10.59987/ads/2012.2.44-50
The purpose of this study is to evaluate macroscopic and microscopic appearance of a new implant design, with particular emphasis given to the type of prosthesis connection. Two dental implants of the same type (Torque Type®, WinSix®, BioSAFin. S.r.l. - Ancona, Italy), with sandblasted and acid etched surfaces ( Micro Rough Surface®), but differing from each other for the prosthesis connection system, were examined by scanning electron microscope (SEM) analysis at different magnifications: TTI implant, with a hexagonal internal connection, and TTX implant, with a hexagonal external connection. SEM analysis showed that the Torque Type® implant is characterized by a truncated cone shape with tapered tips. The implant body showed a double loop thread and double pitch with blunt tips. For both types of connection, the implant neck was 0.7 mm in height with a 3% taper. This implant design may be able to guarantee osteotomic properties at the time of insertion in a surgical site suitably prepared, a facilitated screwing, thanks to the thread pitch and to the broad and deep draining grooves, thereby ensuring a good primary stability. The different connection design appears defined and precise, in order to ensure a good interface between the fixture and the prosthetic components. Therefore, this design appears to be particularly suitable in cases where a good primary stability is necessary and a precise coupling between endosseous and prosthetic components, as it allows an easy insertion of the fixture even in conditions of reduced bone availability, and in cases of immediately loaded full-arch rehabilitations.
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implant connection
Macroscopic and microscopic evaluation of a new implant design supporting immediately loaded full arch rehabilitation
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Macroscopic and microscopic evaluation of a new implant design supporting immediately loaded full arch rehabilitation
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                                                                                                   Original article



Macroscopic and microscopic evaluation of a new
implant design supporting immediately loaded full arch
rehabilitation




                                                                                        li
                                                                                     na
Stefano Tetè, MD, DDS1                                     coupling between endosseous and prosthetic com-
Vincenzo Zizzari, DDS2                                     ponents, as it allows an easy insertion of the fixture
Alessandro De Carlo, DDS1                                  even in conditions of reduced bone availability, and




                                                                                  io
Bruna Sinjari, DDS1                                        in cases of immediately loaded full-arch rehabilita-
Enrico Gherlone, MD, DDS3                                  tions.




                                                                               az
1
   Department of Medical, Oral and Biotechnological        Key words: dental implant, Scanning Electron
Sciences, “G. d’Annunzio” University, Chieti, Italy        Microscope (SEM), implant connection.
2
  Department of Drug Science “G. d’Annunzio” University,
Chieti, Italy




                                                                   n
3
  Department of Oral Sciences,”Vita-Salute San Raffaele”   Introduction
University, Milano, Italy




                                                                er
                                                           Osseointegrated implantology, thanks to many studies,
                                                           is now considered a surgical discipline with proven ef-
Corresponding author:                                      fectiveness. Success in implant dentistry consists in get-
Stefano Tetè, MD, DDS                                      ting a good rate of integration between implant and host

                                         nt
Department of Medical, Oral and Biotechnological
Sciences, “G. d’Annunzio” University, Chieti, Italy
e-mail: tete@unich.it
                                                           bone, which defines a good osseointegration according
                                                           to the principles initially introduced by Branemark and
                                                           subsequently developed by numerous studies over the
                                       iI
                                                           years (1-3).
                                                           The implant design is a key factor to achieve good pri-
                                                           mary stability. It should be designed to guarantee the es-
                                     on

Summary                                                    tablishment of a direct connection between bone tissue
                                                           and implant surface during the early stages of the heal-
The purpose of this study is to evaluate macroscop-        ing process, without the interposition of fibrous tissue,
ic and microscopic appearance of a new implant de-         as well as to achieve an even distribution of the loads
                              i


sign, with particular emphasis given to the type of        which, through the masticatory system, are transmitted
                           iz


prosthesis connection. Two dental implants of the          to the peri-implant bone tissue whilst chewing (4,5).
same type (Torque Type®, WinSix®, BioSAFin. S.r.l.         There are two fundamental aspects of implant design:
- Ancona, Italy), with sandblasted and acid etched         the macro-structure, characterized by the shape of the
               Ed




surfaces ( Micro Rough Surface®), but differing from       body, the characteristics of the neck and the apex, by
each other for the prosthesis connection system,           the design, by the number and pitch of the thread, and
were examined by scanning electron microscope              the microstructure, characterized by the surface treat-
(SEM) analysis at different magnifications: TTI im-        ment. In addition, there is also the good accuracy of the
plant, with a hexagonal internal connection, and           prosthetic components (6-8).
TTX implant, with a hexagonal external connection.         It is known that differences in implant shapes induce
 IC




