Dr. C. asks:
I have placed my first implants in the maxilla in # 4 [maxillary right second premolar], #6 [maxillary right canine], #11 [maxillary left canine] and #13 [maxillary left second premolar] sites. These are NobelBiocare Replace Select regular platform implants. The radiographs look great and there is no evidence of any pathologic radiolucent lesion. The soft tissue around the implants looks great. There is no evidence of anything being wrong. But how do I determine if the implants are osseointegrated? I am going to place 4 Locators and make a maxillary overdenture. I do not want to proceed unless I am sure that they have osseointegrated?
How Do I Determine if the Implants are Osseointegrated?
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a simple way to test osseointegration is by percussion.
an integrated implant will have a high pitched sound ( as if tapping on a marble) while a none integrated implant will have a low, dull sound.
hope it helps
We have a new system called BIO-MICRON on the market.Has anyone used it? Any comments??
ostell mentor
There are many ways to test if the implants are osseointegrated. Percussion, x-ray, probing (checkning for pus), and the clinical situation of the soft tissue. The Ostell mentor can also be of help. One last check after the healing period can be to use the implant driver and wrench and “loading” the fixture to approx. 35Ncm, if the implant don´t rotate the implant is integrated for sure.
Best of luck / Erik
if your implant rotate and the patient yell for pain, you have to wait for another 3 mths.
ostell is safe and easy.
The above comments on the clinical checking are very useful but remember that the “osseointegration” is a term defined for a light microscope specimen evaluation and no one can judge about the type of contact between bone and the implants you’ve placed even if they seem securely placed . So it is wise to wait the standard time before loading them. In your case (being maxilla and overdenture that will bear more load comparing single tooth replacement)it might be better to wait at least 6 months before evaluation.
Good luck
Ehsan
as osseointegration is histological term the only clinical sign is absent mobility.as long as every thing went fine & the implant has agood intial stability.then it is expected that bone formation well follow,the time of loading has to do with the intial stability & bone quality.according to the parameter u have during surgery u can tell when to load the implant,& I think this ur qustion.cos osseointegration definition includ bone formation around loaded implant.so according to bone quality u can tell when to load.some cases u have to wait longer than 6 months in poor bone quality or just prolong the the prosthetic period.Good luck
This is good also read Misch’s text. He covers this very well.
Ostel Mentor solves your doubts in seconds.
There is a machine called the Periotest that is good for assessing osseointegration and also for the relative mobility of teeth.
Do a block – section!
)))
In my experience, we are able to determine the integration of the implants through radiographs. They usually appear radiopaque and there is no raldiolucency between the implant and bone. Also, no pus is exhibited on the gingival area around the implant.
Second, you test it clinically by tapping or moving the implant. Upon uncovering of the mucosa, (on second stage surgery) There should be NO mobility on the abutment.
Hope it helps.
Simple testing for osseointegration, percuss vertically and horizontally, nice metalling sound for both almost always confirms osseointegration, x’rays do not confirm could be deceptive. If two stage implant confirm percussing vertically then conect abutment and test horizontally
Percussion is always done but a simple test I learned from Lee Walker, DDS,MD out of Los Gatos, CA is the “reverse torque test”. You place the torque wrench in counter clockwise direction to 15 to 20 ncm and observe for any movement or pain from the patient. If either occurs then give local anesthesia and then clockwise tighten the implant to 35 to 40 ncm and leave un loaded for several more months then re test. If no movement or pain occurred then clear for final restoration. This has proven very reliable to me and prevents advancing a patient to final restoration too soon and seeing an expensive disaster with unhappy patient and an even more unhappy restorative doctor.
sound at the percusion plus radiopaque are the standard
always keep the implants as much as u can without loading to be osseoentegrated
The ONLY valid and scientifically proven test is the measurement of the Implant Stability Quotient, measured by the resonance frequency device Osstell Mentor. Please refer to the relevant literature.
Validity and clinical significance of biomechanical testing of implant/bone interface.
Clin Oral Implants Res. 2006 Oct;17 Suppl 2:2-7
Aparicio C, Lang NP, Rangert B.
CONCLUSIONS: Factors such as bone density, upper or lower jaw, abutment length and supracrestal implant length seem to influence both RFA and Periotest measurements. Data suggest that high RFA and low Periotest values indicate successfully integrated implants and that low/decreasing RFA and high/increasing Periotest values may be signs of ongoing disintegration and/or marginal bone loss. However, single readings using any of the techniques are of limited clinical value. The prognostic value of the RFA and Periotest techniques in predicting loss of implant stability has yet to be established in prospective clinical studies.
prof.Dr.Hossam Barghash,You are correct !! But, sound at the percusion plus radiopaque are the standard.
Every patient is different.
Good point Dr. Callan.
percusion make a good sound for the doctor ears,but it is not indicative of the quantity of bone formation.bone formation 15% of surface area of implant gives a good sound.
