fig. 5. intraoral view after dentis implants on

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Part 2

Fig. 7. Radiograph before second surgery. Fig. 8. Radiograph after second surgery.

Fig. 6. Post-surgical radiograph afterplacement of the Dentis implant.

Fig. 9. Intra-oral view after removal of healingabutment for taking impression.

Fig. 10. Pick-up impression taking by impressioncoping and connection of lab analogue.

Fig. 5. Intraoral view after Dentis implants on #44- #46 (#44 : 3.7mm in diameter and 12mm long,#45 : 4.3mm in diameter and 10mm long, #46 :4.3mm in diameter and 12mm long).

Fig. 11. Intra-oral view after abutment try-in. Fig. 12. Intra-oral view after temporary setting.

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Fig. 13. Intra-oral view after permanent setting. Fig. 14. Intraoral view at 1 year after installationof the final prosthesis.

Fig. 15. Panoramic view at 1 year afterinstallation of the final prosthesis.

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Part 2

Fig. 1. X-ray taken before implant surgery. Fig. 2. Pre-surgical photograph of the intraoralview.

6. Guided bone regeneration (GBR)

Age / gender▶ 62 years / female

Diagnosis and treatment plan▶ The defect in the right molar tooth and teeth #42, #43, #45, #46 were restored byprosthesis with the placement of a Dentis implant after GBR using by Tutoplast.

Fig. 3. Photograph showing the occlusalrelationship before incision and subsequentreflection of the flap.

Fig. 4. Intraoral view with surgical stent.

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Fig. 5. Intraoral view with surgical stent showingthe occlusal relationship before incision andsubsequent reflection of the flap.

Fig. 6. Photograph after incision and subsequentreflection of the flap.

Fig. 9. Perforation of buccal cortical bone in therecipient site.

Fig. 10. Transplanting bone material (tutoplast).

Fig. 7. Photograph after drilling. Fig. 8a. Dentis implant.

Fig. 8b. Photograph after implant placement (#42 :3.7mm in diameter and 8mm long, #43, #45, #46 :4.3mm in diameter and 8mm long).

Fig. 8c. Dentis implant.

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Part 2

Fig. 15. Panoramic view before second surgery.


Fig. 16. Radiograph after second surgery.

Fig. 11. Placement of pericardium membrane. Fig. 12. Intraoral view after suture.

Fig. 13. X-ray taken after placement of theDentis implant.

Fig. 14. Radiograph taken after 3 months.

Fig. 1. X-ray taken before the implant. Fig. 2 Intraoral view before surgery.

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Fig. 3. Intraoral view after incision andsubsequent reflection of the flap.

Fig. 4. Intraoral view after placing a Dentisimplant (3.7mm in diameter and 10mm long).

Fig. 5. Panoramic view after placing a Dentisi m p l a n t .

Fig. 6. Hyperplastic gingiva on left mandible.

7. Overdenture (1)


Chief complaint▶ lower denture unsatisfaction,▶ treatment plan : Implant overdenture

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Part 2

Fig. 8. Removal of gingiva using Nd:YAG laser.

Fig. 9. Intraoral view at 1 week after Nd:YAG lasertreatment.

Fig. 10. Intraoral view at 2 weeks after Nd:YAGlaser treatment.



Fig. 13. Radiograph before second surgery (4months after implant placement).

Fig. 14. Intraoral view before second surgery.

Fig. 7. Nd:YAG (Neodymium-doped Yttrium-Aluminium-Garnet) laser (Anybeam ENTM, B&BSystems, http://dental.bnbsys.co.kr).

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Fig. 16. Intraoral view after second surgery.

Fig. 17. Radiograph after second surgery. Fig. 18. Intraoral view at 3 weeks after seconds u r g e r y .

Fig. 19. Panoramic view at 3 weeks aftersecond surgery.

Fig. 20a. Intraoral view at 1 year after installationof the final prosthesis.

Fig. 20b. Intraoral view at 1 year after installationof the final prosthesis.


Fig. 15. Intraoral view after incision andsebsequent reflection of the flap.

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Part 2

Fig. 1. X-ray taken before the implant. Fig. 2 Intraoral view before surgery.

Overdenture (2)


Chief complaint▶ root rests on #32, #33, #42, #43, ▶ treatment plan : implant overdenture after extraction of root rests


Fig. 4. Intraoral view after placing Dentis implants(#32, #42 : 3.7mm in diameter and 12mm long, #34,#44 : 4.3mm in diameter and 10mm long).

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Fig. 6. Transplanting bone material (tutoplast) intothe exposed threads.

Fig. 7. Intraoral view after suture. Fig. 8. Panoramic view after placing a Dentisi m p l a n t .

Fig. 9. Intraoral view at 3 months after placing aDentis implant.

Fig. 10. Radiograph at 3 months after placinga Dentis implant.

Fig. 11. Radiograph before second surgery (4 months after implant placement).

Fig. 12. Intraoral view before second surgery.

Fig. 5. Exposure of threads around #33 implant.

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Part 2

Fig. 14. Intraoral view after second surgery.

Fig. 15. Radiograph after second surgery.

Fig. 16a. Intraoral view at 1 year after installationof the final prosthesis.

Fig. 16b. Intraoral view at 1 year after installationof the final prosthesis.

Fig. 16c. Intraoral view at 1 year after installationof the final prosthesis.


Fig. 13. Intraoral view after incision andsebsequent reflection of the flap.

Fig. 1. X-ray taken before implant surgery.

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8. Horizontal alveolar bone distraction using a distractor

Age / gender▶ 26 years / male

Diagnosis and treatment plan▶ mesiodistal width deficiency in the area of teeth #24~#26 were prosthetically restoredby placing a Dentis implant after DO (distraction osteogenesis).

Specific chara c t e r i s t i c s▶ DO is a surgical method of bone formation that involves an osteotomy and sequentialstretching of the healing callus by gradual movement and sequent remodeling.

