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GENERAL REVIEW

Dental implants: A review


Les implants dentaires : revue

B. Guillaume a,b,∗

a
Collège Français d’Implantologie (CFI), 6, rue de Rome, 75005 Paris, France
b
Groupe d’Études sur le Remodelage Osseux et les bioMatériaux (GEROM), IRIS-IBS Institut de biologie en
santé, Université d’Angers, CHU d’Angers, 49933 Angers cedex, France

KEYWORDS Summary A high number of patients have one or more missing tooth and it is estimated that
Dental implants; one in four American subjects over the age of 74 have lost all their natural teeth. Many options
Implantology; exist to replace missing teeth but dental implants have become one of the most used biomaterial
Dental prosthesis; to replace one (or more) missing tooth over the last decades. Contemporary dental implants
Maxillo-facial made with titanium have been proven safe and effective in large series of patients. This review
surgery; considers the main historical facts concerned with dental implants and present the different
Bone graft critical factors that will ensure a good osseo-integration that will ensure a stable prosthesis
anchorage.
© 2016 Elsevier Masson SAS. All rights reserved.

Résumé Un nombre élevé de patients ont une ou plusieurs dents manquantes et on estime
MOTS CLÉS qu’un Américain, âgé de plus de 74, sur quatre a perdu toutes ses dents naturelles. Plusieurs
Implants dentaires ; options existent pour remplacer les dents manquantes, mais les implants dentaires sont devenus
Implantologie ; l’un des biomatériaux le plus utilisé pour remplacer une (ou plusieurs) dents manquantes au
Prothèses dentaires ; cours des dernières décennies. Les implants dentaires actuels sont composés de titane et se sont
Chirurgie avérés sûrs et efficaces dans de larges séries de patients. Cette revue présente les principaux
maxillo-faciale ; faits historiques concernant les implants dentaires ainsi que les différents facteurs critiques
Greffe osseuse qui assureront une bonne ostéo-intégration, permettant une fixation stable de la prothèse.
© 2016 Elsevier Masson SAS. Tous droits réservés.

Introduction

In our society of appearance, teeth must be white and the


dentition harmonious. Teeth participate primarily as one of
∗ Correspondence at: Collège Français d’Implantologie (CFI), 6, the main attributes of smile. When decayed, grey or black-
rue de Rome, 75005 Paris, France. ish, they can scare and must be hidden. Today, patients
E-mail address: doct.guillaume@wanadoo.fr are still suffering from this evil of another age confining

http://dx.doi.org/10.1016/j.morpho.2016.02.002
1286-0115/© 2016 Elsevier Masson SAS. All rights reserved.

