The use of dental implants to replace the form and

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1 Mcro design morphology of endoseous dentl implnts Indir G. Shiwl, BDS, DMD, MS, Ronld D. Woody, DDS, Byron W. Benson, DDS, MS, c nd Guillermo E. Guillen, DDS d Bylor College of Dentistry, Texs A&M University System, Dlls, Texs Sttement of prolem. The identifiction of dentl implnt odies in ptients without ville records is considerle prolem due to incresed ptient moility nd to the lrge numer of implnt systems with different designs. Purpose. The purpose of this study ws to document the designs of selected implnts to help clinicins identify these implnts from their rdiogrphic imges. Mteril nd methods. More thn 50 implnt mnufcturers were contcted nd sked to provide implnts with dimensions s close s possile to 3.75 mm (dimeter) 10 mm (length). Forty-four implnts were donted, seprted into threded nd nonthreded ctegories, nd further sorted into tpered nd nontpered ctegories. The implnts were exmined visully, nd fetures on the entire circumference nd length of ech implnt were recorded nd ctegorized s coronl, midody, or picl. Results. A series of tles descrie the 44 implnts ccording to coronl, midody, nd picl fetures. Conclusion. The results of this project offer dentists sic knowledge of the design of selected dentl implnts. Such knowledge cn id the rdiogrphic identifiction of these implnts. (J Prosthet Dent 2002;87: ) CLINICAL IMPLICATIONS The identifiction of dentl implnt systems in ptients without ville records is necessry for successful restortion nd in forensic dentistry. This study documents the sic design of significnt numer of implnts, therey enling dentists to identify implnts from rdiogrphic imges. The use of dentl implnts to replce the form nd function of lost nturl dentition hs ecome significnt tretment option. 1 Vrious mnufcturers hve responded to enthusism for this protocol y developing new implnt designs to improve tretment outcomes. Binon 2 indicted tht more thn 90 rootform implnts re ville in vriety of dimeters, lengths, surfces, pltforms, interfces, nd ody designs. While dentistry hs enefitted from these developments, keeping up with the continuous influx of new implnts is difficult. The identifiction of older nd newly developed designs cn pose prolem for the restortive dentist treting ptient with no records or for the forensic dentist ttempting to identify victim. 3 Rdiogrphic imging is useful djunct in ll phs- Finncil support ws provided y Bylor College of Dentistry. Privte prctice, Plo Alto, Clif. Professor, Grdute Prosthodontics, Deprtment of Restortive Sciences. c Professor, Orl nd Mxillofcil Rdiology, Deprtment of Dignostic Sciences. dassocite Professor, Grdute Prosthodontics, Deprtment of Restortive Sciences. es of implnt tretment. The urgeoning cceptnce of rdiogrphic devices hs een ttriuted, in prt, to the incresingly sophisticted imging techniques used in preopertive tretment plnning, intropertive ssessment, nd postopertive ssessment. 4 Rdiogrphs lso could e djuncts in implnt identifiction. Sewerin 3 stted tht dentist must e fmilir with implnt designs nd with the principles of rdiogrphic imge formtion efore rdiogrphs cn e used for implnt identifiction. This study documents the 3-dimensionl design of selected implnts. Different horizontl rottions or verticl inclintions of the implnt reltive to the rdiogrphic em cn produce numerous 2-dimensionl representtions of the 3-dimensionl design. The informtion provided in this study will fcilitte clinicl understnding of the 2-dimensionl representtion of implnts seen in rdiogrphs. MATERIAL AND METHODS Letters were sent to more thn 50 implnt mnufcturers requesting implnts with dimensions s close s possile to 3.75 mm (dimeter) 10 mm (length). Forty-four implnts were donted (Tle I). Some MAY 2002 THE JOURNAL OF PROSTHETIC DENTISTRY 543

