Biomaterials / orthodontic pliers

BIOMATERIALS AND
BIOCOMPATIBILITY F0R IMPLANTS
(PART – 2)
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.
com

 INTRODUCTIONINTRODUCTION
 HISTORYHISTORY
 PHYSICAL AND MECHANICAL, AND CHEMICALPHYSICAL AND MECHANICAL, AND CHEMICAL
REQUIREMENTS FOR IMPLANT MATERIALSREQUIREMENTS FOR IMPLANT MATERIALS
 METALS AND ALLOYSMETALS AND ALLOYS
 OTHER METALS AND ALLOYSOTHER METALS AND ALLOYS
 OTHER MATERIALSOTHER MATERIALS
 FUTURE AREAS OF APPLICATIONFUTURE AREAS OF APPLICATION
 BIOACTIVE AND BIODEGRADABLE CERAMICS BASEDBIOACTIVE AND BIODEGRADABLE CERAMICS BASED
ON CAL.PHOSPHATESON CAL.PHOSPHATES
www.indiandentalacademy.comwww.indiandentalacademy.com

 SURFACE CHARACTERIZATIONSURFACE CHARACTERIZATION
 TISSUE INTERACTIONTISSUE INTERACTION
 POROUS AND FEATURED COATINGSPOROUS AND FEATURED COATINGS
 OTHER SURFACE MODIFICATIONSOTHER SURFACE MODIFICATIONS
 SURFACE CLEANLINESSSURFACE CLEANLINESS
 SURFACE ENERGYSURFACE ENERGY
 PASSIVATION AND CHEMICAL CLEANINGPASSIVATION AND CHEMICAL CLEANING
 STERILIZATIONSTERILIZATION
 SELECTION EVALUATION ANDSELECTION EVALUATION AND
PREPARATION OF BIOMATERIALSPREPARATION OF BIOMATERIALS
 FINAL MATERIAL PREPARATIONFINAL MATERIAL PREPARATION
 BIOCOMPATIBILITY TESTSBIOCOMPATIBILITY TESTS
 CONCLUSIONCONCLUSION www.indiandentalacademy.comwww.indiandentalacademy.com

SURFACESURFACE
CHARACTERIZATION ANDCHARACTERIZATION AND
TISSUE INTERACTIONTISSUE INTERACTION

Metal and Alloy SurfacesMetal and Alloy Surfaces
 Standard grades of alpha (unalloyed) titaniumStandard grades of alpha (unalloyed) titanium
 Alpha-beta and beta-base alloys of titaniumAlpha-beta and beta-base alloys of titanium
(Ti)(Ti)
 Exist with an oxide surface at normalExist with an oxide surface at normal
temperatures, with ambient air or normaltemperatures, with ambient air or normal
physiologic environments that act as oxidizingphysiologic environments that act as oxidizing
media.media.
 Surface properties are due to this oxideSurface properties are due to this oxide
layer and differ fundamentally from thelayer and differ fundamentally from the
metallic substratemetallic substrate..www.indiandentalacademy.comwww.indiandentalacademy.com

 The type of oxide on surgical implants is primarily amorphous inThe type of oxide on surgical implants is primarily amorphous in
atomic structure (Brookite) and thin in thickness dimensionsatomic structure (Brookite) and thin in thickness dimensions
(less than 20 nanometers).(less than 20 nanometers).
 The grain structure of the metal and the oxidation conditionsThe grain structure of the metal and the oxidation conditions
also condition the microstructure and morphology of the surfacealso condition the microstructure and morphology of the surface
oxides. Porosity, density, and general homogeneity of theoxides. Porosity, density, and general homogeneity of the
substrate are all related to this process.substrate are all related to this process.
 Depending on the mechanical aspects of polishing and theDepending on the mechanical aspects of polishing and the
chemical / electrochemical aspects of cleaning and passivating,chemical / electrochemical aspects of cleaning and passivating,
these amorphous or crystalline oxides can exhibitthese amorphous or crystalline oxides can exhibit
microscopically smooth or rough topographies at themicroscopically smooth or rough topographies at the
micrometer level.micrometer level.
 surface macroscopic roughness is normally introduced into thesurface macroscopic roughness is normally introduced into the
substrate beneath the oxide zone by mechanical (Grinding),substrate beneath the oxide zone by mechanical (Grinding),
particulate blasting (resorbable blast media or other), orparticulate blasting (resorbable blast media or other), or
chemical (Acid etching) procedures.chemical (Acid etching) procedures.www.indiandentalacademy.comwww.indiandentalacademy.com