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2 B. Guillaume

to archaism. Total edentulism is the ultimate degree of


the parodontal disease and is still observed nowadays [1].
A poorly treated decay, a genetic alteration of enamel or
dentine (e.g., amelogenesis or dentinogenesis imperfecta)
and a trauma are sufficient to lose a tooth. Fortunately, in
most cases, a solution exists for a tooth replacement such as
bridge, dental implant, pivot tooth or denture. The solution
depends of the local conditions, of the dental status and also
of the financial aspect of the treatment.
Uncemented endosseous implants have become a most
valuable alternative to dental prostheses supported by
remaining teeth or adjacent oral soft tissues. The method
started in the late sixties. During the last decades, metallic
implants have become the most frequently used treatment.
Titanium is one of the most commonly used biomaterial
in oral and maxillo-facial surgery. Excellent clinical results
have been obtained with threaded titanium implants by pio-
neer workers [2—4]. After more than four decades, dental
implantology is now a well-recognized therapeutic advance
in the treatment of partial or complete teeth loss [5]. The
technique is reliable and suppresses the use of fixed or
removable dentures, which invariably alter the supportive
adjacent teeth after a short or medium period.
The sustainability of dental implantology is primarily
based on the overall analysis of the patient’s clinical sit-
uation (periodontal condition, occlusion, available bone
volume, general health condition) and the appropriate adap-
tation of surgical-prosthetic options. The threaded implants
currently available meet strict criteria of manufacturing and Figure 1 A. Intra-osseous needles implanted in bone of the
surgical procedures for their bone fixation and adaptability mandible and supporting a bridge. B. Complex systems made
are now done according to specific prosthetic concepts. with metallic grids used to support a complete denture.
The pre-implant bone site is the most important point to A. Aiguilles intra-osseuses implantées dans la mandibule et sup-
consider in its ability to favor the implant osseo-integration portant un bridge. B. Nombreux implants-lames métalliques
(i.e., primary bone anchorage of this metallic biomaterial) utilisés pour la mise en place d’un dentier complet.
and its long-term stability. However, a reduced bone vol-
ume (constantly observed in the edentulous patient) impairs
the placement of implants [1]; this has led to develop bone During the 1950s, some authors have proposed gold
grafting techniques and the use of synthetic biomaterials or nickel-chrome grids and intra-osseous needles inserted
[6]. in the maxillary bone cortex. Secondarily these devices
received the prosthesis to correct tooth loss (Fig. 1).
However, a secondary infection was frequently observed
Historical overview associated with alveolar bone resorption requiring the with-
drawal of these devices after a very short time period.
Correction of a tooth loss has been observed in the ancient Modern implantology was made possible thanks to Bråne-
civilizations: small prostheses, ligated to the adjacent mark’s studies in the 1960s in Sweden. He was the first
teeth, have been found in some Egyptian mummies. A metal to propose the concept of osseo-integration of a metallic
false-tooth dating from the 1st century was found in a biomaterial implanted in bone. In an experimental study,
Gallo-Roman necropolis in France [7]. In the XVIIth century, he found that bone was firmly anchored at the surface
ancestor of dentures was carved in animal ivory. Modern den- of titanium devices implanted into bony defects [4]. From
tistry appeared in the XXth century with the possibility to this observation, he concluded that biocompatibility and
replace a missing tooth and the first bridges appeared at excellent bone-titanium bonding were the major biologi-
that time. The principle of the correction of an edentulism, cal properties of this metal. This also led to the creation
whether for one or several teeth, is always the same. The of a bone screw (he called it a fixture) that he implanted
dentist can use either a fixed prosthesis (imposing to prune in different bone sites. In each location, implantation was
the adjacent teeth with a ceramic or metal cap, replac- successful and the screw remained fixed in the bone. He
ing the missing tooth), a denture or bridge (composed of originally designed a fixture to be implanted in the tempo-
resin-based teeth supported by a resin or metal plate). In ral bone to support ear prosthesis in maxilla-facial surgery.
both cases, the surrounding teeth support the prosthesis, a This concept was extended in animal and human studies to
function that is the source of decay, infiltration under the replace a missing tooth root capable to receive an overly-
crowns or bridge, periodontal mobility and finally, loosen- ing dental prosthesis. The prosthesis device was extended to
ing of teeth on which the carrier brackets of the removable the placement of several implants on a dental arcade; these
prosthesis are anchored. fixtures being secondarily the carrier of a full trans-screwed

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more accurately define the biological interactions of bone


and titanium [8—10]. Nevertheless, Brånemark defined the
principles of the surgical placement of dental fixtures and
the methodology of the secondary prosthetic steps. During
the 1980s, dental implantology was considerably developed
due to its immense therapeutic possibilities. The clinical
success of the method was based on the following points:

• the use of grade II ASTM titanium (American Society for


Testing and Materials) threaded implants adapted to the
patient’s specific anatomy;
• a drilling at low speed and an implementation of the
fixture under irrigation to avoid a thermal rise which is
particularly harmful to osteocytes and osteoblasts and
deleterious to osseo-integration [11—14];
• locking the fixture at the end of screwing (so-called ‘pri-
mary locking’). It is estimated that locking is obtained for
a torque of 20—30 N;
• suture of the gingival tissue above the implant at the end
of the surgical procedure;
• placement of the prosthesis on the implant after a 6-
month period to ensure that it is firmly attached to the
bone whose texture is lamellar with a high biomechanical
competence at the tissue level [15].