2 THE JOURNAL OF PROSTHETIC DENTISTRY SAHIWAL ET AL Tle I. Implnts used in this study nd their mnufcturers Implnt nme Ace Cylinder Ace Screw Astr Fixture 4.0 Astr Fixture ST 4.5 Bicon Biohorizons 4 mm D1 Biolock IHSSHA410 Brånemrk SDCA 023 Brånemrk MkII SDCA 220 Brånemrk MkIll Fritec-2 stepped cylinder Fritec-2 stepped screw Innov 01B-9I1 Integrl 0802 Spline 1980 Imtec Imtec ITI HC S ITI Solid Screw S LminOss IMZ TPS 8039SR Minimtic IHCSHA315 Minimtic IHPSS410 O Compny 4010TE O Compny 4010 Osteoimplnt Prgon Bio-Vent BV10 (00112) Prgon Micro-Vent MTH10 (01141) Prgon Complete Screw-Vent CSVB10 (01129) Prc Press-fit Str V057 Prc Strlock Str V003 Prc Strvent Str V044 Restore R Srgon Replce Sterioss Cyl 2810 TPS Sterioss 2210 Sterngold Implmed Sterngold Implmed Sustin Tenx 10X-S 3i Cylinder TP413 3i Osteotite OSS 410 3i TG 2410 Implnt mnufcturer Ace Dentl Implnt System, Brockton, Mss. Ace Dentl Implnt System Astr Tech Inc, Lexington, Mss. Astr Tech Inc Bicon Dentl Implnts, Boston, Mss. Biohorizons Implnt System Inc, Birminghm, Al. Biolock Interntionl Inc, Deerfield Bech, Fl. Noelphrm AB, Goteerg, Sweden Noelphrm AB Noelphrm AB Frident, Irvine, Clif. Frident Innov, Toronto, Ontrio, Cnd Sulzer Clcitek, Crlsd, Clif. Sulzer Clcitek Imtec Corportion, Ardmore, Okl. Imtec Corportion Institut Strumnn AG, Wldenurg, Switzerlnd Institut Strumnn AG Impldent Ltd, Holliswood, N.Y. Interpore Interntionl, Irvine, Clif. Minimtic Implnt Technology, Boc Rton, Fl. Minimtic Implnt Technology O Compny Inc, Aluquerque, N.M. O Compny Inc Osteo-Implnt Corportion, New Cstle, P. Prgon Implnt Compny, Encino, Clif. Prgon Implnt Compny Prgon Implnt Compny Prk Dentl Reserch Corp, New York, N.Y. Prk Dentl Reserch Corp Prk Dentl Reserch Corp Lifecore Biomedicl Inc, Chsk, Minn. Srgon Dentl Implnts, Beverly Hills, Clif. Sterioss Dentl Implnts, Yor Lind, Clif. Sterioss Dentl Implnts Sterioss Dentl Implnts Sterngold Implmed Dentl Implnt Systems, Attleoro, Mss. Sterngold Implmed Dentl Implnt Systems Lifecore Biomedicl Inc Tenx Dentl Implnt System, Collingwood, Ontrio, Cnd Implnt Innovtions Inc, Plm Bech Grdens, Fl. Implnt Innovtions Inc Implnt Innovtions Inc mnufcturers sent multiple implnts of vrious designs. The implnts were seprted into threded nd nonthreded ctegories nd then further sorted into tpered nd nontpered. Within ech group, the implnts were rrnged lpheticlly, nd ech implnt ws ssigned numer. All implnts were plced in storge ox with multiple sections, ech mrked with the nme nd numer of ech implnt. The division of the implnts is represented in Figure 1 (to relte implnt numer nd nme, see Tles II through IV). The implnts were exmined individully. Fetures were chosen ritrrily to help descrie the implnts nd were ctegorized s coronl, midody, or picl. Ech of these ctegories represented one third of the implnt. The coronl fetures (Tle II) included description of the prosthetic interfce, the flnge (the re etween the prosthetic interfce nd the implnt ody), nd ny unique chrcteristics in the coronl 544 VOLUME 87 NUMBER 5

3 SAHIWAL ET AL THE JOURNAL OF PROSTHETIC DENTISTRY Tle II. Coronl fetures of implnts used in study Implnt Implnt Externl Internl Morse Wider Stright Flred Unique numer nme hex hex tper Other flnge flnge flnge feture 1 Fritec-2 stepped cylinder 2 Innov 01B-9I1 3 Ace Cylinder O Biolock IHSSHA410 5 Imtec IMZ TPS 8039SR 7 Integrl ITI HC S 9 Minimtic IHCSHA O Compny 4010TE Groove just elow flnge 11 Prgon Bio-Vent BV10 (00112) 12 Prc Press-fit Str V Sterioss Cyl 2810 TPS 14 Sterngold Implmed Tenx 10X-S 16 3i Cylinder TP Fritec-2 stepped screw 18 Prgon Micro-Vent MTH10 (01141) 19 Replce Restore R Ace Screw Astr Fixture Astr Fixture ST 4.5 Fine threds on entire flnge 24 Bicon No flnge 25 Biohorizons 4 mm D1 26 Brånemrk SDCA Brånemrk MkII SDCA Brånemrk MkIll Imtec ITI Solid Screw S 31 LminOss Ellipticl flnge 32 Minimtic IHPSS O Compny Osteoimplnt Prgon Complete Screw-Vent CSVB10 (01129) 36 Prc Strlock Str V Prc Strvent Str V Srgon 39 Spline Sterioss Sterngold Implmed Sustin i Osteotite OSS i TG 2410 Apicl prt of flre grooved MAY

