This is translated as a lower ISQ value by a measuring device by AFR method on implants with light and non-contact occlusal contacts compared with normal. (17)

(1)

(2)

(3)

(4)

UNIVERSITAS INDONESIA

THE EFFECT OF TEMPORARY CROWN IN THE OSSEOINTEGRATION OF DENTAL IMPLANT

ABSTRACT

Osseointegration is an important factor in determining success of dental implant, and the criteria is assessed from the osseointegration process that occurs between the implant and the bone. The stability of an implant is determined by the osseous support at the implant-bone interface, which is commonly evaluated by histomorphometric analysis. The purpose of this study was to evaluate histomorphometric around the implant—bone interface after placement of dental implants. This study compared 4 different types of occlusal contact and implant loading. Six male Macaque fascicularis aged about 6 years, weight from 4.5 to 6 kg were used in this study. The first, right and left mandibular premolars and the first right mandibular molar were extracted. Ninety days after removal, five 2,1 mm—

diameter, 8—mm—long screw—type implants were placed with differ-

ent occlusal contact and loading in mandibula. The macacas received 3 implants (lmtec, 3M ESPEE) of each of the following occlusal contact: immediate loading with light occlusal contact, immediate

loading with normal occlusal contact, and delayed loading were maintained unloaded for 90 days. After this period, the animals were sacriﬁced, and the posterior regio of mandibles were extracted and histologically processed to obtain decalciﬁed sections.Two longitudinal ground sections were made for each implant and analyzed under light microscopy coupled to a computerized

system for histomorphometry.The following means were obtained for bone—im—

lant contact percentage: immediate loading with normal occlusal contact = 41.7%,

(5)

immediate loading with light occlusal contact = 57.9%, and delayed loading = 68.5%. The means of treatments showed the difference and was statistically signiﬁcant between groups immediate loading with normal occlusal contact and delayed loading (Tukey test, P < .05).There was no signiﬁcant ”

different between groups of immediate loading with light contact and delayed loading (Tukey test, P > .05).The group of delayed loading implant provided a greater bone-implant contact than a normal contact. It can be conclude that occlusal contacts and the time of loading inﬂuence the value of histomorphometry.

Keywords: histomorphometry, dental implant, occlusal contact, loading.

(6)

INTRODUCTION

Tooth loss is a common case for dentists in everyday practice. The effort to overcome tooth loss to restore the function of mastication and patient appearance is a challenge for dentists. Today, dental implants are one of the alternative treatments for the rehabilitation of tooth loss, among others with artificial crowns supported by implant embedded in bone. If implant treatment is successful, it will support the restoration with good aesthetics and also comfortable for the patient. In addition, implant treatment is also not invasive to existing teeth^{. (1)}

The success of implant treatment is judged by the occurrence of osseointegration, the occurrence of a healing process that coincides with the timing of implant fixation in bone due to the formation of a direct structural relationship between the bone and the implant. These structural relationships, microscopically demonstrated by the absence of connective tissue between the implant and bone (2,3)

The success of osseointegration can be evaluated using several methods, including percussion, radiographic and Resonance Frequency (AFR) methods.

Resonance, can be determined the value of Implant Stability Quotient (ISQ) as the value of implant stability. The ISQ score is in the range of 1-100, indicating the rigidity of the encounter between the implant and the bone. High ISQ values indicate better implant stability, (5) When implant stability is good, bone remodeling around the implant may occur, resulting in osseointegration. In other words, the success of osseointegration is indirectly shown by the stability of the absence of mobility in the implant. Therefore, regular control and maintenance of implant stability need to be done to achieve successful implant treatment.6 One that can disrupt this stability is the excessive load implant received.

Implant dental loading support can be done in two ways: the loading with immediate loading and delayed loading. Load loading with immediate loading is the installation of the restoration immediately after installation of the implant. While delayed loading is the installation of restoration after osseointegrasi. At immediate loading,

(7)

the crown crown is installed immediately after the installation of the implant used in the short term as a temporary restoration to help soft tissue healing form, so that the implant treatment produces a good aesthetic; in addition, this temporary restoration may also increase the patient's confidence due to the dental area the missing patient has been replaced, the patient does not see his teeth removed (7,8) The success of treatment with immediate loading is not different from delayed loading. ^(9,10) However, another opinion suggests that the short duration of healing before implant loading on immediate loading implants may increase the risk of implant failure. ⁽¹¹⁾

Implant failure may occur with respect to the load received by the implant through the occlusal contact (12) In the immediate loading of temporary restoration may be installed in contact or not in contact with its antagonist. If temporary restorations are installed in contact with antagonizing teeth, there is a risk of increased implant failure. Sanchez (2015), states that an excessive occlusal load on the implant may lead to osseointegration failure resulting in implant treatment failure. Therefore, the release of occlusal contacts on the implant from its antagonists may reduce the risk of implant failure failure. (10) Similarly, Lopes (2005), states that occlusal contact should be kept to a minimum in implant-supported restorations, either on implant installation with immediate loading and delayed loading. (13) This opinion is consistent with the results of Dewi's research (2010), which states that osseointegration can be achieved well in the installation of implants with immediate loading with temporary restoration of mild occlusal contact with its antagonists. (14) with Nedir, et al (2004), which states that in the installation of implants with immediate loading, restorations should be made contact-free for osseointegration to be achieved.15 Research on the interventions of occlusal restoration contact variations after implant installation with either immediate loading or delayed loading not too many found. Based on this, then in this study conducted further research to determine the effect of occlusal contact on the implant installed with immediate loading on the implant stability.

