Guías Quirúrgicas y Radiográficas en Implantología

JOMI on CD-ROM, 1988 Feb (85-97 ): Biomaterials and Biomechanics in Dental Implant … Copyrights © 1997 Quinte…
Biomaterials and Biomechanics in Dental Implant

Design
John B. Brunski, PhD
This article seeks to give the clinician insight into the design process and
biomaterial/biomechanical aspects of endosseous implant design. Specific facets
considered relate to materials, implant shape, special surface coatings,
shock-absorbers, and the implant-tissue interface.
(Int J Oral Maxillofac Implants 1988;3:85-97)
Key words: biomaterials, biomechanics, design, forces, interface, stress transfer
Bioengineering is critical in dental implant design. The object of this article is to

summarize knowledge about biomaterials and biomechanics of dental implants to
help a clinician confront the following questions: Why are there so many different
implant biomaterials and shapes? Should implants have special coatings on the
surface, and if so why? Should an implant have some sort of built-in shock absorber?
Is there a certain optimal implant-tissue interface, and if so, in what respect is it
optimal?
The goal is to give the clinician insight into the design process and biomaterial
and biomechanical aspects of implant design. A clinician who thinks about dental
implants from the design perspective will demand answers to the following
questions: What are the objectives for a particular dental implant system? What is
the rationale for trying to achieve the objectives in the way proposed? Are the
objectives achieved in practice?
Attention will be restricted to endosseous (endosteal) dental implants.
Design process
Design means to create according to a plan.1 The word design indicates a process,
not an end product such as the particular shape or material of a dental implant. Shape
and material are only two of the many considerations in the multivariable design
problem for dental implants.
The design process is a generic approach to problem solving and consists of
these steps1:
1. Identification of a need
2. Definition of the problem (and sub-problems) to be solved
3. Search for necessary background information and data
4. Formulation of objectives and criteria