The relevance of this surgical process and the nature of


the biomaterial used were rapidly adopted by the dental and
stomatology communities due to long-term success rates.
For the first time, such a precise protocol ensured the per-
sistence of the implant after 10 years in 95% of cases [16]. All
Brånemark’s recommendations were considered as a dogma
Figure 2 A. Histological section of a dental implant placed during two decades and a pre-requisite to the success in den-
in a beagle dog for 6 months. Note that the threads of the tal implantology. This Swedish discovery was echoed in all
titanium implant are covered by bone. Undecalcified bone industrial countries. A large number of companies special-
section, surface-stained with toluidine blue, original magnifi- ized in surgical equipment’s developed different clones or
cation × 100. B. Same section viewed at higher magnification variants of the original implants developed by the Swedish
(× 200) under polarized light. The Haversian systems and the firm Nobel Biocare. If the concept of the threaded implant
lamellar texture of the bone matrix are clearly identified. remains to this day immutable, significant changes appeared
A. Analyse histologique d’un implant dentaire mis en place in the manufacturing (use of grade V titanium, i.e., TA6
depuis 6 mois dans une mandibule de chien Beagle. Remar- V) and the surgical protocol. In Germany, the concept that
quez que tous les filets de l’implant en titane sont recouverts an implant should remain buried was discussed and new
de tissu osseux. Tranche d’os non décalcifié avec coloration implant systems appeared emerging at the gum surface.
de surface au bleu de toluidine, grossissement de × 200. B. This new process, which did not alter the sustainability of
Même coupe à plus fort grossissement vue en lumière polarisée. the prosthesis supported by implants, was soon accepted by
Les systèmes de Havers et la texture lamellaire de la matrice the scientific community. However, the realization of a full
osseuse sont bien mis en évidence. prosthesis screwed on several emerging implants at the gin-
giva does not give an aesthetic result. Implant placement
was gradually proposed for the treatment of partial eden-
denture. Histological analysis of the direct attachment of tulism and for a single tooth loosening. In 2015, all types of
bone to the surface of the layer of the passivated titanium tooth loss can be, theoretically, cured by the placement of
surface (titanium is always covered by a layer of titanium an implant.
oxide[s]), was confirmed in a number of studies. The bone-
titanium interface increased after implantation (Fig. 2). This
led Brånemark to define the concept of ‘osseo-integration’ The dental implants
of titanium as ‘direct structural and functional connection
between ordered living bone and the surface of a load- The vast majority of implants that have been placed in
carrying implant’ [3,4]. One should note that a considerable patients all over the world in 2015 have a similar shape:
number of confusions occur in the literature and the precise a hollow supporting screw that receives, in a second time,
definition of term ‘osseo-integration’ has changed over the a supra-prosthetic device. There are numerous variations
years. Other terms have been proposed in the literature to in the overall shape of the implants (e.g., a rounded or
describe this phenomenon and terminology such as bio or pointed apex; more or less spaced threads, cylindrical or
‘osseotolerance’, ‘bone bonding’ or ‘bone ankylosis’ would conical body) (Fig. 3). The surface quality of an oral implant

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increased risk of wear debris and the leakage of metal ions


[22].

Particle blasting and acid etching

Blasting the implant surface with hard ceramic particles


(corundum) at high velocity causes numerous impacts and
tears at the material surface creating irregularities. How-
ever, the surface is made by defects with acute angles
(Fig. 4E) and can retain impacted foreign particles. For these
reasons, an additional acid treatment using strong acids
such as HF, HCl and HNO3 is usually done after the blast-
ing step. This produces a very typical rough surface with
the appearance of waves and valleys, a condition that favor
osseo-integration (Fig. 4D) [23]. Other treatments can also
induce surface irregularities such as sodium fluoride since
titanium can be attacked by halogens.

