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The International Journal of Periodontics & Restorative Dentistry Celletti.qxd 3/14/08 3:41 PM Page 144 The International Journal of Periodontics & Restorative Dentistry Celletti.qxd 3/14/08 3:41 PM Page 145 145 Bone Contact Around Osseointegrated Implants: Histologic Analysis of a Dual–Acid-Etched Surface Implant in a Diabetic Patient Calogero Bugea, DDS* The clinical applicability and pre- Roberto Luongo, DDS** dictability of osseointegrated implants Donato Di Iorio, DDS* placed in healthy patients have been *** Roberto Cocchetto, MD, DDS studied extensively. Long-term suc- **** Renato Celletti, MD, DDS cess has been shown in both com- pletely and partially edentulous patients.1–6 Although replacement of teeth with dental implants has become The clinical applicability and predictability of osseointegrated implants in healthy an effective modality, the implants’ pre- patients have been studied extensively. Although successful treatment of patients dictability relies on successful osseoin- with medical conditions including diabetes, arthritis, and cardiovascular disease tegration during the healing period.7 has been described, insufficient information is available to determine the effects of diabetes on the process of osseointegration. An implant placed and intended Patient selection criteria are to support an overdenture in a 65-year-old diabetic woman was prosthetically important. The impact of systemic unfavorable and was retrieved after 2 months. It was then analyzed histologically. pathologies on implant-to-tissue inte- No symptoms of implant failure were detected, and histomorphometric evaluation gration is currently unclear. The liter- showed the bone-to-implant contact percentage to be 80%. Osseointegration can ature cites the inability of a patient to be obtained when implants with a dual–acid-etched surface are placed in properly undergo an elective surgical proce- selected diabetic patients. (Int J Periodontics Restorative Dent 2008;28:145–151.) dure as a contraindication for dental implant therapy. However, successful implant treatment of patients with medical conditions including dia- betes, arthritis, and cardiovascular dis- ease, as well as patients on long- *Researcher, Dental School, University “G d’Annunzio,” Chieti-Pescara, Italy. standing steroid treatment, has been ** Researcher, Dental School, University “G d’Annunzio,” Chieti-Pescara, Italy; Private documented in case reports.8,9 Practice, Bari, Italy. ***Visiting Professor, Dental School, University “G d’Annunzio,” Chieti-Pescara, Italy; Private Diabetic patients represent a sig- Practice, Verona, Italy. nificant portion of the population. By ****Professor of Periodontology I and Director of Postgraduate Studies in Periodontology and the year 2050, it is estimated that 45 Implantology, Dental School, University “G d’Annunzio,” Chieti-Pescara, Italy. to 50 million people in the United Correspondence to: Renato Celletti, Via Cola di Rienzo 217, 00192 Rome, Italy; e-mail: States will have diabetes, according [email protected]. to research based on data gathered Volume 28, Number 2, 2008 Celletti.qxd 3/14/08 3:41 PM Page 146 146 between 1983 and 2000 from more In dentistry, diabetic patients generally were clinically osseointegrated, but the than 360,000 respondents to the have been more prone to tooth loss. central implant was removed with a 6- National Health Interview Survey and Thus replacement of the dentition with mm-diameter trephine drill because it the U.S. Census. Diabetes is the most dental implants may be an important was too far lingual and thus interfered common cause of blindness, the option. However, diabetic patients with the base of the denture. The pros- most important cause of lower have demonstrated increased morbid- thetic rehabilitation was nevertheless extremity amputation not related to ity and failure of these devices. The satisfactorily completed on the two trauma, and a major cause of end- exact mechanism by which diabetes remaining implants. stage renal disease.10 down-regulates bone formation There are two major types of around dental implants is not known. diabetes. Type 1 (previously termed The purpose of this case report Histologic preparation “insulin-dependent“) is caused by an was to evaluate histometrically the rate autoimmune reaction that destroys the of bone-to-implant contact in an im- The central implant was retrieved and beta cells of the pancreas, leading to plant retrieved from a diabetic human stored immediately in 10% buffered insufficient production of insulin. Type patient after 2 months of healing. formalin and then dehydrated in an 2 (previously termed “non–insulin- ascending series of alcohol rinses and dependent”) is viewed as a resistance embedded in a glycolmethacrylate to insulin in combination with an inabil- Method and materials resin (Technovit 7200 VCL, Kulzer). After ity to produce additional compen- polymerization, the sample was sec- satory insulin. Type 2 diabetes, often The patient was a 65-year-old woman tioned longitudinally along the major linked to obesity, is the predominant who had been affected by type 2 axis of the