Fig. 2. Intraoral view showing distrator placement.

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Part 2

Fig. 5. Intraoral view 9 months after distrator placement.

Fig. 4. Panoramic view after DO finishing.

Fig. 6. Intraoral view showing the occlusalrelationship at 9 months after distrator placement.

Fig. 7. Radiograph taken before implantplacement.

Fig. 3. X-ray view after distrator placement.

Fig. 8. Intraoral view before removal of the distractor.

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Fig. 9. Photograph showing the occlusalrelationship before removal of the distractor.


Fig. 11. Intraoral view after remove of thed i s t r a c t o r .

Fig. 12. Removed distractor.

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Part 2

Fig. 13c. Dentis implant.

Fig. 14. Radiograph taken after implant placement.

Fig. 13a. Dentis implant. Fig. 13b. Placement of Dentis implant on #26(4.3mm in diameter and 12mm long).

Fig. 15. Radiographtaken before seconds u r g e r y .

Fig. 16. Intraoral view before second surgery. Fig. 17. Photograph showing the occlusalrelationship before second surgery (6.5 monthsafter implant placement).

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Fig. 19. Intraoral view after suture. periotest : -2,-2, -2.

Fig. 20. Intraoral view showing the occlusalrelationship after suture.

Fig. 21. Radiograph taken after seconds u r g e r y .

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Part 2

Fig. 23. Radiograph at 1 year 6 months after installation of the final prosthesis.

Fig. 22. Intraoral view at 1 year 6 months after installation of the finalp r o s t h e s i s .

Part. 3Published Articles

Implant placement using theSAVE implant

Published Articles

Implant placement usingthe SAVE implant

S U M M A R Y

Implants with wide diameters, greater than or equal to 4.5 mm, havebeen developed for specific bone and prosthetic situations,including poor bone quality, insufficient ridge height, a singlemissing molar, immediate replacement of a non-osseointegrated orfractured implant, and immediate implant placement following toothextraction. I introduce characteristics of the SAVE fixture andapplication of the SAVE fixture.

I n t ro d u c t i o nImplant diameter selection depends on the following parameters:residual bone volume, bone quality, anchoring surface, anatomy ofthe replaced tooth, available mesiodistal space, prostheticemergence profile, and biomechanical factors1 ). Different implantdiameters have been proposed since the late 1980s 1 ). During thepast 10 years, the development of new surgical and prosthodonticcomponents has allowed optimization of functional and estheticresults. The use of small-diameter implants is not recommended in thepresence of poor-density bone. Implants with wide diameters,greater than or equal to 4.5 mm, have been developed for specificbone and prosthetic situations, including poor bone quality,insufficient ridge height, a single missing molar, immediatereplacement of a non-osseointegrated or fractured implant, andimmediate implant placement following tooth extraction1 ).

Key words : Implant placement, SAVE implant, wide diameters

191Implant placement using the SAVE implant ｜

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C h a racteristics of the SAVE fixture

1. The SAVE fixture is a switching platform method (Fig. 1) whose application to the fixtureshoulder area can minimize the loss of alveolar bone.

Fig. 1. Switching platform method.

2. This is a micro-thread to prevent bone loss (Fig. 2). Even in thin cortical bones, itmediates a wedge effect. Together with primary stability, it helps to minimize bone loss byappropriate stimulation of cortical bone and distribution of stress. It has also been shown toplay a role in preventing cortical bone resorption caused by bacterial infection.

Fig. 2. Micro-thread.

3. This shows the safe cutting edge/tapered design (Fig. 3), which minimizes boneresistance and allows safe and smooth implantation. Double threads were selected for thetapered design, and, in addition to the cutting edge of the lower part of the screw, a micro-cutting edge was added along the rotation direction of the entire thread. Using this device,along with the application of constant force, excessive friction on the bone is noticeablyreduced, allowing smooth and stable implantation. The device was also designed to achievehigh initial fixation and excellent bone union.


Part 3

Fig. 3. Safe cutting edge/tapered design.

4. Convenient abutment compatibility (Fig. 4)The additional SAVE abutment system is not required, and existing products can be used.The availability of compatible abutments from other companies (Astra, Osstem Implant,Dentium) makes the SAVE fixture an economical choice.

Fig. 4. Couple abutment with convenient abutment compatibility.

5. Optimal RBM surface treatment (Fig. 5)A resorbable blast medium (RBM) method is favored because the surface of the fixture isinserted to the alveolar bone, and a surface roughness value of approximately 1.5 mprovides an ideal value for osseointegration.

Fig. 5. Optimal RBM surface treatment.

N - H e xH e x

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6. No-mount system (Fig. 6)The SAVE fixture no-mount system directly assesses the path during surgery and is notinfluenced by adjacent teeth, thus allowing shorter operation time and accurate surgery.

Fig. 6. No-mount system.

Application of the SAVE fixture

1. When the depth of alveolar bone is not sufficient, properly sized fixtures can be implantedthrough alveolar augmentation. However, for cases in which an appropriate healing time orsuitable systemic condition cannot be achieved due to health conditions or personalsituations of patients, an implant appropriate to the existing alveolar bone must be selected.Furthermore, if sufficient surface length cannot be obtained, a wide-diameter fixture shouldbe selected to maximize the surface available for osseointegration in order to form a finalprosthesis able to withstand the occlusal load.

2. If a necessary initial fixation is not obtained because of the loss of a wide fixture or thewidening of the alveolar bone during surgery, two treatment options are generallyconsidered: postpone implantation until alveolar bone is formed or treat the extractionsocket to promote bone formation. Either option requires a wait of more than 3 monthsbefore implantation can be attempted again. However, by using the newly developed SAVEfixture, implantation can be performed immediately, and sufficient initial fixation can beobtained, allowing the successful completion of the implantation.

