Measuring Dental Implant Safety and Performance
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1 ISSN Russian Journal of Biomechanics Vol. 19, No. 3: MOBILITY OF DENTAL IMPLANTS: NEW CAPABILITY OF A KNOWN DEVICE V.A. Eroshin 1, M.V. Dzhalalova 1, A.V. Boyko 1, S.D. Arutyunov, A.G. Stepanov, A.N. Daov 1 Institute of Mechanics of Lomonosov Moscow State University, 1 Michurinsky Prospekt, Moscow, Russia, margarita-vd@mail.ru Moscow Evdokimov State Medical Stomatologic University, 0/1 Delegatskaya St., 17473, Moscow, stepanovmd@list.ru Abstract. We used classical screw-type dental implants from the Conmet company (Russia) and miniimplants from the 3М ESPE company (USA) fixed in osseous tissue analogs of polyurethane and linden, having different geometric parameters. Devices Periotest (Medizintechnik Gulden, Germany) and Osstell Mentor (Sweden) are used to monitor the stability of dental implants since its installation, the level of osseointegration and functional determinetion of allowable loads, especially in the initial period of their use as an artificial supports for dental and mandibular prostheses. Due to permanent technical development, the last versions of these devices (Periotest M and Osstell ISQ) have been considerably improved while there were some weak points in previous versions. We must stress that both devices give results of strength measurement for dental implants fastening in osseous tissue in some standard units which have no physical sense, therefore guidelines on the basis of only these measurements are not sufficiently proved and convincing. In this work, the last version of Periotest M was examined and parameters measured by this device were interpreted as coefficients of damping. Methods for measuring these factors through the special device for determining the mobility of the teeth or implants were proposed to achieve higher accuracy. Distribution of vertical displacement of dental implants obtained in numerical simulations by finite element method using a virtual model of a full-scale test bench is consistent with the physical experiment. A simple linear relationship between damping ratio and compliance based on the results obtained by the laser test and numerical experiment, allowing for the dental implant fixed in the bone analogue, based on readings of Periotest M to determine the value of its movement, depending on the longitudinal and transverse loads. Key words: orthopedic dentistry, dental implant, mini dental implant, coefficients of damping, compliance coefficients. INTRODUCTION Orthopedic dental rehabilitation of patients with the use of dental implants has established in daily ambulatory practice of dentists. Appearance of mini dental implants and, in particular, a low invasive protocol for their installation has considerably enlarged a number of dental implants use supporters among both dentists and their patients. But for such operations to be successful, dental implants stability should be monitored from the moment of installation and Eroshin V.A., Dzhalalova M.V., Boyko A.V., Arutyunov S.D., Stepanov A.G., Daov A.N., 015 Vladimir A. Eroshin, Ph.D., Professor, Leading Research Scientist, Institute of Mechanics, Moscow Margarita V. Dzhalalova, Ph.D., Senior Research Scientist, Institute of Mechanics, Moscow Sergei D. Arutyunov, Ph.D., Professor, Chair of Clinical Dentistry, Moscow Alexander G. Stepanov, Ph.D., Assistant Professor of Clinical Dentistry, Moscow Azamat N. Daov, Assistant of Clinical Dentistry, Moscow
2 Mobility of implants: new capability of a known device allowable functional (masticatory) load should be adjusted especially on the initial stage of their use as artificial supports for dental and maxillary prostheses. Currently, Periotest (Medizintechnik Gulden, Germany) and Osstell Mentor (Sweden) devices are most widely used for this purpose. Due to permanent technical development, the last versions of these devices (Periotest M and Osstell ISQ) have been considerably improved while there were some weak points in previous versions []. We must stress that both devices give results of strength measurement for dental implants fastening in osseous tissue in some standard units which have no physical sense, therefore guidelines on the basis of only these measurements are not sufficiently proved and convincing. What about the Osstell ISQ device, recent researches enable to considerably enlarge its capability and to establish connection between coefficients of implant stability and coefficients of fastening rigidity of dental implants