早期负重状态下三种种植体形态对骨结合的影响
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摘要
种植体-基台系统能够替代失去的天然牙为全冠提供良好的支持作用,使患者的美观和功能得以恢复。种植体目前已在很多国家普及应用,广受好评。但也有不少患者因为种植疗程过长而放弃了这种治疗方式。要推进种植治疗在临床上的应用,使更多牙列缺失缺损患者受益于种植治疗,优化方案缩短疗程刻不容缓。
自从上世纪60年代Branemark提出现代口腔种植技术,传统的种植体延期负重方案被广泛应用于临床。直到1986年Babbush首先提出了即刻负重的概念,许多学者才相继对种植体即刻负重和早期负重进行了研究。到目前为止,种植体即刻负重和早期负重仍然是种植学领域的研究热点。
即刻负重是指种植体植入后2-3天内负重,而早期负重介于即刻负重和传统的延期负重之间,是指种植体植入2天后或3个月内对种植体进行加载。一系列关于种植体早期负重的临床研究得到了与延期负重近似甚至更高的种植体存留率以及更少的种植体周围骨吸收。
虽然有关种植体早期负重的研究很多,但这些研究都集中于螺纹种植体,并无观察鳍型种植体在早期负重状态下骨结合的基础研究,也并无基础研究比较鳍型和螺纹种植体的骨愈合情况。鳍型种植体与螺纹种植体最大的区别就是在鳍型种植体的骨内部分有一系列独立的环状翼。种植体植入后会在相邻的环状翼之间留下大量的空间,为血痂和编织骨的形成提供场所。研究证实在鳍型种植体提供的这种空间里形成血管和编织骨能获得较快的骨愈合和较好的种植体生物力学方面的稳定性。
本研究的目的即观察鳍型种植体与螺纹种植体在种植体-骨界面上应力分布的区别,考察鳍型种植体在早期负重状态下的骨愈合情况,并与螺纹种植体进行比较。本课题的研究内容分为以下三个部分：
第一部分三种形态种植体周围应力分布的三维有限元分析
[目的]本实验的研究目的是比较鳍型种植体与螺纹种植体在种植体-骨界面上应力分布情况。
[材料与方法]本实验设三个实验组：柱状螺纹(CT)种植体(种植体为柱状,外径3.3mm)、柱状鳍型(CP)种植体(种植体为柱状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)和锥状鳍型(TP)种植体(种植体为锥状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)。三种种植体均为一段式,长度均为14mm,骨内长度为8mm,穿龈高度为2mm。参考下颌骨皮质骨和松质骨的弹性模量,应用大型3D造型软件PRO/E中建立各实验组种植体和周围软硬组织的三维有限元几何模型。应用ANSYS Workbench有限元分析程序自动对模型划分节点和单元。设计了3种负荷加载方式：①垂直向负荷100N,方向与种植体长轴一致,由(?)方指向龈方,载荷部位为胎面中央；②水平向负荷100N,方向与种植体长轴垂直,由颊侧指向舌侧,载荷部位为(?)1/3与中1/3交界处；③斜向负荷100N,方向与种植体长轴呈45°,由(?)颊侧指向龈舌侧,载荷部位为(?)1/3与中1/3交界处。利用三维有限元分析法计算不同负荷条件下各实验组种植体内部和周围粘膜、皮质骨和松质骨的等效应力峰值。
[结果]应力分布云图显示：垂直加载条件下,种植体内部应力分布较为均匀,CT和CP组应力较高点位于种植体末端,TP组位于种植体颈部；各实验组种植体颈部皮质骨应力集中出现在种植体顶部周围皮质骨中；各组松质骨应力集中均位于种植体末端；各组粘膜组织应力集中于基台穿龈部位顶端。水平加载条件下,CT组种植体内部应力集中位于种植体颈部,而CP和TP组在种植体内部的应力分布均匀；各实验组皮质骨应力均集中于顶部；CT组种植体周围松质骨的应力集中于种植体末端,而CP和TP组在松质骨中的应力分布均匀；各组在粘膜组织中的应力集中位于基台穿龈部位的顶部。斜向加载条件下,CT组种植体内部的应力集中于种植体颈部,而CP和TP种植体内部应力分布均匀；各组在皮质骨中的应力集中均位于顶部皮质骨中；CT组在松质骨中的应力集中于种植体末端,而CP和TP组种植体周围松质骨应力分布均匀；各实验组粘膜组织中的应力均集中于基台穿龈部位的顶端。不同加载条件下,各实验组种植体等效应力峰值的比较结果表明：①同一实验组相同部位的等效应力峰值比较：垂直载荷<斜向载荷<水平载荷；②相同加载方式下相同部位,不同实验组的等效应力峰值比较：CT种植体组在种植体内部分布的MVMS较其它实验组大；CT种植体组在种植体颈部皮质骨中的MVMS较其它组小；CP种植体组在松质骨中的MVMS较其它组小；粘膜中CT组MVMS最大,CP组MVMS最小,但各组MVMS均较小。③除了CT组在垂直载荷下种植体颈部皮质骨的应力峰值略低于松质骨,其它所有情况下种植体颈部周围皮质骨的应力峰值均高于松质骨,种植体内部的应力峰值均最大,粘膜中的应力峰值均最小。
[结论]垂直载荷下,三种形态种植体周围组织的应力均较小且分布情况相似；非垂直载荷下,三种形态种植体周围组织的应力均较大,柱状螺纹种植体在松质骨中的应力集中于种植体末端处,而柱状鳍型和锥状鳍型种植体周围松质骨中的应力分布均匀。三种载荷作用下,不同形态种植体颈部皮质骨中的应力均集中位于皮质骨包绕种植体界面的顶端。柱状螺纹种植体在三种加载方式下将较大的应力分布于种植体内部,将较小的应力分布于种植体颈部皮质骨中,有利于抵抗皮质骨吸收。
第二部分三种形态种植体在早期功能性负重下的成骨情况比较
[目的]本实验的目的是为了探讨种植体外形和相应的植入技术在早期功能性负重状态下对成骨过程的影响。
