Ovariectomy hinders the early stage of bone-implant integration: histomorphometric, biomechanical, and molecular analyses.

Postmenopausal osteoporosis is a contributing factor to alveolar bone atrophy associated with tooth loss in the elderly. The use of dental titanium implants has been increasingly adapted to treat these edentulous patients. This study examines whether female gonadal hormone deficiency interferes with the critical integration process between bone and implants. Two types of experimental titanium implants with acid-treated surfaces were placed in the femurs of ovariectomized (ovx) and sham-operated control rats: T-cell implants with a hollow chamber for histomorphometric and steady-state mRNA expression assays, and unthreaded cylindrical implants for biomechanical push-in tests. At week 2, less bone area was found in the ovx-implant group (p = 0.0495) than in the sham-implant group. The implant push-in test showed that the ovx-implant group had approximately half of the withstanding value of the sham-implant group (p = 0.009). However, these differences between the ovx and sham groups became diminished at week 4. Total RNA samples were examined by a reverse transcriptase-polymerase chain reaction assay for col1a1, col3a1, bone sialoprotein (bSP) II, osteonectin, osteopontin, osteocalcin, integrin beta1 and integrin beta3. In untreated bones and in created bone defects without implant placement, ovx did not affect the steady-state levels of the mRNAs tested. When implants were placed, significant upregulation of these genes was observed in the sham-implant group; however, only osteocalcin and integrins were upregulated in the ovx-implant group. The results suggest a biphasic effect of female gonadal hormone deficiency that may temporarily interfere with the early implant-tissue integration process, and which may be associated with a failure to upregulate a selected set of bone extracellular matrix genes. Once established, however, functional bone-implant integration can be achieved even in ovx rats.

Early endosseous integration enhanced by dual acid etching of titanium: a torque removal study in the rabbit.

Textured implant surfaces are thought to enhance endosseous integration. Torque removal forces have been used as a biomechanical measure of anchorage, or endosseous integration, in which the greater forces required to remove implants may be interpreted as an increase in the strength of bony integration. The purpose of this study was to compare the torque resistance to removal of screw-shaped titanium implants having a dual acid-etched surface (Osseotite) with implants having either a machined surface, or a titanium plasma spray surface that exhibited a significantly more complex surface topography. Three custom screw-shaped implant types - machined, dual acid-etched (DAE), and titanium plasma sprayed (TPS) - were used in this study. Each implant surface was characterized by scanning electron microscopy and optical profilometry. One DAE implant was placed into each distal femur of eighteen adult New Zealand White rabbits along with one of the other implant types. Thus, each rabbit received two DAE implants and one each of the machined, or TPS, implants. All implants measured 3.25 mm in diameter x 4.00 mm in length without holes, grooves or slots to resist rotation. Eighteen rabbits were used for reverse torque measurements. Groups of six rabbits were sacrificed following one, two and three month healing periods. Implants were removed by reverse torque rotation with a digital torque-measuring device. Three implants with the machined surface preparation failed to achieve endosseous integration. All other implants were anchored by bone. Mean torque values for machined, DAE and TPS implants at one, two and three months were 6.00+/-0.64 N-cm, 9.07+/-0.67 N-cm and 6.73+/-0.95 N-cm; 21.86+/-1.37 N-cm, 27.63+/-3.41 N-cm and 27.40+/-3.89 N-cm; and 27.48+/-1.61 N-cm, 44.28+/-4.53 N-cm and 59.23+/-3.88 N-cm, respectively. Clearly, at the earliest time point the stability of DAE implants was comparable to that of TPS implants, while that of the machined implants was an order of magnitude lower. The TPS implants increased resistance to reverse torque removal over the three-month period. The results of this study confirm our previous results that demonstrated enhanced bony anchorage to dual acid-etched implants as compared to machined implants. Furthermore, the present results indicate that dual acid etching of titanium enhances early endosseous integration to a level which is comparable to that achieved by the topographically more complex TPS surfaces.

Fabrication of a custom silicone tracheostomal prosthesis.

Patients with a tracheostomy stoma experience compromised speech due to the associated changes in airflow patterns. Prosthetic obturation of the stoma restores the normal airflow patterns required for proper speech. Standard stent tubes may not adequately obturate the defect and may be uncomfortable to wear. The fabrication of a custom silicone tracheostomal prosthesis, incorporating a speaking valve, provides proper obturation of the defect and improved patient comfort, fit, and function. This article presents the procedures used to make a functional impression of a tracheostomy stoma and to fabricate a custom tracheostomal prosthesis.

Photoelastic stress analysis of load transfer to implants and natural teeth comparing rigid and semirigid connectors.