in osseous tissue measured according to the technique of laser testing [1, 3]. All it enables to describe relationship between masticatory load on implants and their corresponding moving. In this work, the last version of Periotest M was examined and parameters measured by this device were interpreted as coefficients of damping. The ratio was established between them and compliance coefficients determined by results of a laser testing and a numerical experiment. MATERIALS, DEVICES, AND MEASUREMENT METHODS During research, we used classical screw-type dental implants from the Conmet company (Russia) and miniimplants from the 3М ESPE company (USA) (Fig. 1) fixed in osseous tissue analogs of polyurethane and linden. To measure coefficients of damping for dental implants fixed in osseous tissue analogs, a Periotest M device of the Medizintechnik Gulden company (Germany) was used. Compliance of implant fastening was determined using an installation by coefficient of rigidity measurement []. Data of implant dimensions and mass are given in Table 1, where l is length of implants (in brackets, length of thread), d is the greatest diameter, m is mass. In 1985, W. Shulte offered a method of periotestometry for estimation of periodontium conditions of natural teeth [4, 5], and only later on it began to be used for estimation of dental implant fastening strength. The measurement technique is based on correlation between density of osseous tissue around of dental implants and its ability to damp impact load [4, 5]. Parameters of various implants No. l, mm d, mm m, g 1 11 (8) (10) (1) (1) (16) (9) (9) (10) (15) (15) Table 1 ISSN Russian Journal of Biomechanics Vol. 19, No. 3:
3 V.A. Eroshin, M.V. Dzhalalova, A.V. Boyko, S.D. Arutyunov, A.G. Stepanov, A.N. Daov Fig. 1. Shapes of Conmet (Russia) dental implants (1-5) and 3M ESPE (USA) mini implants (6-10) Aim pulse actuated at impact (Fig. ) passes through a dental implants and is passed to a osseous tissue. A waveform of the echo signal and its duration depend on elasticity of osseous tissue; microprocessors analyze them and the display screen shows an integrated digital value of osseous tissue damping ability. Recommendations for users of Periotest are presented in Table. Let us note that along with coefficients of damping at a transverse impact (see Fig. ), the Periotest device also enables to determine coefficients of damping at a longitudinal impact when dental implants are loaded along symmetry axis. Further, it will be demonstrated that both coefficients conform well with appropriate compliance coefficients determined numerically and according to the technique of laser testing. For the first time, comparison of coefficients of damping and coefficients of rigidity was performed in work [] where satisfactory qualitative conformity of these results was specified. However, it was difficult to judge quantitative conformity while fastening strength of a dental implant in osseous tissue increases, coefficients of rigidity also increase, but coefficients of damping decrease and even become negative (see Table ). 1 Fig.. Measurement of coefficient of damping (1) and the echo signal waveform () 38 ISSN Russian Journal of Biomechanics Vol. 19, No. 3: 36-43
4 Mobility of implants: new capability of a known device Recommendations for users of Periotest Table Periotest value range Interpretation Good osseointegration; the implant is well integrated and can be loaded Clinical examination is required; in most cases implant loading is not (yet) possible Osseointegration is insufficient; the implant must not be loaded So then, to obtain a clearer image, compliance coefficients П were introduced instead of dental implants coefficients of rigidity as a ratio of dental implants load point displacement to an applied force magnitude: П = /F, where (micron) is of a dental implants load point, F is force magnitude. Fig. 3 presents the displacement measuring schema at implant transverse load. Here, 1 is mini dental implants; is osseous tissue analog; pin 3 supported on an mini dental implants head is rigidly connected with lever 4 rotating on an axis passing through point O; pin 3 is loaded by force F, and the impact point of laser 5 fixed on lever execntes movement ξ on screen 6; 7 is a gum shield with apertures; 8, 9 are elements of osseous tissue analog fastening. The value of lever OA angle of rotation φ and vertical movement of an implant head are determined according to formulas: φ = ξ/l, = φ OA, where L is distance from lever rotation center O to the screen (ξ << L). As it has been already noted, a scatter of measurement results was large enough when previous versions of Periotest were used. This imperfection has been substantially overcome in the last version of the device due to modifications in software. Nevertheless, in some cases more accurate measurements are required because of a series of research technique disadvantages. First of all, a human factor matters: it is impossible to avoid physiological tremor of researcher's hands and to control exactness of the sensor place of impact; the distance between the sensor and the tooth vestibular surface (or the dental implants abutment center) should make mm and the sensor axis should be directed completely perpendicularly to the tooth surface. 5 F O A Fig. 3. Scheme of displacement measure at transverse load ISSN Russian Journal of Biomechanics Vol. 19, No. 3:
5 V.A. Eroshin, M.V. Dzhalalova, A.V. Boyko, S.D. Arutyunov, A.G. Stepanov, A.N. Daov To achieve this goal, a technique was offered for coefficient of damping measurement with a special unit for determination of tooth or implant mobility (Patent Decision of the Russian Federation under application No of 06/04/14). This unit is a transparent a gum shield which shape corresponds to specific features of anatomy of patient's established implants and alveolar jaws. Such shield is made of 4 mm thick rigid plastic by a method of vacuum thermopressing. There is a perimeter gap of mm between the shield surface and examined teeth and cones through holes are formed in the shield in projection of the center of clinical equator of the examined teeth vestibular surface; conicity of the holes conforms to conicity of the measuring sensor nozzle. Experiments have shown that, in the course of monitoring of dental implants mobility through holes in a shield, the device tip impacts uniformly to the same point and at a required angle to an implant, i.e. this technique really reduces a scatter of measurement results and works quite effectively. COMPARISON OF DAMPING AND COMPLIANCE COEFFICIENTS A number of series of experiments with the use of dental implants (Fig. 1) fixed in various osseous tissue analogs were carried out to compare coefficients of damping P measured by Periotest M and compliance coefficients П determined by the technique of laser testing. Experimental data are shown in Table 3 and in Fig. 4 where coefficients of damping are on the horizontal axis and compliance coefficients are on the vertical one. First, let us consider relationship between P and П at transverse load (lines I-III in Table 3). We see that the relationship between these coefficients is close to linear in the range ( 8 < P < 9), i.e. when there is a good osteointegration and when an additional clinical examination is required. It tells of expedience to introduce a new value of coefficient of damping according to the formula: P n = P с +10, (where n means new value and c means old value). In this case, we obtain the following relationship between compliance and damping coefficients: П = 0.57 P n. So, the new coefficient of damping will immediately give an idea of dental implants fastening strength in the most important range of measurement. Moreover, since П = /F, then after introduction of the new coefficient of damping, we can estimate, using Periotest M, the value of displacement of implant's point under the action of an applied force: = П F = 0.57 P n F. Table 3 Values of damping and compliance coefficients of dental implants fixed in various osseous tissue analogs (No. is a dental implant) No. Coefficients I P П, μm/n II P П, μm/n III P П, μm/n IV P П, μm/n V P П, μm/n VI P П, μm/n ISSN Russian Journal of Biomechanics Vol. 19, No. 3: 36-43
6 Mobility of implants: new capability of a known device П, Fig. 4. Dependence of compliance coefficients П on coefficients of damping P. Transverse load: linden is classical screw-type dental implants, is mini dental implants; polyurethane is classical screw-type dental implants, is mini dental implants. Longitudinal load: linden is classical screw-type dental implants, is mini dental implants; polyurethane is classical screw-type dental implants, is mini dental implants; linden ( ) is calculation; polyurethane (+) is calculation Therefore, measurements made with the use of Periotest M will also give information on DI mobility as well as on osteointegration process. When P > 10 (or P n > 0), dental implants fastening strength quickly decreases and, according to manufacturer's guidelines, dental implants cannot be functionally