[材料与方法]本实验设计加工制作了三种形态的种植体：柱状螺纹(CT)种植体(种植体为柱状,外径3.3mm)、柱状鳍型(CP)种植体(种植体为柱状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)和锥状鳍型(TP)种植体(种植体为锥状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)。三种种植体均为两段式,种植体长度均为8mm。在基台与种植体连接部分设计了1.5°锥度。拔除比格犬下颌骨双侧第2、3、4前磨牙,10周后将三种形态的种植体随机植入比格犬双侧下颌骨缺牙区的牙槽骨中,每侧下颌骨3-4枚种植体,保证在每侧下颌骨内每种形态的种植体至少有一枚,1周后行二期手术安装基台并粘固自凝塑料义齿。使用Periotest稳定性测试仪动态监测所有种植体加载时以及加载后2、4、6周的稳定性。6只比格犬在种植体负重后3周和6周分批处死。获取的埋植有种植体的下颌骨标本用来进行显微CT和组织形态计量学的分析。
[结果]CT种植体的稳定性在负重初期显著高于CP和TP种植体,负重6周后,CT和CP种植体的稳定性无显著性差异,且此二者的稳定性明显高于TP种植体。显微CT和组织计量学分析的结果显示：负重3周后,CT种植体的骨-种植体结合率和骨量百分比均显著高于CP和TP种植体；而负重6周后,CT和CP种植体的骨-种植体结合率显著高于TP种植体。另外,负重6周后CT和CP种植体的骨量百分比无统计学差异。
[结论]在种植体植入后1周开始功能性负重可能会促进柱状种植体的骨愈合但阻碍锥状鳍型种植体的骨愈合。不论是螺纹还是鳍型,柱状种植体可能比锥状种植体更适合在早期(种植体植入后1周)负重情况下使用。
第三部分早期负重对鳍型种植体骨结合的影响
[目的]本实验的目的是为了比较鳍型种植体在早期负重和延期负重下的成骨情况。
[材料与方法]本实验设置了三个实验组,即早期负重(early loading, EL)组、不负重的对照组以及延期负重(delayed loading, DL)组。拔除6只比格犬双侧下颌第2、3、4前磨牙,伤口愈合10周后,将柱状鳍型种植体植入比格犬下颌缺牙区的牙槽骨中,每侧下颌骨植入3枚种植体。将6只比格犬随机分配至三个实验组,每组2只犬。早期负重组种植体在植入1周后即进行二期手术,安装基台及自凝塑料义齿；不负重的对照组种植体在种植体植入1周后也将牙槽嵴顶粘膜切开翻瓣缝合,但不安装基台；延期负重组种植体在种植体植入后10周安装基台和上部义齿。使用Periotest稳定性测试仪动态监测所有种植体安装基台后第0、2、4和6周的稳定性。所有动物处死前3周注射钙黄绿素,处死前1周注射茜素红。6只比格犬在种植体负重后3周和6周分批处死。获取的埋植有种植体的下颌骨标本用来进行荧光观察以及显微CT和组织形态计量学的分析。
[结果]早期负重种植体在安装基台时稳定性较低,但是在负重后第2周和第4周的稳定性高于延期负重种植体。在负重后的0-2周和3-5周两个时间段,早期负重种植体和未负重对照组种植的矿化沉积速率均无统计学差异。在负重后3-5周,早期负重种植体的矿化沉积速率显著高于延期负重组。负重后3周时,早期负重种植体的骨-种植体结合率显著低于延期负重组,而到负重后第6周时,早期负重组和延期负重组的所有组织学参数均未见统计学差异。并且,负重6周后早期负重种植体的骨-种植体结合率已经高于未负重的对照组。
[结论]在早期负重状态下,种植体愈合时间缩短到1周即开始加载对柱状鳍型种植体周围骨组织的改建有积极影响。
综上所述,由于提前加载对种植体周骨愈合的促进,柱状鳍型种植体在早期负重(种植体植入后1周)下能够获得良好的骨结合,与柱状螺纹种植体一样适用于该种早期负重方案。而锥状鳍型种植体在早期负重情况下的应用还有待进一步的长期考察。
The implant-abutment system can replace the lost natural teeth as the support for crown, restorating the aesthetics and function of patients. Although the implants have been widely used in many countries currently, some patients choose to give up the implant therapy due to the long schedule. Thus, the conventional implant therapy should be improved immediately to shorten the course of treatment, so as to make more patients benefit from the implant treatment.
Since the introduction of modern dental implant techanique by Branemark in1960s, the conventional delayed loading protocol has been widely used in clinical practice. Many researchers began to study the immediate and early loading protocol until the development of immediate loading by Babbush in1986. The immediate and early loading are still the the hot area of research until now.