This study uses animals try Macaca Fascicularis. Macaca Fascicularis is chosen because it has anatomical structures of teeth and jawbone that are similar to humans.

(8)

(16) The implant stability was measured using the Resonance Frequency Analysis method based on the contactless, light, and normal occlusal contact interventions.

The success of denture implant support is determined by obtaining initial stability (primary stability) at the time of installation. Efforts to maintain this stability are influenced by the occlusal load received through temporary restoration. Occlusal loads received by implants during the installation of the restoration can be directly implanted (Immediate Loading) or after osseointegration (delayed loading).

Nevertheless, there is still considerable controversy over the immense influence of load on implant stability. Therefore, it is necessary to research how much influence the occlusal contact on the restoration of implant stability installed in immediate loading.

Research purposes

To analyze the effect of occlusal restorative occlusal contact on an implant installed with immediate loading on implant stability.

Implant support artificial teeth can be recognized as the most important breakthrough in the field of modern dentistry. The implant consists of several components, the fixture embedded in the bone and the crown or denture that fills the edentulous space in the oral cavity, both of which are connected by abutment.Once the implant is implanted in the bone, imitation crown restoration, bridge denture or overdenture can be used. ⁽¹⁷⁾

To this day, implants have become the treatment option in place of the loss of one, some or all of the teeth because they are not invasive to the adjacent tooth structure, esthetic, comfortable, stable, and like the original tooth. (19) It was reported that between 2004 and 2008 in Hong Kong 84% of dentists offered implant treatment. ⁽²⁰⁾

Installation of Implants

There are various methods of mounting dental implants on the jawbone in terms of implant installation time and installation time of restoration to the implant as well as

(9)

contact of the restoration occlusion with its antagonist teeth. When viewed from the time of installation of implants after retraction, there are methods of immediate placement, immediate-delayed placement, and delayed placement. In the immediate placement method, the implants are immediately installed after tooth extraction.

While on the method of immediate-delayed placement, the implant is installed within 8 weeks after retraction. In the delayed placement method, the implant is placed within a range of time more than 8 weeks after retraction.^(8).

When viewed from the time of restoration of implants and occlusal contacts, there are methods of immediate loading, early loading, and delayed loading. In the use of the immediate loading method, restoration of the implant is installed shortly after the installation of the implant. In the use of the early loading method, restorations for implants are installed within the time span of 48 hours to 3 months after implant installation. Whereas, in the use of the delayed loading method, restorations for implants are installed within 3 to 6 months after implant installation. (8) Lately the development of implant installation method that reduces maintenance time, the method of immediate loading. In the use of the immediate loading method, the restoration of the implant is functionally installed shortly after implant installation of the jaw bone. This makes the dentist function of the missing patient can be restored immediately. When compared to the delayed loading method, the immediate loading method gives more satisfaction to the patient because there is no delay in the installation of the restoration. The benefit for the patient is also derived from the unnecessary removable denture as a temporary restoration used in the delayed loading method. In addition, aesthetically this method is better because it reduces the patient's edentulous period. Reduced edentulous periods also have an impact on the reduction of possible alveolar bone resorption. When compared to the delayed loading method, the immediate loading method requires fewer surgical frequencies. In the immediate loading method, surgery is only performed during implant installation. Meanwhile, in the delayed loading method, surgery is performed during implant installation and in the restoration installation procedure. Reduced frequency of surgery can reduce the trauma of surgical procedures that may occur.

(8.21)

(10)

Implant Stability Implant stability is a measure that indicates the existence of a clinically stable implant. Dental implant stability is a combination of mechanical stability and biological stability in which both are interconnected. Mechanical stability is the friction that occurs between the bone and the implant. In addition, there are also those that define mechanical stability as sufficient fixation between bone and implant at the time of implant installation. Mechanical stability is generated by the resistance produced by biomechanical implants by the bone so that the implant is in a rigid contact condition in place as a result, good mechanical stability can reduce the micro movement of the implant. Implant micro movements produce fibrous tissue around the implant. However, if micro movement is limited, it will further support the occurrence of biological stability. (22) Biological stability or secondary stability is the stability generated by the formation of new cancellous bone cells around the implant which ultimately supports the occurrence of osseointegration. Mechanical stability usually has a high value after implant installation so it is also called primary stability whereas biological stability does not occur after implant installation, but its value increases with time. Therefore, biological stability is also referred to as secondary stability. (4,6,11,12)

The stability of the implant is determined by several factors, including implant design, surgical process, bone structure, and occlusal load (11). To ensure the stability of the dental implants last for a long period of time, the burden of the artificial crown to the bone through the implant must be observed. Continued loads should not be less or more because if so, the bones respond by resorption or deposition process. (11) Chewing load from crown to bone crown is influenced by several things. Winkler et al. (2000) states that the implant diameter affects the resulting stability value. Larger implant diameters may be used in cases of poor bone quality because these types of implants have a larger contact surface area between the implant and the larger bone so that the load received by the bone is smaller. (23) Likewise with long-sized implants, the contact surface area between the implant and the bone is also greater. (24) In addition, the surface texture of the implant may also

