OSTEOINTEGRATION IN DENTAL IMPLANTS
Jilonova Zukhra., Rakhmatullayeva Oygul., Olimov Azimjon.,
Mannanov Javlon., Turgunov Mukhammadali.
Assistants department of surgical dentistry and dental implantology,
Tashkent State Dental Institut, Uzbekistan
Issue DOI http://dx.doi.org/10.37057/2433-202x-209-2020-1-6
The popularity of orthopedic treatment using the method of dental implantation
causes the interest of researchers to study the integration of implants in bone tissue. Analysis of the
literature shows that the improvement of research technology and interdisciplinary approach to the
study of the phenomenon of osteointegration of dental implants has led to a change in traditional
concept in recent years. This article summarizes information about the physiological processes and
cellular interactions occurring on the border "implant-bone tissue" in various stages of integration.
The results of studies indicate the need for revision notions of bio inertness of titanium implants
and consideration of the integration process in the immunological aspect.
osteointegration, dental implantation, osteoblast, bone regeneration, contact
Osteointegration of dental implants refers to the process of bone growing
right up to the implant surface. No soft tissue connects the bone to the surface of the implant. No
scar tissue, cartilage or ligament ﬁbers are present between the bones and implant surface. The
direct contact of bone and implant surface can be very ﬁed microscopically. When osteointegration
occurs, the implant is tightly held in place by the bone. The process typically takes four to six
months to occur well enough for the implant dentist to complete the restorations. This article
provides a comprehensive review of osteointegration in dental implants.
Today, dental implantation is successfully used for orthopedic rehabilitation of patients with
various types of dental defects. The relevance of this method of dental treatment is dictated by the
high prevalence of partial and complete absence of teeth and the need for patients to effectively
restore the integrity of the dental system in the conditions of increasing requirements for aesthetics
and comfort. The world experience of using prosthetics based on dental implants demonstrates the
ability to use this method in various clinical situations (both for fixed prosthetics and for improving
the fixation of removable structures) and at the same time achieve predicted success in treatment.
The steady growth in the popularity of dental implantation in recent decades has led to an
increasing interest of researchers in studying the mechanisms of implant integration in bone tissue.
Traditionally, the most favorable way of integration is considered to be osteointegration, which Per-
Ingvar Branemark, the founder of modern dental implantology, defined as "obvious direct (direct)
attachment or attachment of living bone tissue to the implant surface without introducing a layer of
connective tissue". Its achievement is considered a necessary condition for the success of
prosthetics based on implants in the long term.
The phenomenon of osteointegration was discovered by p.-I. Branemark accidentally, when
studying microcirculation in bone tissue using a small optical camera surgically implanted in the
tibia of a rabbit. Over the four decades following this discovery, an extensive scientific database
describing the mechanisms of implant integration in bone tissue has been accumulated and
continues to be updated.
A. Kulakov et al. (2012) proposes to consider the integration of the implant into the bone
tissue as a dynamic process of interaction between the living and non-living, provided that the
balance of compensatory and homeostatic mechanisms is reached, which allows the living and the
dead to coexist in a single system. The criteria for the success of this interaction are the absence of
inflammatory, necrotic and allergic processes in peri-implant tissues, i.e. the absence of rejection
reactions; formation of morphofunctional determinants of the integration process in the zone of
contact between the implant and the surrounding tissue (in the case of dental implantation - osteoid
or bone substance); relative stability of these determinants over time.
According to the literature, there are the following ways of organizing tissues at the
- osteointegration, as defined by p. I. Branemark , is the direct contact of the bone with the
- fibroosteointegration implies the presence of a connective tissue layer between the actual
bone and the implant, consisting of collagen-new fibers and coarse-fiber connective tissue;
- connective tissue integration that occurs when the implant surface is surrounded by
fibrous connective tissue.
In the literature, the first two options are described as the normal reaction of the bone to
implant insertion, and the latter is considered as its rejection.
