Você está na página 1de 8

ONE STAGE IMPLANT PLACEMENT

Implant Dentistry

Thomas D. Taylor, DDS, MSD


Professor and Head, Department of
Prosthodontics and Operative Dentistry
University of Connecticut School of Dental Medicine
Farmington, Connecticut

John R. Agar, DDS, MA


Associate Professor, Director of Graduate Prosthodontics
University of Connecticut School of Dental Medicine
Farmington, Connecticut

Charles J. Goodacre, DDS, MSD


Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION

The surgical and prosthodontic protocols that led to the development of implant
osseointegration involved a number of different factors. Professors Albrektsson and
Brnemark (reference 1) indicated that implants should be submerged underneath the
mucosa to avoid infection and epithelial downgrowth,1 as well as to provide an
environment for healing that did not apply loading forces on the implants (figures 1A,
1B). This submerged protocol achieved a high level of clinical success. Since
submerged implants require an additional surgery to uncover the implants after
osseointegration, they have been called two stage implants.

Osseointegration also occurs when a one stage protocol is used and clinical studies have
shown that one stage titanium implant systems are highly predictable.2-26 With a one
stage protocol, the implants are not submerged beneath the oral mucosa during the
postsurgical healing period. The implants penetrate the soft tissue and there is
communication with the oral cavity during the period of osseointegration with the
surrounding bone.

A one stage protocol can be used with any titanium implant by attaching an abutment at
the time of surgical placement and suturing the soft tissue around the abutment. There
are also implant systems specifically designed for one stage implantation, whereby the
implant is surgically placed so the occlusal aspect of the implant is positioned
approximately 2-3 millimeters above the bone surface (figures 2A, 2B, 2C, 2D, 2E, 2F,
3A, 3B). The mucoperiosteal flap is not sutured over the implant but is closely adapted
around the implant neck (figure 4).

1
ITI SYSTEM

For the one stage protocol, the implant system with the longest record of scientific
investigation is the ITI Implant System10-26 (International Team for Oral Implantology),
developed by Professor Andre Schroeder in the 1970s (reference 2). These implants are
characterized by a non-submerged design, using a one stage surgical protocol (figures
5A, 5B, 5C, 5D, 6A, 6B). ITI implants are available with either a TPS (titanium plasma
sprayed) coating or a new SLA(sand blasted large grit acid etched) surface. The implants
are also characterized by a flaring at the neck of the implant (occlusal to the bone). This
flaring facilitates the development of a normal emergence profile (figures 5B, 5C, 5D).

The success rate reported with the use of the ITI one stage implant system is comparable
to that reported for two stage implants (references 3, 4, 5) and recognition has occurred
that implants can penetrate the mucosa from the time of placement and be successful
(reference 6).

ADVANTAGES

The one stage protocol provides the following advantages:

1. When using implant systems specifically designed for one stage implantation, the
connection between the implant and the next component that will be attached to the
implant is not located subgingivally. This supragingival location presents a potential
advantage16 from a microbiological point of view since a junction between two parts
produces a microgap where plaque and microorganisms can accumulate (reference7).

While a direct linkage between the location of microgaps and bone loss has not been
definitively established, a gap located below the tissue, as occurs with two stage
implants, could serve as a potential site from which a peri-implant infection could
begin. Some clinicians feel there is support for this concept since it has been
demonstrated that crestal bone loss occurs around two stage implants to a position
approximately 2 mm below the microgap (reference 8), resulting in radiographically
discernible changes. It has been suggested that the minimal crestal bone changes
observed around one stage implants are due to the absence of a screw retained
connection (microgap) located near the crestal bone.

2. Esthetics can be enhanced with one stage implants due to the flared neck which
results in a smooth transition in contour as the implant exits through the soft tissue
(figures 5C, 5D, 7A, 7B).

3. The one stage protocol does not require a second surgical procedure to uncover the
implant and place a healing abutment. This process decreases patient discomfort and
can decrease the cost26 (figures 8A, 8B, 8C, 8D).

2
4. With a one stage procedure, the mucosa-implant "seal" is formed during the primary
healing period and is not disturbed by placement of the secondary part. With a two
stage protocol, the epithelial and connective tissue attachment is formed after the
second surgical procedure and is disturbed when parts are removed (references 8, 9).