The SAVE kit includes a final drill kit for both internal and submerged implantation. It is asurgical kit with 5.5 diameter and 6mm diameter exclusively for fixture. As for emergencytreatment, it has only a final drill. The no-mount driver is identical to the dentist’s existingdriver and is constructed to allow shorter operation time and accurate surgery. It is aconvenient stopper-attached drill, with basically a rotation-type stopper attached to the drill.In addition, the very hard tungsten monocarbide (WC) coating of the drill increases itsdrilling power. The length of the short stopper can be easily adjusted to 2, 4, or 6mmaccording to removal and application, and 8mm. The length of the long stopper can beeasily adjusted to 2 or 4mm according to removal and application, and 10 or 12mm. Theremoval and application of the stopper can be smoothly and easily accomplished, and it is arotation type during contact with the bone, thus decreasing surgical trauma to the alveolarb o n e .


Part 3

D i s c u s s i o n

The diameter, length, and stability of an endosseous dental implant at placement are criticalfactors in achieving and maintaining osseointegration. In the event of slight implant mobilityat placement, the conventional or accepted treatment is to place a longer implant and/orone of wider diameter2 ). The most commonly used standard-diameter dental implant isinadequate in patients with poor bone quality or quantity, and wider-diameter implants havebeen used to overcome these bone deficiencies3 ). Kido et al.3 ) reported that wider-diameterimplants appear to have advantages over smaller-diameter implants. However, moreextensive testing is needed to quantitatively determine the increased load-carrying capacityof wider-diameter implants.

Good results can be achieved using thick implants in posterior areas where the width of thebucco-lingual alveolar crest is sufficient, and initial fixation by cortical bone can beachieved after implantation. However, thick implants do not always guarantee success, andsome investigators have reported failures. In a survey data analysis that excluded prosthesistype from the modeling process, Scurria et al.4 ) reported that posterior location and implantwidth < 4.0 mm were associated with implant failure (all P 〈 0.05). In the molar areas, wide-diameter implants may withstand the occlusal force and may evenly distribute the force,owing to the wide surface area. Nonetheless, if the implant is too wide, initial bone unionmay be impaired because of insufficient blood supply and a prolonged implant healingperiod. Therefore, it is desirable to carefully choose an implant based on the bone conditionand volume.

Aparicio and Orozco5 ) reported the installation of 185 machined-screw implants (NobelBiocare, Gothenburg, Sweden) in 45 patients, to strengthen 58 prostheses. Of these, 91implants were 3.75 mm in diameter, and 94 were 5.0 mm wide. They retrospectivelyevaluated indications, marginal bone remodeling, Periotest values (PTvs), and survival rates.PTv and radiographic measurements were made at abutment connections and wererepeated 3, 6, and 12 months later, and every year thereafter. The follow-up period rangedfrom 16 to 55 months (mean, 32.9 months) post-loading. The cumulative success rates (CSR)with the 5.0-mm implant were 97.2% in the maxilla and 88.4% in the mandible after 1 year offunction, and 97.2% and 83.4% in the maxilla and mandible, respectively, after 48 months.The PTvs in the maxilla and mandible were 1.1 and 0.6 units lower, respectively, with the5.0-mm implant than with the 3.75-mm implant in the same patients. The PTv results supportthe hypothesis that the damping capacity of the bone surrounding a 5.0-mm implant differsfrom that surrounding a 3.75-mm implant.

In a 3- to 5-year retrospective study involving 67 patients, aged 16~86 years, Ivanoff et al.6 )

focused on implant survival and marginal bone remodeling in relation to implant diameter. Atotal of 299 Branemark implants (141 with 3.75-mm diameter, 61 with 4.0-mm diameter, and97 with 5.0-mm diameter) were placed in 16 completely and 51 partially edentulous arches.Seven (5%) of the 141 implants with 3.75-mm diameter failed, and two (3%) of the 61 implantswith 4.0-mm diameter failed. The highest failure rate, 18% (17/97), occurred with the 5.0-mmimplants. The least favorable CSRs occurred in mandibles after 5 years and involved the4.0-mm- and 5.0-mm-diameter implants (CSR, 84.8% and 73.0%, respectively). The marginalbone loss was generally low over the 5-year period. Cox regression analysis revealed arelationship between implant failure and diameter (P < 0.05), with a higher failure rate for the5.0-mm-diameter implants. However, no relationship was seen between implant failure andjaw type or between implant failure and bone quality/quantity (P > 0.05). According to themultiple linear regression analysis, there was no relationship between marginal bone lossand bone quality/quantity, implant diameter, or jaw type (P > 0.05). A learning curve, poorbone quality, and altered implant design have been suggested as possible reasons for the

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less positive outcome seen with the 5.0-mm implant. Another plausible explanation is thatthe 5.0-mm implant was often used as a rescue implant when standard implants were notconsidered suitable or did not reach initial stability.Winkler et al.2 ) analyzed the data for 2917 implants that were placed, restored, and followed-up. All implants with 3- to 3.9-mm diameters were pooled into a “3 +”group, and allimplants with 4- to 4.9-mm diameters were pooled into a “4 +”group. The analysis indicatedthat implants with diameters of 3+ mm had a lower survival rate and were less stable (morepositive PTvs) than those with diameters of 4+ mm. In addition, crestal bone loss betweenplacement and uncovering did not differ significantly between the two different-diameteri m p l a n t s .

After matching for several identified risk factors, Shin et al.7 ) compared 64 wide-bodiedimplants placed consecutively in the posterior jaws of 43 patients with 64 regular-diameterimplants (3.75- or 4-mm diameter) placed in the posterior jaws of 25 of the same patientsand 14 other patients. Ten of the wide-bodied implants failed (CSR, 80.9%), whereas onlytwo of the regular-diameter implants failed (CSR, 96.8%). The difference between the groupswas statistically significant. Wide-bodied implants placed in the posterior jaw can suffer asignificantly elevated risk of implant failure in comparison with regular-diameter implants.This susceptibility may be related to implant design or to the relative relationship betweenthe implant and host-bone dimensions.