For a long time, the generally accepted theory of osteointegration remains the blood clot
According to this theory, the first phase of the osteointegration process is osteoconduction,
the essence of which is reduced to migration and adhesion of mesenchymal cells and osteoblasts to
the implant surface through the remainder of the blood clot. The second phase, osteoinduction,
involves the direct formation of bone, the deposition of mineral salts in the newly formed bone
matrix. The final stage of bone regeneration around the implant is remodeling , which is a long
process of restructuring consisting of alternating cycles of resorption and bone formation.
Insertion of the implant into the bone is a surgical trauma for the tissue, which results in
inflammation, initial manifestations of resorption, and a cascade of vascular-tissue reactions with
subsequent regeneration. An important role in this process is played by the state of the vascular bed
and the level of blood supply in the area of damage. In conditions of ischemia there is a tendency to
form fibrous and cartilaginous tissues instead of forming bone structures.
It was found that even when the implant is twisted at high speeds and good primary stability
is achieved during the positioning of the implant, there is a gap of up to 60 microns between it and
the surrounding bone. Depending on the degree of trauma of the operation in the future, it may
increase to 100-500 microns in some areas. This space is filled with blood and tissue fluid, which
are sources of biologically active substances and proteins necessary for initiating the process of
osteointegration of the implant. Although different properties of the implant surface can affect the
composition and conformation of binding proteins, cell membrane receptors interact with the
titanium surface, and eventually the initial attachment of cell elements to it occurs.
At the initial stage of osteointegration, the extracellular protein fibronectin and
transmembrane heterodimers - integrins take an active part in the recognition and adhesion of cells
on the implant surface.
Blood from the vessels of the implant's bone bed forms a clot that includes platelets, fibrin,
vascular growth factors, transforming growth factor, insulin-like growth factor, etc. These
components stimulate the formation of new blood vessels and the healing of bone tissue.
The network of fibrin fibers allows the migration of osteogenic cells under the influence of
growth factors synthesized by platelets to the implant surface. Growth factors attract fibroblasts and
other undifferentiated cells to the zone of the fibrin matrix, and also stimulate their differentiation.
The peculiarities of this stage largely determine the further integration of the implant. The
dense attachment of a blood clot to the implant surface and the formation of fibrin "bridges"
between it and the viable bone create conditions for the proliferation of osteogenic cells along the
fibrin filaments towards the implant and the formation of de novo bone on the surface of the
implant itself contact osteogenesis, the main mechanism of osteointegration.
Given the importance of the area and density of attachment of blood components and bone
elements to the implant surface at the initial stages of the integrative process, the need for a
developed topography and micro-relief of the surface of the intraosseous part of the dental implant
is not in doubt today. To create a complex surface topography with optimal roughness indicators,
various processing methods are used, which can be divided into two basic approaches:
1) treatment of the implant surface using physical or chemical factors (sandblasting, acid
etching, laser treatment, etc.);
2) deposition on the surface of biologically active components that stimulate bone formation
(hydroxyapatite, tricalcium phosphate, amino acids, etc).
However, the integration of the implant only through contact osteogenesis seems to be a
kind of ideal model. Most likely, the processes of contact and distant osteogenesis occur in parallel
on different parts of the bone - implant interface. In this case, the latter is characterized by the
formation of bone tissue not on the surface of the dental implant, but on the surface of the
surrounding bone. Osteogenic cells of the implant bed produce a bone matrix in the direction of the
The attachment of osteoblasts to the implant surface is observed in the first days after its
installation. Osteoblasts synthesize a number of proteins that are markers of osteogenesis, such as
osteopontin, osteocalcin, and sialoprotein, which promote the adhesion of osteogenic cells on the
implant surface, as well as the consolidation of mineral compounds in the newly formed organic
matrix of the bone. Then begins the construction of a collagen matrix directly on the surface of the
implant, the deposition of osteoid substance, which later transforms into bone.
Bone mineralization is associated with the accumulation of calcium and phosphorus ions in
the newly formed bone matrix, and in addition to calcium-binding proteins, phospholipids and
chondroitin sulfate of the main substance participate in it.
Young bone tissue is then subjected to a long-term structural adjustment. This stage, bone
remodeling, combines two multidirectional processes-bone resorption and new bone formation.
