first corticals were mostly different and away from second and third corticals. Usually, longer implants were placed and bent while splinting, preferably, cross-arch, to bring masticatory surfaces within the “supporting polygon.” The concept of accepted principle “primum nihil nocere”, that is, limiting treatment and restorations was adopted with the least traumatic of the methods used. Also, all aforementioned procedures were performed in routine dental operatories, whereas procedures done were mostly flapless, except in cases, where extraction was done. After implant placement, impression was made by additional silicon putty with impression caps while master cast was readied with laboratory analogs on the same day. Next day, metal cobalt-chromium alloy try-in was followed by checking fit for circular bridges using jaw relations. Occlusal plane was recorded by fox bite plane, while on the very third day, prosthesis was delivered. The bridge was cemented with Fuji Plus by GC. The occlusal scheme provided, preferably, was a lingualized occlusion, whereas group function occlusion was provided when an opposite arch had natural teeth. The patient was provided with all necessary instructions while recall/follow-up schedule was formulated and explained to patient. On follow-up visits, clinical assessment of implant stability based on principles of osseointegration/osseofixation/osseoadaptation was done by absence of implant mobility and absence of pain and dysesthesia, whereas radiographically, immediate postoperative crestal bone level was compared with that observed on follow-up visits. Also, integration of apical and/or crestal threads of implants were assessed radiographically for any signs of radiolucency along with healing of sockets and crestal bone levels in relation to abutment margins in cases, wherein implants were placed in extraction sockets immediately post the conduct of extractions. In addition, evaluation of prosthetic supra-structures was done for any evidence of fracture and/or distortion or decementation and vertical mobility, while persistence/complaint of pain, discomfort, and radiolucency around the force transmitting threads were considered as cases with failure. Any such complication was dealt with using clinical and/or radiographic data on follow-up visits of patients while an assessment of the level of discomfort and pain starting from the postoperative day till the seventh day and on further follow-up visits of patients was done on a sequential basis using the Patient's Satisfaction Questionnaire.
| Case Findings|| |
A total of 26 patients including 19 male and seven female patients were operated, whereas 25 maxillary and 25 mandibular full arch rehabilitations were done with metal-to-plastic/acrylic prosthesis. One maxillary and one mandibular segment were restored with metal-to-ceramic prosthesis on same patient. A total of 447 BECES, 20 BECES EX, 4 KOC MICRO, and 2 ZDI implants were used for rehabilitation procedures on different patients based on their bone status. Within 72 hours, prosthesis was fixed over implants and a desirable occlusal scheme was restored. Till 1-year follow-up period, none of the patients had complained of any mobility or fracture of prosthesis or implants and were free of pain and swelling and any other sign of ailing. One patient having a history of fracture of right body region of mandible with callus formation as noticeable on orthopantomograph of patient was rehabilitated with strategic implants and when recalled after 6 months, resorption of callus was noticed radiographically, whereas normal contour of the inferior body region of mandible was observed physically. The fracture part got splinted with circular bridge as done over implants and thus, got additional stability facilitating healing. Overall, the results obtained were found to be satisfactory with successful clinical outcomes as assessed on follow-up visits of patients with adjunctive information received from radiographs starting from immediate postoperative period to 1-year follow-up in accordance with the principles of strategic implantology [Figure 6] and [Figure 7].
|Figure 7: Sixth month's postoperative orthopantomograph (OPG) of patient|
Click here to view
| Discussion|| |
Immediate, functional loading dental implants have become an established treatment protocol for the prosthetic rehabilitation of missing/lost teeth, although the concept was first discussed/proposed by Schnitman et al. In the same context, both cortical and cancellous bones adapt favorably following Frost's 'Mechano-stat' theory with bone in function., There is always a need to have high insertional torque depending upon the design of implants and its rigidity or cross-arch splinting for the success of these types of implants. Also, Krekmanov et al., showed no difference in bending movements on tilted implants. The said observation was substantiated since bending movements are measured rarely more than 20 Ncm and rigidity of prosthesis counteracts the relatively small bending movements applied to tilted implants. Furthermore, cross-arch splinting allows enough micro-motion for function but not enough to prohibit osseointegration of implant, thereby making off-axis loading go hand in hand with cross-arch splinting in such designs of implants.