implant with a high-precision form in adults who typically need diabetes for 10 years. Because of peri- diamond disk (Precise System, Assing) implant therapy. odontitis, she had been totally eden- at 150 µm and ground down to about Fiorellini et al11 compared osseous tulous for more than 5 years. A non- 30 µm. Three slices were obtained from healing around endosseous implants smoker, she had developed diabetic the retrieved implant. The slices were in normal non-diabetic and insulin- retinopathy, but her wound healing stained with basic fuchsin and toluidine controlled diabetic rats. Their results was normal and she was not osteo- blue. A double staining with von Kossa indicated that insulin therapy was able porotic. She was administering 10 and basic fuchsin was done to evaluate to up-regulate the formation of bone rapid units + 15 units insulin 30/70 the degree of bone mineralization. around implants inserted in a strepto- each morning and 10 rapid units each Histomorphometric evaluation of the zotocin-induced diabetic rat model. evening to control her blood sugar to percentage of bone contact was carried However, histometric analysis showed 180 mg/dL; her glycosylated hemo- out using a light microscope (Laborlux that although the total quantity of globin was 12%, total cholesterol was S, Leitz) connected to a high-resolution bone formed was greater in the insulin- 250 mg/dL, triglycerides were 230 video camera and interfaced with a controlled diabetic group, there was mg/dL, and blood pressure was monitor and personal computer. This significantly less bone-to-implant con- 150/85 mmHg. optical system was associated with a tact in the insulin-controlled diabetic Three Prevail implants (BIOMET/ digitizing pad and a histometry soft- group, when compared to the normal 3i), all 4.0 mm in diameter and 10 mm ware package with image-capturing nondiabetic group.11–19 long, were inserted in the anterior capabilities.21 A multicenter, multidisciplinary clin- mandible for prosthetic rehabilitation ical study of implant survival in patients with an overdenture. The surgery was with type 2 diabetes revealed signifi- carried out in a single stage, with cantly more failures in diabetic patients, immediate insertion of healing abut- compared to nondiabetic patients.20 ments. After 2 months, all implants The International Journal of Periodontics & Restorative Dentistry Celletti.qxd 3/14/08 3:41 PM Page 147 147 Fig 1 (left) Overview of a histologic sec- tion obtained from the retrieved implant (basic fuchsin; original magnification ϫ1.5). Fig 2 (right) The pre-existing bone (B) is connected to the newly formed bony tra- beculae (T), which are in close contact with the implant surface (basic fuchsin; original magnification ϫ20). B T Fig 3 (left) On the right side of implant, the bone is well-adapted to the implant sur- face and gradually thins as it extends toward the threads (basic fuchsin; original magnification ϫ20). Fig 4 (right) On the left side of implant, the separation between the bone and the implant surface appears to be an artifact. At the thread level, the newly formed bone follows the implant profile (basic fuchsin; original magnification ϫ20). Results Histomorphometric analysis revealed implant’s left profile, suggesting that that the right side of the implant was the apparent gap was probably The implant was clinically osseointe- in contact with the bone (Figs 1 to 3), caused by an artifact (Fig 4). grated and stable. No mobility or while a gap appeared to be present At the coronal level, no infrabony pathologic symptoms were present. on the left side. However, at higher pockets, Howship lacunae, or osteo- Prior to retrieval, slight vertical crestal magnification, the bone surface clasts were present. No gaps or dense bone loss was noted radiographically. clearly appeared to follow the fibrous connective tissue were found at Volume 28, Number 2, 2008 Celletti.qxd 3/14/08 3:41 PM Page 148 148 Fig 5 (left) Around the bone trabeculae, osteoblasts can be seen depositing osteoid matrix undergoing mineralization (basic fuchsin; original magnification ϫ45). Fig 6 (right) A continuous layer of bone is evident on the implant surface, and the marrow spaces are closed with smooth, rounded borders (basic fuchsin; original magnification ϫ20). Fig 7 (left) Near the implant apex, the new bone appears to be flowing over the surface and is interposed between the old bone and the implant surface (basic fuchsin; original magnification ϫ15). PO Fig 8 (right) The bone is in close contact with all the parts of an implant thread (basic fuchsin; original magnification ϫ50). PO = primary osteon; O = osteocytes. O the bone-metal interface. No apical one thread of the implant. Around the between the old bone and implant epithelial migration was evident, nor bone trabeculae, there were surface (Fig 7) and a primary osteon was any inflammatory infiltrate present osteoblasts depositing an osteoid (Fig 8). Histomorphometric evaluation around the implant. The implant was matrix that was undergoing mineral- showed that the bone-to-implant con- surrounded by newly formed bone, ization (Figs 5 and 6).
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