5. Consideration of alternative solutions to the problem
6. Analyses and evaluations of alternative solutions
7. Decision-making and optimization
Design has some identifying characteristics. A complicated design problem will
usually be broken down into sub-problems, so these can be addressed separately and
then considered together in reaching final solutions. Often, design must go forward
even when there is missing or unknown information. In design, judgments about the
quality of a solution are made by measuring performance against the stated goals,
not the other way around.
Finally, design is often iterative. There may be a need to design and redesign
several times to optimize performance with respect to goals. There may be no perfect
solution to a design problem, but instead a compromise solution representing the
best solution under conflicting constraints.
Engineering design
In applying the design process to dental implants, it is easy to identify the need (step
1) for an implant. It is also easy to define the problem (step 2). What can be difficult
is translating these generalities into specifics. Exactly how will the problem be
solved? Initial questions are: What are the "masticatory functions" that will be
restored (step 3)? How will design criteria for implants evolve from this (step 4)?
What are alternative approaches to achieving the goals (step 5)?
It is critical that steps 1 to 4 be followed. If these steps are clear, then steps 5, 6,
and 7 outline a path toward creating, evaluating, and optimizing a proposed solution
to the problem. But if steps 1 to 4 are missing or ambiguous (as they are for some
current dental implants), then it becomes difficult if not impossible, to understand
the whole process.
The importance of clearly stating the problem to be solved; the design goals; the
rationale for solving the problem via a certain approach; and the evidence that the
chosen approach does, or does not, satisfy the design objectives can't be
overemphasized.
Trial and error and intuition have legitimate places in design, but if these are the
only elements in the process, then this should be acknowledged. There is nothing
intrinsically wrong about a trial-and-error solution to a design problem. However, it
usually indicates that the designer isn't sure why the solution works. This also means
that the designer may not be sure when it will not work. Even if something "works,"
it is useful to know why.
How do biomaterials and biomechanics fit into dental implant design? These
subjects represent only two of many subproblems in the entire design effort. Any
implant must be constructed from a biomaterial. The biological performance of the
chosen biomaterial will be of concern. Dental implants must function
biomechanically, so biomechanical issues will arise. Implantation surgery,
postoperative care, periodontal health, patient physiology, costs to the patient, and
other aspects also are key subproblems in implant design, but these go beyond the
scope of this review.
Subproblems
Biomechanics is the application of engineering mechanics (statics, dynamics,
strength of materials, and stress analysis) to the solution of biological problems.
Biomechanics pertains to dentistry because the teeth and jaw perform biomechanical
activities during mastication.2 Biomaterials deals with the effects of an implanted
material on the body and vice versa.
Biomechanical and biomaterial subproblems are depicted in Fig 1. First, any
dental implant, regardless of its biomaterial or shape (Fig 2), will be exposed to
intraoral forces and moments. These loadings may be appreciable and the implant
must withstand these loadings without being damaged.
Second, the implant has to be supported within the jaw by some method which
will involve biomaterial and shape factors.
Third, the implant will transmit loading to the interfacial tissues around the
implant, which then must tolerate them without adverse tissue response. The
problem is selecting the material and shape of the implant so the implant functions
properly.
Background
A design problem cannot begin to be solved without background data or
information. For implants, prior research has provided some—but not all—of the
biomechanical and biomaterial data for design.
Following is a synopsis of background research pertaining to implant design.
In vivo loadings. Vertical components of chewing forces have been reported for
patients with natural teeth and for patients wearing conventional and
implant-supported dentures (Table 1).
The normal human dentition is capable of exerting large forces. Axial
components are in the range of 200 to 2,440 N, and lateral force components are of
the order of 30 N (a newton is approximately the weight of one apple; 1 N = 0.2249
lb). For dentures supported by dental implants (fixtures) workers in Sweden8 have
measured vertical closure forces of 42 to 412 N.
Implant design must distinguish between closure forces and vector components
of forces and moments on individual implants supporting a bridge (Fig 3). While
closure forces are useful, individual loading components on implants are required for
detailed design analyses of implants and surrounding interfacial tissues.
Unfortunately, except in animal studies,14 no direct measurements are available
for loading components on dental implants in vivo, although data may be
forthcoming.15 Without these data, in vivo forces must be estimated on dental
implants, and the estimates used for stress analyses of implants or interfacial tissues.
These analyses will only be as good as the input information, which is approximate
at this time.
Implant properties. Implants should not fracture, yield, fatigue, wear, or
otherwise fail during in vivo use. Failure prevention necessitates testing and stress
analyses of the implants and tissues. Assuming there is accurate background data on
typical implant loading (which is limited, as previously noted), the problem is to
select adequate intrinsic and structural mechanical properties of implants.
Intrinsic properties pertain to the material and not its shape. They include a
material's elastic moduli, yield point, ultimate tensile strength, compressive strength,
fatigue strength, and hardness. (For corrosion behavior, intrinsic properties could
also be defined.) Values can be found in textbooks and literature, or they may be
directly measured via standard test methods.16-19 Caution is advised in using
handbook values, because manufacturing processes can cause significant property
differences between raw material and the finished product.
Structural mechanical properties embody both the intrinsic material property and
the geometrical shape of the device being considered. For example, the
deformability of a beam in bending depends on the product EI (flexural rigidity),
where E is Young's modulus of elasticity and I is the second moment of area of the
beam's cross-section. The deflections of a cantilevered dental bridge could be
inappropriate even when the bridge is made of a strong, high-modulus (E) dental
alloy because its deflection under load will depend on both modulus and dimensions.
There are handbooks and articles on proper structural design that can be applied to
implant design.20-22
Biomechanical properties. When considering an implant design, it would also
be helpful, if not essential, to have data on:
• The percentage of an implant's surface that will actually be supported by hard
versus soft interfacial tissues
• The mechanical properties of the interfacial tissues
• The extent to which the implant will rely on mechanical support from trabecular
versus cortical bone
• The response of interfacial tissues to the imposed mechanical conditions arising
from in vivo loads on the implant
• The presence or absence of significant attachment or bonding of interfacial