(11)

affect the stability of the implant. In implants with a rougher surface, the risk of failure that may occur decreases 5 times compared to implants with a smooth surface. The rough surface of the implant increases the contact surface area between the implant and bone and the osseointegration is also better. (25)

Surgical process affects implant stability. Therefore, the process of surgery should be done carefully so that the success of implant treatment can be achieved. (11, 26) One of the stages of the surgical process that can affect the stability of the implant is the method of implant installation. Esposito, et al (2013) investigated the difference of the immediate, early, and delayed loading method of implant stability and the result, the delayed loading method is better than the immediate loading. However, the immediate loading method still produces better stability than the early loading method. In addition to the mounting method, the torque used to install the implant may also affect the stability of the implant. The larger the torque used, the more stable the impulse is expected. But this is also influenced by the quality of the bone where the implant will be installed. If the bone density is good, then this condition can occur. On the other hand, in good bone density, it is desirable to use excessive torque so that the implant installation can be performed atraumatically. (27)

Bone tissue consists of the bones of the trabeculae and the cortical bone. In a body part, the two bone types become one in different compositions and the ratio is used to determine the classification of bone type.28 In implant treatment, bone structure has a significant effect to support good implant stability (29) Bones are classified into 4 types by Lekholm and Zarb (1985) based on their density as homogeneous cortical bone with a trabecular bone (type 1), thick cortical bone with solid trabecular bone (type 2), thin cortical bone surrounding the solid trabecular bone (type 3 ), and thin cortical bone with non-solid trabecular bone (type 4). Meanwhile, Misch (2005) also classified bone density into solid cortical (D1), porous cortical and rough trabeculae (D2), porous cortical and fine trabeculae (D3), fine trabecula (D4), and soft bones with imperfect mineralization (D1) D5). In the Misch classification, misch (2005) also classified bone density into solid cortical (D1), porous cortical and rough trabeculae (D2), porous cortical and fine trabeculae

(12)

(D3), fine trabecula (D4), and soft bones with imperfect mineralization (D1) D5). In the Misch classification, the D1 and D2 classifications in the mandible region show the highest contact surface area between the implant and the bone. While in the maxillary region, the presentation of contact surface area between the implant and bone is lower. Therefore the healing that occurs in the maxilla is also slower (30,31)

Oklusal Contacts

In addition to the above three factors, other factors that may affect the implant stability are occlusal contacts. The weights of occlusal contacts are influenced by the magnitude of the force received during occlusion. Excessive occlusal contact will cause implant instability. Occlusal load determines clinical success and duration of an implant can persist in the oral cavity 32.33 Sanchez, et al (2014) states that restorations that are installed in immediate loading and occurring with their antagonistic teeth, exhibit lower stability than those that do not beroklusi. In another study, excess occlusal loads indicated the possibility of implantable peri- inflammatory symptoms resulting in implant failure failure (34) Misch (2005), suggesting that excessive occlusal loads will lead to the loss of alveolar crest.

Given the importance of the occlusal load, in performing the implant treatment, a dentist should consider the selection of occlusion for the prosthesis to be implanted.

The concept of occlusion used for implant treatment is in line with the concept of occlusion that occurs in the original tooth because the patient who has the implant has the same chewing habit as the patient with the original tooth. Therefore, the position of the ^implant, its contact with the antagonist gear should be well established to keep the occlusal load forwarded to the implant still within acceptable physiological limits. ⁽¹¹⁾

Measurement of Occlusal Contacts

The method commonly used in dental practice to measure occlusal contact is articulating paper. This material is easy to use to determine the severity of occlusal contacts qualitatively based on the lesions left on the ingredients after the patient has

(13)

occluded. Before the patient is occluded, the paper is placed on the tooth to be measured by contact weight. After the patient is oily, there is a lesion left on the occlusal surface of the tooth. 43 However, the use of articulating papers does not provide accurate results. According to the study, only 38% of lesions match the size of the occlusal load. ⁽³⁵⁾

Immune Response

In the installation stage of the implant, smelting is done so the implant is embedded in the bone. Thus, this stage causes injury to the patient. The gap between the implant and the bone, will be filled with a matrix containing lots of fibrin, just like any other wound healing process. After that, mesenchyme tissue will enter the wound area and differentiate into various cells, including osteoblasts. The osteoblasts will then form new bone around the implant, so the implant becomes stable. (26)

Healing Bone Post Implant Installation

After the implant is placed on the bone, wound healing immediately occurs. Between the meeting between the implant and the bone, woven bone will form, as a form of bone response to the biomechanics that occur. This bone will then be replaced by new bone^{. (22)}

This bone formation is affected by the load received by the implant. Installed implants will push the bone, so the bone will change shape. This change in bone form will be measured as a strain. At the limit of physiological strain, bone is capable of remodeling at a rate of 40% per year. Whereas if the strain received exceeds the physiological limit, there will be an overload indicated by the production of cytokines that may lead to bone resorption around the implant. (22) Measurement of Implant Stability.