Typically, the delayed loading protocol was used to ensure successful and predictable placement of dental implants. However a number of clinical and experimental studies regarding early loading directly challenged this notion with convincing outcomes. The early loading protocol refers to load applied to implants between2days and3months post surgery (between immediate loading and conventional loading). Comparable or even better survival rates and less peri-implant bone loss for early loaded implants were achieved in a series of clinical trials.
Although many studies were conducted to determine the outcomes of early loading applied to threaded implants, few experimental studies exist that investigate peri-implant bone reactions under early loading applied to plateaued implants. The cylinder plateaued implant has a series of separate circumferential fins existing along the intra-osseous portion of the implant, and a large space between the fins which have previously been described for blood clot formation and woven bone development. It has been suggested that a relatively rapid bone healing and thus biomechanical stabilization of the implant could result from the vascularization and woven bone filling in this space.
The aim of this PhD thesis was to evaluate the effect of implant configuration on bone-implant osseointegration under early loading. Three parts were included:
1. The effects of implant configurations on stress distribution:a3D finite element analysis
Materiala and Methods:Three experimental groups were designed according to the implant configurations:cylindrical threaded (CT) implant, cylindrical plateaued (CP) implant and tapered plateaued (TP) implant. The CT dental implants used in this study were3.3mm in diameter. The CP dental implants were3mm in diameter with a1.0mm plateau pitch and0.2mm thickness of each plateau. The TP implants were of the same plateau pitch, thickness of plateau and diameter in the coronal part as the CP implants. The only difference between CP and TP implants was that the latter had a tapered implant body. The3D one-stage implants with various configurations and the peri-implant tissure were modeled by means of the PRO/E program. The100-N static axial, horizongtal and oblique (45°) load were applied to the top of one-stage implant. The3D finite element analysis (FEA) was run at the ANSYS Workbench program. The images showing the distribution of von Mises stresses were abtained to locate the stress concentration in implants and different tissues under load of different directions. In addition, the maximum von Mises stresses (MVMS) at implants of various configurations and different tissues under load of varous directions were quantitatively compared.