Anodization of the implant surface

Anodization can produce micro or nano-textured rough sur-


faces. This causes an increase in the passivation layer of
Figure 3 Different types of dental implants proposed by sev- titanium oxide associated with pores [24] (Fig. 4C).
eral companies. A. ETK, implant AestheticaTM . B. MIS, implant
C1TM . C. TBR, implant InfinityTM . D. Anthogyr, implant AxiomTM . Coatings
E. Zimmer, implant Swiss plusTM . F. Nobel Biocare, implant
ActiveTM . G. Straumann, implant Standard plusTM . H. ADIN,
Several coating methods have been also proposed to modify
implant TouaregTM .
the roughness and improve cell attachment [25]. Hydroxy-
Différents types d’implants proposés par plusieurs compag-
apatite can be deposed by plasma-spraying but the layer
nies. A. ETK, implant AestheticaTM . B. MIS, implant C1TM . C.
tends to delaminate, leading to implant failure in mid-term
TBR, implant InfinityTM . D. Anthogyr, implant AxiomTM . E. Zim-
studies [26]. These implants are nowadays abandoned. Sim-
mer, implant Swiss plusTM . F. Nobel Biocare, implant ActiveTM .
ilar problems were also encountered with coatings made
G. Straumann, implant Standard plusTM . H. ADIN, implant
of other orthophosphate calcium salts. Biomimetic calcium
TouaregTM .
phosphate have also been electro-deposited or created by
immersion in synthetic body fluids (gel-sol technique) [27].
is one of the essential features for a successful early clinical Whatever the mechanisms used to induce a surface
outcome. The manufacturers have developed a number of roughness, this favors fibronectin deposition, cell attach-
specific processes to improve the rate of osseo-integration ment and spreading as evidenced by in vitro and in vivo
and the long-term biomechanical anchorage of the implant studies [28,29].
on the bone matrix. Implants with a rough surface have a
better osseo-integration, evaluated by histomorphometric Placement methods
parameters, than the original machined titanium implant of
Nobel Biocare, which had a smooth surface (Fig. 4 A and
The placement of a dental implant can be done under local
B) [17]. Roughness results in a better interlocking between
or general anaesthesia; the local anaesthesia being the most
the implant and bone ongrowth by increasing the devel-
commonly used in daily practice. The implantation protocols
oped surface at the micrometer scale. However, an excess
are totally painless regardless of the maxillary or mandibu-
of roughness, especially in the upper threads, can increase
lar location. Occurrence of intra-operative pain is the result
peri-implantitis as well as ionic leakage [18]. It is generally
of incomplete anaesthesia or an iatrogenic act. Although
accepted that a moderate roughness of 1—2 ␮m is the most
occurring in the oral cavity which contains many of sapro-
suitable condition [19,20]. Several methods have been pro-
phytic bacteria, the asepsis protocol must be strict and
posed by the manufacturers to produce a rough surface on
similar to the general rules of surgery with the use of sterile
a dental implant [21].
implant packages and sterile drapes to cover the patient. CT
scans are necessary to ensure a correct implant placement
Titanium plasma-spraying in bone at distance from nerves or vessels which would be a
source of complication.
The method uses a plasma torch under argon (hot titanium The principle for an implant placement is based on the
powder is explosive in the air) to project titanium particles use of calibrated drills with increasing size until the width
onto the surface of the implant. They fuse and constitute a of the implant is obtained. Depending of the bone density,
layer more or less uniform (Fig. 4F). However, some incon- drilling is more or less intensive. This step ends with a con-
veniences have been described with filaments of metals, an trol of locking the implant on the bone with a torque wrench.

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Figure 4 Different aspects of the surface of dental implants viewed by scanning electron microscopy. A. Original machined implant
from Nobel Biocare with a smooth surface. B. Rough surface of an ETK implant which was sandblasted and acid-etched. C. Surface
of a Ti UniteTM implant from Nobel Biocare with a thick layer of titanium creating smooth asperities. D. High magnification of an
implant surface after sandblasting and HF acid etching. E. Surface of a TA6 V implant whose surface was sandblasted with corundum
particles. F. Surface of a titanium implant, which was sprayed with titanium beads with a plasma torch.
Différents aspects de surface des implants dentaires vus en microscopie électronique à balayage. A. Implant original usiné par
Nobel Biocare et présentant une surface lisse. B. Surface rugueuse d’un implant ETK qui a été sablé et mordancé à l’acide. C.
Surface d’un implant TiUniteTM de Nobel Biocare présentant une couche épaisse d’oxyde de titane créant des aspérités et des
porosités douces. D. Analyse à fort grossissement de la surface d’un implant qui a été sablé et mordancé par l’acide fluorhydrique
HF. E. Surface d’un implant dentaire en TA6 V dont la surface a été sablée avec des particules de corindon. F. Surface d’un implant
en titane qui a été recouvert de billes de titane projeté une torche à plasma.