Radiograph shows mesial & distal surface of the implant,doesn,t show the buccal surface which is mostly affected.
reverse torque test, if your implant move during the expected loading time= there was fibrous tissue formation,which is going to reform again.
absence of mobility of loaded implant is the clincal sign of osseointegrated implant.
primary stability & all precautions taking to ensure good bone healing around the implant.are the main keys for sucess of bone formation around implant.
load distribution & direction are the main factores to keep it.
mobility @ any stage(after insertion ,after loadong) means failuer
Regarding RFA and ISQ-values
From Periodontology 2000, Vol. 47, 2008, 51–66:
“The resonance frequency analysis technique can
supply clinically relevant information about the state
of the implant–bone interface at any stage of the
treatment or at follow-up examinations. The resonance
frequency analysis technique evaluates implant
stability as a function of the stiffness of the
implant–bone interface and is influenced by factors
such as bone density, jaw healing time and exposed
implant height above the alveolar crest. Studies
indicate that implants with high implant stability
quotient values during follow-up examinations are
successfully integrated, whilst low and decreasing
implant stability quotient values may be a sign of
ongoing implant failure and ⁄ or marginal bone loss.”
I approach osseointegration of maxillary implants using the protocol of a mentor who has been placing implants for over 20 years. When implants are placed without immediate loading (ie left 4-6 months with healing abutments), then at the time of the restoration phase if the non invasive tests (percussion , radiograph, good gingival health, absence of pain) seem to indicate that the implant is OK, then progression with the restorative phase is begun with the belief that integration has occurred but the ‘cement is weak’. This means that low torques are used with both the impression coping and subsequent placement of the abutment. Typically 15Ncm is it. The crown is cemented with tempbond/vaseline.
Three months later the crown is removed and the abutment torqued up to the manufacturers normal figure (32Ncm ish). He believes that the 3 months of function results in a stronger integration and in effect, ‘strengthens the cement’. I should mention that his approach came about from his occasional encountering of seemingly ‘sound’ implants that rotated on being loaded with high ‘test’ torques. All makes sense to me so its what I do to. You could probably do this with locators as well – would have to worn the patient about possible loosening of the locator though.
regards John
I like Dr. Clark’s method.
Just got a Periotest M-instructions say an integrated implant tests at -9 to 0. In the Misch text it states -9 to +9. Is +9 an implant that shouldnt be loaded on yet? Anyone have any thoughts or comments?
Periotest quantifies the mobility of an implant by measuring the reaction of the periimplant tissues to a defined impact load. The instrument’s handpiece has an electronically controlled translational hammer bearing an 8-gram rod with a sensor at its tip. When activated, the rod taps the implant abutment up to 16 times in four seconds with an action similar to that of a retractable ball point pen. The rod decelerates when it touches the implant and accelerates when it first rebounds off the implant. Periotest measures elapsed time from initial contact to the first rebound off the implant. The greater the implant stability, the shorter the elapsed time is. Conversely, the longer the rod is in contact with the implant, the less stable the implant is.
the consistency of the PTV readings can be altered significantly by even slight changes in the recording position and angulation of the instrument. In addition, placing an abutment or crown on the implant changes the dynamic characteristics of the implant and significantly alters the PTV. This lack of consistency may cause clinical confusion and uncertainty. In addition, Periotest does not assess the implant when it is unencumbered by the testing apparatus, or in a free state. Therefore, the contact of the Periotest tip to the implant during the testing can affect the data. In summary, the studies did not find Periotest to be a useful instrument.
Does anyone know if either the Ostell mentor or the periotest is available in Australia? I can’t seem to find a supplier. Does anyone know the cost?
percussion,x-rays adn gingival health do help in finding osseointegration of implant but they are not the indicators alone.probing does help too. read proff carl misch text.
In an uneventfull healing all implants will osseointegrate.
Take an Xray : no black lines or images.
Unscrew the cover or the healing screw: no pain or movement.
Torque down the abutment up to 30 or 35 N/cm: no pain or movement.
Then, the implant is osseointegrated.
Periotest is available in Australia from Imtec Dental
NR.
I’m pretty sure -9 is better than +9.
It is easier to determine if they are not….
X-ray evaluation and percussion sound are clinical ways to determine if a dental implant is osseointegrated.
The only clinical way is stability and non mobility. The actual definition is based on the microscopic/histologic level.
1-Radiographical assessment:
bone level,proximity of bone to the implant surface,homogenous trabeculation.
2-Clinical
Abscence of micro mobilitybility,resistance to counter torque(care must be taken during this type of examination especially in the posterior maxillary region.Abscence of pain or infection.
Due to the inability of the naked eye to detect micro-movement,use the Periotest device,it is helpful.
The literature supports allowing the lower arch due to its denser bone to heal for 3 months and the upper arch with its softer bone 6 months. There are exceptions and waiting longer causes no harm and this may be wise in very soft bone. With Locators or other free standing attachments the C/I ratio is low compared to fixed applications so lateral loads are decreased. In the maxilla I am not a fan of completely eliminating the palate as leaving the anterior palate will help have a hard stop to limit loading of the fixtures. if we also dont have vestibular depth and palatal depth then the ridges cant brace against lateral loads placed on thje fixtures and this can lead to bone loss and failure. In those cases IMHO a bar is better as it cross arch stabilizes the fixtures and braces from lateral loads. Getting back to Locators, I prefer to keep the patient initially in the black processer males till they loose retention. this allows the patient to gain experience in inserting and removing the prothesis and initial retentive forces are lower. Remember with free standing fixtures for rmovable prosthetics the implants are there to retain the prosthesis not support it. We know that it may take up to a year or more for the integration to reach its maximum level. So progessive loading is beneficial.