Immature bone resorption occurs primarily as a result of matrix metalloproteinases secreted
by osteoclasts. At the same time, there is an increase in the activity of the acid phosphatase enzyme.
The construction of a new bone in the direction of the implant surface is due to the high functional
activity of osteoblastic cells and is accompanied by the expression of alkaline phosphotase.
The remodeling process is closely related to the load conditions of the implant and as a
result leads to the replacement of immature bone tissue with a functionally more complete structure.
The result of structural adjustment is the connection of the newly formed bone with the surrounding
Interdisciplinary research in immunology and implantology over the past two decades has
significantly enriched and deepened the understanding of the mechanisms of reparative regeneration
of bone tissue, including in implantation. In 2012, the results of the work of L. Chen and K. Rahme
were published, showing the ability of titanium to form nanoparticles in water at room temperature.
There is a growing number of publications reflecting changes in the receptor apparatus of
immune system cells as a result of exposure to metal nanoparticles. It is experimentally established
that particles of titanium, iron, and silicon oxides can undergo phagocytosis. This study, as well as a
number of publications demonstrate the need to consider metal alloys not from the point of view of
"bio-inertness", but from the point of view of their immunological compatibility with div tissues.
Based on foreign and own research, V. V. Labis, E. A. Bazikyan (2016) showed that there is
an emission of nanoscale particles from the oxide layer of the surface of dental implants of various
manufacturers (Nobel Replace, Astra Tech, Straumann, MIS, Alfa - Bio, etc.). Forming conjugates
with plasma proteins, these nanoparticles are then presented to immunocompetent cells. Interactions
of cells in perimplant tissues further determine the adaptive immune response, which is assigned a
regulatory function in determining the course of reparative osteogenesis.
The authors also proposed a method for testing activation of peripheral blood basophils by
metal nanoparticle supernatants from the surface of the dental implant, which will allow selecting
the implant system in each clinical case based on the individual sensitivity of the patient to a
Immunocompetent cells play an important role in regulating the process of osteointegration
at different stages. Interleukins, chemokines, and tumor necrosis factor synthesized by myeloid cells
are involved in regulating the interactions of cells and intercellular substance with the implant
surface and stimulate angiogenesis.
During the migration of lymphocytes in the collagen matrix, a selective group of cells
accumulates that can influence the proliferation of fibroblasts and the secretion of collagen proteins.
Reparative regeneration of bone tissue around the implant is a complex multi-stage process,
which involves coordination of not only local cellular elements and signaling molecules. The
regulatory function is also performed with the participation of the nervous and endocrine systems,
whose action is realized through such biologically active substances as serotonin, P-endorphin, etc.
Many studies have been devoted to the objective evaluation of implant osseointegration
parameters. A group of scientists with the participation of Dr. T. Albrektsson conducted a
morphological study of 33 extracted osteointegrated implants of the Nobel Pharma system. During
the work, an average of 70-80% of bone contacts with the implant surface were detected throughout
the entire interface. According to the authors, for reliable osseointegration of the implant, it is
necessary that at least 60% of the periimplantation density is bone substance.
Professor T. Albrektsson, a representative of the Swedish implantology school, who worked
on the problem of osteointegration together with P.-I. Branemark, named the main factors that
affect the integration process:
- the material from which the implant is made;
- design of the implant;
- the surface quality of the implant;
- load conditions;
- surgical technique for implant placement;
- condition of the bone tissue around the implant.
In various domestic and foreign publications, you can find other factors, but on closer
examination, their essence is reduced to the above. In recent decades, work on improving the
technique of dental implantation is aimed at optimizing the process in these six areas.
Thus, a large number of studies conducted in this direction indicates the high
relevance of the problem of osteointegration and a consistently high interest of dentists in finding
ways to achieve the predicted success in dental implantation. New horizons are opening up in the
study of implant integration into bone tissue using an interdisciplinary approach to the problem. It
seems that the disclosure of immune, humoral and neural mechanisms of regulation of the
integration process will create additional opportunities for targeted impact on them and will make
dental implantation an even more predictable and effective method.
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