STATEMENT OF PROBLEM: Controversy exists regarding the connection of implants to natural teeth. PURPOSE: This simulation study measured photoelastically the biologic behavior of implants. Stress transfer patterns with variable implant support and simulated natural teeth through rigid and nonrigid connection were examined under simulated functional loads. MATERIAL AND METHODS: A photoelastic model of a human left mandible edentulous distal to first premolar was fabricated having 2 screw type implants (3.75x13 mm) embedded within the edentulous area. Two fixed prosthetic restorations were fabricated with either a nonsplinted proximal contact or a soldered proximal contact, and cast precision dowel attachment between implant areas and simulated tooth. Simulated vertical occlusal loads were applied at fixed locations on the restorations. Stresses, which developed in the supporting structure, were monitored photoelastically and recorded photographically. RESULTS: The rigid connector in the 1 implant situation caused only slightly higher stresses in the supporting structure than the nonrigid connector. The distally loaded 1 and 2 implant-supported restoration produced the highest apical stresses, which occurred at the distal implant. The rigid connector demonstrated the greatest stress transfer in the 2 implant-supported restoration. CONCLUSIONS: Lower stresses apical to the tooth or implant occurred with forces applied further from the supporting abutment. Although the least stress was observed when using a nonrigid connector, the rigid connector in particular situations caused only slightly higher stresses in the supporting structure. The rigid connector demonstrated more widespread stress transfer in the 2 implant-supported restoration. Recommendations for selection of connector design should be based on sound clinical periodontal health of a tooth and the support provided by implants.

Restoration of partially edentulous patients using customized implant abutments.

The ideal placement of implants is not always possible in partially edentulous patients. The diverse and unique implant positions that occur in clinical practice may be difficult or impossible to restore through the use of conventional abutments. Customized abutments permit the fabrication of aesthetic restorations that correct deficiencies in implant angulation, alignment, and position. These abutments also enhance the soft tissue emergence profile of the restorations and allow the prosthetic margins to be properly positioned in all dimensions. Additional benefits include ease of treatment delivery and comparative expense.

Anterior implant-supported reconstructions: a surgical challenge.

Reconstructive procedures are able to provide improved aesthetics for implant patients who present with anatomical limitations (e.g., vertical or horizontal tissue loss) in the anterior maxilla. Aesthetic results, however, are directly related to the ability of the treatment team to reconstruct the lost bone and soft tissue, place the implant into its proper tridimensional position in the patient's arch, and use precise restorative techniques. This article presents comprehensive treatment steps for the utilization of single-unit and multiple-unit implant-supported restorations in the anterior maxilla.

Filgrastim (r-metHuG-CSF) and its potential use in the reduction of radiation-induced oropharyngeal mucositis: an interim look at a randomized, double-blind, placebo-controlled trial.

We wished to determine if filgrastim administration to chemotherapy/radiation therapy-naive patients receiving external-beam irradiation for head-and-neck malignancies would reduce the incidence and severity of oral/oropharyngeal mucositis. Patients were randomized to receive subcutaneous injections of either filgrastim or placebo beginning on day 1 of radiation and continuing daily throughout treatment. Study medication was titrated to keep the neutrophil count between 10 x 10(9) and 30 x 10(9)/l. The left and right buccal mucosa, hard palate, and posterior pharyngeal wall were scored weekly, by a blinded evaluator using two different scales, and the most severe score per week was used in data analysis. Fourteen of a planned 54 patients were randomized (8 filgrastim, 6 placebo), and were evaluable for a planned interim analysis. No statistically significant between-group differences were seen in mean worst scores across time using repeated measures analysis of variance (Hickey, p = 0.231; WHO, p= 0.288). At almost all timepoints, however, the worst mean scores were lower in patients treated with filgrastim compared with those in patients treated with placebo, and the number of severe (i.e., grade 3) mucositis scores was significantly lower in the filgrastim-treated group. Filgrastim may decrease the severity of radiation-induced oral/oropharyngeal mucositis.

Restoration of irradiated patients using osseointegrated implants: current perspectives.

STATEMENT OF PROBLEM: The success rates of osseointegrated implants used to restore patients who were irradiated for head and neck tumors are influenced by radiation-induced changes in the hard and soft tissues. PURPOSE: This article examined, by review of the literature, current perspectives on the restoration of irradiated patients using osseointegrated implants. RESULTS: In published reports that investigated both intraoral and extraoral applications, irradiation decreased implant success rates and the amount of reduction was dependent on the location within the craniofacial skeleton. The limited number of implants and patients in these studies precludes definitive conclusions regarding the efficacy of placing implants into irradiated tissues. The implants placed into the irradiated anterior mandible have demonstrated an acceptable implant success rate of 94% to 100% with a minimal risk of osteoradionecrosis. The efficacy of implants in the posterior mandible has not been examined. Implant success rates ranged from 69% to 95% in the irradiated maxilla for intraoral applications. Extraoral applications demonstrated excellent implant success rates in the temporal bone (91% to 100%). The rates in the anterior nasal floor have varied from 50% to 100%. The implant success rates in the frontal bone decreased as the length of the studies increased (96% to 33%). The long-term efficacy of implants in the irradiated frontal bone is poor.