Results:The images showing the distribution of von Mises stresses under axial load revealed that no stress concentration was observed within the implant, and high stress values were detected at the end of implants for CT and CP groups and at the cervical part of implant for TP group. The stress concentratons at cervical cortical bone and cancellous bone were lacated at the top regions arround the implants and the end of implants respectively for all groups. Under horizontal load, the stress concentrations within implant were located at the cervical region for CT group, while the stress distributed equally within CP and TP implants. The stress concentrations in the cortical bone were also located at the cervical region for all groups. The stress concentrations in the cancellous bone were located at the end of implant for CT group, while the stress distributed equally in cancellous bone adjacent to CP and TP implants. Under oblique load, the stress concentrations within the implant were lacated at the cervical region for CT group, while no stress concentration was observed within the CP and TP implants. The stress concentrations in cortical bone were still located in cervical regions for all groups. The stress concentrations in cancellous bone were lacated at the end of CT implants, while the stress distributed equally again in cancellous bone for CP and TP implants. In addition, the stress concentrations in mucosa existed at gingival margin for all groups under load of varous directions. The quantitative comparison of MVMS between implants of different configurations indicated that①The MVMS at the same tissue of the same group were compared: axial load> oblique load> horizontal load.②For MVMS at the same tissue under load of the same direction:The CT group had a higher MVMS within the implants and a lower MVMS at the cervical cortical bone than the CP and TP groups. The MVMS at cancellous bone adjacent to the CP implants was lower than others. The MVMS existed in mucosa adjacent to the CT implants was the highest of all groups, while the MVMS existed in the CP implants was the lowest.③The MVMS existed in different tissues for the same group under the load of the same direction were compared:implant> cortical bone> cancellous bone> mucosa.
Conclusions:Higher stress existed within the implant and lower stress distributed in the cervical cortical bone for cylindrical threaded implant, which favours the resistance of cervical bone loss. Under non-axial load, the stress concentrations in cancellous bone were located at the end of implant for cylindrical threaded group, while the stress distributed equally in cancellous bone for both plateated implants. The configuration of implants did not affect the stress distribution in vertical cortical bone, as the stress concentration always existed in the top region of interface between implant and cortical bone.
2. Bone formation adjacent to implants of various configurations under early functional loading in a dog model
Materials and Methods:This study was designed to evaluate the effect of combining implant configuration and surgical technique on bone formation under early functional loading in a dog model. Bone formation adjacent to customized cylindrical threaded, cylindrical plateaued, and tapered plateaued dental implants were compared post-early loading. The Periotest values were monitored dynamically for6weeks. Peri-implant bone healing was evaluated by bone-to-implant contact, and bone volumes fraction analysis after3and6weeks of loading.
Results:The cylindrical threaded implants showed the highest stability when load began, while both the cylindrical threaded and cylindrical plateaued implants had higher stability than tapered plateaued implants after6weeks of loading. No difference in stability was found between cylindrical threaded and cylindrical plateaued implants after6weeks of loading. The data from both micro-focus computed tomography and histomorphometric analysis showed that the cylindrical threaded implants had significantly higher bone-to-implant contact and bone volumes fraction compared to cylindrical plateaued and tapered plateaued implants after3weeks of loading, and the tapered plateaued implant had a lower bone-to-implant contact than the cylindrical threaded and cylindrical plateaued implants after6weeks. In addition, no significant difference was detected for bone volumes fraction between cylindrical threaded and cylindrical plateaued implants after6weeks of loading.
Conclusions:Based on these results, we concluded that the cylindrical implant, whether threaded or plateaued, might be more suitable for early loading (1week) when compared to the tapered implant.
3. Effect of decreased implant healing time on bone (re)modelling adjacent to plateaued implants under functional loading in a dog model
Materials and Methods:The purpose of this study was to evaluate the effect of early functional loading to plateaued implants on bone formation and implant stability in a dog model. Early loading (EL), non-loading control and delayed loading (DL) groups were compared using6Beagle dogs under functional loading. The Periotest values (PTV) were measured dynamically for6weeks. Peri-implant bone architecture was evaluated qualitatively by micro-computed tomography (μCT) and analyzed quantitatively by mineral apposition rates (MAR), bone-to-implant contact (BIC) and bone volumes (BV/TV) after the euthanasia at3and6weeks after loading.
Results:The EL implants showed poor stability at1week, but greater stability at2and4weeks after loading compared to DL implants. There was no significant difference between MAR of EL and unloaded implants at both time intervals. The EL implants displayed a significantly higher MAR when compared to DL implants at3-5weeks. A significantly higher BIC for the DL group was observed when compared to the EL group at3weeks following loading, however at6weeks, no significant difference between these groups was observed. The EL group gained a higher BIC than the no-treatment control group at6weeks.
Conclusions:For plateaued implant, the decreased healing time (1week) displays a positive effect on peri-implant bone (re)modelling under functional loading during the early phase.