One of the factors that determine the occurrence of good osseointegrasi is trabecular

(14)

bone density. This bone plays a role in the biological response and support to the implant mechanically. In mechanical terms, the process of bone remodeling and its regeneration between bones and implants, supported by the presence of trabecular bone. ⁽³⁶⁾

The radiographic images used in examining implant stability are periapical radiographs, either conventional or digital. The sensitivity of the radiographic shooting technique is low, but overall the accuracy is better. (37,38) In this method, the light is directed from the buccal, the film is placed parallel to the alveolar bone so that the direction of the perpendicular light rays of the film. With proper position and technique, the enlargement and distortion are minimal. ⁽³⁶⁾

RESEARCH METHODS

This Research Type is Experimental Research on experimental animals. The sample size of the study was calculated using "G Power" obtained by large sample 6 The study was conducted in January - November 2015. Place of Research Laboratory of Primate Animal Studies Center of Institutut Pertanian Bogor. The study was conducted using a trial animal in the form of Macaca Fascicularis

Research Procedures

The experiment was conducted using 3 animals of Macaca fascicularis with age ranging from 3.5 to 4 kg with general condition without contact from systemic or local disease.

Animal quarantine

After the selection of experimental animals then quarantine is done on the animal try for 6 weeks.

Making individual tray

(15)

The print spoon is made from an existing model of study from previous studies, the model of which is a study model of Macaca fascicularis jaw. Next, manufacture an individual print spoon from Shellac material baseplate material.

Animal experiment printing. Prior to the printing, the print spoon that has been made is adjusted to the jaws of Macaca fascicularis. Macaca fascicularis maxillary and maxillary toothpick printing is done using a pre-made print spoon, using alginate printing material. The next print is casted with stone gypsum.

Tooth extraction

Teeth removed is the lower mandibular right lateral incisor, right first premolar, right first molar teeth, left lateral incisors, left first premolar, left molar teeth and left 3rd molar teeth. Animals were treated with ketamine hydrochloride 20 mg / kg, intra- muscular (IM). Then placed on a heating pad to regulate the body temperature of the experimental animals. Monitoring of vital signs: Mucosa, turgor, heart rate, blood pressure, as well as breathing performed every 10 - 15 minutes. Installation of intra venous catheter in left saphenous vein for administration of 5% Ringer Dextrose infusion, Propofol bolus 4 mg / kg bolus, IV. Installation of an intra venous catheter in the right saphenous leg vein is associated with NaCl and syringe pump for propofol infusion. Propofol infusions are administered at a dose of 0.2 - 0.4 mg / kg / min. If the experimental animal has undergone sedation through reflex examination and vital signs, the extraction procedure can be started. Then the mouth gag is done and the installation of gauze and cotton in the gingival area. Furthermore, tooth extraction is done by using pliers pull and elevator bein. The extraction was performed on day 1 of right lateral incisor, right first premolar, maxillary right mandibular teeth and one week later extraction was performed on the left lateral incisor, left premolar tooth, left molar and left third molar. After the seven teeth were extracted, the extraction was given topical antiseptic and anelgesic, then suturing using 4/0 vycril yarn, cutting edge. Animals injected antibiotics amoxicillin long acting, dose 11 mg / kg body weight. Dioption of ketoprofen dose 5 mg / kg BW.

Subsequently, the animals were given a subcutaneous infusion of NaCl at a dose of

(16)

30 ml / kg if necessary. Propofol can be stopped and animals enter stage recovery stage. After the animals are conscious, all the infusions are removed, then the animals are returned to the cage and monitored intensively.

Observation of wound healing post-retraction

Observations were performed at least 3 times daily on the day of operation, 2-3 times daily on the second day up to day 7 (figure 4.3) depending on the condition of the animal. Observations were recorded in the observation sheet to assess the pain by referring to the pain scoring guidelines. Feed is given in the form of wet and dry monkey chow of 10 pieces, bananas, guava and oranges are given in the morning and afternoon for 3 to 5 days. If the animal condition is declared free of pain with improved appetite conditions, given wet and dry monkey chow feed as needed 4% of body weight.

Injectable antibiotic Amoxicillin IM 11 mg / kg body weight 1 times daily for 3 consecutive days. Diagntivated analgesic Ketoprofen 5 mg / kg body weight 2 times daily for 2 - 3 days is adjusted based on pain scoring results. If possible, after 2 days of administration of Ketoprofen, may be replaced with Ibuprofen 7 mg / kg of body weight peroral, twice daily.

Evaluation oh healing process after extraction.

(17)

Temporary restoration

The anatomical model prior to tooth extraction is duplicated and casted with stone gypsum, the model is planted in the articulator. In the planted model, the right and left molar teeth are cascaded to the cervical margin, followed by the provision of temporary restoration of the acrylic heat cured material on the right 1st molar, the left molar tooth is adjusted to the shape and size of the original Macaca fascicularis teeth.

has been so subsequently mounted and adjusted its occlusions with the antagonist gear

Picture of working model with temporary restorasi

Implants Placement

The installation of titanium implants is performed on the Macaca fascicularis jaw, two months after tooth extraction, ie on the right 1st molar, 1st molar teeth and 3 left molar teeth. Before the implant installation procedure, a sedative with ketamine (15 mg / kg) is given. After the effects of sedation proceeded, about 5 minutes later general anesthesia was performed with bolus propofol of 1.8 ml in intravenous (4 mg / kg). The first step determines the location of the implant installation by making a mark using sonde, then do the implant installation with flapless method.