5. The connection of the implant with subsequent components is located at or above the
soft tissue which permits visual verification that the parts have been properly
assembled. When the junction between two components is located below the soft
tissue, a radiograph is frequently required to assure proper assembly (figure 9).

6. The height of the restorative components with a one stage implant system is
shorter(distance from the occluding surface of a crown to the implant-abutment
connection) and therefore there is a more favorable lever arm condition than with two
stage systems. It has been proposed that the lever arm relationship present with one
stage systems may be more favorable when forces are not directed along the long axis
of the implant and its restoration components (figures 10A, 10B).

7. While there is no supporting clinical data, some clinicians have noted that the ITI
implant-abutment connection (a Morse Taper) produces a mechanical joint adaptation
that is more resistant to abutment loosening26 than an external hex connection (figure
10B).

DISADVANTAGES

1. ITI implants sometimes have to be used with a submerged technique when bone
grafts are required at the time of implant placement and this process is more difficult
due to the height of the transmucosal portion of the implant. Bone grafting procedures
for correction of small dehiscences and fenestrations with ITI non submerged implant
procedures requires careful closure of the gingival tissue around the implant when
they are not used in a submerged fashion.

2. Non-submerged implants can limit the use of certain types of interim restorations or
can make them more difficult to fabricate.

3. One-stage implants require precise treatment planning and placement (figures 11A,
11B, 11C). Two stage implants can incorporate minor corrections for height and
angle variations. The corrections can begin at the point where the abutment connects
to the implant and the minor changes can sometimes be completed while the
abutment passes through the soft tissue.

4. Esthetics can be compromised if one stage implants are not placed deep enough
below the gingival tissues to avoid seeing the titanium metal. Careful planning and
exact implant placement are required with patients who have a high smile line
(figures 5A, 5B, 5C, 5D). These implants should generally be placed 1 mm apical to
the gingival margin. An esthetic plus (figure 12) implant with a shorter

3
transmucosal collar is available for situations that require deeper placement to help
avoid the possibility of showing the titanium collar.

REFERENCES

1. Albrektsson T, Brnemark PI, Hansson HA, Lindstrom J. Osseointegrated


titanium implants. Requirements for ensuring a long-lasting, direct bone-to-
implant anchorage in man. Acta Orthop Scand 1981;52:155-70.

In order to achieve and to maintain a direct contact between living bone and implant,
threaded, titanium screws with a defined finish and geometry were surgically placed
using a delicate surgical technique and were allowed to heal beneath the soft tissue,
without loading, for a period of at least 3-4 months.

2. Schroeder A, van der Zypen E, Stich H, Sutter F. The reaction of bone,


connective tissue and epitelium to encosteal implants with sprayed titanium
surfaces. J Maxillofac Surg 1981;9:15-25.

Schroeder published his first paper about one stage titanium plasma sprayed implants in
1976 in German. This 1981 publication, in English, discusses 30 implants placed in
primates, and presents results of experiments started in the mid-1970s. The authors state
in the introduction that the success of endosteal implants is largely if not totally
determined by material biocompatibility.

They found the bone applied itself ankylotically to the implant surface and adapted to
all the irregularities and gaps in the titanium plasma sprayed surface. They found living
osteocytes in direct contact with the metal. There was macroscopic evidence of epithelial
adhesion to the implant that could not be verified histologically because of technical
difficulties in obtaining specimens with the implant in situ.

3. Babbush CA. Titanium plasma spray screw implant system for reconstruction of
the edentulous mandible. Dent Clin North Am 1986 Jan;30(1):117-31.

The author indicates that the one stage ITI implant system is a predictable, cost-effective
means by which patients can be restored. In this paper, the author discussed a meeting in
Switzerland where results from the United States, Switzerland, Sweden and Germany
were presented. There were 1739 implants placed in 484 patients. The implants were in
place up to 8 years with a mean post-placement time of 33 months. The success rate was
94%.

4
4. Buser D, Weber H P, Bragger U, Balsiger C. Tissue integration of one stage ITI
implants: 3-year results of a longitudinal study with hollow-cylinder and hollow-
screw implants. Int J Oral Maxillofac Implants 1991;6:405-412.