Based on the three studies above, we concluded:Favourable osseointegration can be obtained for the cylindrical plateaued implants under early loading (1week after the implant installation) due to the positive effect of decreased healing time. The early application of functional loading on cylintrical plateaued implants could be used clinically to shorten the course of treatment and improve aesthetics.
自从上世纪60年代Branemark提出现代口腔种植技术,传统的种植体延期负重方案被广泛应用于临床。直到1986年Babbush首先提出了即刻负重的概念,许多学者才相继对种植体即刻负重和早期负重进行了研究。到目前为止,种植体即刻负重和早期负重仍然是种植学领域的研究热点。
即刻负重是指种植体植入后2-3天内负重,而早期负重介于即刻负重和传统的延期负重之间,是指种植体植入2天后或3个月内对种植体进行加载。一系列关于种植体早期负重的临床研究得到了与延期负重近似甚至更高的种植体存留率以及更少的种植体周围骨吸收。
虽然有关种植体早期负重的研究很多,但这些研究都集中于螺纹种植体,并无观察鳍型种植体在早期负重状态下骨结合的基础研究,也并无基础研究比较鳍型和螺纹种植体的骨愈合情况。鳍型种植体与螺纹种植体最大的区别就是在鳍型种植体的骨内部分有一系列独立的环状翼。种植体植入后会在相邻的环状翼之间留下大量的空间,为血痂和编织骨的形成提供场所。研究证实在鳍型种植体提供的这种空间里形成血管和编织骨能获得较快的骨愈合和较好的种植体生物力学方面的稳定性。
本研究的目的即观察鳍型种植体与螺纹种植体在种植体-骨界面上应力分布的区别,考察鳍型种植体在早期负重状态下的骨愈合情况,并与螺纹种植体进行比较。本课题的研究内容分为以下三个部分：
第一部分三种形态种植体周围应力分布的三维有限元分析
[目的]本实验的研究目的是比较鳍型种植体与螺纹种植体在种植体-骨界面上应力分布情况。
[材料与方法]本实验设三个实验组：柱状螺纹(CT)种植体(种植体为柱状,外径3.3mm)、柱状鳍型(CP)种植体(种植体为柱状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)和锥状鳍型(TP)种植体(种植体为锥状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)。三种种植体均为一段式,长度均为14mm,骨内长度为8mm,穿龈高度为2mm。参考下颌骨皮质骨和松质骨的弹性模量,应用大型3D造型软件PRO/E中建立各实验组种植体和周围软硬组织的三维有限元几何模型。应用ANSYS Workbench有限元分析程序自动对模型划分节点和单元。设计了3种负荷加载方式：①垂直向负荷100N,方向与种植体长轴一致,由(?)方指向龈方,载荷部位为胎面中央；②水平向负荷100N,方向与种植体长轴垂直,由颊侧指向舌侧,载荷部位为(?)1/3与中1/3交界处；③斜向负荷100N,方向与种植体长轴呈45°,由(?)颊侧指向龈舌侧,载荷部位为(?)1/3与中1/3交界处。利用三维有限元分析法计算不同负荷条件下各实验组种植体内部和周围粘膜、皮质骨和松质骨的等效应力峰值。
[结果]应力分布云图显示：垂直加载条件下,种植体内部应力分布较为均匀,CT和CP组应力较高点位于种植体末端,TP组位于种植体颈部；各实验组种植体颈部皮质骨应力集中出现在种植体顶部周围皮质骨中；各组松质骨应力集中均位于种植体末端；各组粘膜组织应力集中于基台穿龈部位顶端。水平加载条件下,CT组种植体内部应力集中位于种植体颈部,而CP和TP组在种植体内部的应力分布均匀；各实验组皮质骨应力均集中于顶部；CT组种植体周围松质骨的应力集中于种植体末端,而CP和TP组在松质骨中的应力分布均匀；各组在粘膜组织中的应力集中位于基台穿龈部位的顶部。斜向加载条件下,CT组种植体内部的应力集中于种植体颈部,而CP和TP种植体内部应力分布均匀；各组在皮质骨中的应力集中均位于顶部皮质骨中；CT组在松质骨中的应力集中于种植体末端,而CP和TP组种植体周围松质骨应力分布均匀；各实验组粘膜组织中的应力均集中于基台穿龈部位的顶端。不同加载条件下,各实验组种植体等效应力峰值的比较结果表明：①同一实验组相同部位的等效应力峰值比较：垂直载荷<斜向载荷<水平载荷；②相同加载方式下相同部位,不同实验组的等效应力峰值比较：CT种植体组在种植体内部分布的MVMS较其它实验组大；CT种植体组在种植体颈部皮质骨中的MVMS较其它组小；CP种植体组在松质骨中的MVMS较其它组小；粘膜中CT组MVMS最大,CP组MVMS最小,但各组MVMS均较小。③除了CT组在垂直载荷下种植体颈部皮质骨的应力峰值略低于松质骨,其它所有情况下种植体颈部周围皮质骨的应力峰值均高于松质骨,种植体内部的应力峰值均最大,粘膜中的应力峰值均最小。
[结论]垂直载荷下,三种形态种植体周围组织的应力均较小且分布情况相似；非垂直载荷下,三种形态种植体周围组织的应力均较大,柱状螺纹种植体在松质骨中的应力集中于种植体末端处,而柱状鳍型和锥状鳍型种植体周围松质骨中的应力分布均匀。三种载荷作用下,不同形态种植体颈部皮质骨中的应力均集中位于皮质骨包绕种植体界面的顶端。柱状螺纹种植体在三种加载方式下将较大的应力分布于种植体内部,将较小的应力分布于种植体颈部皮质骨中,有利于抵抗皮质骨吸收。
第二部分三种形态种植体在早期功能性负重下的成骨情况比较
[目的]本实验的目的是为了探讨种植体外形和相应的植入技术在早期功能性负重状态下对成骨过程的影响。