.

(18)

Temporary Restoration

Picture of implant placed in the region of left molar 1 and 3.

Installation of temporary restoration and examination of occlusal contacts After the installation of the implant has been completed, then the installation of the temporary restoration directly with the following procedure:

Placement of temporary restoration on the same day with implant installation on left 1st molar with light contact. To determine the light contact is done by clamping the lower jaw to the upper jaw with the help of 60 μm thick articulation paper Furthermore, a temporary restoration of right molar to normal contact is performed.

To determine the normal contact is done by clamping the lower jaw to the upper jaw with the help of 20 μm thick articulation paper.

Inspection of Implant Stability

Examination of implant stability using Ostell ISQ (figure 4.7) performed on the same day with implant installation, one month and two months after implant installation.

Examination was performed on right 1st molar, left molar teeth and left 3rd molar teeth. Prior to examination of implant stability with Ostell ISQ, the magnet is

(19)

mounted on the buccal and lingual side of the temporary restoration functioning as the transducer, then the probe is directed to the magnet in a bololingual direction at a distance of approximately 2-3 mm, when the probe is at the correct distance, will produce a short beep. Longer beep indicates that the measurement is valid so that the ISQ value can be seen on the ISQ ostell instrument display screen. ⁽³⁵⁾

Data analysis

Test Normality Data Test data normality using Saphiro-Wilk test The Average Comparison Test, used to check whether there are differences in ISQ implant values between the three types of occlusal contacts in the baseline period, first month, and second month after installation, a One Way Anova test is used if the data is normally distributed or Kruskal Wallis if the data is not normally distributed.

This is to know in the occlusal contact pair where meaningful difference of implant ISQ value occurs, unpaired t test is used if the data is normally distributed or post- hoc Mann Whitney if the data is not normally distributed. This analysis is aimed to determine whether or not the difference in ISQ implant values between baseline periods, first and second months of the three types of occlusal contacts is used Anova Repeated Measure test and followed by post-hoc Bonferroni if the data is normally distributed or Friedman if the data is not normally distributed.

RESEARCH RESULT

In this study, 9 implants were paired to immediate loading on 3 Macaca fascicularis,

Evaluation of Implant Stability

(20)

each Macaca fascicularis tail was installed 3 implants with contactless, light, and normal occlusal contacts. Furthermore, an implant stability measurement was performed using the method of resonance frequency analysis (Ostell ISQ) for a moment (baseline), 1 month, and 2 months after installation. All data were collected and processed using SPSS version 17. The impeded impedance impedance impedance value with the occlusal, non-contact occlusal, light and normal occlusal contacts at baseline, first and second months after installation can be seen in table 5.1 and graph 5.1.

Table 5.1. Immediately loading implant stability values with contactless, light, and normal occlusal contacts at baseline, first and second months after installation.

Type of Contact

Value of ISQ

Baseline Month 1 Month 2

Mean Median SD mean Median SD Mean Median SD No

Contact

66 66 0 69 69 0 70,66 71 0,57

Light Contact

66 66 0 68,66 69 0,57 70,33 70 0,57

Normal 66 66 0 66,33 66 0,57 67,33 67 0,57

(21)

Graphic 5.1 Immediately loading implant stability values with contactless, light, and normal occlusal contacts at baseline, first and second months after installation

The average implant stability value installed instantly loading immediately after installation with the contactless, light, and normal occlusal contact is 66. While at 1 month after installation, the ISQ value with occlusal contact without occlusive, light, and normal occlusal contacts is 68 , 66; 66,33 and 69. At 2 months after installation, the implant stability value is 70,33; 67.33 and 70.66.

In the normality test results, it was found that the whole test group had data with abnormal distribution (p <0.05) so it did not meet the requirements for the Anova 1- way test. Therefore, the data analysis was performed using a non parametric Kruskal Wallis analysis to determine whether there was a difference in implant stability between the three types of occlusal contacts in the first and second months after installation (Table 5.2).

Table 5.2. Differences in implant stability to occlusal contact during baseline period, first and second month.

Periode Occlusal Contact

n Occlusal Contact

Median (Minimum-Maximum)

P

Baseline No Contact 3 66(66-66) 1,000

Light 3 66(66-66)

Normal 3 66(66-66)

Month 1 No Cantact 3 69(69-69) 0,034*

Light 3 69(68-69)

Normal 3 66(66-67)

Month 2 No Contact 3 71(70-71) 0,048*

Light 3 70(70-71)

Normal 3 67(67-68)

Using Kruskall Wallis test

* significant (p<0,05)

In the baseline period, Statistical Analysis using Kruskall Wallis test, there was no significant difference of ISQ value (p> 0.05) between contactless, light, and normal occlusal contact groups. While in the first and second months after installation, the Statistical Analysis using Kruskall Wallis test showed there was a significant difference of ISQ value (p <0.05) between the contactless, light, and normal occlusal contact groups. Subsequently, a Post Hoc Mann Whitney test was conducted to

(22)

determine which groups had significant differences with the results as listed (Table 5.3)