Re fe re n c e s

1. Davarpanah M, et al: Clinical manual of implant dentistry. Quintessence.

2. Winkler S, et al: Implant survival to 36 months as related to length and diameter. AnnPeriodontol, 5: 22, 2000.

3. Kido H, et al: Implant diameter and bone density: effect on initial stability and pull-outresistance. J Oral Implantol, 23: 163, 1997.

4. Scurria MS, et al: Prognostic variables associated with implant failure: a retrospectiveeffectiveness study. Int J Oral Maxillofac Implants, 13: 400, 1998.

5. Aparicio C, Orozco P: Use of 5-mm-diameter implants: Periotest values related to aclinical and radiographic evaluation. Clin Oral Implants Res, 9: 398, 1998.

6. Ivanoff CJ, et al: Influence of variations in implant diameters: a 3- to 5-year retrospectiveclinical report. Int J Oral Maxillofac Implants, 14: 173, 1999.

7. Shin SW, et al: A retrospective study on the treatment outcome of wide-bodied implants.Int J Prosthodont, 17: 52, 2004.

Re s t o ration of a partial edentulous ridge with a Dentis implant: A case re po r t

Published Articles

Restoration of a partialedentulous ridge with aDentis implant: A case

r e p o r t

A b s t r a c t

The recent active development of domestic Korean implants hasmade them very competitive with imports. Although the domesticDentis implant was developed in 2005, few studies have comparedit to well-known overseas products. We believe that the relative lackof clinical research may make patients and dentists reluctant to usethe Dentis implant. Here we present a case report of a patientmissing multiple teeth who was treated with Dentis implants and adental prosthesis to assess the stability of the domesticallymanufactured Dentis implant.

I. Intro d u c t i o n

Based on the concept of osseointegration in the field of dentaltreatment promulgated by Branemark, prosthodontic restorationusing implants gives a more clear-cut effect than other treatmentmethods in terms of fusing with completely edentulous bone,stability, and long-term prognosis. Consequently, it is presentlyused in most cases involving the loss of teeth, such as the loss ofpartial edentulous jaw or a single tooth.

Numerous implants have been developed and are used worldwide,and further technical development is ongoing continuously. Implantshave recently been developed in Korea and are competitive in animplant market that was dependent on imports. The market share ofKorean implants has increased, and Dentis, which was developed inKorea in 2005, is one of such Korean implant product.The Dentis implant (Daegu, Republic of Korea) incorporates all of the

Key words : Dentis, Implant, Resorbable blasting media, Microthread, Root formd e s i g n

197Restoration of a partial edentulous ridge with a Dentis implant: A case report ｜

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advantages of previous implants. With the production of three types of implant, i.e., internal,external, and submerged types, it can be applied in diverse cases. The surface of thefixture is treated using resorbable blasting media (RBM) and the upper part of the fixtureconsists of microthreads. The root form design is used to improve the overall appearance ofthe fixture.In this study, Dentis implants were placed in the maxilla and mandible of a partialedentulous patient simultaneously and a dental prosthesis was completed. Good results wereobtained, and the case is reported here.

2. Case re p o rt

1. Clinical findingsA 47-year-old female visited our hospital with the chief complaint of partial tooth loss in themolar area. She had refused the use of dentures, and was referred to us from theDepartment of Prosthetic Dentistry for implant placement. She had lost teeth #14, #24 - 26,and #44 - 46. The patient had undergone a gastrectomy for gastric cancer 18 months ago,but was presently well, and she desired early recovery of occlusal function. She requestedthe use of a Korean implant restoration.

2. Radiographic findings (Fig. 1)Initial panoramic radiographs and root apex radiographs showed the loss of teeth #24 - 26and #44 - 46, with residual roots in the area of #14 and #45. The volume of residual bonewas sufficient for implant placement.

Fig 1. Panoramic view at first visit.

3. Treatment and outcomeTo shorten the treatment period, the patient requested that all seven implants be placedsimultaneously. Therefore, we decided to place seven submerged-type Dentis implantssimultaneously, and to perform guided bone regeneration (GBR) as needed. Two monthsbefore placing the implants, the residual dental roots of #14 and #45 were extracted. Underlocal anesthesia, a full thickness flap was lifted, and the implants were placed according tothe bone height measured radiographically (Table 1). All implants showed good earlyosseointegration and were sutured using vicryl and nylon (Fig. 2). Postoperatively, antibioticsand analgesics were administered orally for 5 days to control pain and prevent infection,and the sutures were removed after 1 week. Three months later, at the time of the second


Part 3

Tooth No. T y p eF i x t u r e

diameter (mm)

P l a t f o r md i a m e t e r( m m )

L e n g t h( m m )

G r a f t i n gm a t e r i a l

# 1 4 s u b m e r g e d 4 . 3 4 . 3 1 0 B i o - o s s

# 2 4 s u b m e r g e d 4 . 3 4 . 3 1 2 _

# 2 5 s u b m e r g e d 4 . 3 4 . 3 1 2 _

# 2 6 s u b m e r g e d 4 . 3 4 . 3 1 2 _

# 4 4 s u b m e r g e d 4 . 3 4 . 7 1 2 _

# 4 5 s u b m e r g e d 4 . 3 4 . 3 1 0 _

# 4 6 s u b m e r g e d 4 . 3 4 . 3 1 2 _

Table 1. Implant type, diameter, length, and grafting materials

Table 2. Periotest results

Tooth No. 1 s t 2 n d 3 r d

# 1 4 - 4 - 5 - 5

# 2 4 - 2 - 3 - 2

# 2 5 - 5 - 4 - 5

# 2 6 - 2 - 3 - 4

# 4 4 - 5 - 5 - 5

# 4 5 - 6 - 6 - 6

# 4 6 - 6 - 6 - 6

surgery, a well-healed scar was observed in the implant placement area and goodosseointegration was confirmed radiographically. The seven maxillary and mandibularimplants were then placed simultaneously, and after the second surgery, the Periotest wasused to evaluate their stability. The value of the Periotest measured three times ranged from-2 to +6, and there was good osseointegration (Table 2). Temporary restoration was madeafter taking an impression (Fig. 3), and after functioning for 1 month, the final denture wasplaced permanently (Fig. 4). On the radiographs taken 1 month after placement of the finaldenture, the bone height was stable. The patient has expressed satisfaction with nodiscomfort or complications. Good occlusion was maintained (Fig. 5).

