Tissue Healing of Immediate Implant Placement in Extraction Sockets with Titanium Versus Zirconium Oxide Implants: an Experimental Study in the Beagle Dog
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UNIVERSIDADE DE LISBOA FACULDADE DE MEDICINA DENTÁRIA TISSUE HEALING OF IMMEDIATE IMPLANT PLACEMENT IN EXTRACTION SOCKETS WITH TITANIUM VERSUS ZIRCONIUM OXIDE IMPLANTS: AN EXPERIMENTAL STUDY IN THE BEAGLE DOG HELENA CRISTINA DE OLIVEIRA FRANCISCO Orientadores: Prof. Doutor João Manuel Mendez Caramês Prof. Doutor António Duarte Sola Pereira da Mata Tese especialmente elaborada para a obtenção do grau de Doutor em Medicina Dentária, especialidade de Periodontologia 2016 UNIVERSIDADE DE LISBOA FACULDADE DE MEDICINA DENTÁRIA TISSUE HEALING OF IMMEDIATE IMPLANT PLACEMENT IN EXTRACTION SOCKETS WITH TITANIUM VERSUS ZIRCONIUM OXIDE IMPLANTS: AN EXPERIMENTAL STUDY IN THE BEAGLE DOG HELENA CRISTINA DE OLIVEIRA FRANCISCO Orientadores: Prof. Doutor João Manuel Mendez Caramês Prof. Doutor António Duarte Sola Pereira da Mata Tese especialmente elaborada para a obtenção do grau de Doutor em Medicina Dentária, especialidade de Periodontologia Júri Presidente: Doutor Mário Filipe Cardoso de Matos Bernardo, Professor Catedrático e Presidente do Conselho Científico da Faculdade de Medicina Dentária da Universidade de Lisboa; Vogais: Dennis Perry Tarnow, Clinical Professor of Dental Medicine do College of Dental Medicine da Columbia University, USA; Doutor António Cabral de Campos Felino, Professor Catedrático da Faculdade de Medicina Dentária da Universidade do Porto; Doutor Ricardo Manuel Casaleiro Lobo de Faria Almeida, Professor Catedrático da Faculdade de Medicina Dentária da Universidade do Porto; Doutor Femando Alberto Deométrio Rodrigues Alves Guerra, Professor Associado com Agregação da Faculdade de Medicina da Universidade de Coimbra; Doutor João Manuel Mendes Caramês, Professor Catedrático da Faculdade de Medicina Dentária da Universidade de Lisboa; Doutor António Duarte Sola Pereira da Mata, Professor Catedrático da Faculdade de Medicina Dentária da Universidade de Lisboa; Doutor Paulo Alexandre Mascarenhas Lopes, Professor Auxiliar da Faculdade de Medicina Dentária da Universidade de Lisboa; 2016 To my parents and brothers with love. ACKNOWLEDGEMENTS The research presented in this thesis would not have been possible without the help of many people to whom I am gratefully indebted. It will be simple to name all the people that helped to get this done, but it will be tough to thank them enough. First and foremost, my sincere thanks go to my two Ph.D. supervisors Professor João Manuel Mendez Caramês and Professor António Duarte Sola Pereira da Mata. I would like to express my sincerest gratitude to my supervisor Professor João Manuel Mendez Caramês, Full Professor at the University of Lisbon College of Dentistry, who has supported me throughout my thesis with his patience and knowledge. Professor Caramês welcomed me to his office when I arrived from New York and has been a strong guiding influence on my professional career ever since. I have been extremely lucky to have a supervisor whose care and attention has made this such a thoughtful and rewarding journey. His expertise in animal research in particular was a great asset to the research. His continuing effort, commitment and mentorship has helped me to bring this study to its conclusion. His sincere enthusiasm, absolute commitment and generous support continue to inspire me. Professor António Duarte Sola Pereira da Mata, Full Professor at the University of Lisbon College of Dentistry, introduced me to academic and research life in my second year of dental school when I became a member of GIBO (Oral Biology and Research Group) at ISCS-S (Instituto Superior de Ciências da Saúde Sul). He influenced my graduate and postgraduate career in an ineffably positive way. His thoroughness and understanding of biology, his passion for academia and research remain a tremendous source of inspiration, support and an example to follow. Moreover, his patient guidance and valued friendship were crucial in helping me to reach my goals. During my training at New York University College of Dentistry I had the chance to meet and work with a number of wonderful people. There are however, two people that had a profound impact on my academic and professional life. I will always be iii deeply grateful to one of my earliest mentors Dr. Dennis Tarnow who really showed me how to appreciate scientific curiosity and integrity through his guidance, expertise and thoughtful criticism. More than a mentor, he is an extraordinary friend. My sincere thanks for inspiring me to pursue my ideas, go further and keep it simple. I will always cherish his lectures. To Dr Gary Greenstein whose everlasting support and encouragement, excellent sense of humor and dedication to the profession throughout the years was truly priceless. My work at New York University College of Dentistry would not have been as enjoyable without him. I am very grateful and wish to acknowledge the