Table 5.3. Differences in implant stability between occlusal contacts in the first and second month periods

Periode Occlusal Contact P

No contact Light Normal

N Median (min-max)

Median (min-max)

Median (min-max) Month

1

3 69(69-69) 69(68-69) 0,317

3 69(69-69) 66(66-67) 0,034*

3 69(68-69) 66(66-67) 0,043*

Month 2

3 71(70-71) 70(70-71) 0,456

3 71(70-71) 67(67-68) 0,042*

3 70(70-71) 67(67-68) 0,043*

Using Post Hoc Mann Whitney test

From the statistical analysis using the Post Hoc Mann Whitney test, In the first month after implant installation there was a significant difference (p <0.05) of implant stability value between normal, non-normal, normal occlusal contact groups and normal occlusal contacts. While significant differences (p> 0.05) implant stability values were found in the light and non-contact occlusal contact pair.

In the second month after implant installation there was a significant difference (p

<0.05) of implant stability values between normal, non-normal, normal occlusal contact groups and normal occlusal contacts. While significant differences (p> 0.05) implant stability values were found in the light and non-contact occlusal contact pair.

To determine whether or not the difference in implant stability values between the baseline period, the first and second months of the three types of occlusal contacts, the Friedman test was used.

(23)

Table 5.4 Differences in implant stability values between baseline periods, first and second months in all three occlusal contact groups.

Occlusal Contact Periode Value ISQ Implan Median (Min-Max)

p

No Contact Baseline 66(66-66) 0,050

Month 1 69(69-69)

Month 2 71(70-71)

Light Baseline 66(66-66) 0,050

Month 1 69(68-69)

Month 2 70(70-71)

Normal Baseline 66(66-66) 0,061

Month 1 66(66-67)

Month 2 67(67-68)

Using Friedman test

Based on statistical analysis using Friedman test, there was no significant difference (p> 0,05) implant stability value between baseline period, first month and second month in contactless occlusal contact group. There was also no significant difference (p> 0.05) implant stability value between baseline period, first month and second month in the mild, occlusal contact group. In addition, there was no significant difference (p> 0.05) implant stability value between baseline period, first month and

second month in normal occlusal contact group.

DISCUSSION

This study was an analytic study with an experimental design aimed at examining the effect of contactless, light, and normal contactless occlusal contact restorations of implants placed in immediate loading to implant stability values, measured using Ostell ISQ at moment, 1 month and 2 months after installation in a trial animal, Macaca fascicularis.

In achieving the objectives of this study, the use of experimental animals should be

(24)

in accordance with the ethics of experimental animal research including the 3R principles of Replacement, Reducing, and Refaintment. In the principle of replacement, it should be considered as much as possible not to use experimental animals, but using in vitro research. In the reducing principle, it is emphasized to use as few animals as possible and maximize the retrieval of data from the experimental animals used. In this study, this principle is met, because of the experimental animals used, data were taken for 3 studies. The last principle is refaint ment, where modification of the procedure so that animals try to feel minimal pain. Thus in this study, the principle of refaintment has also been met, in which the action of jaw printing, tooth extraction, implant installation, and measurement of implant stability is performed under total anesthesia and has been approved by the Ethics Commission.

The subjects were implanted on Macaca fascicularis according to the inclusion criteria of the study subjects. Macaca fascicularis is made into experimental animals due to similarity with humans in the genetic side, as well as tooth and alveolar bone.

(16) Implant implantation stage, and the measurement of implant stability is performed by a single operator, since good skills and techniques are required to avoid bias in the study.

Measurement of occlusal restorative contacts is performed using articulating paper.

articulating paper is a material widely used in dentistry practice. According to Qadeer et al Although articulating paper is widely used, only 38% of lesions match the size of the occlusal load. (35) While the measurement of implant stability is performed using the resonance frequency analysis method measured using Ostell ISQ. The concept of the resonance frequency analysis method (AFR) is that when a wave with a certain frequency is continuously applied to an implant, when an implant is stable, the resulting resonance occurs at a higher frequency. This frequency is measured by the AFR method, which translates as ISQ values by 1-100.

The higher the ISQ score, the more rigid the implant and bone contact surfaces the higher the implant stability. According Ostell, Ostell ISQ value of reproducibility of 0.97 means very good. (44)

(25)

One of the goals of implant treatment is to restore stomagtonatic function. In order for that purpose to be achieved, the contact between the implant and the bone must be stable resulting in osseointegration. Osseointegration is defined as the relationship that occurs between the bone and the surface of the implant, requiring the formation of new bone around the implant being installed. (2)

(26)

In this study, there was a significant difference in ISQ implant values attached to normal and non-contact occlusal contacts, as well as between mild and normal contact in the first and second months after installation.

These findings are consistent with those of Miyata et al. (2000), which suggest that large occlusal contact pressures that exceed the physiological limit may affect the extent of bone resorption around dental implants. This may be due to the effects of occlusal contact biomechanics on the bone on a cellular basis. (48)

Bone remodeling that occurs around dental implants is affected by bone stretching. The amount of strain that occurs depends on the amount of pressure provided. Likewise with implants, the occlusal pressure on the implant will continue until the implant contact area with bone. If the applied occlusal pressure is greater, the resulting strain is also greater.