tissues to implant
Data exist on the mechanical behavior of both trabecular and compact bone,
including elastic behavior, viscoelastic properties, anisotropy, yielding, fracture,
fatigue behavior, and related aspects.23 However, little is known about the
biomechanical properties of bone adjacent to a dental implant.
Those who advocate fibro-osseous integration wish to have fibrous tissue at the
interface.24 It would be appropriate to study mechanical properties of this tissue also.
For interfacial bone, it is not clear if properties measured on standard bone
samples should be extrapolated to bone found adjacent to implants, where there can
be variations in porosity, maturity and degree of mineralization. In the case of
interfacial fibrous tissue, there is little information on its properties.25,26
It is clear that interfacial bonding— whether at the endosseous or permucosal
interface—can make a difference in the interfacial load transfer problem. The results
of finite element stress analyses of implants in bone depend on whether interfacial
bonding is assumed in the computer models27 (Fig 4).
Interfacial load transfer. In dentistry and orthopedics it has long been
appreciated that bone is a living tissue capable of responding to its biomechanical
environment (Wolff's Law). However, recent studies have only begun to unravel the
nature of this law and some of its possible mechanisms at bone-implant interfaces. A
recent review article gives references on this topic in connection with implant design
28
It is suspected that mechanical factors such as relative motion (sometimes called
micromotion) stress, strain, and related factors at the interface can influence tissue
response to implants. Relative motion is meant to describe the situation in which an
implant moves or displaces with respect to interfacial tissues (Fig 4).
Studies (Table 2) indicate that relative motion correlates with fibrous tissue
formation around implants in bone, especially if this motion occurs during the early
healing stages after implantation. Brånemark's osseointegration system is predicated
on a two-stage implantation method that discourages relative motion of fixtures with
respect to interfacial tissues during early postoperative healing, leading to a close
adaptation of bone (rather than soft tissue) to fixture surface.
Finally, there can be long-term bone reactions at interfaces in response to
biomechanical loading. Brånemark's long-term results show "laminalization" of
trabeculae around a loaded fixture.40 Likewise, biomechanically-mediated bone
remodeling has been of interest in orthopedics.41
In both orthopedics and dentistry, the search continues for a quantitative
understanding of the biomechanics of bone remodeling in relation to implant design
and load transfer at the interface.

Implant materials. When material is implanted into a surgically prepared site in
bone, there are numerous critical issues relating to biomaterial-biological
interactions (Fig 5). From the biological side, the dentist needs to consider water,
ions, macromolecules, cells, and tissue responses—inflammatory response, wound
healing, and cell attachment—in the presence of a biomaterial surface.
On the biomaterial side, the structure and properties of the biomaterial's surface,
release of corrosion products, surface energy, and oxide stability should be
considered. Recent textbooks and articles discuss these topics in further detail.42-47
NIDR publications have also summarized biomaterials research as it relates to
dental implants.48,49 A continuing challenge for each dental implant designer is to
clearly define design goals in specific biomaterial terms.
Objectives of various implant systems
The text by Linkow and Cherchève50 and a recent article51 provide a history of the
evolution of dental implants. Implants have been made from metallic, ceramic, and
polymeric biomaterials. The myriad of early modalities included both one- and
two-stage configurations.
For example, Greenfield's buried two-stage latticed cage was patented about
1909 and predates more recent two-stage systems. Other early shapes for implants
included pins; screws; root forms; single and double spirals; screws with holes
(vent-plants); sapphire-coated screws; numerous varieties of blade-vents; and
two-stage designs such as Cherchève's "sleepaway" implant, screws with protruding
pins, and designs with expansion mechanisms analogous to those of a hollow wall
anchor.
More recently, there has been the osseointegrated system of Brånemark,
followed by analogous systems of various shapes, sizes, and biomaterials (Fig 2).
The early evolution of dental implants reveals the main design strengths to be
creativity, cleverness, boldness, and pioneering spirit. However, as a rule, the main
weakness has been incomplete understanding and execution of the steps in
engineering design.
Sometimes designers have blurred the difference between design rationale,
which may be theoretical, and design evaluation, which requires experimental
evidence. Also, there has been a tendency toward teleological interpretation of
evidence. That is, after observing limited experimental results, the investigator
claims to understand and see evidence of nature's purpose in these results.
The following sections summarize and discuss the main design rationales,
objectives, alternative strategies, and results for a variety of dental implants. The
emphasis is on biomechanical and biomaterial subproblems. No clinical comparisons
are made. It will be evident that a main theme relates to the question of how best to
fix a dental implant in its interfacial tissues.
Pseudoperiodontal ligament. Rationale. An influential early design rationale
was the "pseudoperiodontal ligament," discussed by Linkow and Cherchève in 1970
50 and more recently by James52 as well as Weiss in connection with fibro-osseous
integration.24 Linkow and Cherchève asserted that "a good implant design . . . must
either complement or supplement the natural biomechanical forces of the site," and
"the operative procedure. . . must be so precise as to cause as little trauma and
destruction to the site as possible."
Moreover, Linkow and Cherchève proposed that the part of a dental implant in
bone "should be irregularly shaped so bone could grow into and through the
irregularities." They stated that "a band of collagenous connective tissue forms
between the implant and its surrounding bone. . . which will firmly wrap around and
bind itself to the implant."
They also claimed that this collagenous tissue was a pseudoperiodontal ligament
that could behave as follows: (a) the fibers connect to bone in a way reminiscent of
Sharpey's fibers; (b) the fibers can pull on the bone when the implant is loaded; and
( c) this pulling on the bone recreates the tension on bone necessary for its healthy and
continued growth.
Critique. A difficulty with this rationale is that the argument is teleological.
There is little detailed experimental evidence that interfacial collagenous tissue
actually functions in the ways proposed. It is alleged that dental implants with
interfacial fibrous tissue do function properly in humans and there must therefore be
functional capabilities of fibrous tissue around such implants. However, these are
frequently anecdotal clinical reports with no attempts to quantify any functional
capabilities of this fibrous tissue.
Theories can be proposed to suggest how fibrous tissue may be functioning.
However, data are still needed on the structure, function, properties, and formation
of this tissue in relation to implant success.
Actually, the evidence is strong that fibrous tissue forms as a result of relative
motion of implant and healing bone, regardless of biomaterial used (Table 2). This
suggests that fibrous tissue is a byproduct of mechanical interference with bone
healing around the implant. Whether it also functions as a pseudoperiodontal or
suspensory ligament for a dental implant is a separate question that has not been
fully answered, according to some researchers.
Ten Cate,53 for example, disputes the analogy between fibrous tissue and normal
periodontium on the basis of its cellular makeup and biological origin. Therefore, in
terms of design, the problem remains for advocates of fibrous tissue to explain the
rationale and objectives for this interfacial tissue, and, most importantly, to properly
demonstrate that these objectives are achieved in practice.