 The titanium alloys used for dental implantThe titanium alloys used for dental implant
components include micro structural phases of alphacomponents include micro structural phases of alpha
and beta or room temperature stabilized beta (only).and beta or room temperature stabilized beta (only).
 Electrochemical investigations have shown that theElectrochemical investigations have shown that the
alpha and beta phase oxides provide substratealpha and beta phase oxides provide substrate
coverage and a high degree of chemical andcoverage and a high degree of chemical and
biochemical inertness (resistance to corrosion and ionbiochemical inertness (resistance to corrosion and ion
transfer) for titanium and alloys of titanium.transfer) for titanium and alloys of titanium.
 Adequately processed and finished titanium alloysAdequately processed and finished titanium alloys
have shown integration with bone and soft tissuehave shown integration with bone and soft tissue
environments for a wide range of dental and medicalenvironments for a wide range of dental and medical
implant devices.implant devices.

Tissue InteractionsTissue Interactions
 Oxide modification during in vivo exposure has beenOxide modification during in vivo exposure has been
shown to result in increased titanium oxide layershown to result in increased titanium oxide layer
thickness of up tothickness of up to 200 nm200 nm..
 The highest oxide growth area corresponded to aThe highest oxide growth area corresponded to a
bone marrow sitebone marrow site
 while the lowest growth was associated with titaniumwhile the lowest growth was associated with titanium
in contact with cortical regions of bone.in contact with cortical regions of bone.
 Increased levels of calcium and phosphorus wereIncreased levels of calcium and phosphorus were
found in the oxide surface layers and seemed tofound in the oxide surface layers and seemed to
indicate an active exchange of ions at the interface.indicate an active exchange of ions at the interface.

Integration with Titanium andIntegration with Titanium and
AlloysAlloys
 Titanium may interact with the recipient livingTitanium may interact with the recipient living
tissues over several years results in the releasetissues over several years results in the release
of small quantities of corrosion products evenof small quantities of corrosion products even
though there is a thermodynamically stablethough there is a thermodynamically stable
oxide film.oxide film.
 The presence of the surface impurities such asThe presence of the surface impurities such as
iron found on some implant parts, and otheriron found on some implant parts, and other
contaminants related to the machining processcontaminants related to the machining process
could result in loss of bone and integration incould result in loss of bone and integration in
crestal areas exposed to corrosion products.crestal areas exposed to corrosion products.www.indiandentalacademy.comwww.indiandentalacademy.com

Integration with Cobalt and IronIntegration with Cobalt and Iron
AlloysAlloys
 The alloys of cobalt (Vitallium) and ironThe alloys of cobalt (Vitallium) and iron
(surgical stainless steel-316L) exhibit oxides of(surgical stainless steel-316L) exhibit oxides of
chromium (primarily Cr2O3 with some subchromium (primarily Cr2O3 with some sub
oxides) under normal implant surface finishingoxides) under normal implant surface finishing
conditions after acid or electrochemicalconditions after acid or electrochemical
passivation.passivation.
 These chromium oxides, result in a significantThese chromium oxides, result in a significant
reduction in chemical activity andreduction in chemical activity and
environmental ion transfers.environmental ion transfers.

Integration with CeramicsIntegration with Ceramics
 Aluminum oxide (Al2O3) ceramics have beenAluminum oxide (Al2O3) ceramics have been
extensively investigated related to surface propertiesextensively investigated related to surface properties
an d how these properties related to bone and softan d how these properties related to bone and soft
tissue integrationtissue integration
 The forms of the oxide structure are poly crystallineThe forms of the oxide structure are poly crystalline
(alumina) and single crystalline (sapphire)(alumina) and single crystalline (sapphire)
 Ceramic coatings (Al2O3) have been shown toCeramic coatings (Al2O3) have been shown to
enhance the corrosion resistance and biocompatibilityenhance the corrosion resistance and biocompatibility
of metal implants, in particular surgical stainless steelof metal implants, in particular surgical stainless steel
and Ni-Cr, Co-Cr alloys.and Ni-Cr, Co-Cr alloys.