When the value exceeds the physiological limit, bone can induce cytokine production to initiate bone resorption. As a result, there is bone loss in the bone implant contact area so the area decreases its stability.

This is translated as a lower ISQ value by a measuring device by AFR method on implants with light and non-contact occlusal contacts compared with normal. (17)

On the other hand, the ISQ values resulting from implants with occult contactless contactless and light restoration contacts were not significantly different. This may be due to the force generated from the mild, temporally light restorative occlusal contact has not produced a strain whose value exceeds the physiological threshold of bone resorption. (17)

Furthermore, the magnitude of the occlusal force imparted to the implant depends not only on the magnitude of the occlusal contact. Other factors such as the number of implants, implant angulation, implant size and bone quality may affect the magnitude of the occlusal force imparted to the implant.

The stages in the implant installation process are mucosa incisions, and

mechanical implants that can cause injury to the mucosa and bone. In

these circumstances, cortical bone compression occurs around the

implant and damages the blood vessels. This results in nutrients in the

bones to be disturbed and bone become necrosis. (47)

(27)

Bone formation occurs immediately after the implant is installed. This new bone formation supports the implant stability that occurs immediately after the implant is installed is called primary stability. Over time, new bone forms of 100 μm per day in all directions. But the biomechanical capacity of this bone is low. After a few months, gradually the bones are replaced with lamela bone. After 18 months, the implant inside the jawbone can achieve a steady stability. The existence of this biomechanically better lamellar bone results in secondary stability of the implant. (44,47)

The process of forming new bone around the implant as described above may be the cause of the significant increase in ISQ implant value in the first and second months after implant installation. As time passes, the number of lamellar bones increases. Thus, implant contact with bone also increases. This condition is translated by means of the AFR method as the addition of ISQ values in the first and second months after implant installation with contactless, light, and normal occlusal contacts.

The weakness of this study lies in the small number of samples, the limited time of measurement of implant stability. This happens because it takes a lot of money to cover the cost of animal care try. In addition, there is also difficulty in making the occlusal form of temporary restorations to be equal to the neighboring teeth due to the very small shape and size of the teeth.

CONCLUSION

From this research, it can be concluded that:

1. There is no occlusal occlusal contact effect on the implant installed in immediate loading to the implant stability value shortly after installation

2. There is a difference in the value of implant stability installed in immediate loading between normal and non-contact occlusal contacts, and normal and light occlusal contact, but light and non-contact occlusal contacts have no difference in the implant stability value at 1 month after installation.

3. There is a difference in the value of implant stability installed in immediate loading between normal and non-contact occlusal contacts, and normal and light occlusal contact, but light and non-contact occlusal contacts have no difference in

(28)

the implant stability value at 2 months after installation.

5. The occlusal contact resulting in the greatest stability value after implant installation is an unattached restoration.

Suggestion

Further studies of experimental animals on the effect of occlusal restorative occlusal contacts on implants are implanted in immediate loading to implant stability values using more sample quantities and longer measurement times.

(29)

DAFTAR PUSTAKA

1. Wang G, Gao X, Lo EC. Public perceptions of dental implans: a qualitative study. J Dent. 2015;43(7):798-805.

2. Mavrogenis AF, Dimitriou R, Parvizi J, Babis GC. Biology of implan osseointegration. J Musculoskelet Neuronal Interact. 2009;9(2):61-71.

3. Parithimarkalaignan S, Padmanabhan T. Osseointegration: An Update. J Indian Prosthodont Soc. 2013;13(1):2-6.

4. Atsumi M, Park SH, Wang HL. Methods used to assess implan stability:

current status. Int J Oral Maxillofac Implans. 2007;22(5):743-54.

5. Herrero-Climent M, Santos-García R, Jaramillo-Santos R, Romero-Ruiz MM, Fernández-Palacin A, Lázaro-Calvo P, et al. Assessment of Osstell ISQ's reliability for implan stability measurement: a cross-sectional clinical study.

Med Oral Patol Oral Cir Bucal. 2013;18(6):e877-82.

6. Rao PL, Gill A. Primary stability: the password of implan integration. J Dent Impl. 2012;2(2) : 1-6

7. Santosa RE. Provisional restoration options in implan dentistry. Aust Dent J.

2007;52(3):234-42

8. Chung S, McCullagh A, Irinakis T. Immediate loading in the maxillary arch:

evidence-based guidelines to improve success rates: a review. J Oral Implanol. 2011;37(5):610-21.

9. Esposito M, Grusovin MG, Achille H, Coulthard P, Worthington HV.

Interventions for replacing missing teeth: different times for loading dental implans. Cochrane Database Syst Rev. 2009(1):CD003878.

10. Sanz-Sánchez I, Sanz-Martín I, Figuero E, Sanz M. Clinical efficacy of immediate implan loading protocols compared to delayed loading depending on the type of the restoration: a systematic review. Clin Oral Implans Res.

2015;26(8):964-82.

11. Heinemann F, Hasan I, Bourauel C, Biffar R, Mundt T. Bone stability around dental implans: Treatment related factors. Ann Anat. 2015;199:3-8.

12. Esposito M, Grusovin MG, Coulthard P, Worthington HV. Different loading strategies of dental implans: a Cochrane systematic review of randomised controlled clinical trials. Eur J Oral Implanol. 2008;1(4):259-76.