Macro-irregularities. Rationale. Macro-irregularities in an implant include
macroscopic threads, fenestrations, pores, grooves, steps, threads, or other surface
irregularities that are visible. The idea is to create mechanical interlocking between
implant and bone at the macro level.
The concept has a long history, as evident from the 1909 "buried cage" of
Greenfield up through the many vented screws and blades mentioned earlier.
Porous implant systems have also been devised by researchers. To make a
porous implant, beads of material are typically sintered or fused together onto the
surface of an implant core, which is frequently a cylindrical shape. Metallic,
ceramic, and polymeric porous materials have all been employed.54-63
A variation on this theme is the fiber metal (fibermesh) system of Weiss and
Rostoker,64 in which a fine meshwork of titanium alloy is sintered onto a titanium
core to create a macroporous surface morphology.
Because Brånemark's fixtures and other similar shapes (Fig 2) have grooves,
steps, and ledges for bone ingrowth, it can be argued that these systems are also
based on macro-interlocking. However, they will be discussed later under the
separate heading of osseointegration.
Critique. Concerning this design rationale, there are five key findings. First,
bone can grow into the pores of porous systems, provided the pores are
interconnected and have a diameter of about 100 microns, since this allows proper
vascularity and mineralization.65,66 This result is seen in metallic, ceramic, and
polymeric systems.
A second key finding is that bone ingrowth will not occur if there is relative
motion during post-implantation bone healing.67,68 Fibrous tissue ingrowth will
occur instead (the threshold of relative motion beyond which bone ingrowth will not
occur has not been established). It follows that a two-stage implantation procedure is
advisable in porous dental implant systems to minimize interfacial fibrous tissue
formation.
Third, a two-stage implantation method alone may not guarantee stability during
early healing, since stability also depends on the initial fit and stability of the implant
in the bone site. Porous implants are frequently intended to be press-fit into a
carefully prepared bone site. Even this does not guarantee that they will remain
immobile during subsequent bone healing, which will include a resorptive phase that
can expand the size of the prepared site and loosen the implant.
Also, although the buried portion of a two-stage implant is not directly loaded, it
might still be indirectly loaded by jaw deformations,69 which in turn can lead to
relative motion and fibrous tissue. Buried, screw-shaped fixtures of the Brånemark
type may provide greater resistance to relative motion than press-fit shapes.
Alternatively, the hollow basket70 and single crystal sapphire (Al2O3) screw71
are one-stage implants that apparently afford enough stability during the early
healing—probably because of their geometry—to allow bone ingrowth into surface
asperities and holes.
Fourth, interfacial shear strengths for porous designs have been measured and
give some insight into mechanical integrity and loading limits of the bone-implant
interface. Tests of porous Ti-6AI-4V and polyethylene63 show interfacial shear
strength values of 2 to 10 MPa, depending on implantation time. Based on the
dimensions of the implants (approximately 4 mm diameter, 8 mm long), these
stresses convert to failure loads of 176 to 1,407 N. These may be interpreted as
upper bounds for safe axial biting loads on implants of this geometry. However, if
bite force data in Table 1 are realistic, these porous implants would seem to be
underdesigned and liable to fail by overload.
Finally, with porous systems in orthopedics there has been concern about
adverse interfacial bone remodeling (stress protection atrophy), possibly related to
nonphysiological interfacial stress distribution caused by porous implants.72 It is
uncertain if this is also a problem with porous dental implants. Until more is known
about the physiological desirability of one stress field over another, this subject is
difficult to discuss with respect to implant design.
Micro-irregularities. Rationale. Here, the surface irregularities are at the
microscopic level, possibly in conjunction with macro-irregularities. This would
afford the possibility of microscopic interlocking of bone and implant, which might
enhance the load transmitting capabilities of the interface.
For instance, the Tubingen dental implant is a tapered stepped cylinder of
aluminum oxide ceramic (Al2O3) with rounded edges so pressure points can be
avoided in these bone contact zones.73 The shape is intended to require force transfer
to bone mainly at right angles to the transfer surface. The Tubingen implant also has
shallow, circular depressions (about 0.9 mm in diameter) repeated over the entire
surface, which are designed to encourage osteonal bone apposition at the micro
level.
Carbon and carbon-coated dental blade-vent implants can also be made to have a
microporous surface texture, with soft undulations of about 10-micron depth. A
blade-type implant consisting of a graphite substrate and a 0.03-inch coating of
low-temperature isotropic (LTI) pyrolitic carbon, was manufactured, tested,74 and
implanted in baboons.75
The rationale for use of this material was its general biocompatible performance
in blood-contacting applications, its possible prevention of corrosion if used as a
coating on macroporous metallic implants, and the surface microtexture of the LTI
material.
Also, experiments have explored the use of grit-blasting and other texturing
methods for enhancing fixation properties such as stiffness and strength of the
interface for carbon-coated and noncoated implants.76-78
Critique. The interface observed for micro-irregular surfaces tends to be close, if
not direct bone-implant apposition, suggesting that the goal of microscopic
interlocking could indeed be achieved. Thomas, Anderson, Cook, and co-workers76
used a dog femoral transcortical plug model in which 6-mm diameter × 18-mm long
cylinders of various materials and surface textures were inserted in dog femora and
then pushed out via a special mechanical test rig after various implantation times.
The testing provided data on interface shear strength and interface shear stiffness
as a function of implant material and surface texture. The former is the shear stress
(in MPa) at maximum load during a push-out test and the latter is the ratio between
shear stress and displacement (units GPa/m).
Data from this model76-78 indicate that the interface shear strength for LTI
pyrolitic carbon samples—and a number of other materials and surface textures—is
about one order of magnitude less (range: 1.56 to 4.48 MPa) than values for
macro-irregular, porous systems (roughly 2 to 16 MPa). These stress values help
define how large a force (axial) can be taken by the implant before the interface fails.
For a typical LTI carbon cylinder in the transcortical dog model (where the
bone-implant contact area is about 80 mm2), the push-out force is of the order of 150
N. This force is low with respect to anticipated axial biting forces (Table 1).
Therefore, more surface area would be required to increase the failure load for a
dental implant based on this geometry and fixation rationale.
In a recent study by Cook79 using hydroxylapatite (HA) coated onto Ti-6Al-4V
cylinders in the same transcortical plug model, HA-coated samples did have larger
interfacial shear strengths (6.07 to 7.27 MPa) than uncoated pure titanium samples
(0.93 to 1.21 MPa) with implantation times from 5 to 32 weeks.
Assuming approximately the same interfacial areas of bone-implant contact for
all samples, this result means that HA samples have larger failure forces (about 500
N) than uncoated samples, but these values are still low compared to possible axial
components of in vivo forces.
It is also noteworthy that the pushout interfacial strength for HA-coated
cylinders was limited by the bond between HA and metal substrate rather than HA
and bone (90 percent of the cases at the 32-week implantation time failed by
separation of the Ti-6Al-4V cylinder from its HA coating). Further research is
needed to establish the biomechanical integrity of the coating in the presence of the
body environment and fatigue-type loading.
Regardless of whether failure occurs at the bone-HA interface or the