HydroxyapatiteHydroxyapatite
 In addition to the bulk aluminum oxideIn addition to the bulk aluminum oxide
biomaterials, calcium phosphate-based ceramicbiomaterials, calcium phosphate-based ceramic
or ceramic-like coatings have been added toor ceramic-like coatings have been added to
titanium and cobalt alloy substrates to enhancetitanium and cobalt alloy substrates to enhance
tissue integration and biocompatibility.tissue integration and biocompatibility.
 These coatings, for the most part,These coatings, for the most part, are appliedare applied
by plasma spraying small size particles ofby plasma spraying small size particles of
crystalline hydroxyapatite ceramic powders.crystalline hydroxyapatite ceramic powders.

 The surface topography is characteristic of the preparationThe surface topography is characteristic of the preparation
process.process.
 Surface roughening by particulate blasting can be achieved bySurface roughening by particulate blasting can be achieved by
different media.different media.
 SandblastingSandblasting provides irregular rough surfacing with < 10provides irregular rough surfacing with < 10 µµmm
scales and a potential for impurity inclusions.scales and a potential for impurity inclusions.

 Niznick used a titanium alloy Ti-6A1-4V toNiznick used a titanium alloy Ti-6A1-4V to
improve the mechanical properties and electedimprove the mechanical properties and elected
toto electro polishelectro polish the surface to reduce surfacethe surface to reduce surface
roughness to be only in the 0.1roughness to be only in the 0.1 µµm scale bym scale by
controlled removal of the surface layer bycontrolled removal of the surface layer by
dissolution.dissolution.
 Titanium implants may be etched with aTitanium implants may be etched with a
solution of nitric and hydrofluoric acidssolution of nitric and hydrofluoric acids toto
chemically alter the surface and eliminate somechemically alter the surface and eliminate some
types of contaminant products.types of contaminant products.www.indiandentalacademy.comwww.indiandentalacademy.com

 Recently, concerns have been expressedRecently, concerns have been expressed
regardingregarding embedded media from glassembedded media from glass
beadingbeading (satin finish)(satin finish) and grit blastingand grit blasting
(alumina Al2O3)(alumina Al2O3) and a possible risk ofand a possible risk of
associated osteolysis caused by foreign debris.associated osteolysis caused by foreign debris.
 A relatively new process (resorbable blastA relatively new process (resorbable blast
media) has been said to provide a comparablemedia) has been said to provide a comparable
roughness to an alumina grit blast finish, whichroughness to an alumina grit blast finish, which
can be a rougher surface than the machined,can be a rougher surface than the machined,
glass beaded, or acid etched surfaces.glass beaded, or acid etched surfaces.www.indiandentalacademy.comwww.indiandentalacademy.com

Porous and Featured Coatings
 The implant surface may also be covered with a
porous coating. These may be obtained with
titanium or hydroxyapatite particulate-related
fabrication processes.
 Examples of coatings include –
Titanium Plasma Sprayed
Hydroxyapatite Coating
Other Surface Modifications

Titanium Plasma Sprayed
 Porous or rough titanium surfaces have been fabricated by
plasma spraying a powder form of molten droplets at high
temperatures.
 At temperatures in the order of 15,000°C, argon plasma
is associated with a nozzle to provide very high velocity
600 m/sec partially molten particles of titanium powder
(0.05 to 0.1 mm diameter) projected onto a metal or alloy
substrate.
 The plasma sprayed layer after solidification (fusion) is
often provided with a 0.04 to 0.05 mm thickness.

 Porous titanium surface increase the total surface
area and attachment by osteoformation,
enhance attachment by increasing ionic
interactions, introduce a dual physical and
chemical anchor system, and increase the
load-bearing capability 25% to 30%.
 Proponents of porous surface preparations
reported that there have been results showing
faster initial healing compared with noncoated-
porous titanium implants and that porosity allows
bone formation within the porosities even in the
presence of some micro movement during the
healing phase. www.indiandentalacademy.com

Titanium Plasma Sprayed surfaces
result in increased TSA

Hydroxyapatite Coating :
 Hydroxyapatite coating by plasma spraying was brought to
the dental profession by deGroot.
 Kay et al showed with scanning electron microscopy
(SEM) and spectrographic analyses that the plasma-
sprayed HA coating could be crystalline and could offer
chemical and mechanical properties compatible with
dental implant applications.
 Cook et al measured the HA coating thickness after
retrieval from specimens inserted in animals for 32 weeks
and showed a consistent thickness of 50 µm, which is in
the range advocated for manufacturing.www.indiandentalacademy.com

