1. The Biology of Dental Implants James Q. Swift, DDS Division of Oral and Maxillofacial Surgery University of Minnesota

3. Concepts of Connective Tissue Healing Around Implants • Osseous Integration / Osseointegration • Fibrous Integration • Fibro-osseous Integration

5. Bone Healing • Phase I: Inflammatory Phase • Phase II: Proliferative Phase • Phase III: Maturation Phase

6. Phase I Bone Healing: Day 1-10 • Absorption of plasma proteins • Platelet aggregation and activation • Clotting cascade activation • Cytokine release

7. Phase I Bone Healing: Day 1-10 • Nonspecific cellular inflammatory response • Specific cellular inflammatory response • Macrophage mediated inflammation

9. Phase II Bone Healing: Day 3-42 • Neovascularization • Differentiation, proliferation and activation of cells • Production of immature connective tissue matrix

10. Phase III Bone Healing: After Day 28 • Remodeling of the immature connective tissue matrix with coupled resorption/ deposition of bone • Bone remodeling in response to implant loading • Physiologic bone recession

11. Mucoperiosteal Healing • Phase I: Inflammatory Phase • Phase II: Proliferative Phase • Phase III: Maturation Phase

12. Phase I Mucoperiosteal Healing Inflammatory Phase: Day 1-10 • Platelet aggregation and activation • Clotting cascade activation • Cytokine release • Nonspecific cellular inflammatory response • Macrophage mediated inflammation

13. Phase II Mucoperiosteal Healing Proliferative Phase: Day 2-42 • Neovascularization • Differentiation, proliferation and activation of cells • Deposition of immature collagen, elastin, and ground substance

14. Phase III Mucoperiosteal Healing Maturation Phase: After Day 21 • Connective Tissue Remodeling

15. Bone Implant Interface • Dependent on implant material • Calcified bone, unmineralized osteoid matrix, and connective tissue • Zone of amorphous material • Proteoglycans and glycosaminoglycans • 100-3000 angstroms • Collagen filaments

17. Chemical Bonds Between Bone and Implants • van der Waals • Local direct chemical bonds (ionic, covalent) • Chemical bonding well described with calcium phosphate ceramics • Some materials have no chemical bond but have excellent bone contact • (CP titanium vs. HA)

23. Factors Affecting Healing • Surgical technique • Premature loading • Surgical fit • Extraction sites

24. Factors Affecting Healing • Peri-implantitis • Bone quality • Staged healing

26. Logic CONTROL

27. STUDY DESIGN 3 Healing Groups Experiment Control 12 Pigs 6 Pigs Healing Healing 1 Month 1 Month 2 Month 2 Month (4) (4) 4 Month 4 Month (4) (4) (4) (4) 5 Months Non-Loading 5 Months Controlled Loading

28. Radio-Subtraction (S3D, MDRCBB) One Month Healing Four Months Healing

29. Micro-CT Images Four Months Two Months One Month

30. Stevenel’s Blue and Van Gieson’s Picro-Fuchsin Stain Four Months Two Months One Month

31. Issues Relating to Physical Status of Recipient • Nutritional status • Age • Hematologic issues

32. Issues Relating to Physical Status of Recipient • Diabetes • Corticosteroids • Radiation

33. 51 year old man • CC- “I ‘ve been referred for evaluation and treatment for a growth in my jaw” • HPI • 2 month duration • mobile teeth • facial swelling

34. 51 year old man • PMH • Hypertension-well controlled • PDH • Imaging findings • 4 cm x 2 cm radiolucent lesion left mandibular body causing tooth displacement

39. 51 year old man • Problem list • Radiolucent lesion • Teeth vital • Buccal plate perforation • No paresthesias • Differential diagnosis • ameloblastoma • central giant cell lesion • odontogenic myxoma

43. 51 year old man • Treatment plan • Incisional biopsy for histologic typing • Prosthodontic consultation • Definitive imaging (CT scan) • Biopsy results • Acanthomatous ameloblastoma

44. 51 year old man • Treatment • Arch bars/surgical stent construction • Transcervical approach for exposure and lateralization of IAN/Mental nerve • Transoral marginal resection preserving inferior border • Reconstruction plate applied for stabiliation