Osseointegrated implants and orbital defects: U.C.L.A. experience.

PURPOSE: A clinical study of 23 craniofacial implants placed in 8 irradiated and nonirradiated orbital detects was conducted over a 7-year period. MATERIAL AND METHODS: Implant-retained orbital prostheses were fabricated, implant success rate was determined, and the soft tissue responses were recorded at 6-month intervals. As a result of patient death, no data were gathered on three implants. A five-point scale was used to record the health of the peri-implant soft tissues and the patients were followed from 9 to 72 months. The unit of measure was a visit/site that was assigned for each instance an implant site was evaluated. Evaluations were conducted at 6-month intervals, and for the study period, there were 80 visit/sites. RESULTS: The study revealed that 42.5% (34/80) of the visit/sites demonstrated an absence of inflammation; 23.7% (19/80) of visit/sites demonstrated slight redness; 13.8% (11/80) demonstrated peri-implant red and moist tissues; 6.2% (5/80) demonstrated granulation tissue associated with the implants; and 13.8% (11/80) infection of the peri-implant soft tissues was noted. Implant success rate was 35% (7/20); implant success rate in the nonradiated patients was 37.5% (3/8) and the success rate for radiated patients was 33.3% (4/12). Implants placed in the orbital region demonstrated a high failure rate. Most implant failures occurred late as opposed to early in the study period. CONCLUSION: Orbital implants should be placed in patients who understand that long-term success rates may be low and require meticulous hygiene maintenance.

Implants in the partially edentulous patient: restorative considerations.

Restorative considerations are critical to the long-term success of fixed implant-supported prostheses, especially in the posterior quadrants of the partially edentulous patient. The parafunctional habit of bruxism must be identified and addressed. The restoration should dictate implant placement. Control of forces directed upon the prosthesis and implants is critical to long-term success. Anatomic limitations to implant placement and surgical procedures to correct these deficiencies must be considered for their impact on the prosthetic restoration. Nonaxial forces or bending moments should be minimized by the use of an adequate number, position and alignment of implants; by control of the occlusion; and by design of the prosthesis. The patient must understand the risks, limitations, costs and time commitments of implant restorations prior to treatment.

Prosthetic-surgical collaborations in the rehabilitation of patients with head and neck defects.

Resection of head and neck tumors often results in severe facial disfigurement and functional disabilities. Superior rehabilitation efforts rely on close collaboration between the resection surgeon, reconstructive surgeon, and the maxillofacial prosthodontist. Trauma patients are best rehabilitated surgically, whereas patients with head and neck tumors are best rehabilitated prosthetically in combination with specific surgical reconstruction procedures. This article describes these modifications. Surgical advancements such as microvascular free flaps and endosseous implants have greatly enhanced rehabilitative efforts.

Clinical evaluation of implants retaining edentulous maxillary obturator prostheses.

PURPOSE: Fabricating a maxillary obturator can be challenging. Placement of implants can have a dramatic effect on the stability and retention of the prosthesis in the edentulous maxillectomy patient. This article provides clinical retrospective analysis of osseointegrated implants used to retain maxillary obturators. MATERIAL AND METHODS: Patient charts and radiographs were reviewed to determine implant status, bone loss patterns, and implant survival rates. Twenty-six patients were included with 102 implants placed, from which there were 19 intact withdrawals (implants lost because of recurrent disease or patient death), five implants with unknown status, 24 implant failures, and 54 functional implants. RESULTS: The overall survival rate for implants in this patient population was 69.2%. The percent implant survival rate was 63.6% for the irradiated group (67.0% before radiation, 50.0% after radiation) and 82.6% for the nonirradiated group. Implants located in anterior sites demonstrated statistically significant differences in annual bone height changes compared with posterior sites. CONCLUSIONS: The majority of implant failures (18 of 24) occurred either at stage II surgery or before loading. Implants placed during tumor resection, implants placed within the maxillectomy defects, and implants receiving postoperative radiation demonstrated low survival rates.

Osseointegration enhanced by chemical etching of the titanium surface. A torque removal study in the rabbit.