loaded. Here, we must note that, despite considerable difference in implant shapes, the difference between values of coefficients of mobility for classical screw-type dental implants (points 1, 3, 5, 7 in Fig. 4 and Table 3) and mini dental implants (points, 4, 6, 8) is insignificant and they practically do not differ within the measurement accuracy (the linear regression line in Fig. 4 for experimental data, including longitudinal loads, is obtained by the method of least squares, dispersion σ y 0.58). Fig. 4 also shows similar experimental data on connection between damping and compliance coefficients in case of longitudinal impact and longitudinal static load (lines IV-VI in Table 3). It demonstrates that these experimental results are situated on the same curve but lower than in case of transverse load. But, it is no coincidence. Calculations show [3] that in case of elastic deformation of osseous tissue analogs, dental implants displacement at longitudinal loads is approximately.5 times less than at transverse loads. Numerical calculations determining compliance coefficients were made for reliability of results obtained by the method of laser testing. We considered parallelepiped-shaped specimens of linden and polyurethane with dimensions of mm with four screwed classical dental implants structures. The photo of a full-scale specimen of polyurethane with implants is shown in Fig. 5. Fig. 6 demonstrates the distribution of vertical dislacements obtained in a numerical experiment by the finite element method using a virtual model of a full-scale bench. When the extreme implant is loaded by F = 5 N, its displacement comprises = mm = = 10. μm (see the right column in Fig. 6). And since П = /F, then 10. μm / 5 N =.04 μm/n, this value is marked with cross in Fig. 4 (also, the value of compliance coefficient П = 3.75 μm/n for a specimen of polyurethane is marked there with plus + ). ISSN Russian Journal of Biomechanics Vol. 19, No. 3:
7 V.A. Eroshin, M.V. Dzhalalova, A.V. Boyko, S.D. Arutyunov, A.G. Stepanov, A.N. Daov Fig. 5. Photo of a full-scale specimen of polyurethane with screwed implants Fig. 6. Distribution of displacements in a virtual model (the extreme implant is loaded longitudinally) To visualize a picture of displacements distribution, parts of the specimen are cut out near each implant. The transparent grid signifies condition of the virtual model prior to implant loading (an exaggerated scale was chosen specially); the displacement of the first implant slightly pulling the second one is well visible. CONCLUSIONS The research shows that the last version of Periotest M can be used in estimation of an osteointegration level and dental implants readiness for functional load because the manufacturer has managed to eliminate the majority of disadvantages noted before: the value of impact momentum has been reduced (so the device is now less traumatic) and recurrence of measurement results has been improved. Accuracy and representativeness of the research are possible and are reached with the use of a developed device for determination of teeth mobility. Moreover, our research shows that there are excellent opportunities for a further device improvement. Introduction of the new scale will give a physical meaning to measurements and enable to estimate not only dental implants readiness for functional load but also dental implants load-carrying ability on the basis of coefficient of longitudinal damping measurement, i.e. a scientific background will be generated for correction of allowable functional (masticatory) loads. 4 ISSN Russian Journal of Biomechanics Vol. 19, No. 3: 36-43
8 Mobility of implants: new capability of a known device REFERENCES 1. Arutyunov S.D., Eroshin V.A., Stepanov A.G., Boyko A.V., Daov A.N., Matsaberidze L.G. New trends in use of mini dental implants. Russian Bulletin of Dental Implantology, 013, vol. (8), pp Eroshin V.A., Arutyunov S.D., Arutyunov A.S., Unanyan V.E., Boyko A.V. Mobility of dental implants: devices and diagnostic methods. Russian Journal of Biomechanics, 009, vol. 13, no., pp Eroshin V.A., Dzhalalova M.V. Stress-strain state of biomechanical system implant-elastic foundation. Russian Journal of Biomechanics, 01, vol. 16, no 3(57), pp Shulte W. Lukas D. The Periotest method. Int. Dent. J, 1990, vol. 4, no 6, pp Shulte W. What is the significance of the Periotest method currently? Dtsch Zahnarzt Z., 1985, vol. 40, no. 7, pp Received 1 June 015 ISSN Russian Journal of Biomechanics Vol. 19, No. 3:
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