SEM analysis showed that the Torque Type® implant          significant changes in force distribution on the surround-
is characterized by a truncated cone shape with ta-        ing bone (9). The macroscopic geometric pattern of a
pered tips. The implant body showed a double loop          dental implant can assume a cylindrical or conical form.
C




thread and double pitch with blunt tips. For both          For some years some companies have marketed the ta-
types of connection, the implant neck was 0.7 mm           pered form, with the aim of combining the advantages
in height with a 3% taper. This implant design may         of both designs. A tapered implant creates the basis for
be able to guarantee osteotomic properties at the          an excellent primary stability by gradually allowing thin
©




time of insertion in a surgical site suitably prepared,    ridge expansion and determining the least stress pos-
a facilitated screwing, thanks to the thread pitch and     sible at the interface with the surrounding bone (10,11).
to the broad and deep draining grooves, thereby            The design of the implant neck, or crestal module, has
ensuring a good primary stability. The different con-      undergone considerable evolution in recent years. The
nection design appears defined and precise, in order       implant neck represents the transosseous area of the
to ensure a good interface between the fixture and         implant body where the highest concentration of me-
the prosthetic components. Therefore, this design          chanical stresses are evinced and where the transition
appears to be particularly suitable in cases where         between the hard tissue and soft tissue support occurs.
a good primary stability is necessary and a precise        Discriminating elements of the crestal module could be

44                                                                               Annali di Stomatologia 2012; III (2): 44-50
Implant design for full arch rehabilitation



identified in the geometrical design and in the surface          tant role regarding the long-term survival of the osseoin-
type. The possible geometric profiles of the implant neck        tegrated implants (18).
are essentially three: straight walls, diverging walls and       The titanium surface can be prepared with different tech-
converging walls. Despite the diverging walls type seem-         niques in order to obtain an optimal degree of roughness
ing to be the best form, as it can provide a slightly higher     of the surface, as it has been shown that the wider the




                                                                                              li
primary stability after the implant insertion, from the clini-   functional surface is in contact with the bone, the better
cal point of view the behavior of the bone before and            the support for the prosthesis (19,20).




                                                                                           na
after the load is not dissimilar between the three geo-          The rough implant surfaces determine a slightly better
metric figures. In fact, an aspect commonly observed at          bone tissue response in quantitative terms of bone-
the level of the crestal module is the different bone level      implant contact percentage (21-23). The purpose of
before and after the occlusal loading. Before loading, if        the surface treatment is to increase the contact area




                                                                                        io
the implant was positioned so that the prosthetic plat-          between the bone and the implant, thus improving the
form is at the level of the crestal bone, there will always      osseointegration. Even with only the threads, the resis-
be a clinical situation where the bone covers the entire         tance degree to tensile forces and compression is great-




                                                                                     az
implant neck. After application of the load there is invari-     er than smooth implants not threaded, and the presence
ably a vertical bone loss, the level of which is located in      of microretentions on the surface of the fixture allows to
correspondence of the first thread. All this takes place         increase the tensile and torsion strength of the implant.
independently from the geometrical shape and the level           In addition, some authors have demonstrated how mac-




                                                                         n
of the first thread.                                             rophages, epithelial cells and osteoblasts, have a high
The crestal module height was reduced over time by               tropism against rough surfaces (24,25).




                                                                      er
various manufacturers, until today, when the height of           In order to obtain a surface topography able to promote
the smooth collar is reduced to less than 2 mm.                  the process of osseointegration, various surface treat-
The morphology of the crestal module evolved in the              ments have been tried out, such as sandblasting (26),
same way - from a smooth surface to a treated sur-               acid etching (27), combined treatment of blasting and

                                                  nt
face with microthreads for increased stability of bone in
the coronal zone, to favour aesthetics and peri-implant
health (12).
                                                                 etching (28), surface coating with micro-granules of
                                                                 hydroxyapatite (29) or particles of titanium oxide (30),
                                                                 or electrochemical deposition (31). Recent researches
                                                iI
The use of the smooth neck arises from the necessity             highlighted how the micro-roughness obtained by blast-
to limit the plaque retention at the border zone between         ing and acid etching is compatible with best clinical and
the implant, bone and soft tissue. The presence of micro         histological results.
                                              on