The authors reported 3-year results of 54 implants placed in 38 partially edentulous


patients. Following at least 3 months of healing, all 54 implants were free of peri-implant
infections and there was no detectable mobility. Radiographs showed no signs of peri-
implant radiolucencies, and the implants were in positions that permitted appropriate
prosthetic restoration. After 3 years of observation, 51 of 53 implants (96.2%) were
successfully integrated. The results indicate one stage implants achieve successful
integration that can be maintained for at least 3 years.

5. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, Belser


UC, Lang NP. Long-term evaluation of non submerged ITI implants. Clinical
Oral Impl Res.1997;8:161-172.

In this multi-center prospective study of 1003 complete and partially edentulous


patients, 2359 implants placed between 1985 and 1994 various surgical and
success rates were analyzed. The 8 year survival rate based on statistical life table
analysis was 96.7%. A 5 year survival rate for the first 536 inserted implants was
actually 97.9% indicating the 96.7% survival rate was a conservative estimate and
will probably be higher. This and other studies continued to confirm the success
of non-submerged implants.

6. Albrektsson T, Sennerby L. State of the art in oral implants. J Clin Periodontol


1991;18:474-481.

The authors found the ITI implant to be well documented from a scientific as well as a
clinical aspect. Though these implants penetrate the mucosa from the time of placement,
it does not seem to disturb the bone anchorage.

7. Persson LG, Lekholm U, Leonhardt A, Dahlen G, Lindhe J. Bacterial colonization


on internal surfaces of Branemark system implant components. Clin Oral Impl
Res 1996; 7: 90-95

In 10 patients restored with implant surported fixed partial dentures the internal
surfaces of 28 Brnemark two stage implant/abutment components were examined for
microbiota. After varying lengths of time in the oral cavity, these surfaces contained a
wide variety and large number of microorganisms.

8. Hermann JS, Cochran DL, Nummikoski PV, Buser D. Crestal bone changes
around titanium implants. A radiographic evaluation of unloaded nonsubmerged

5
and submerged implants in the canine mandible. Journal of Periodontol. 1997;
68:1117-1130.

Fifty-nine implants were placed in foxhounds to study the effect of the microgap
between implants and abutments. They found the coronal bone-to-implant contact
was always located approximately 2 millimeters below the microgap. Loss of bone to
this level below the microgap occurred rapidly and then stabilized at the 2 millimeter
level.

The authors also studied the rough and smooth surfaces of the implants. Similar to
previous studies they found that bone integration requires a rough (treated) surface
whereas soft tissue integration occurs best with a smooth surface on the implant.

9. Cochran DL, Herman JS, Schenk RK, Higginbottom FL, Buser D. Biological
width around titanium implants. A histometric analysis of the implanto-gingival
junction around unloaded and loaded non submerged implants in the canine
mandible. J Periodontol 1997; 68:186-198.

Sixty-nine ITI titanium plasma sprayed (TPS) and sandblasted acid-etched (SLA)
implants were placed in 6 foxhounds. These were evaluated before and after loading.
Mean values for sulcus depth, junctional epithelium and connective tissue contact were
found to be similar in dimensions to natural teeth. The authors felt these findings indicate
that a biologic width develops around the implants and that provides a biologic barrier for
one stage implants.

REFERENCE LIST

1. Albrektsson T, Brnemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium


implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage
in man. Acta Orthop Scand 1981;52:155-170.
2. Schroeder A, van der Zypen E, Stich H, Sutter F. The reactions of bone, connective
tissue, and epithelium to endosteal implants with titanium-sprayed surfaces. J
Maxillofac Surg 1981;9:15-25.
3. Babbush CA. Titanium plasma spray screw implant system for reconstruction of the
edentulous mandible. Dent Clin North Am 1986;30:117-131.
4. Buser D, Weber HP, Brgger U, Balsiger C. Tissue integration of one-stage ITI
implants: 3-year results of a longitudinal study with Hollow-Cylinder and Hollow-
Screw implants. Int J Oral Maxillofac Implants 1991;6:405-412.
5. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, Belser UC,
Lang NP. Long-term evaluation of non-submerged ITI implants. Part 1: 8-year life
table analysis of a prospective multi-center study with 2359 implants. Clin Oral
Implants Res 1997;8:161-172.
6. Albrektsson T, Sennerby L. State of the art in oral implants. J Clin Periodontol
1991;18:474-481.