 Implants of solid sintered hydroxyapatite have
been shown to be susceptible to fatigue failure.
 This situation can be altered by the use of a CPC
coating along metallic substrates.
 New biocompatible coatings based on
tricalcium phosphate or titanium nitride.
 One advantage of CPC coatings is that they
can act as a protective shield to reduce
potential slow ion release from the Ti-6A1-4V
substrate. www.indiandentalacademy.com

 The concerns related to calcium phosphate
coatings have focused on
 (1) the biomechanical stability of the coatings and
coating-to-substrate interface under in vivo
conditions of cyclic loading, and
 (2) the biochemical stability of these coatings and
interfaces within the gingival sulcus (especially in
the presence of inflammation or infection) and
during enzymatic process associated with
osteoclastic remodeling of the bone-to-coating
interfacial zones.

Other Surface Modifications
 Surface modification methods include controlled
chemical reactions with nitrogen or other elements or
surface ion implantation procedures.
 The reaction of nitrogen with titanium alloys at elevated
temperatures results in titanium nitride compounds being
formed along the surface.
 These nitride surface compounds are biochemically inert
(like oxides) and alter the surface mechanical properties to
increase hardness and abrasion resistance.
 Increased hardness, abrasion, and wear resistance can
also be provided by ion implantation of metallic substrates.

Surface Cleanliness
 A clean surface is an atomically clean surface with
no other elements than the biomaterial constituents.
 Contaminants can be particulates, continuous
films (oil, fingerprints), and atomic impurities or
molecular layers (inevitable) caused by the
thermodynamic instability of surfaces

 Lausmaa et al showed that titanium implants had large
variations in carbon contamination loads (20% to 60%) in
the 0.3 to 1 nm thickness range, attributed to air exposure
and residues from cleaning solvents and lubricants used
during fabrication.
 Trace amounts of Ca, Si, Cl and Na were noted from
other studies.
 Residues of fluorine could be attributed to passivation and
etching treatments; Ca, Na, and Cl to autoclaving; and Si
to sand and glass beading processes.www.indiandentalacademy.com

Surface Energy:
 Surface property values of an implant’s ability to integrate within bone
can be measured by - contact angle with fluids, local pH, and
surface topography.
 High surface energy implants showed a threefold increase in fibroblast
adhesion and higher energy surfaces such as metals, alloys, and
ceramics are best suited to achieve cell adhesion.
 Surface tension values of 40 dyne/cm and higher are characteristic of
very clean surfaces and excellent biologic integration conditions.
 Because a spontaneously deposited, host-dependent “conditioning film”
is a prerequisite to the adhesion of any biologic element, it is suggested
that the wetting of the surface by blood at the time of placement can be a
good indication of the high surface energy of the implant.

Passivation and Chemical
Cleaning
 The ASTM specifications for final surface treatment of
surgical titanium implants require pickling and descaling
with molten alkaline base salts.
 This is often followed by treatment with a solution of nitric
or hydrofluoric acid to decrease and eliminate
contaminants such as iron.
 Ways to intentionally modify the surface of the implant
include conventional mechanical treatment (sand
blasting), wet or gas chemical reaction treatment,
electroplating or vapor plating, and ion-beam
processing, which leaves bulk properties intact and has
been newly adapted to dentistry from thin film technology.

Titanium implant etched with a solution
of nitric and hydrofluoric acidswww.indiandentalacademy.com

Sterilization:
 Manipulation with bare fingers or powdered gloves,
tap water, and residual vapor-carried debris from
autoclaving can all contaminate implant surfaces.
 If an implant needs to be resterilized, conventional
sterilization techniques are not normally
satisfactory.
 Studies suggested that alteration of the Ti surface
by sterilization methods might in turn affect the
host response and adhesive properties of the
implant.