4 THE JOURNAL OF PROSTHETIC DENTISTRY SAHIWAL ET AL Tle III. Midody fetures of implnts used in study Reverse Implnt Implnt Non- Non- V-shped Squre uttress Unique numer nme Tpered tpered Threded threded threds threds threds Grooves feture 1 Fritec-2 stepped cylinder 3 Stepped 2 Innov 01B-9I1 3 Ace Cylinder O Biolock IHSSHA410 Dimond-shped mtrix 5 Imtec IMZ TPS 8039SR 7 Integrl ITI HC S 9 Minimtic IHCSHA O Compny 4010TE 11 Prgon Bio-Vent BV10 (00112) 3 12 Prc Press-fit Str V057 Multiple short grooves 13 Sterioss Cyl 2810 TPS 2 14 Sterngold Implmed Tenx 10X-S 16 3i Cylinder TP Fritec-2 stepped screw 3 Stepped 18 Prgon Micro-Vent MTH10 2 types of cotings nd (01141) threds 19 Replce Very thin threds 20 Restore R Ace Screw Astr Fixture Astr Fixture ST Bicon 25 Biohorizons 4 mm D1 26 Brånemrk SDCA Brånemrk MkII SDCA Brånemrk MkIll Imtec ITI Solid Screw S 31 LminOss Very wide threds 32 Minimtic IHPSS O Compny Osteoimplnt Prgon Complete Screw-Vent Top treted, ottom CSVB10 (01129) mchined 36 Prc Strlock Str V003 Threds comintion of reverse uttress nd squre 37 Prc Strvent Str V Srgon Expnding screw in middle of ody 39 Spline Sterioss 2210 Very thin threds 41 Sterngold Implmed Sustin Threds on top hlf of ody 43 3i Osteotite OSS 410 Top mchined, ottom treted 44 3i TG VOLUME 87 NUMBER 5

5 SAHIWAL ET AL THE JOURNAL OF PROSTHETIC DENTISTRY Tle IV. Apicl fetures of implnts used in study Implnt Implnt V-shped Flt Curved Round Olong Apicl Unique numer nme pex pex pex hole hole chmer Grooves feture 1 Fritec-2 stepped cylinder 3 Grooves continuous with ody 2 Innov 01B-9I1 3 Ace Cylinder O rows of holes 4 Biolock IHSSHA410 5 Imtec IMZ TPS 8039SR 4 7 Integrl ITI HC S 3 9 Minimtic IHCSHA315 4 Grooves continuous with ody 10 O Compny 4010TE 2 2 grooves with 1 dimple ech 11 Prgon Bio-Vent BV10 (00112) 3 Holes t end of ody grooves 12 Prc Press-fit Str V Sterioss Cyl 2810 TPS 2 Holes nd grooves lternte 14 Sterngold Implmed Tenx 10X-S 16 3i Cylinder TP Fritec-2 stepped screw 3 Grooves continuous with ody 18 Prgon Micro-Vent MTH10 (01141) 2 19 Replce Restore R Ace Screw Astr Fixture Astr Fixture ST Bicon 25 Biohorizons 4 mm D Brånemrk SDCA Brånemrk MkII SDCA Very wide grooves 28 Brånemrk MkIll Very wide grooves 29 Imtec ITI Solid Screw S 31 LminOss 32 Minimtic IHPSS O Compny Dimples in grooves 34 Osteoimplnt Prgon Complete Screw-Vent 2 2 Holes in grooves CSVB10 (01129) 36 Prc Strlock Str V Prc Strvent Str V Srgon Split flred pex. Expnding screw in middle 39 Spline Sterioss Holes in grooves 41 Sterngold Implmed Sustin picl dimples 43 3i Osteotite OSS i TG MAY