HA-substrate interface, the failure forces remain low compared to anticipated axial
biting force components in vivo.
In terms of interface shear stiffness, there is little difference among materials
with macro- versus micro-irregular surfaces. Stiffness values are in the range of 5 to
60 GPa/m.76 Stiffness values for HA-coated samples (33.7 to 55.45 GPa/m)
exceeded those for uncoated samples in the most recent experiment of Cook (5.66 to
11.77 GPa/m), but did not exceed the values for uncoated materials (28.7 to 59.8
GPa/m) reported in earlier experiments.76 The clinical design significance of
different stiffness values is not immediately obvious from these studies alone.
Bioactive materials. Rationale. Some implant materials are bioinert; others are
surface-active or bioactive.80 These terms are misleading, as any implanted
biomaterial must provoke biological activity and is thus bioactive. However,
bioactive is meant to imply the design objective that biomaterials should enhance or
stimulate new bone formation and promote bone-implant attachment.80
The rationale for bioactive implants in bone comes from observations that
implant loosening is the leading cause of implant failure, and that failure usually
follows movement at the tissue-implant interface.80 The idea is to have an interfacial
bond to prevent this movement.
Ceramics such as bioglass,80 tricalcium phosphates,81 hydroxylapatite,82-84 plus
metals or ceramics coated with these substances85-89 represent alternative means for
achieving this objective.
Critique. From a design standpoint, there are strengths and weaknesses of this
approach, starting with the rationale itself. The assertion80 that failure usually
follows movement at the interface requires clarification, since the nature of this
movement is not detailed.
For example, it is known that bioglass dental implants can develop interfacial
fibrous tissue instead of bone bioglass bonding if they are loaded during the early
healing period.34 This is due to relative motion in much the same way as with other
implant shapes and materials (Table 2, Fig 5). Therefore, use of bioglass material
alone does not prevent movement (relative motion) of this type and subsequent
fibrous tissue formation.
Alternatively, bone-implant bonding may be a valid way to limit or prevent
interfacial movement of the type discussed by Sir John Charnley,87 a pioneer in early
hip joint replacement. He noted the possibility of relative motion between surfaces
of two substances of different elastic moduli occurring after some sort of initial
bone-implant apposition has been formed.
Assuming that it is possible to produce bone in close apposition to implant
materials, Charnley pointed out that the only mechanical difference between glued
(bonded) and interlocking surfaces is the inability of simple mechanical interlocking
to resist perpendicular (tensile) forces tending to pull the surfaces apart.
It is implicit in Charnley's remarks that relative motion would cause fibrous
tissue formation and implant failure. Bioactive materials may be beneficial in
producing a bone-implant bond capable of resisting tensile forces across an interface.
One problem is that the extent to which tensile interfacial forces are present
depends on the specifics of the situation. Implant loading, implant geometry, and
mechanical properties of bulk implant and bone should be considered. Finite element
models of screw-shaped implants27 suggest that it is possible to have regions of
tensile separation at the interface if there is no bonding assumed in the model (Fig 4
).
Brånemark points to the importance of having intimate adaptation and
attachment of bone to the implant surface to resist tensile and shear loadings.88 Other
investigators believe it possible to design implants so the majority of load
transmission will be compressive,89 obviating the necessity for a bond to resist
tensile or shear loads. Two Dutch research teams90,91 are using hydroxylapatite
dental implants, intending that bone will bond along the surface and thus resist
tensile and shear loading. The best design rationale with respect to this issue awaits
continuing evaluation of both the bond strengths and the overall physiological
acceptability of the intraosseous stress fields produced by the various shapes of
implants.
For 45S5 bioglass, Hench and Wilson estimate bond strengths to be 117 MPa,80
but push-out experiments in animals (similar to those conducted by Cook) show
values of 3 MPa, which is little more than that for smooth titanium ( 1 MPa), and
less than that for hydroxylapatite-coated titanium (6 to 7 MPa).
Evidence indicates that bioactive implant materials may form interfaces that
resist tensile and shear forces. However, precise data on the bond strength and its
limitations remain to be fully documented, according to some researchers.
Finally, there has been a continuing concern about the mechanical properties of
bioactive materials themselves, since most are relatively brittle ceramics. Dutch
workers have seen fatigue fractures of HA implants in vivo, and are now using
prestressed cylinders to reduce the likelihood of such fractures.91
Osseointegration. Rationale. Brånemark92 coined the term osseointegration
(OI) to mean a direct structural and functional connection between ordered living
bone and the surface of a load-carrying implant. Brånemark's objective was to avoid
getting fibrous tissue. He sought direct bone-implant apposition instead.
The rationale was that if the deeper connective tissues were allowed to heal
properly around a dental implant, then the implant would be firmly fixed in bone and
better able to support forces and allow formation of a proper permucosal interface.
To achieve OI, he devised, developed, and tested an implant material (pure Ti),
geometry (screw shape), surgical protocol (slow speed bone cutting, two-stage
implantation), and appropriate prosthodontic techniques. He and his team evaluated
the system using biomechanical, biomaterial, biological, and clinical testing.93
Other workers have based their implant designs on the concept of obtaining
close bone apposition into screw threads or similar geometry. Not all of the designs
have involved two-stage implants; the hollow basket,70 and the single crystal
sapphire (Al2O3) implant71 are examples of one-stage implants in which the
observed bone-implant interface resembles, at least at the light microscopic level, the
close bone apposition seen in Brånemark-type fixtures.
Critique. In terms of the design process, the development of the OI system also
shows strengths and weaknesses.
The main strengths have been the published goals and rationale for design
features, followed by appropriate evaluations via theory and experiments. The
selection of a two-stage implant, the gentle surgical technique, and the screw-shaped
fixture geometry were devised to maximize stability of the fixture in bone during
postoperative healing, which discourages fibrous tissue formation.
Biomechanical evaluations of the OI system have included measurements of
closure forces in patients with OI fixtures8 discussions of the mechanics of load
transfer at the fixture-bone interface, and theoretical discussions of load sharing
among multiple fixtures.88
Also, biomechanical aspects of prosthodontic design have been discussed.22
Biomaterial evaluations have used optical and electron microscopy to characterize
the nature of the bone-implant interface,94 and surface analytical studies95 to relate
surface properties and tissue response.
However, even the OI system, which is arguably the most extensively
documented of all dental (if not orthopedic) systems, has some weaknesses.
• What is the exact structural definition of OI? Over what percentage of the total
surface area of a fixture must there be direct bone contact for OI to exist? (The
percentage may depend on the relative amounts of cortical versus cancellous bone at
implantation sites—Fig 6.) Must there be a bond between bone and the fixture in
order for OI to exist, and if so, what is the nature and strength of the bond?
• What is the detailed functional definition of OI? What rules govern the alleged
mechanically related bone remodeling adjacent to fixtures? Are existing fixtures
optimized with respect to load transfer in cancellous versus cortical bone? What are
the loading limits in vivo?
• Are fixtures stiffer than normal teeth, and if so, does this have clinical
significance when fixtures are used with natural tooth abutments?