6
7. Persson LG, Lekholm U, Leonhardt A, Dahlen G, Lindhe J. Bacterial colonization on
internal surfaces of Brnemark system implant components. Clin Oral Implants Res
1996;7:90-95.
8. Hermann JS, Cochran DL, Nummikoski PV, Buser D. Crestal bone changes around
titanium implants. A radiographic evaluation of unloaded nonsubmerged and
submerged implants in the canine mandible. J Periodontol 1997;68:1117-1130.
9. Cochran DL, Hermann JS, Schenk RK, Higginbottom FL, Buser D. Biological width
around titanium implants. A histometric analysis of the implanto-gingival junction
around unloaded and loaded nonsubmerged implants in the canine mandible. J
Periodontol 1997;68:186-198.
10. Scacchi M. The development of the ITI DENTAL IMPLANT SYSTEM. Part 1: A
review of the literature. Clin Oral Impl Res 2000;11 (Suppl):8-21.
11. Schroeder A, Sutter F, Krekeler G. Oral Implantology. Stuttgart, Georg Thieme
Verlag, 1991.
12. Sutter F, Schroeder A, Straumann F. ITI hollow cylinder system. Principles and
methods. Swiss Dent 1983;4:21-8, 30, 32-35
13. Krekeler G, Schilli, Sutter F. The ITI Type H implant: Technical development,
animal experiments, and clinical experience. J Pract Dent 1985, 16.
14. Babbush CA, Kent JN Misiek DJ. Titanium plasma-sprayed (TPS) screw implants
for the reconstruction of the edentulous mandible. J Oral Maxillofac Surg
1986;44:274-282.
15. Sutter F, Schroeder A, Buser DA. The new concept of ITI hollow-cylinder and
hollow-screw implants. Part 1: Engineering and design. J Oral Maxillofac Implants
1988;3:161-172.
16. Buser DA, Schroeder A, Sutter F. The new concept of ITI hollow-cylinder and
hollow-screw implants: Part 2. Clinical aspects, indications, and early clinical
results. Int J Oral Maxillofac Implants 1988;3:173-181.
17. Buser D, Weber HP, Brgger U. The treatment of partially edentulous patients with
ITI hollow-screw implants: Presurgical evaluation and surgical procedures. Int J
Oral Maxillofac Implants 1990;5:165-174.
18. Davis DM The role of implants in the treatment of edentulous patients. Int J
Prosthodont 1990;3:42-50.
19. Gotfredsen K, Hjrting-Hansen E, Budtz-Jrgensen E. Clinical and radiographic
evaluation of submerged and nonsubmerged implants in monkeys. Int J Prosthodont
1990;3:463-469.
20. Weber HP, Buser D, Fiorellini JP, Williams RC. Radiographic evaluation of crestal
bone levels adjacent to nonsubmerged titanium implants. Clin Oral Implants Res
1992, 3:181-188.
21. Buser D, Weber HP, Donath K, Fiorellini JP, Paquette DW, Williams RC. Soft tissue
reactions to non-submerged unloaded titanium implants in beagle dogs. J Periodontol
1992;63:226-236.
22. Leimola-Virtanen R, Peltola J, Oksala E, Helenius H, Happonen R-P. ITI titanium
plasma-sprayed screw implants in the treatment of endentulous mandibles: A follow-
up study of 39 patients. Int J Oral Maxillofac Implants 1995;10;373-378.

7
23. Wismeyer D, van Waas MAJ, Vermeeren JIJF. Overdentures supported by ITI
implants: A 6.5-year evaluation of patient satisfaction and prosthetic aftercare. Int J
Oral Maxillofac Implants 1995;10:744-749.
24. Behr M, Lang R, Leibrock A, Rosentritt M, Handel G. Complication rate with
prosthodontic reconstructions on ITI an IMZ dental implants. Clin Oral Implants Res
1998;9:51-58.
25. Weber HP, Crohin CC, Fiorellini JP. A 5-year prospective clinical and radiographic
study of non-submerged dental implants. Clin Oral Implants Res 2000;11:144-153.
26. ITI Dental Implants. Planning, Placement, Restoration, and Maintenance edited by
Wilson TG, Jr. Chicago, Quintessence Publishing Co, 1993, pp 15-99.