 Presently, proteinaceous deposits and their
action as films can be best eliminated by
radio-frequency glow discharge
technique (RFGDT), which seems to be a
suitable final cleaning procedure.
 The principal oxide at the surface is
unchanged by the RFGDT process.
 studies suggest that RFGDT may enhance
calcium and / or phosphate affinity
because of an increase in elemental zone
at the surface resulting in the formation of
amorphous calcium phosphate compounds.www.indiandentalacademy.com

 A modified ultraviolet (UV) light
sterilization protocol showed to enhance
bioreactivity, which was also effective for
eliminating some biological contaminants.
 Adequate sterilization of clean,
prepackaged dental implants and related
surgical components has resulted in an
ever-expanding use of gamma radiation
procedures.
 The healing screws, transfer elements,
wrenches, and implants are all exposed to
the gamma sterilization, which reduces
opportunities for contamination.

PLASMA SPRAYING
 In order to coat a metallic substrate with a bioactive
glass, loaded bioactive glass or ceramic layer, one of
the most common techniques is that of plasma
spraying, which is based on the existence of a
particular state of matter that is stable even at
very high temperature.
 This state is defined by many as the fourth state, and
exists in addition to the solid, liquid, and gaseous
states.
 The gaseous state acquires energy and thereby turns
to plasma, which then returns to gas owing to loss of
energy. www.indiandentalacademy.com

PLASMA SPRAY COATINGS
 sandblasting treatment is performed on
the surface to be coated to remove any
residual trace of oxides or mineral salts.
 The great advantage of this treatment is
that it makes the surface in question
suitably rough.
 Sandblasting however, which generally
consists in the shooting of corundum sand,
is in turn liable to leave residues in the
form of micro grains.www.indiandentalacademy.com

 These micro grains cannot be removed by
cleaning, either by the use of compressed
air or chemically or electro statically.
 Where there are such micro grains there is
normally a poorer adhesion of the plasma
sprayed layer, and precisely these areas
are the locations of future cracking.
 Since it was noticed that the amount of
stuck grains is inversely proportional to
their size, it is advisable to utilize
sands with a sufficiently large grain
size. www.indiandentalacademy.com

 The reasons for inability of the coating material to
provide good adhesion when applied directly to the
substrate include –
1.low wettability between the two materials
2.low chemical compatibility, and
3.a difference in thermal expansion
coefficient.
 With respect to the process mechanism, the
effectiveness of plasma spray covering is based on
the interaction that develops between the substrate
surface and the hot material that is impacted on to
it.

ALUMINA COATING
 One of the first substances used in prosthetic
surgery for coating metallic stems was alumina.
 This material proved to possess reasonably bioinert
characteristics and had already been applied as a
substitute for the ball component of the hip
endoprosthesis.
 Alumina powder grain size must range between 20
and 40 micrometer.
 Alumina coating formed by spraying leads to pore
dimensions of between 0.02 and 0.4 micrometer,
with a distribution peak centered on 0.18
micrometer. www.indiandentalacademy.com

 All the plasma spray operations are carried
out on rotating and heated specimens in
order to produce layers of homogenous
thickness, and to give a certain margin of
elasticity, thus avoiding cracking during the
exercise
 Experiments by either plasma spray or
flame technique with alumina-coated
metallic substrates proved that Alumina-
based coverings are often unable to resist
human body fluids
 The best metallic pre-coating layers proved
to be those made from molybdenum or
titanium. www.indiandentalacademy.com

SELECTION, EVALUATION AND
PREPARATION OF BIOMATERIALS

SELECTION OF MATERIALS FOR
IMPLANTS:
 Biomaterials regardless of use fall into four general categories:
metals and metal alloys,
ceramics (carbons are included in this
group)
Synthetic polymers and
natural materials.
 Metals and metal alloys utilized for oral implants have included
titanium, tantalum and alloys of titanium
aluminium, vanadium,
cobalt/chromium / molybdenum and
iron / chromium / nickel among others.
 These materials are selected on the basis of their overall strengths;
metals and metal alloys also bend themselves to shaping and
machining and to a wide range of sterilization techniques.

 The choice of ceramics as implant materials for
hard tissue replacement or augmentation has
increased in recent years, primarily because of
suggestions that bone, as well as soft tissue, must
biochemically “accept” implants in order to
promote rapid healing.
 The use of synthetic “hydroxyapatite” is an
example.
 Other ceramic groups are aluminium oxides (such
as aluminium and sapphire), tri calcium phosphate,
and calcium aluminates.