[材料与方法]本实验设计加工制作了三种形态的种植体：柱状螺纹(CT)种植体(种植体为柱状,外径3.3mm)、柱状鳍型(CP)种植体(种植体为柱状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)和锥状鳍型(TP)种植体(种植体为锥状,外径3.0mm,环状翼厚度0.2mm,间距0.8mm)。三种种植体均为两段式,种植体长度均为8mm。在基台与种植体连接部分设计了1.5°锥度。拔除比格犬下颌骨双侧第2、3、4前磨牙,10周后将三种形态的种植体随机植入比格犬双侧下颌骨缺牙区的牙槽骨中,每侧下颌骨3-4枚种植体,保证在每侧下颌骨内每种形态的种植体至少有一枚,1周后行二期手术安装基台并粘固自凝塑料义齿。使用Periotest稳定性测试仪动态监测所有种植体加载时以及加载后2、4、6周的稳定性。6只比格犬在种植体负重后3周和6周分批处死。获取的埋植有种植体的下颌骨标本用来进行显微CT和组织形态计量学的分析。
[结果]CT种植体的稳定性在负重初期显著高于CP和TP种植体,负重6周后,CT和CP种植体的稳定性无显著性差异,且此二者的稳定性明显高于TP种植体。显微CT和组织计量学分析的结果显示：负重3周后,CT种植体的骨-种植体结合率和骨量百分比均显著高于CP和TP种植体；而负重6周后,CT和CP种植体的骨-种植体结合率显著高于TP种植体。另外,负重6周后CT和CP种植体的骨量百分比无统计学差异。
[结论]在种植体植入后1周开始功能性负重可能会促进柱状种植体的骨愈合但阻碍锥状鳍型种植体的骨愈合。不论是螺纹还是鳍型,柱状种植体可能比锥状种植体更适合在早期(种植体植入后1周)负重情况下使用。
第三部分早期负重对鳍型种植体骨结合的影响
[目的]本实验的目的是为了比较鳍型种植体在早期负重和延期负重下的成骨情况。
[材料与方法]本实验设置了三个实验组,即早期负重(early loading, EL)组、不负重的对照组以及延期负重(delayed loading, DL)组。拔除6只比格犬双侧下颌第2、3、4前磨牙,伤口愈合10周后,将柱状鳍型种植体植入比格犬下颌缺牙区的牙槽骨中,每侧下颌骨植入3枚种植体。将6只比格犬随机分配至三个实验组,每组2只犬。早期负重组种植体在植入1周后即进行二期手术,安装基台及自凝塑料义齿；不负重的对照组种植体在种植体植入1周后也将牙槽嵴顶粘膜切开翻瓣缝合,但不安装基台；延期负重组种植体在种植体植入后10周安装基台和上部义齿。使用Periotest稳定性测试仪动态监测所有种植体安装基台后第0、2、4和6周的稳定性。所有动物处死前3周注射钙黄绿素,处死前1周注射茜素红。6只比格犬在种植体负重后3周和6周分批处死。获取的埋植有种植体的下颌骨标本用来进行荧光观察以及显微CT和组织形态计量学的分析。
[结果]早期负重种植体在安装基台时稳定性较低,但是在负重后第2周和第4周的稳定性高于延期负重种植体。在负重后的0-2周和3-5周两个时间段,早期负重种植体和未负重对照组种植的矿化沉积速率均无统计学差异。在负重后3-5周,早期负重种植体的矿化沉积速率显著高于延期负重组。负重后3周时,早期负重种植体的骨-种植体结合率显著低于延期负重组,而到负重后第6周时,早期负重组和延期负重组的所有组织学参数均未见统计学差异。并且,负重6周后早期负重种植体的骨-种植体结合率已经高于未负重的对照组。
[结论]在早期负重状态下,种植体愈合时间缩短到1周即开始加载对柱状鳍型种植体周围骨组织的改建有积极影响。
综上所述,由于提前加载对种植体周骨愈合的促进,柱状鳍型种植体在早期负重(种植体植入后1周)下能够获得良好的骨结合,与柱状螺纹种植体一样适用于该种早期负重方案。而锥状鳍型种植体在早期负重情况下的应用还有待进一步的长期考察。
The implant-abutment system can replace the lost natural teeth as the support for crown, restorating the aesthetics and function of patients. Although the implants have been widely used in many countries currently, some patients choose to give up the implant therapy due to the long schedule. Thus, the conventional implant therapy should be improved immediately to shorten the course of treatment, so as to make more patients benefit from the implant treatment.
Since the introduction of modern dental implant techanique by Branemark in1960s, the conventional delayed loading protocol has been widely used in clinical practice. Many researchers began to study the immediate and early loading protocol until the development of immediate loading by Babbush in1986. The immediate and early loading are still the the hot area of research until now.