Pilliar et al.,,, also, suggested that micro-motion more than150 microns would lead to failure of implants having fibrous encapsulation more than 1 angstrom; however, 25-50 microns movement was desirable for the bone contact with implants leading to essential, initial foreign body response by bone protein adsorbtion, platelet activation, coagulation, and healing inflammatory component. A similar hypothesis was suggested in studies conducted by Cameron et al. and Maniatopoulos et al., wherein the term pressure necrosis was generally used for any resorption because of high insertional torque, although there are sufficient evidences in the literature to support bone apposition and favorable healing with fixtures placed of high insertional torque.,,,
Routinely, in discussion of graftless solution for the rehabilitation of nonatrophied to moderately atrophied jaws in conventional/alveolar implantology, the “All on Four” treatment protocols are preferred. The “All on Four” treatment protocols are a modification of the “All on Six” protocol devised by Brånemark et al., where the most distal implant is tilted 15 degrees bilaterally to reduce the anteroposterior span of the cantilever with high clinical success rates. The current concept proposes to have four implants between the intermental foramen span of lower jaw and in premaxilla, wherein distal implant is tilted up to 45 degrees. Recently, however, literature is repleted with such studies which are not in support of these treatment protocols as there is violation of biomechanics when used with long cantilever designs. Another debatable issue in such treatment protocols is that although these implants are rough-surfaced and have additive benefits in the form of contact osteogenesis, there is high risk that their surface gets secondarily infected by pathogens and bacteria leading to “peri-implantitis'' which is not the case with smooth-surfaced/machined implants.,
Smooth-surfaced implants are preferred because in them, attached mucosa is not compulsorily required to be present as is the case with rough-surfaced implants. Also, the thin but strong body of smooth-surfaced implants resists bone resorption at a crestal level, whereas there is continuous bone loss crestally seen with rough-surfaced implants. Again, following the principles of strategic implants, immediate, functional loading implantology has turned out to be the most predictable implant treatment options which is being accepted globally. Strategic implants are smooth-surfaced, self-tapping type of threaded implant designs which are meant to engage and transfer the masticatory load to basal bones, buttresses like pterygo-maxillary, zygomatico-maxillary, and fronto-maxillary buttresses, and other corticals as mentioned and briefed in the introductory part of the literature.,, Also, herein, cancellous or alveolar bone is the least significant and woven bone is not desirable near implant vicinity unlike conventional implantology and the aim behind this is to restrict or delay bone remodeling.
In the given concept, long, polished smooth-surfaced implants are used to reach the most load-resisting, highly mineralized bone as is the case with conventional implants while the insertional point at the first cortical level does not fall in axis with the site engaging masticatory load transmission threads. Also, in case of splinting with cross-arch designs, these implants resist load better than load transmission on parallel implants. Furthermore, in these designs, implants are bent along the long body of implants. It is of, further, interest to note that the longer the implants, the easier it is to bend without disturbing the crystal structure of the alloy and to bring the abutments for the desirable prosthetic plane inside the “supporting polygon.”
As per the law of physics, the long arm/body of implant resists the forces and transmits them inside the bone where load is transferred by short abutments open to oral environment. As the forces delivered are inversely proportional to the area of distribution, in the long endosseous body of these implant designs, force transmission is also minimized. An important consideration in this is that there is a need to splint implants within 72 hours before the remodeling sequence “activation resorption formation” kicks-in. The preferred implant designs in these situations include the BECES, BECES EX, and KOC MICRO implants. Among these, BECES implant designs work on the principle of osteosynthesis screws used in orthopedics and traumatology, whereas BECES EX and KOC MICRO implant designs, being root form, taper in design with the former being smooth-surfaced and the latter, with modified NOITIS surface. Furthermore, KOC implants compress the cancellous bone to achieve high primary stability with their mode of function being termed as “corticallization of the cancellous bone.” All the said implant designs are single-piece, mono-implant designs, thus associated with minimal chances of screw loosening and micro-motion at first corticals leading to crestal bone loss in these implant designs. In fact, postbone-remodeling bone apposition is appreciated at buttress sites in these implant designs.
As it is widely known that circular bridges are not accepted in lower jaw because of mandibular flexion, sufficient evidences exist supporting horse-shoe shaped bridges in mandible providing fixtures engaging strategic positions and isoelastic-type implant designs compatible with mandibular flexion., The preferred prosthesis material in such cases is the metal cobalt-chromium alloy framework with chewing table of acrylic or indirect composite with ceramic to be rigidly splinted to have modulus of elasticity as close as possible to the bone., The ideal requirements of a strategic occlusion include bilaterally symmetrical occlusion with a symmetrical mastication and muscle function and no front contacts in occlusion and mastication. Cases are completed with lingualized occlusion, whereas group function is the most desired occlusal scheme with shallow guidance and compensatory curves and with ideal freeway space in case opposite arches consist of natural teeth.,,,,
| Conclusion|| |
Strategic implantology is a long-proven, simplified technology for the rehabilitation of stomatognathic system following immediate, functional loading implant treatment protocols. There is virtually no contraindication for restoration/rehabilitation with strategic implants other than the patient being on intravenous bis-phosphonates. Herein, even the patients with the most complex and atrophied jaws can be treated with the most atraumatic treatment protocols avoiding painful, unpredictable, and unwarranted expensive augmentation procedures done otherwise, although considerable experience and a thorough anatomic and prosthetic knowledge on part of operators are the basic prerequisites for successful clinical outcomes as in any other implant therapy.
To all the patients who contributed in the study without whom this study would not have been feasible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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