6 THE JOURNAL OF PROSTHETIC DENTISTRY SAHIWAL ET AL Fig. 1. Division of implnts. Fig. 2. () Externl hex in Brånemrk SDCA 023. () Internl hex in Prgon Bio-Vent BV10 (00112). (c) Morse tper in ITI Solid Screw S. (d) Spline interfce in Spline c d c d Fig. 3. () Wider flnge in Brånemrk SDCA 023. () Stright flnge in IMZ TPS 8039 SR. (c) Flred flnge in ITI HC S. (d) Stright flnge in Astr Fixture 4.0. Fig. 4. () Threded Osteoimplnt () Nonthreded Ace Cylinder Fig. 5. () Tpered Fritec-2 stepped cylinder. () Nontpered 3i Ossteotite OSS410. re. The prosthetic interfce ws descried s n externl hex, internl hex, Morse tper, or other (Fig. 2). The ltter included ll prosthetic interfces not mentioned, such s the spline interfce of the Spline The flnge ws descried s wider (flnge ws wider thn the implnt ody), stright (stright trnsition from the implnt ody to the flnge), or flred (smooth flre from the implnt ody to the prosthetic interfce) (Fig. 3). When there ws dout s to whether the flnge ws wider or stright, the outer ends of the implnt threds were exmined with ruler nd mgnifiction. If the lterl end of the threds nd the outer end of the flnge coincided, the flnge ws considered stright. Tle III lists the midody fetures: threded or nonthreded (Fig. 4), tpered or nontpered (Fig. 5), the shpe of the threds when present, the presence of grooves, nd ny unique chrcteristics. Three shpe ctegories were estlished for thred design (Fig. 6): v-shped point = oth rms of the threds were equl in length nd ended in point; squre = the rms of the threds were nerly prllel nd ended in flt; nd reverse uttress = one rm of the thred (usully the upper) ws longer thn the other nd the 2 rms met in point, creting Christms tree effect. Tle IV lists the pcil fetures: the shpe of the pex, the presence of ny holes, the presence of n picl chmer (Fig. 7), the presence of grooves, nd ny 548 VOLUME 87 NUMBER 5

7 SAHIWAL ET AL THE JOURNAL OF PROSTHETIC DENTISTRY c d Fig. 6. () V-shped threds in Brånemrk SDCA 023. () Squre threds in Biohorizons 4 mm D1. (c) Reverse uttress threds in Minimtic IHPSS410. (d) Reverse uttress threds in Sterioss c d Fig. 7. () Apicl chmer in Minimtic IHCSHA315. () V-shped pex in Tenx 10-S. (c) Flt pex in Astr Fixture 4.0. (d) Curved pex in Integrl Fig. 8. () Olong hole in Sterngold Implmed () Round hole in Prgon Micro-Vent MTH10 (01141). unique chrcteristics. Three shpe ctegories were estlished (Fig. 7): v-shped = the pex ended in point; flt = the tip ws flt; nd curved = the pex ws neither v-shped nor flt, regrdless of the mount of curvture. The holes were descried s olong or round (Fig. 8). RESULTS Tles II through IV descrie the 44 implnts ccording to coronl, midody, nd picl fetures, respectively. DISCUSSION Mny implnts hve perfortions, grooves, picl chmers, nd threds tht influence the rdiogrphic imge of the implnt. Some fetures my e unique nd enle recognition of specific products, ut mny fetures my confuse the interprettion of n implnt imge. 5 Such confusion results from the fct tht multiple imges cn e produced y the sme implnt depending on the reltionship of the feture in question to the rdiogrphic em. Sewerin 3 demonstrted the complexity of rdiogrphic imges with Brånemrk Mrk I implnt. He explined tht, ecuse verticl cuts or grooves re present piclly, the picl prt of the implnt could Fig. 9. () Prc Strlock V003 threds were clssified s reverse uttress even though ends of threds re squre. () Prgon Complete Screw-Vent CSVB10 (01129) flnge ws descried s wider even though top is flred. pper conicl in rdiogrphic imge. The implnt ppers most cylindricl when the grooves re perpendiculr to the rdiogrphic em. As the orienttion of the grooves to the rdiogrphic em chnges, the shpe of the picl prt chnges nd looks tpered to vrious degrees t different horizontl rottions. Knowledge of implnt designs could id in the rdiogrphic identifiction of implnts. Consider the Brånemrk stndrd implnt t different horizontl rottions to the x-ry em. The implnt hs 2 holes nd chmer in the picl region. It cn e predicted tht the picl perfortions my pper differently depending on the degree of rottion of the implnt. 6 If the longitudinl xes of the picl holes re perpendiculr to the film plne, they will pper s rdiolucent circle on the rdiogrph s the 2 perfortions coincide nd the rdiogrphic em psses through oth holes, without ostruction, long the sme line. If the implnt is horizontlly rotted pproximtely 45 degrees, 2 less rdiolucent circles will pper. As t ltered rottions, the holes will not line up with the rdiogrphic em, nd the em therefore will pss through ech hole individully, creting 2 imges. As prt of the implnt ody overlps MAY