Fig 2. Panoramic view after primary surgery.

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Fig 3. Prosthodontic procedures.


Part 3

Fig 4. Final restoration.

Fig 5. Panoramic view after 1 month final restoration.

3. Summary and Discussion

Implants have various shapes depending on their macrostructure, microstructure, andabutment patterns. The ultimate purpose of implant design is to accelerate osseointegration.Depending on their macrostructure, implants can be classified as tapered and non-taperedtypes. The use of tapered-type implants allows firm early osseointegration as a result of theedge effect, pushing the bone laterally. Since they become narrower toward the root apex,the possibility of injuring adjacent natural teeth during implant placement is very low. Evenin cases with insufficient bone volume, the possibility of inducing bone dehiscence orfenestration is decreased substantially. In addition, they allow implant placement immediatelyafter extraction, shortening the edentulous period. Implant microstructure depends on themethod of implant surface treatment.

Albrektsson et al.1 ) listed six factors influencing the integration with bone, of which thesurface property was the major factor influencing osseointegration. Numerous studies haveexamined bone healing for implants with diverse surfaces. The roughness of the implantsurface increases the surface of the implant adjacent to bone, cell attachment to the implantsurface, the volume of osteoid present on the implant surface, and the mechanical andbiological reaction between the implant and adjacent bone.2 ) Buser et al.3 ) found a correlationbetween the roughness of the implant surface and the osseointegration. One method ofaltering the implant surface involves treatment with resorbable blast media (RBM), abiocompatible hydroxyapatite or oxidized titanium that avoids the shortcomings of sand-blasting methods that may leave oxidized aluminum and other residues after the treatment,

202

which may induce nerve injury or impede osseointegration. A roughened surface has abetter effect on osseointegration than a smooth one.4 )

The maximal stress in implants is concentrated in the crestal region where the contactbetween the bone and implant is initiated.5 , 6 ) N o r t o n7 ) reported rapid bone resorption to thefirst screw with the Branemark implant, which has a dental crown with a smooth slope, whilethe Astra Tech Single Tooth Implant, which has a rough surface resulting from Tioblast™treatments and microthread™, maintained very stable bone levels. This shows theimportance of the implant surface pattern on maintaining the alveolar crest.

IV. Conclusion

Although implant treatment methods have numerous advantages compared to previous toothrestoration methods, implants are often refused because of the high costs and longrestoration period. Therefore, numerous ways to decrease the cost or time have beendeveloped. In this patient, seven Korean Dentis implants were placed in the maxilla andmandible simultaneously to shorten the treatment period; the surgery was performedrelatively easily, and good early osseointegration was obtained for all seven implants.Continuous follow-up is required to obtain clinical information on the success rates,supplemented by objective information, such as radiological and histological evaluations, toevaluate the long-term safety of Korean Dentis implant products.

Re fe re n c e s

1. Albrektsson T, Branemark PI, Hansson HA, et al. Osseointegrated titanium implants.Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. ActaOrthop Scand 1981;52:155-170.

2. Cooper LF. A role for surface topography in creating and maintaining bone at titaniumendosseous implants. J Prosthet Dent 2000;84:522-534.

3. Buser D, Schenk RK, Steinemann S, et al. Influence of surface characteristics on boneintegration of titanium implants. A histomorphometric study in miniature pigs. J Biomed MaterRes 1991;25:889-902.

4. Piattelli M, Scarano A, Paolantonio M, et al. Bone response to machined and resorbableblast material titanium implants: an experimental study in rabbits. J Oral Implantol 2002;28:2-8.

5. Kitoh M, Matsuhsita Y, Yamaue S, Ikeda H, Suetsugu T. The stress distribution of thehydroxyapatite implant under the vertical load by the two-dimensional finite element method.J Oral Implantol 1988;14:65-71.

6. Meijer HJ, Starmans FJ, Steen WH, et al. A three-dimensional, finite-element analysis ofbone around dental implants in an edentulous human mandible. Arch Oral Biol 1993;38:491-4 9 6 .

7. Norton MR. Marginal bone levels at single tooth implants with a conical fixture design. Theinfluence of surface macro- and microstructure. Clin Oral Implants Res 1998;9:91-99.

E ffect of vertical distraction osteo g e n e s i susing a nitrified distractor on the

o s s eo i n t e g ration of Dentis implants

Published Articles

Effect of verticaldistraction osteogenesis

using a nitrifieddistractor on the

osseointegration ofDentis implants

A b s t r a c t

This study evaluated the effect of using a nitrified vertical distractoron osseointegration after implantation. Four adult mongrel dogs,weighing 9-10 kg, were used in this study. The lower premolarswere extracted and vertical distraction was performed after 10weeks using eight distraction devices (left, 4 titanium; right, 4nitrified). A 7-day latency period was allowed before distraction wasbegun. The distraction device was activated at a rate of 0.5 mmtwice/day for 5 days. After completing distraction, the device wasremoved after a retention period of 6 weeks and 24 Dentis implantswere installed. The dogs were sacrificed after 4 or 8 weeks.Histological examinations were performed. Direct bone contact wasachieved and there were no significant differences between thecontrol and experimental groups in the implantation area. Theresults suggest that the nitrified distraction device has potential foruse in augmentation of the atrophic edentulous ridge.