administration of FMDUL for the institutional support, in particular to the Director Professor Luís Pires Lopes, Vice- Director Professor Jaime Portugal and Past-Director Professor João Aquino and who always expressed interest in this research project and also to o the Scientific Board at FDMUL, and its President, Professor Mário Bernardo. My deepest gratitude to the team of Professor Ramiro Mascarenhas, Dr João Maria Nobre and Paulo Dias at the Experimental Surgery Center at National Zoothecnical Station in Santarém. Without their help this work could not have taken place. I would like to extend my sincere thanks to Professor Fernando Guerra and his team at the University of Coimbra. My personal thanks to Professor Paulo Palma and Dr João Martins for their skillful support. I cannot thank Cláudia Brites enough for spending long hours struggling to have the zirconia sections ready on time. My sincere gratitude to Professor José Rino, responsible for microscopy at Champalimaud Foundation who willingly shared his expertise and gave me access to the laboratory and research facilities. I am grateful to my dear long time friend Professor Joana Rita da Silva Fialho for her help in the phase of the conclusion of this thesis. Her statistical assistance during the final stretch was greatly appreciated. iv This thesis would not have been possible without the help of Franz Berghaenel from Metoxit who I would like to thank specially for his help and commitment and also to Ulrich Voltz whose help in the initial phases of this project and knowledge on zirconia implants was crucial in bringing this thesis to fruition. My thanks also to Professor Duarte Marques for being a loyal friend and colleague and for his continuous encouragement and friendship throughout our years working together. His sound advice and support have been invaluable on an academic level for which I am extremely grateful. I would like to express my gratitude to my dear friends and colleagues at the University of Lisbon College of Dentistry, Dr André Chen and Dr João Canta, for the great support and friendship that they have given me over the years. To Professor Joana Marques and Professor João Silveira my dearest friends I would like to thank them for all the support and mostly for their friendship since we started working in the Oral Biology Research Group (GIBO) in 2001. To all the staff and friends at the Implantology Institute. I would like to thank Manuela André especially who was very important during the experimental phase. Her human qualities, help and enthusiasm were always present during experimental surgery. To my dental assistant Filipa Teixeira for being patient, for organizing everything at the office and for taking everything she could off my shoulders so that I could focus on this thesis. The dedication needed to complete this work would not have been possible without the understanding and support of my family and friends. First and foremost, I cannot thank my parents Celeste and Manuel enough. They have encouraged me in my studies and gave me both the freedom and support that I needed to become the person I am today. They were excellent teachers and role models, but still trusted me enough to let me choose my own goals. They have served as my guiding light throughout my education and I hope that I have lived up to their expectations. Last v but not least, to my brothers João and Rui for their continuous support and for always believing in me. vi ABSTRACT Objectives: To compare and evaluate the biomechanical, radiographic and histological behavior of zirconia and titanium implants placed into extraction sockets. Materials and methods: Five Beagle dogs received 15 titanium implants (Ti) and 15 zirconia implants (Zr) immediately placed into the distal socket of the second, third and fourth premolars. Implant stability and radiographic evaluation was performed at the time of implant placement and sacrifice. Animals were sacrificed at 1, 2, 4, 8 and 12 weeks. Peri-implant mucosa dimensions, marginal bone loss and bone-to-implant contact were evaluated. Kruskall-Wallis test, Mann-Whitney test and Spearman correlation analysis were used when appropriate. Values of p < 0.05 were taken as significant. Results: The primary stability values were 82.53 ± 1.10 ISQ (Ti) and 57.6 ± 3.29 ISQ (Zr) (p = .05). After 12 weeks, implant stability was 79.33 ± 0.58 ISQ (Ti) and 84.67 ± 6.11 (Zr) (p > .05). The buccal peri-implant mucosa ranged between 3.54 ± 0.23 mm (Zr) and 3.93 ± 0.49 mm (Ti) (p > .05). The buccal bone crest was located 1.53 ± 0.15 mm (Ti) and 1.55 ± 0.12 mm (Zr) (p > .05) below the implant shoulder (p = .05). The BIC, NBF and TBA were 59.4 ± 0.75 % (Ti) and 57.8 ± 2.26 % (Zr), 65.37 ± 3.05 % (Ti) and 63.63 ± 3.79 % (Zr), 77.97 ± 2.08 % (Ti) and 75.1 ± 2.31 % (Zr) respectively (p > 0.05). Conclusions: Even though zirconia implants exhibited less primary stability when compared to titanium implants they reach a similar degree of stability over time. Zirconia implants did not prevent the remodeling of the extraction socket.