 In comparison to metals and ceramics, polymers
are “weak” and generally flexible.
 Examples of polymeric dental implant materials
include polymethyl methacrylate, silicone
rubber, polyethylene, polysulfone and
polytetra fluroethylene.
 Like the ceramics, polymers are being chosen
mainly as additives for beneficial secondary
purposes, such as structural isolation or
introduction of shock absorbing qualities in load
bearing metallic implants.

IMPLANT MATERIAL EVALUATION
 Evaluation of materials generally falls into two
categories:
bulk characterization and
surface characterization.
 In the course of device manufacture, storage,
sterilization and implantation, a material is exposed
to a myriad of conditions that are more than likely to
change it in one way to another.
 It is imperative to confirm that the range of
manufacturing, storage and surgical procedures to
which the materials is subjected to does not produce
defects within or on the devices that diminish its
safety and effectiveness.www.indiandentalacademy.com

BULK CHARACTERISATION
 BULK MATERIAL PARAMETERS IMPORTANT TO THE
EVALUATION OF DENTAL MATERIALS
 Mechanical Aspects (Primarily obtained via stress / strain
analysis)
 Elastic Modules
 Plastic Deformation
 Tensile strength
 Fatigue
 Physical aspects (obtained via several different analysis)
 Hardness
 Thermal Properties
 Wear properties
 Density
 Chemical stability
 Toxicity
 Conductivity www.indiandentalacademy.com

SURFACE CHARACTERISATION
The surface properties of an implant are fundamental to the
near term and long-term success of the device.
KEY PARAMETERS FOR EVALUATION OF
MATERIAL AND IMPLANT SURFACES
 Surface energy, critical surface tension, chemical composition and
stability.
 Morphology and texture.
 Thickness of surface coating or oxide layer surface electrical
properties.
 Corrosion resistancewww.indiandentalacademy.com

FINAL MATERIAL PREPARATION:
 In addition to selection and evaluation of biomaterials for implantation,
the steps by which the implant is produced must be carefully considered for
their potential impacts on implant safety and efficacy (Baar in 1988.)
 PASSIVATION
 The use of acid passivation for cobalt-chromium implant has been
recommended by the (ASTM).
 This technique generally is used for conventionally polished implants to
establish and stabilize the protective surface oxide layers that protect
against electrochemical corruption of the material in saline environments.
 STERILISATION
 Conventional sterilization methods applicable to most oral implants include
steam autoclaving, dry heat, glass bead sterilization, and ethylene oxide
treatment.
 Sterilization by radiation techniques by electron beam, gamma rays,
ultraviolet radiation convoluted geometries of many types of oral implants.
 Other approaches to sterilization such as radio frequency glow discharge
treatment and recent developments in liquid solution techniqueswww.indiandentalacademy.com

BIOCOMPATIBILITY TESTS
 1. Initial Tests
Cell culture methods:
 Cell attachment and growth tests – DNA
synthesis, protein synthesis, anyone
histochemical analysis.
 Chemo taxis assays
 Mutagenesis assays
 Other assays

2. Secondary or intermediate tests
3. Usage tests
* Intradental or pulp irritation tests.
* Dental implants into bone
4. Materials – ceramic, carbon, metals,
polymers
* Ceramic – combination of metal oxides
* Sio2, Al2O3 and MgO and MgAl2O3
and HA
* Carbon – Vitreous carbon, LTI or
pyrolytic

At present the best estimates of the
success and failure of implants are
gained from three tests.
 Penetration of pd’s probe along the side
of the implant.
 Mobility of the implant
 Radiographs

CONCLUSION
 Dental implants are still predominantly constructed from
only a few historically accepted metals and alloy systems
and even these are criticized in some quarters, where as
ceramics, polymers and some natural materials are
again receiving interest for their special properties.
 A variety of new or improved bone and tooth implant
products have been developed using HA ceramics and
thus this system has lead to overall improvements in
dental hard tissue repair and replacement.
 Unquestionably, the trend for conservative treatment of
oral diseases will continue to accelerate. Thus, it can be
anticipated that dental implants will frequently be a first-
treatment optionwww.indiandentalacademy.com

REFERENCES:
 Carl E. Misch – Contemporary Implant
Dentistry
 Charles M. Weiss – Principles and practice
of Implant Dentistry
 Babbush – Dental Implants The art and
Science
 Benner – Implants and Restorative
Dentistry.
 JPD 1983, vol -49,832-837
 DCNA Jan92, vol -36,19-25www.indiandentalacademy.com

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