Typically, the delayed loading protocol was used to ensure successful and predictable placement of dental implants. However a number of clinical and experimental studies regarding early loading directly challenged this notion with convincing outcomes. The early loading protocol refers to load applied to implants between2days and3months post surgery (between immediate loading and conventional loading). Comparable or even better survival rates and less peri-implant bone loss for early loaded implants were achieved in a series of clinical trials.
Although many studies were conducted to determine the outcomes of early loading applied to threaded implants, few experimental studies exist that investigate peri-implant bone reactions under early loading applied to plateaued implants. The cylinder plateaued implant has a series of separate circumferential fins existing along the intra-osseous portion of the implant, and a large space between the fins which have previously been described for blood clot formation and woven bone development. It has been suggested that a relatively rapid bone healing and thus biomechanical stabilization of the implant could result from the vascularization and woven bone filling in this space.
The aim of this PhD thesis was to evaluate the effect of implant configuration on bone-implant osseointegration under early loading. Three parts were included:
1. The effects of implant configurations on stress distribution:a3D finite element analysis
Materiala and Methods:Three experimental groups were designed according to the implant configurations:cylindrical threaded (CT) implant, cylindrical plateaued (CP) implant and tapered plateaued (TP) implant. The CT dental implants used in this study were3.3mm in diameter. The CP dental implants were3mm in diameter with a1.0mm plateau pitch and0.2mm thickness of each plateau. The TP implants were of the same plateau pitch, thickness of plateau and diameter in the coronal part as the CP implants. The only difference between CP and TP implants was that the latter had a tapered implant body. The3D one-stage implants with various configurations and the peri-implant tissure were modeled by means of the PRO/E program. The100-N static axial, horizongtal and oblique (45°) load were applied to the top of one-stage implant. The3D finite element analysis (FEA) was run at the ANSYS Workbench program. The images showing the distribution of von Mises stresses were abtained to locate the stress concentration in implants and different tissues under load of different directions. In addition, the maximum von Mises stresses (MVMS) at implants of various configurations and different tissues under load of varous directions were quantitatively compared.