retentions at the level of the crestal module is designed        Several options also affect the types of connections
to adequately dissipate forces that are expressed at the         between the endosseous fixture and implant prosthetic
cervical area of the bone-implant interface in the pres-         components.
ence of occlusal stress, in all implant types, thus allow-       External hexagonal connection was the first connec-
                                      i


ing to maintain the height of the bone spikes in accor-          tion system used in implantology which was ideated by
                                   iz


dance with the law of Wolff (13), a phenomenon that in           Branemark only as coupling mechanism to easily guide
the presence of a smooth neck does not happen.                   the stump insertion; its function was then expanded to
As regards the design and the pitch of the threads,              become a real anti-rotation mechanism. The interface
                   Ed




these must be designed to maximize the transmission              and the tightening screw are subject to very high mas-
of forces between the implant and surrounding bone tis-          ticatory loads, subjecting the screw to insidious lateral
sue, and to correctly distributed stress arising between         bending forces, tilting and elongation that may mobilize
the bone interface and the implant (14). Their main role         it (32).
is to increase primary stability and extend the available        Of the internal connections, the most widely used are
 IC




surface of the implant for bone contact.                         internal hexagonal, internal octagonal, conical screw
Among the various thread designs, the V-shaped threads           and Morse connections. The internal connections have
and the broader square threads have been shown to                shown an increased stability, better mechanical stability
generate less stress and to better distribute the loading        and resistance to lateral forces than external ones.
C




forces compared to the thin threads and tapered apex             The aim of this study is to describe the macroscopic and
threads (15). The phenomenon is best appreciated in the          microscopic appearance of a new implant design, with
bone marrow, while no difference have been found in              particular emphasis on the type of prosthesis connec-
cortical bone.                                                   tion.
©




Another important factor necessary to achieve success
in implantology is represented by the surface properties
of the material used (16). The micro-topography of the           Materials and Methods
implant surface is able to affect the percentage of BIC
(Bone-to-Implant Contact) and the cellular response of           In this study, the macroscopic and microscopic appear-
the host tissue (17). The treated surfaces stimulate os-         ance of a new implant design was evaluated, with par-
teoblast proliferation, as demonstrated by the increased         ticular emphasis on the type of prosthetic connection.
expression of biological markers, which transposes into          Two dental implants of the same type (Torque Type®,
an increase of osteogenesis, thus assuming an impor-             WinSix®, BioSAFin S.r.l., Ancona, Italy), with sandblast-

Annali di Stomatologia 2012; III (2): 44-50                                                                             45
S. Tetè et al.



ed and acid etched surfaces (Micro Rough Surface®),
but differing from each other for the prosthesis connec-
tion system, were examined by scanning electron micro-
scope (SEM) analysis at different magnifications: TTI im-
plant (Torque Type® Implant I), with a hexagonal internal




                                                                                                    li
connection, and TTX implant (Torque Type® Implant X),
with a hexagonal external connection.




                                                                                                 na
The macrostructure of the geometrical design of the
different segments of the fixture, the characteristics of
the prosthetic connection, and the microstructure of the
implant surface were analyzed by Scanning Electron




                                                                                              io
Microscope (Zeizz EVO-50, Cambridge, UK). Electron
acceleration potential was kept between 15 and 25 kV,
and the working distance kept between 9 and 12 mm,




                                                                                           az
according to the different requirements and types of
samples.
                                                                    Figure 2 - SEM visualization of a TT implant-prosthetic connec-
                                                                    tion with a deep lodging of hexagonal form and smooth crestal




                                                                            n
Results                                                             module.




                                                                         er
At SEM analysis, both TTI and TTX implants were char-
acterized by a truncated cone shape, with a tapered
apex (Fig. 1).
Both implants showed a reduced crestal module repre-

                                               nt
sented by a smooth neck 0.7 mm height and 3% taper.
The implant-prosthetic connection was characterized
by a very deep lodging for the fixing screw, with a hex-
                                             iI
agonal form with a double parallel type connection (Fig.
2). The TTX implant includes a crestal module with a
smooth surface, dominated by the external hexagonal
                                           on

connection module (Fig. 3). At SEM analysis, the neck
surface seemed completely smooth and well polished; at
3000x magnification there were signs of lathing, typical
of machined surfaces (Fig. 4).
                                   i


With regard to the implant body, this was equipped with
                                iz


a double thread and double pitch. The thread pitch was
0.60 mm. The threads are “V” shaped with rounded tips
and slopes inclined at approximately 45°.                           Figure 3 - SEM visualization of a TTX external implant-prosthetic
                 Ed




The main thread has a step along its apical side which              connection constitute of smooth crestal module dominated by an
                                                                    hexagonal connection.
forms the smaller thread (Fig. 5). The depth of the main
threads is 0.375 mm, as long as the depth of the second-
ary threads is 0.125 mm. The main thread width ranges
from 0.07 mm at the top to 0.50 mm at the base, while
 IC
C
©




Figure 1 - SEM visualization of WinSix® TT and TTX implants.        Figure 4 - SEM visualization of the machined neck surface (149x
It may be noticed the truncated shape of the fixture with tapered   magnification).
apex.