Roughened implant surfaces are thought to enhance osseointegration. Torque removal forces have been used as a biomechanical measure of anchorage or osseointegration in which the greater forces required to remove implants may be interpreted as an increase in the strength of osseointegration. The purpose of this study was to compare the torque resistance to removal of screw shaped titanium implants having an acid etched (HC1/H2SO4) surface (Osseotite) with implants having a machined surface. Two custom screw shaped implants, 1 acid etched and the other machined, were placed into the distal femurs of 10 adult New Zealand White rabbits. These implants were 3.25 mm in diameter x 4.00 mm in length without holes, grooves or slots to resist rotation. Following a 2 month healing period, the implants were removed under reverse torque rotation with a digital torque measuring device. Two implants with the machined surface preparation failed to achieve osseointegration. All other implants were found to be anchored to bone. Resistance to torque removal was found to be 4 x greater for the implants with the acid etched surface as compared to the implants with the machined surface. The mean torque values were 20.50 +/- 6.59 N cm and 4.95 +/- 1.61 N cm for the acid etched and machined surfaces respectively. The results of this study suggest that chemical etching of the titanium implant surface significantly increases the strength of osseointegration as determined by resistance to reverse torque rotation.

Implants in the partially edentulous patient: restorative considerations.

Restorative considerations are critical to the long-term success of fixed implant-supported prostheses, especially in the posterior quadrants of the partially edentulous patient. The parafunctional habit of bruxism must be identified and addressed. The restoration should dictate implant placement. Control of forces directed upon the prosthesis and implants is critical to long-term success. Anatomic limitations to implant placement and surgical procedures to correct these deficiencies must be considered for their impact on the prosthetic restoration. Nonaxial forces or bending moments should be minimized by the use of an adequate number, position and alignment of implants; by control of the occlusion; and by design of the prosthesis. The patient must understand the risks, limitations, costs and time commitments of implant restorations prior to treatment.

Nasal defects and osseointegrated implants: UCLA experience.

A clinical study of 23 craniofacial implants placed in 11 nasal defects was conducted over a 7-year period. Implant-retained nasal prostheses were fabricated, implant success rate was determined, and the soft tissue responses were recorded at 6-month intervals. No data were gathered on two implants because of patient death. The implant success rate was 71.4% (15/21) but varied significantly by anatomic site. The implant success rate in the glabella was 0% (0/4), whereas the success rate in the anterior nasal floor was 88.1% (15/17). All implant failures occurred within the first year of loading. A five-point scale was used to record the health of the peri-implant soft tissues, and the patients were followed up from 6 to 74 months. The unit of measure was a visit/site, and a unit was assigned for each instance an implant site was evaluated. Evaluations were conducted at 6-month intervals for a total of 76 visit/sites for the study period. The results revealed that 85.5% (65/76) of the visit/sites demonstrated an absence of inflammation; 10.5% (8/76) of the visit/sites demonstrated slight redness; 1.3% (1/76) demonstrated peri-implant red and moist tissues; 2.6% (2/76) demonstrated granulation tissue associated with the implants; and 0% (0/76) demonstrated infection of the peri-implant soft tissues. Severe soft tissue reactions around implants placed in the anterior nasal floor are rare.

Auricular prostheses and osseointegrated implants: UCLA experience.

A clinical study of 40 craniofacial implants placed in 13 auricular defects was conducted over a 6-year period. Implant-retained prostheses were fabricated, the implant success rate was determined, and the soft tissue responses were recorded at regular intervals. All of the implants became osseointegrated and none demonstrated failure during the study period. A five-point scale was used to record the health of the peri-implant soft tissues and the patients were followed up for up to 69 months. The results were as follows: 55.1% of the visit/sites demonstrated an absence of inflammation; 32.3% of the visit/sites demonstrated slight redness; 4.7% demonstrated red and moist peri-implant tissues; 5.5% demonstrated granulation tissue associated with the implants; and in 2.4% of the implants, infection of the peri-implant soft tissues was noted. Good patient hygiene compliance combined with thin and immobile peri-implant soft tissues resulted in minimal soft tissue complications.

Etched metal cingulum rest retainer.

The etched metal cingulum rest retainer provides a viable alternative to the use of an incisal rest or a conventional cast restoration incorporating a cingulum rest. It is not intended for use in every case, but may be useful when indicated.

Identification and characterization of an exotoxin from Staphylococcus aureus associated with toxic-shock syndrome.

Toxic-shock syndrome (TSS) is believed to be caused by a toxin produced by Staphylococcus aureus. An exotoxin has been identified that is associated with strains of S. aureus isolated from patients with TSS. Coded strains of S. aureus were tested for the presence of the exotoxin by polyacrylamide gel isoelectric focusing. Sixty isolates of S. aureus were tested; 28 (100%) of 28 isolates from patients with TSS but only five (16%) of 32 control isolates produced the toxin (P much less than 0.001). This protein exotoxin, which was purified by differential precipitation with ethanol and thin-layer isoelectric focusing, had an isoelectric point of 7.2. When tested by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, the toxin migrated as a homogeneous protein with a molecular weight of 22,000. The exotoxin produced fever in rabbits and enhanced susceptibility to lethal shock caused by endotoxin. Other biologic properties of the exotoxin included lymphocyte mitogenicity and the capacity to suppress synthesis of IgM antibody to sheep erythrocytes.