• Is the present fixture geometry the only one that will work? Is the current shape
optimized, and if so, with respect to what criteria? Can fixtures be loaded earlier
without problems at the interface?
Intramobile elements. Rationale. The design of at least two dental implant
systems (IMZ and Flexiroot) has been based on theoretical and clinical concerns
about the in vivo, biomechanical behavior of osseointegrated dental implants,
particularly if these implants are used in conjunction with natural teeth.
IMZ literature96 suggests that it may be necessary to integrate flexible and
shock-absorbing elements into the implants to imitate the flexibility of natural teeth
and to bring about improved force transfer to bone. Also, computer models suggest
improvements in intrabony stress fields when there is an intramobile element (IME)
in an implant.97 On the other hand, Flexiroot literature asserts that there may be
"excessive mobility" in the IMZ system, which "creates the opposite problems
encountered by the rigid Brånemark system. . . if it is connected to the natural
dentition, the natural dentition will bear an overwhelming portion of the occlusal
strains and stresses."98 Flexiroot therefore favors a design based on limited mobility.
Critique. One of the problems in assessing these systems is a lack of
experimental data. In theory, simplified biomechanical models can illustrate how
stiffness of implants and teeth might play a role in load partitioning among bridge
supports (Fig 7). The results of such a model, however, will depend entirely on the
assumed biomechanical behavior of the teeth and implant abutments, which at
present are not known.
Experimental evaluation of both IMZ and Flexiroot systems would require
careful measurements of both tooth and implant mobility in all relevant directions,
but so far only limited data are available.
Tooth mobility has been studied for years, but implant mobility has not.
Likewise, the question of shock absorption by implants has been theoretically
discussed,88 but experimental data are few. Although some of the design rationales
may prove to have merit, it remains for the designers to justify them more fully in
terms of clinical need and experimental performance.
Conclusion
For nearly all implant systems, the major objective is long-term fixation of implants
to bone. To achieve this goal, designers of implant systems must confront
biomaterial and biomechanical subproblems, including in vivo forces on implants,
load transmission to the interface, and interfacial tissue response. These subproblems
have been discussed along with design rationales for the different dental implant
systems that have evolved.
The purpose of this discussion has been to encourage clinicians to think about
dental implants in terms of the design process, which offers a framework to build an
understanding of the burgeoning dental implant field. In confronting the numerous
implant systems on the market, the clinician will do well to seek clear statements of
objectives, rationale, and measures of performance with respect to goals.
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Fig. 1
Biomechanical and biomaterial subproblems are part of dental implant design. They
involve in vivo forces and moments, interfacial load transmission, and interfacial tissue
attachment and response.
Fig.
Charles English, VA Hospital, Augusta, Ga).
Fig.
supporting implants and teeth. The interfacial tissues, in turn, have a biomechanical
function in that they must support the abutments.
Fig.
Fig.
5 When any biomaterial is implanted into tissue, there are a number of possible
biological reactions that must be addressed by implant designers. (Reprinted with
permission from Andrade.44)
Fig. 6 Scanning electron microscopic view of the bone