46                                                                                           Annali di Stomatologia 2012; III (2): 44-50
Implant design for full arch rehabilitation



the distance between each thread is 0.10 mm at the                dental implants play a decisive role in obtaining success
base and 0.53 mm at the peak. The implant shape is                in osseointegrated implantology (33). In particular, the
maintained constant along the entire implant body.                geometrical design of the threads, their position and
The apical portion shows a bevel apex, nearly flat, char-
acterized by broad and deep drainage furrow, with in-




                                                                                                 li
creasing size apically (Fig. 6).
The surface of the implant body, defined by the manu-




                                                                                              na
facturer of Micro Rough Surface®, and realized by a sub-
traction process for etching and sandblasting, was reg-
ularly distributed along the surface (low magnification)
(Fig. 7). In the apical portion, at 1980x magnification, it




                                                                                           io
can be seen how the rough aspect of this surface recalls
that typical of tooth enamel after acid etching. At higher
magnification the surface appears to be characterized




                                                                                        az
by small depressions and elevations of 2-4 µm (Fig. 8).


Discussion




                                                                          n
In scientific literature it is widely reported that the mac-




                                                                       er
roscopic structure and the surface characteristics of             Figure 7 - SEM visualization of the Micro Rough Surface® regu-
                                                                  larly distribuited (721x magnification).




                                                  nt
                                                iI
                                      i       on
                                   iz
                   Ed




Figure 5 - SEM visualization of the continuous step that forms
the smaller threads from the main threads (192x magnification).   Figure 8A
 IC
C
©




Figure 6 - SEM visualization of the bevel apex characterized by   Figure 8B - SEM visualization of the Micro Rough Surface® at
furrows drain.                                                    higher magnification (A:1980x; B: 7330x).


Annali di Stomatologia 2012; III (2): 44-50                                                                                  47
S. Tetè et al.



their pitch along the implant body determine a different       TTi and TTX implants also have a double loop thread, a
response to functional loads and transmission of those         principal and a secondary smaller one, due to the pres-
forces to the surrounding bone tissue (34). The implant        ence of a groove on the apical side of the main thread.
design plays an even more important role if surgical           An implant with double coil has an insertion speed twice
protocols providing immediate loading are adopted. It is       as fast compared to an implant with a single coil. Some




                                                                                             li
known that in the initial stages following implant inser-      studies report that implants with a high number of loop
tion, and especially after immediate loading, implant sta-     threads and a reduced pitch possess a high percentage




                                                                                          na
bility should be guaranteed by mechanical relationship         of BIC, due to increased surface area (40). Some stud-
between the fixture and the bone tissue rather than a          ies showed how the ideal threads pitch to obtain a good
biological bone integration. Therefore, the percentage of      primary stability, and an optimal distribution of the stress
bone-implant contact and the friction that is obtained dur-    should be not more than 0.8 mm (41). A thread pitch less




                                                                                       io
ing the insertion play an important role in the mechanical     than this measurement was seen to positively influence
behaviour of immediate loaded prosthetic implants.             the load distribution along the peri-implant bone walls,
The tapered shape of the implant fixtures TTI and TTX          accompanied by a smaller crestal bone resorption (42).




                                                                                    az
ensures a gradual expansion of the thin crests during          The osteotomic effect at the implant site during the im-
the insertion phase of the fixture by determining the least    plant screwing phase is further achieved through the ta-
possible stress to the surrounding bone. This factor is of     pered apex and the self-tapping implant design with the
fundamental importance in cases of reduced bone avail-         cutting apical portion. Moreover, the presence of deep




                                                                       n
ability, where preserving cortical bone tissue is appropri-    grooves at the apical level, constituting an anti-rotational
ate, as well as carrying out a three-dimensional expan-        system, is necessary for bone chip collection and clot