8 THE JOURNAL OF PROSTHETIC DENTISTRY SAHIWAL ET AL Fig. 10. Prtilly grooved flnge of 3i TG 2410 implnt. Fig. 11. () Mtrix-like pttern on ody of Biolock IHSSHA410 implnt could pper s pseudo-threds on rdiogrph. () Multiple grooves on ody of Prc Press-fit V057 could pper s pseudo-threds on rdiogrph. Fig. 12. () Dimple in picl re of O Compny 4010TE. () Hole in picl re of Brånemrk SDCA 023. the holes on oth sides, the holes will not e completely rdiolucent nd my vry in shpe. If the longitudinl xes of the holes re t 90 degrees to the rdiogrphic em, or prllel to the film, only hlf of ech hole will fce the em. The imge will e seen s 2 semicirculr rdiolucencies t the edge of the implnt ody, with the rdiolucency of the picl chmer in etween. The picl chmer will e cler in this view ecuse it will not e msked y the imge of the holes. When n implnt is descried s hving 2 holes in the picl re, they ctully re 2 openings of the sme chnnel on different surfces of the implnt. Four holes would correlte to 2 chnnels, nd so on. These openings re descried s holes for ese of understnding. Given the lck of stndrdized terminology used to descrie implnt fetures in the literture, few implnt clssifictions in Tles II through IV my confuse some reders. Prc Strlock Str V003 implnts, for exmple, hve threds tht pper to e reverse uttresses ut tht hve flt end like squre threds (Fig. 9). These implnts were clssified s reverse uttress ecuse tht seemed to e the more striking feture. Similrly, the flnge of the Prgon Complete Screw-Vent CSVB10 (01129) implnt ws descried s wider even though the top portion is flred. The former description seemed more pproprite ecuse the flre is not smooth flre from the ody of the implnt to the prosthetic interfce (Fig. 9). Fmilirity with implnt design not only helps with rdiogrphic identifiction ut lso my e n sset in clinicl judgment of rdiogrphic imge. Consider the 3i TG 2410 implnt (Fig. 10), which hs grooves only on the picl hlf of the flred flnge. A clinicin unfmilir with this design feture might ssume (incorrectly) tht rdiogrph with grooves pprent only on the picl hlf is of no dignostic vlue, s the coronl threds cnnot e viewed. Similrly, Biolock IHSSHA410 nd Prc Press-fit V057 implnts hve mtrix-like pttern nd multiple grooves on the entire ody, respectively (Fig. 11). Both implnts could produce pseudo-threded imge on the rdiogrph nd confuse clinicin unfmilir with their design. Yet nother exmple is the O Compny 4010TE implnt, which hs dimple in the picl re rther thn round hole, like the Brånemrk SDCA 023 (Fig. 12). The dimple will produce reltively rdiolucent circle(s) or prts thereof depending on the horizontl rottion of the implnt in the rdiogrph, ut never the completely rdiolucent circle(s) or prts thereof produced y the hole in the Brånemrk SDCA 023. Due to resource, spce, nd time limittions, ll implnt systems on the mrket could not e included in this study. The inclusion or exclusion of ny prticulr system is not ment to infer its superiority or inferiority. CONCLUSIONS The principles of rdiogrphic imge formtion re understood y most clinicins. This project ws undertken to dd to tht knowledge se y documenting 550 VOLUME 87 NUMBER 5

9 SAHIWAL ET AL THE JOURNAL OF PROSTHETIC DENTISTRY the sic design fetures of selected implnts. This informtion should id in the identifiction of implnts from their rdiogrphic imges. The dontion of ll implnts y their respective mnufcturers is cknowledged nd pprecited. REFERENCES 1. Benson BW. Dignostic imging for dentl implnt ssessment. Tex Dent J 1995;112: Binon PP. Implnts nd components: entering the new millennium. Int J Orl Mxillofc Implnts 2000;15: Sewerin I. Identifiction of dentl implnts on rdiogrphs. Quintessence Int 1992;23: Shetty V, Benson BW. Orofcil implnts. In: White SC, Phroh MJ, editors. Orl rdiology: principles nd interprettion. 4th ed. St. Louis: Mosy; p Sewerin IP. Comprison of rdiogrphic imge chrcteristics of Brånemrk nd IMZ implnts. Clin Orl Implnts Res 1991;2: Sewerin I. Rdiogrphic imge chrcteristics of Brånemrk titnium fixtures. Swed Dent J 1992;16:7-12. Reprint requests to: DR INDIRA G. SAHIWAL 15, CRYSTAL SPRINGS TERRACE HILLSBOROUGH, CA FAX: (650) ishiwl@yhoo.com Copyright 2002 y The Editoril Council of The Journl of Prosthetic Dentistry /2002/$ /1/ doi: /mpr MAY