Results:The images showing the distribution of von Mises stresses under axial load revealed that no stress concentration was observed within the implant, and high stress values were detected at the end of implants for CT and CP groups and at the cervical part of implant for TP group. The stress concentratons at cervical cortical bone and cancellous bone were lacated at the top regions arround the implants and the end of implants respectively for all groups. Under horizontal load, the stress concentrations within implant were located at the cervical region for CT group, while the stress distributed equally within CP and TP implants. The stress concentrations in the cortical bone were also located at the cervical region for all groups. The stress concentrations in the cancellous bone were located at the end of implant for CT group, while the stress distributed equally in cancellous bone adjacent to CP and TP implants. Under oblique load, the stress concentrations within the implant were lacated at the cervical region for CT group, while no stress concentration was observed within the CP and TP implants. The stress concentrations in cortical bone were still located in cervical regions for all groups. The stress concentrations in cancellous bone were lacated at the end of CT implants, while the stress distributed equally again in cancellous bone for CP and TP implants. In addition, the stress concentrations in mucosa existed at gingival margin for all groups under load of varous directions. The quantitative comparison of MVMS between implants of different configurations indicated that①The MVMS at the same tissue of the same group were compared: axial load> oblique load> horizontal load.②For MVMS at the same tissue under load of the same direction:The CT group had a higher MVMS within the implants and a lower MVMS at the cervical cortical bone than the CP and TP groups. The MVMS at cancellous bone adjacent to the CP implants was lower than others. The MVMS existed in mucosa adjacent to the CT implants was the highest of all groups, while the MVMS existed in the CP implants was the lowest.③The MVMS existed in different tissues for the same group under the load of the same direction were compared:implant> cortical bone> cancellous bone> mucosa.
Conclusions:Higher stress existed within the implant and lower stress distributed in the cervical cortical bone for cylindrical threaded implant, which favours the resistance of cervical bone loss. Under non-axial load, the stress concentrations in cancellous bone were located at the end of implant for cylindrical threaded group, while the stress distributed equally in cancellous bone for both plateated implants. The configuration of implants did not affect the stress distribution in vertical cortical bone, as the stress concentration always existed in the top region of interface between implant and cortical bone.
2. Bone formation adjacent to implants of various configurations under early functional loading in a dog model
Materials and Methods:This study was designed to evaluate the effect of combining implant configuration and surgical technique on bone formation under early functional loading in a dog model. Bone formation adjacent to customized cylindrical threaded, cylindrical plateaued, and tapered plateaued dental implants were compared post-early loading. The Periotest values were monitored dynamically for6weeks. Peri-implant bone healing was evaluated by bone-to-implant contact, and bone volumes fraction analysis after3and6weeks of loading.
Results:The cylindrical threaded implants showed the highest stability when load began, while both the cylindrical threaded and cylindrical plateaued implants had higher stability than tapered plateaued implants after6weeks of loading. No difference in stability was found between cylindrical threaded and cylindrical plateaued implants after6weeks of loading. The data from both micro-focus computed tomography and histomorphometric analysis showed that the cylindrical threaded implants had significantly higher bone-to-implant contact and bone volumes fraction compared to cylindrical plateaued and tapered plateaued implants after3weeks of loading, and the tapered plateaued implant had a lower bone-to-implant contact than the cylindrical threaded and cylindrical plateaued implants after6weeks. In addition, no significant difference was detected for bone volumes fraction between cylindrical threaded and cylindrical plateaued implants after6weeks of loading.
Conclusions:Based on these results, we concluded that the cylindrical implant, whether threaded or plateaued, might be more suitable for early loading (1week) when compared to the tapered implant.
3. Effect of decreased implant healing time on bone (re)modelling adjacent to plateaued implants under functional loading in a dog model
Materials and Methods:The purpose of this study was to evaluate the effect of early functional loading to plateaued implants on bone formation and implant stability in a dog model. Early loading (EL), non-loading control and delayed loading (DL) groups were compared using6Beagle dogs under functional loading. The Periotest values (PTV) were measured dynamically for6weeks. Peri-implant bone architecture was evaluated qualitatively by micro-computed tomography (μCT) and analyzed quantitatively by mineral apposition rates (MAR), bone-to-implant contact (BIC) and bone volumes (BV/TV) after the euthanasia at3and6weeks after loading.
Results:The EL implants showed poor stability at1week, but greater stability at2and4weeks after loading compared to DL implants. There was no significant difference between MAR of EL and unloaded implants at both time intervals. The EL implants displayed a significantly higher MAR when compared to DL implants at3-5weeks. A significantly higher BIC for the DL group was observed when compared to the EL group at3weeks following loading, however at6weeks, no significant difference between these groups was observed. The EL group gained a higher BIC than the no-treatment control group at6weeks.
Conclusions:For plateaued implant, the decreased healing time (1week) displays a positive effect on peri-implant bone (re)modelling under functional loading during the early phase.
Based on the three studies above, we concluded:Favourable osseointegration can be obtained for the cylindrical plateaued implants under early loading (1week after the implant installation) due to the positive effect of decreased healing time. The early application of functional loading on cylintrical plateaued implants could be used clinically to shorten the course of treatment and improve aesthetics.
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