Indeed, a residual mobility will not permit the stability of expansion of the peri-implant osteolysis of the alveolar
the implant and it will be necessary to remove it (Fig. 5). bone. As previously mentioned, the surgical protocol is now
At the end of surgery, two possibilities exist: (i) Bury no more strictly based on the Brånemark’s concepts pro-
the implant on bone for several months under the sutured posed thirty years ago. The timing for loading the implant
gingiva. Proponents of this method consider that such a has raised a considerable amount of articles and can be done
quiescent condition is more favorable without mechanical in several ways. It has been advocated that after implant
stress, risk of infection or epithelial invasion. (ii) Other placement, the surgical site should be left undisturbed for
authors prefer to immediately place the implant collar 4 to 5 months to allow a good wound healing between the
inside the oral environment by fixing a cover screw at the implant and the bone. This period is in accordance with bone
top of the implant until the impression procedure. Overall, cell physiology: osteoblasts elaborate woven bone rapidly
there is no consensus on the superiority of either of these to ensure the primary bone anchorage and this bone (being
two methods. As mentioned above, the concept of osseo- of poor quality) is secondarily remodelled and replaced by
integration is defined by the tolerance into the living bone lamellar bone which possesses a better quality [15,17]. More
of a foreign and inert body (the titanium implant) which recently, other authors have proposed the concept of imme-
will provide a sustainable and stable bone anchor. An X-ray diate loading of the implant to support provisional fixed
follow-up must confirm the absence of peri-implant osteol- crowns or prosthesis [30,31]. Immediate loading is the place-
ysis (appearing as a radiolucent edging around the implant). ment of a temporary prosthesis on the implants just after
Osteolysis is also associated with a painful inflammatory the implant placement. The benefit of this protocol is to
reaction and an implant mobility. This situation requires immediately correct the tooth loss and to favor maturation
removal of the implant as soon as possible to limit the of the gingival tissues at the implant’s base. The obvious

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Figure 5 Implant placement in clinical practice. A. X-ray of the edentulous mandible. B. CT-scan section of the mandible showing
the alveolar bone. A dot has been placed on the dental canal. C. Clinical aspect of the edentate region. D. Drilling with calibrated
devices; E. Implant placement. F. The implant has been screwed with its healing screw.
Détail de la mise en place d’un implant dentaire en pratique clinique. A. Radiographie panoramique de la région édentée à
implanter. B. Coupes tomographiques de la région montrant la présence de l’os alvéolaire. C. Aspect clinique de la région édentée
avant la pose d’implant. D. Forage avec des mèches calibrées. E. Mise en place de l’implant. F. L’implant est en place avec sa vis
de couverture.

disadvantage of this procedure is that loaded implants are done in adulthood except in case of congenital maxillo-facial
exposed to the chewing force immediately after implan- syndrome [32,33].
tation, a situation that may delay osseo-integration. This
protocol is not the subject of a consensus and the exact defi-
nition of immediate loading may vary from same-day implant In the adult patient and in the elderly
loading to a shortly-delayed loading (usually three days to
one week), making published results difficult to compare. Periodontal diseases are frequent and are characterized by
an alteration of the tooth supporting tissues; changes in the
desmodontal ligament result in both a reduction of bone vol-
Indications ume, tooth mobility and finally a tooth loss at medium-term.
In some cases, it can be a congenital periodontitis but usually
local factors are the rule (poor dental or oral hygiene, dental
Replacement of missing tooth is nowadays common in the
plaque, untreated tooth decay, gingivitis, diabetes, heavy
odonto-stomatological practice.
smoking or alcoholic consumption). Implants can therefore
replace the missing tooth roots, however, the clinical situa-
tion needs to be carefully analyzed in case of a periodontal
In the young patient disease.