"crypt" left behind after a titanium fixture (3.5 mm OD) was removed from a canine
mandible after approximately 7 months. It reveals a larger percentage of bone adjacent
to titanium near the cortical plates of the mandible (left and right borders of photo), and a
lesser percentage distally.
Fig. 7 A
simplified biomechanical model illustrating the relevance of the "stiffness" of implants
versus natural teeth. If abutments and their interfaces are represented as simple elastic
springs, then the fraction of the applied load P taken by each abutment is controlled by
the relative values of k 1 k2, and k3.

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JOMI on CD-ROM, 1988 Feb (85-97 ): Biomaterials and Biomechanics in Dental Implant … Copyrights © 1997 Quinte…

Biomaterials and Biomechanics in Dental Implant

Bioengineering is critical in dental implant design. The object of this article is to

4. Formulation of objectives and criteria

• The presence or absence of significant attachment or bonding of interfacial

and load transfer at the interface.

demonstrate that these objectives are achieved in practice.

Regardless of whether failure occurs at the bone-HA interface or the

significance when fixtures are used with natural tooth abutments?

Quintessence Publ Co Inc, 1985, p 99.

polymethylmethacrylate tooth implant: Preliminary studies. J Prosthet Dent

Dev Art Org 1976;4:181.

Albrektsson T (eds): Tissue Integrated Prostheses. Chicago, Quintessence Publ

Fig. 6 Scanning electron microscopic view of the bone

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