Key words : vertical distraction osteogenesis; nitrified distractor; implants

203Effect of vertical distraction osteogenesis using a nitrified distractor on the osseointegration of Dentis implants ｜

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I N T R O D U C T I O N

For successful implant placement, the appropriate height and width of bone are required. Toplace an implant in alveolar bone that has atrophied severely or been lost due to trauma,tumors, etc., bone grafting or guided bone regeneration (GRB) using bone substitutes arewidely used. However, such techniques require the formation of additional soft tissue flapssince the soft tissues are usually insufficient, and the volume of alveolar bone that can beaugmented is limited. Recently, the vertical distraction of alveolar bone has been developedas a method to replace alveolar bone augmentation, and good clinical results have beenreported. The vertical distraction of bone requires an osteotomy or decortication in the areato be distracted, followed by the gradual separation of the bone fragments to induce thegeneration of new bone between the bone surfaces where blood is supplied, which achievesbone distraction and remodeling.1 ) Snyder et al.2 ) applied the method to the distraction ofcanine mandibular bone. Regarding the augmentation of alveolar bone subject to bonedistraction, Chin and Toth3 ) reported a method to augment the alveolar bone by performing asegmental osteotomy on mandibular anterior teeth with severe involution and, subsequently,inserting a thread pin directly in the alveolar area.The use of a titanium alloy distractor without a tin coating has numerous advantages, andhas long been widely used. Its advantages include its biocompatibility, affinity to fibroblastsand facilitating their attachment, ability to reduce bacterial growth, and resistance tocorrosion and abrasion.4 ) Given these advantages, numerous studies have examined other invivo implants or surgical instruments. Nonetheless, few studies have examined bonedistraction equipment.This study evaluated osseointegration and bone tissues histologically andhistomorphologically, and the difference in the outcomes of vertical distractors with differentsurface treatments.

M AT E R I A LS AND MET H O D S

M a t e r i a l s

Experiment animalsThe study was performed on four healthy 12-month-old dogs weighing 9-10 kg, raisedunder identical conditions.

I m p l a n t sTwenty-four RBM surface Dentis implants (Dentis, Daegu, Korea), 12 mm in length, and 3.75mm in diameter were used.

D i s t r a c t o r sFour titanium vertical distractors and four nitrified titanium vertical distractors prepared inour laboratory were used.

Experimental methodsThe study groups are outlined in Table I and the experimental procedure is outlined in theflowchart in Table II.


Part 3

A n e s t h e s i aSystemic anesthesia was induced with the intramuscular injection of 2 cc each of xylazine(Rompun, Bayer Vetchem-Korea) and ketamine (Ketara, Yoohan Yanghang) in thequadriceps. To prevent hemorrhage and pain, the extraction sites were infiltrated with 2%l i d o c a i n e .

E x t r a c t i o nFrom each adult dog, the 1s t to 4t h mandibular premolars were extracted, and a 10-weekhealing period was allowed. In all groups, to prevent infection after the extraction,distraction, and Dentis implant placement, 2 cc of gentamicin were injected daily for 5 days.

Installing the distractorA conventional alveolar crestal incision was made. A full-thickness buccal flap was reflectedover an area sufficient for the osteotomy. With a reciprocating saw, while protecting thebuccal mucosa, a 20 × 10 mm osteotomy was made. The titanium surface equipment wasinstalled in the left mandible of each dog (experimental group 1), and the nitrified titaniumvertical distractor was installed on the right side (experimental group 2). To verify theoperation of the vertical alveolar distractor, it was distracted and then returned to its originalposition. Then, the wound was sutured.

G r o u p s W e e k sNo. of

i m p l a n t sDistractor surface

Total distraction( m m )

Rate of distraction

4 4 - - -

8 4 - - -

4 4 T i t a n i u m 5 0.5 mm twice a day

8 4 T i t a n i u m 5 0.5 mm twice a day

4 4 Titanium nitride 5 0.5 mm twice a day

8 4 Titanium nitride 5 0.5 mm twice a day

Table I. Study Groups

extraction P1-P4 of Mandible

vertical distraction device fixation,7 days latency period,

5 days distraction period (0.5 mm twice/day)

device removal and implant installation

s a c r i f i c e

10 weeks

6 weeks

4 or 8 weeks

Table II. Protocol

C o n t r o l

Group 1

Group 2

206

Bone distractionWhile waiting for the soft tissues to heal, bone distraction was performed after a 7-daylatency period at a rate of 2 rotations per day (0.5 mm per rotation, morning and evening)for 5 days, for a total of 5 mm. After the distraction was complete, a 6-week consolidationperiod was allowed in all cases.

Removal of bone distractor and Dentis implant placementSix weeks after surgery, the vertical bone distractor was removed and Dentis implants wereplaced simultaneously using a submerged method. For each animal, two implants wereplaced in the distracted area (experiment group), one in the adjacent area (control group)for three implants on each side of the mandible or six implants per animal, and a total of 24Dentis implants.

S a c r i f i c eAt 4 and 8 weeks after implant placement, animals were sacrificed, and the implantedmandible was resected for tissue harvest.

Experiment evaluationFour and 8 weeks after Dentis implant placement, the distracted area and bone in thevicinity of the Dentis implants were examined. The Dentis implant samples were fixed in 70%alcohol for 6 days, dehydrated through an alcohol series, and embedded inglycolmethacrylate resin (Spurr low-viscosity embedding media, Polyscience, Harrington, PA,USA). Polymerized samples were sectioned using a high-precision diamond disc (low-speeddiamond wheel saw 650, SBT, San Clemente, CA, USA) along the long axis in 200-?mthicknesses. Then, using a lapping and polishing machine (OMNILAP 2000, SBT, SanClemente, CA, USA), abraded to 30-㎛ thicknesses. One slide was prepared per implant,stained with Villanueva osteochrome bone stain (San Clemente, CA, USA), and observedunder a light microscope (Olympus BX50, Tokyo, Japan). For the histomorphometricevaluation, the percent of new peri-implant bone formation (NBFR) within the implant screwswas calculated using the following formula:NBFR (%) = (New formed bone / Area outside the implant thread) × 1 0 0The calculated results were analyzed statistically.