Single or multiple tooth agenesis has long been corrected by


orthodontics and/or removable prosthesis (Fig. 6). After X- Traumatisms
ray analysis, it is possible to determine the residual bone
volume in place of the missing tooth. However, in many Maxillo-facial and oral traumas (e.g., road traffic accident)
cases, dental agenesis is associated with bone loss requir- can be responsible for tooth loss especially in the central
ing the use of a bone graft. These complex treatments are maxillary teeth [34]. These lesions are sometimes associated

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Dental implants 7

placement can achieved a complete reconstitution of the


bone tissue.
Indications are particularly numerous and there is a grow-
ing demand from the patients as an alternative to traditional
bridges or a removable denture which is often unstable.
Therapeutic answers are classified either by location in the
mouth or according to the size of the prosthetic repair.

Single tooth edentulism


Replacement of a fractured incisors is the most common
situation among the young patients and is often the conse-
quence of a trauma during sport activities. The replacement
of a premolar or a molar occurs after removal of a decayed
tooth or for a tooth altered after prosthetic restorations.

Complete edentulism
It can interest one or both dental arches and causes a
profound change of the masticatory function. There are
a number of criteria that will influence the therapeutic
choice. It can be either fixed prosthetic systems (bridge
with three or more crowns) or removable appliances with
enhance retention. These treatments associate surgery
and prosthetics and are influenced by several factors:
anatomical conditions (e.g., the amount of bone available,
especially in the posterior region), occlusal factors (e.g.,
the inter-arch volume available to allow any type of pros-
thesis), the general condition of the patient (considering it is
a more or less long surgery), additional surgery (bone graft,
local conditions of the harvesting site in case of autograft)
and the financial aspect which is not supported by the public
healthcare system in France (Fig. 7).

Contraindications

They are now well identified and classified. General


contraindications are psychiatric disorders, severe cardio-
vascular troubles, hematological malignancies and ongoing
therapeutic trials. A special attention is given to patients
receiving intravenous amino-bisphosphonates for a malig-
Figure 6 Example of implant placement in the young patient nant disease. Due to the high risk of inducing an
with Maxillary Lateral Incisor Agenesis. A. Panoramic radiograph osteonecrosis of the jaw, scientific societies and health
before implant application. B. Panoramic radiograph after two agencies consider that dental implants are prohibited in
implants placement. C. Frontal view of the definitive denture these particular cases. However, bisphosphonate treatment
six years after implants placement. for other metabolic bone disease such as osteoporosis is not
Exemple de la mise en place d’un implant unitaire chez un a contraindication and recommendations should be care-
patient jeune avec agénésie des incisives latérales maxillaires. fully followed. Local contraindications are represented by
A. Orthopantomogramme initial. B. Orthopantomogramme an absent oral hygiene, a massive bone loss and occlusal
après pose de deux implants. C. Aspect six ans après la pose disorders. Smoking is a discussed contraindication: it has
des implants. been shown that a significantly higher percentage of implant
failures may occur in smokers (particularly at the maxilla)
[35—37] but smoking do not preclude implant placement;
smokers should be informed that they are more at risk for
with the loss of bone cortex and modification of bone shape
peri-implantitis.
which may necessitate a tissue reconstruction.

Limits and complications of dental implants


Infection foci
The limits of implantology derive from a careful analysis of
Infection foci, especially in the tooth apex, induce the the contraindications but nowadays, there are fewer and
development of cysts which can be source of extended oste- fewer taboos. As an example, a limited bone volume is
olysis. The surgical treatment usually consists in the tooth typical of the evolution and adaptation of the therapeutic
removal and curettage of the cystic tissue. The implant strategies. At the beginning of implantology, a minimum of

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Figure 8 A sinus lift done with ␤-Tricalcium phosphate