                                                                    er
sion and compaction of the walls of the newly formed al-       discharge during the screwing phase (43).
veolar bone. The implant type analyzed showed a thread         With regard to the crestal module, the manufacturer’s
design that allows to release more force and give easy         choice to use a smooth neck reflects the concept to
access to good primary stability. The thread geometry          guarantee the minimum plaque retention, allowing to

                                            nt
contributes to obtaining primary stability, responsible for
the biomechanical behaviour of the bone-implant inter-
face after the healing process (35).
                                                               obtain an optimal integration with the bone tissue (44).
                                                               The constant size of the internal hexagon for the various
                                                               implant diameters allows the use of few components,
                                          iI
The thread height is defined as the distance between           making the prosthetic steps and the eventual choice to
the major and the minor diameter of the coil. A shallow        adopt the Platform Switching technique easier.
thread depth, as well as those present in the Torque           The connection type through a long screw, ensures high
                                        on

Type implants, favors insertion. In fact, although deeper      connection stability, with considerable reduction of the
threads ensure an increase of the surface and represent        stress between abutment and implant, and a greater
an advantage in areas of low density bone and high oc-         contact surface which limits the microcirculation of bio-
clusal stress, on the other hand shallow threads allow an      logical fluids (45).
                                i


easy insertion in alveolar ridges with more dense bone         Another important factor analyzed was the implant sur-
                             iz


without the need to perform tapping before the implant         face, because the surface of the fixture is the only part
insertion (36).                                                to come into direct contact with the host tissue, influenc-
In a study conducted by finite element analysis, it was        ing cellular and biochemical responses, acting also on
                 Ed




demonstrated that the height of the thread more than           the stability between bone and implant (46). SEM analy-
its thickness is able to influence primary stability, and in   sis allowed to assess the degree of roughness present
particular threads with a height exceeding 0.44 mm is          on the implant body and on the apical portion, typical
able to provide excellent biomechanical response when          of a sandblasted and acid etched surface with signs of
inserted into bone tissue of medium or low density with        streaks, depressions and elevations highly variable in
immediate loading (37).
 IC




                                                               size and shape.
In addition, these threads have an osteotomic effect,          Recent clinical studies showed how an implant with a
allowing to pack the peri-implant bone using a surgical        rough surface can be loaded before the traditional treat-
technique that provides preparation of the implant site        ment protocols (47). Some studies showed that dental
C




according to “press-fit” protocol. In vitro studies showed     implants with low roughness values, as for the implant
that in case of poor quality bone, such as in the posterior    with machined surface, can promote the formation of fi-
maxilla, implants with chamfer thread design produced          brous tissue around the implant, reduce the percentage
lateral compressive forces which increased the bone-           of bone-implant contact and show a lower resistance to
©




implant contact and consequently improved the primary          the removal than implants with rough surfaces (48).
stability (38). This factor is very important in case of im-   The implants with sandblasted and etched surfaces,
mediate load technique of several implants, as in the          for the presence of more regular micro-roughness pro-
case of rehabilitation providing the immediate solidifica-     duced by the etching treatment, seem to favor the bone
tion using bar techniques (Just on 4® and Just on 6®).         healing process, also by the marked incidence of the in-
Furthermore, as already demonstrated, under vertical           creased cytokine production, such as osteogenic prosta-
load the presence of threads with bevel peak allows a re-      glandin E2 (PGE2), and transforming growth factor-beta
duction of divergent forces, thereby reducing the stress       (TGF-b1), with the latter less sensitive to surface rough-
at the bone implant interface (39).                            ness than in the case of PGE2 (49). According to some

48                                                                                    Annali di Stomatologia 2012; III (2): 44-50
Implant design for full arch rehabilitation



authors, this treatment promotes osseointegration due to                 Choi YC, Baik HK, Ku Y, Kim MH. Evaluation of design pa-
an increase in initial cell anchorage by osteoblasts (50).               rameters of osseointegrated dental implants using finite el-
All in all, the results obtained prove that dental implants              ement analysis. eJ Oral Rehabil. 2002 Jun; 29(6): 565-74.
of a design that complies with the results of research              15. Hansson S, Werke M. The implant thread as a retention el-
regarding the macrostructural aspect and the micro-                      ement in cortical bone: the effect of thread size and thread




                                                                                                    li
structural surface topography, if used according to cor-                 profile: a finite element study. J Biomech. 2003 Sep; 36(9):
rect surgical and prosthetic protocols assure safe and                   1247-58.




                                                                                                 na
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                                                                         M, Castaldo P, De Cristofaro A, Natali D, Pugnaloni A,
                                                                         Biagini G. In vitro evaluation of bio-functional performanc-
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©




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