Statistical analysisThe filling rate of the Dentis implants and the amount of bone were analyzed using one-wayanalysis of variance (ANOVA) using SPSS ver. 12. In addition, Scheff?’s test was used forinter-group comparisons. P < 0.05 was considered statistically significant.

R ES U LTS

At the time of sacrifice, none of the 24 Dentis implants had moved, there was no sign ofinfection or inflammation. The implant success rate was 100% in the control and experimentg r o u p s .

Histomorphometric resultsIn the experimental and control groups, the new bone filling rate was measured after 4 and8 weeks, and the results are shown in Table III.Histologically, the bone tissues appeared normal and did not differ at the sites of distraction.Osseointegration was observed in all groups (Figs. 1 and 2). The rate of new bone fillingwithin the implant screws did not differ significantly between the control and experimentalgroups (p=0.060 and p=0.191 at 4 and 8 weeks, respectively, ANOVA).


Part 3

D I S C U S S I O N

Distraction osteogenesis is a technique that induces bone generation via the so-called“tension-stress effect”through the gradual distraction of the bone fragments.5 ~ 8 ) I l i z a r o v5 , 6 )

developed a double ring-type distractor for lengthening the ilium and obtained good clinicalresults; he also explained the theoretical background experimentally, and began to drawattention to the technique. Chin and Toth3 ) reported successful alveolar bone distraction inthe mandibular anterior tooth area with the application of transgingival screws. Simion et al.8 )

obtained an average of 3.5 mm of osteogenesis using guided bone regeneration. In thisstudy, with the application of vertical distraction, 5 mm of osteogenesis was obtained.

Distraction osteogenesis requires an osteotomy to divide the bone in two, a latency periodafter the osteotomy before applying distraction, which places traction on the fibrous callus,and a consolidation period once the traction force is terminated until the bone distractor isremoved. For successful distraction osteogenesis, the blood supply to the bone fragmentsplays an important role. Ilizarov6 , 7 ) reported that in the ilium, the blood circulation within thebone marrow is essential for the regeneration of bone after distraction, and the occurrenceof osteogenesis in the distraction area is dependent on the stability at the time of osteotomyand the amount of injury to the bone marrow, periosteum, and nutritional blood vessels, andrecommended performing a cortical osteotomy. In this study, the buccal periosteum was

Table III. Bone to Metal Contact Rate (%) at 4 and 8 Weeks Given As The Mean±S D

4 weeks 8 weeks

C o n t r o l 5 7 . 0 0±1 . 9 0 7 1 . 7 4±1 . 1 0

Group 1 5 3 . 5 2±1 . 6 8 6 9 . 7 6±1 . 3 2

Group 2 5 5 . 5 1±1 . 7 0 7 0 . 6 5±1 . 7 2

T o t a l 5 5 . 3 4±2 . 1 8 7 0 . 7 2±1 . 5 2

* statistically significant difference p<0.05.

Fig. 1. Histologic findings in the control group.Newly formed bone was apparent within thethreads of the implant surface, and direct bonecontact with the implant surface was seen.Villanueva osteochrome bone stain, ×40.

Fig. 2. Histologic findings in the experimentalgroup. Newly formed bone was observed at thedistracted site and adjacent to the implant, anddirect bone contact was seen. Villanuevaosteochrome bone stain, ×4 0 .

208

dissected to the mandibular margin, and the osteotomy was performed carefully so as not todamage the periosteum in the buccal area. This allowed callus formation, and theossification process progressed after distraction without problems. Periosteal reaction andabundant new bone formation on the buccal side were observed after distraction.

Distraction osteogenesis allows the simultaneous augmentation of soft and hard tissues andis considered a very useful technique. Nonetheless, the stability of the distracted bone iscontroversial. Saulacic et al.9 ) reported that to allow for relapse during the consolidationperiod, slight overcorrection is useful, and for alveolar bone, 25% of the distraction amountor approximately 1-3 mm may be required. Rachmiel et al.1 0 ) reported that distractionosteogenesis induces skeletal distraction and the augmentation of soft tissues, and bonetrabeculae was observed 6 weeks after the completion of distraction osteogenesis; toprevent relapse, a long consolidation period is required. Generally, consolidation periods of6-8 weeks for the mandible and 2-3 months for the maxilla are appropriate.1 1 ) We found thata 6-week consolidation period resulted in sufficient bone for implant placement.

Several studies have examined the use of nitrified surface treatment for other biologicalimplants and surgical instruments.1 2 - 1 4 ) Huang15 have reported that a nitrified surface exposedto artificial saliva showed excellent resistance to erosion, and that more cells adhered to thenitrified surface. Scarano et al.4 ) reported that nitrified surface treatment reduced theattachment of bacteria, reducing soft tissue infection near the implants.

In this study, the amount of new bone formation and bone attachment was not significantlydifferent with the nitrified titanium vertical distractor. Nevertheless, we confirmed that verticaldistraction osteogenesis is a useful technique for the placement of implants in atrophiedalveolar bone. A distractor with a nitrified surface is better in terms of the surface hardnessand the prevention of erosion, and should be more effective in certain environments. Futurestudies should evaluate the hardness of the equipment surface, etc.

C O N C LU S I O N S

Alveolar bone was augmented using distraction osteogenesis and good results wereobtained with Dentis implants. The implant success rate was 100% in all of the study groups.There was no significant difference between the distractors with the nitrified surface andthose made of titanium alloy. In general, distraction is a useful technique for vertical bonea u g m e n t a t i o n .

Re fe re n c e s

1. Costantino PD, Friedman CD. Distraction osteogenesis. Applications for mandibularregrowth. Otolaryngol Clinics North Am 1991;24:1433-1443.

2. Snyder CC, Levine GA, Swanson HM, Browne EZ Jr. Mandibular lengthening by gradualdistraction. Preliminary report. Plast Reconstr Surg 1973;51:506-508.