(KasiosTM ). A. CT-scan of an edentulous patient at the right max-
illa. Note the bone atrophy at the posterior zone (red arrow).
B. Same region 6 months after a sinus lift with ␤-TCP gran-
ules, note the thickening of the area on the CT-scan image. C.
Two implants have been inserted in this grafter area. D. The
prosthesis is placed on the two implants. E. Histological anal-
Figure 7 Example of implant placement in a patient with ysis of the bone apposed at the surface of a ␤-TCP granule (*)
complete edentulism at the maxilla. A. Panoramic radio- in a bone biopsy harvested 6 months after a sinus lift. Bone
graph after eight implants placement. B. Intraoral view of the is directly apposed at the surface of the granule. Goldner’s
implants. C. The inserted dental crown bridge prosthesis with trichrome showing calcified bone in green and osteoid tissue
the upper lip pulled back. in red. Original magnification × 100.
Exemple de la mise en place d’implant chez un sujet avec éden- Réalisation d’un soulevé de sinus avec des particules de ␤-
tation maxillaire complète. A. Orthopantomogramme initial. tricalcium phosphate (KasiosTM ). A. Analyse par CT-scanner
B. vue endo-buccale des implants. C. Bridge définitif mis en chez un patient édenté au maxillaire droit. Notez l’atrophie
place sur les impants, lèvre supérieure refoulée. osseuse dans le secteur postérieur (flèche rouge). B. Même
région 6 mois après la réalisation d’un sinus lift avec des gran-
ules de ␤-TCP; notez l’épaisseur de la région en tomographie.
bone volume was required for the placement of the fixtures. C. Deux implants ont été insérés dans cette région greffée. D.
The development of new grafting techniques was proposed La prothèse est mise en place sur deux implants. E. Analyse
to overcome the problem of bone insufficiency. During the histologique du tissu osseux apposé à la surface d’un granule
1990s, filling or apposition grafts were extensively devel- de ␤-TCP (*) dans une biopsie osseuse prélevée 6 mois après la
oped at the maxilla or the mandible after having harvested constitution d’un soulevé de sinus. L’os est directement apposé
a bone autograft at the skull or iliac bone [38]. The history à la surface du granule. Trichrome de Goldner montrant l’os
of sinus lift is characteristic of the huge amount of progress calcifié en vert et le tissu ostéoïde en rouge. Grossissement
made with bone grafts. In this technique, a bone autograft original : × 100.
is added between the jaw and the olfactory epithelium cov-
ering the maxillary sinus (Schneider’s membrane) [39—41]. development of this protocol by eliminating the first surgical
After healing, an increased bone volume is obtained allow- time (harvesting of the autograft). This led to a more easy
ing the placement of the implants after 6 to 9 months. and reliable technique ensuring a high level of success and
The use of biomaterials as bone substitute has led to the a better anchorage of the implant with prosthetic devices.

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Dental implants 9

the migration of an implant in the maxillary sinus or the


lack of a global therapeutic evaluation. These cases usually
have medico-legal consequences.
The lifetime of dental implants is exceedingly high, gen-
erally in the order of two decades if the protocols are
correctly followed. The percentage of complications (loss
of implants) remains low because, usually less than 5% in
the first 5 years for the majority of authors.

Conclusion

At the end of the XXth century, a major advance in the


treatment of tooth loss is represented by the discovery of
dental implants. Although implantology has not the same
importance that other surgical techniques concerned with
life-threatening diseases, the correction of a dental deficit
influences the physiological and psychological condition of
the patients and improves their quality of life. Rigorous
manufacturing processes, the recognition of an operative
consensus and the numerous prosthetic adaptations avail-
able have really accomplished a technological revolution.
The technique remains, however, poorly known among all
the other organ grafts but its therapeutic value is now well
admitted.

Disclosure of interest
Figure 9 Peri-implantitis. A. Clinical aspect of an implant
with advanced peri-implantitis and bone loss. B and C. X-ray The author declares that he has no competing interest.
images depicting loss of supporting bone around the implant, a
radiolucent area at the periphery of the implants (green arrow).
Péri-implantite. A. Aspect clinique d’un implant avec péri-
Acknowledgments
implantite avancée et large perte osseuse vestibulaire. B et
C. Radiographies montrant une zone radio transparente à la Many thanks to Mrs. Lechat for secretarial assistance.
périphérie des implants correspondant à une lyse osseuse.
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