3. Chin M, Toth BA. Distraction osteogenesis in maxillofacial surgery using internal devices:review of five cases. J Oral Maxillofac Surg 1996;54:45-53.


Part 3

4. Scarano A, Piattelli M, Vrespa G, Caputi S, Piattelli A. Bacterial adhesion on titaniumnitride-coated and uncoated implants: an in vivo human study. J Oral Implantol 2003;29:80-8 5 .

5. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. Theinfluence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res1 9 8 9 ; 2 3 8 : 2 4 9 - 2 8 1 .6. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. Theinfluence of the rate and frequency of distraction. Clin Orthop Relat Res 1989;239:263-285.

7. Ilizarov GA. The possibilities offered by our method for lengthening various segments inupper and lower limbs. Basic Life Sci 1988;48:323-324.

8. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane techniqueassociated with osseointegrated implants. Int J Periodontics Restorative Dent 1994;14:496-511.

9. Saulacic N, Somoza-Martin M, Gandara-Vila P, Garcia-Garcia A. Relapse in alveolardistraction osteogenesis: an indication for overcorrection. J Oral Maxillofac Surg2 0 0 5 ; 6 3 : 9 7 8 - 9 8 1 .

10. Rachmiel A, Aizenbud D, Peled M. Long-term results in maxillary deficiency usingintraoral devices. Int J Oral Maxillofac Surg 2005;34:473-479.

11. Swennen G, Schliephake H, Dempf R, Schierle H, Malevez C. Craniofacial distractionosteogenesis: a review of the literature: Part 1: clinical studies. Int J Oral Maxillofac Surg2001;30:89-103.

12. Goldberg JR, Gilbert JL. The electrochemical and mechanical behavior of passivated andTiN/AlN-coated CoCrMo and Ti6Al4V alloys. Biomaterials 2004;25:851-864.

13. Cyster LA, Parker KG, Parker TL, Grant DM. The effect of surface chemistry andnanotopography of titanium nitride (TiN) films on primary hippocampal neurones. Biomaterials2 0 0 4 ; 2 5 : 9 7 - 1 0 7 .

14. Tamura Y, Yokoyama A, Watari F, Kawasaki T. Surface properties and biocompatibility of nitrided titanium for abrasion resistant implant materials. Dent Mater J 2002;21:355-372.

15. Huang HH. Surface characterizations and corrosion resistance of nickel-titaniumorthodontic archwires in artificial saliva of various degrees of acidity. J Biomed Mater Res A2005;74:629-639.

Abutment System Selection Guide / 14, 100

Angled Abutment / 106, 115, 122

Cemented Abutment / 120

Cemented Abutment System / 66

Characteristics of Dentis Implant / 22

Cleaning System / 20

Collatape / 148

Combined KIT / 86

Complete osteotomy / 148

Components of Dentis Products / 32

Couple Abutment / 113

Couple Abutment System / 54

Dentis Abutment System / 26

Dentis Implant System Selection Guide / 12

Dentis Surgical Kit / 84

Distraction osteogenesis / 207

Drilling Sequences : External Type / 95

Drilling Sequences : Internal and Submerged Type / 92

Effect of vertical distraction osteogenesis using a nitrified distractor on the

osseointegration of Dentis implants / 203

Estheticone Abutment / 123

Estheticone Abutment System / 70

External Abutment System / 29

External Fixture / 64, 87

External Implant System Flow / 64

Fixture System Selection Guide / 12

Free Abutment / 104, 112

Gold UCLA Abutment / 108, 114, 121

Guided bone regeneration / 173

Horizontal alveolar bone distraction using a distractor / 182

Implant placement using the SAVE implant / 191

Impression Taking : External Type / 118

Impression Taking : Internal Type / 102

Impression Taking : Submerged Type / 111

InOcta Abutment / 105

InOcta Abutment System / 38

Internal Abutment System / 26

Internal Implant System Flow / 32

Internal/Submerged Fixture / 87

IN D E X . . .

210

Mandibular anterior teeth / 158

Mandibular posterior teeth / 162, 165, 167, 170

Maxillary anterior teeth / 126

Maxillary posterior teeth / 152, 155

Mount Abutment / 119

Nd:YAG laser / 177

Nitrified distractor / 203

Octa Abutment / 109, 116

Octa Abutment System / 42

O-Ring Abutment / 110, 117, 118

O-Ring Abutment System / 46, 62, 74

Overdenture / 176, 179

PROKIT / 89

PRP / 148

RBM(Resorbable Blast Media) / 19

Restoration of a partial edentulous ridge with a Dentis implant: A case report / 197

SAVE fixture / 192

SAVE Internal / 13

SAVE Internal Fixture / 78

SAVE Internal Implant System Flow / 78

SAVE Submerged / 13

SAVE Submerged Fixture / 76

SAVE Submerged Implant System Flow / 76

SAVE KIT / 88

Sinus lift / 130, 134, 138, 141, 144, 147, 150

Sole Abutment / 111

Sole Abutment System / 50

Solid Abutment / 102

Solid Abutment System / 34

Submerged Abutment System / 28

Submerged Fixture / 48

Submerged Implant System Flow / 48

Sub-Octa Abutment System / 58

Surface Treatment / 18

Surgical Kit and Tool / 92

SynOcta Abutment / 107

Tension-stress effect / 207

Vertical distraction osteogenesis / 203

211

Copyright ⓒ 2009 by The JeeSung Publishing Company

All rights reserved. No part of this publication may be reproduced ortransmitted by any means, electronic, mechanical, or otherwise, includingphotocopying and recording, or by any information storage or retrievalsystem, without permission-in-writing from the publisher.

ISBN 978-89-8484-177-2

Printed in Korea245-21, Neung-Dong, Gwangjin-Gu, Seoul 143-848 / Korea

Su Gwan Kim, D.D.S., Ph.D

DENTIS IMPLANTBook Design : Kyung Soon Jang

fig. 5. intraoral view after dentis implants on

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