(30)

13. Lopez J. Immediate Loading in Implan Dentistry: Surgical, Prosthetic, Occlusal, and Laboratory Aspects. Barcelona: Quintessence; 2005. P178-182 14. Dewi RS. Prediksi osseointegrasi pada pemasangan implan secara immediate

loading dan delayed loading dikaitkan dengan kontak oklusal. Jakarta:

Universitas Indonesia - Disertasi; 2010. P 93-94

15. Nedir R, Bischof M, Szmukler-Moncler S, Bernard JP, Samson J. Predicting osseointegration by means of implan primary stability. Clin Oral Implans Res. 2004;15(5):520-8.

16. Swindler DR. Primate dentition. United Kingdom: Cambridge University Press; 2002. P1-13.

17. Misch C. Contemporary Implan Dentistry. Canada: Elsevier Mosby; 2008. P 1-6

18. John V, Chen S, Parashos P. Implan or the natural tooth--a contemporary treatment planning dilemma? Aust Dent J. 2007;52(1 Suppl):S138-50.

19. Vasak C, Fiederer R, Watzek G. Current state of training for implan dentistry in Europe: a questionnaire-based survey. Clin Oral Implans Res.

2007;18(5):668-76

20. Ng PC, Pow EH, Ching SH, Lo EC, Chow TW. Dental implan practice among Hong Kong general dental practitioners in 2004 and 2008. Implan Dent. 2011;20(1):95-105.

21. Lai Y, Kao S, Yeung T, Lee S. Rapid implan therapies: Immediate implan placement and immediate restoration. Journal of Dental Science. 2009;4(1):1- 6.

22. Park J, Lee J, Kim S, Lee J. Implan Dentistry- A Rapidly Evolving Practice.

Implan Stability- Measuring Devices and Randomized Control Trial for ISQ Value Change Pattern from Two Differen Direction of Magnetic RFA: In Tech; 2011. P 100-121

23. Winkler S, Morris HF, Ochi S. Implan survival to 36 months as related to length and diameter. Ann Periodontol. 2000;5(1):22-31.

24. Park IP, Kim SK, Lee SJ, Lee JH. The relationship between initial implan stability quotient values and bone-to-implan contact ratio in the rabbit tibia. J Adv Prosthodont. 2011;3(2):76-80.

(31)

25. Javed F, Almas K, Crespi R, Romanos GE. Implan surface morphology and primary stability: is there a connection? Implan Dent. 2011;20(1):40-6.

26. Tabassum A, Meijer GJ, Walboomers XF, Jansen JA. Evaluation of primary and secondary stability of titanium implans using different surgical techniques. Clin Oral Implans Res. 2014;25(4):487-92.

27. Bayarchimeg D, Namgoong H, Kim BK, Kim MD, Kim S, Kim TI, et al.

Evaluation of the correlation between insertion torque and primary stability of dental implans using a block bone test. J Periodontal Implan Sci.

2013;43(1):30-6.

28. Zarb G, Lekholm U, Albrektsson T, Tenenbaum H. Aging, Osteoporosis, and Dental Implans. Illnois: Quintessence; 2002.

29. Turkyilmaz I, McGlumphy EA. Influence of bone density on implan stability parameters and implan success: a retrospective clinical study. BMC Oral Health. 2008;8:32.P 1-13

30. Isoda K, Ayukawa Y, Tsukiyama Y, Sogo M, Matsushita Y, Koyano K.

Relationship between the bone density estimated by cone-beam computed tomography and the primary stability of dental implans. Clin Oral Implans Res. 2012;23(7):832-6.

31. Mesa F, Muñoz R, Noguerol B, de Dios Luna J, Galindo P, O'Valle F.

Multivariate study of factors influencing primary dental implan stability. Clin Oral Implans Res. 2008;19(2):196-200.

32. Sahin S, Cehreli MC, Yalçin E. The influence of functional forces on the biomechanics of implan-supported prostheses--a review. J Dent. 2002;30(7- 8):271-82.

33. Hoshino K, Miura H, Morikawa O, Kato H, Okada D, Shinki T. Influence of occlusal height for an implan prosthesis on the periodontal tissues of the antagonist. J Med Dent Sci. 2004;51(4):187-96.

34. Pellicer-Chover H, Viña-Almunia J, Romero-Millán J, Peñarrocha-Oltra D, García-Mira B, Peñarrocha-Diago M. Influence of occlusal loading on peri- implan clinical parameters. A pilot study. Med Oral Patol Oral Cir Bucal.

2014;19(3):302-7.

(32)

35. Qadeer S, Kerstein R, Kim RJ, Huh JB, Shin SW. Relationship between articulation paper mark size and percentage of force measured with computerized occlusal analysis. J Adv Prosthodont. 2012;4(1):7-12.

36. Price C, Ergül N. A comparison of a film-based and a direct digital dental radiographic system using a proximal caries model. Dentomaxillofac Radiol.

1997;26(1):45-52.

37. Ajmal M, Elshinawy MI. Subjective image quality comparison between two digital dental radiographic systems and conventional dental film. Saudi Dent J. 2014;26(4):145-50.

38. Whaites E, Drage N. Essentials of Dental Radiography and Radiology.

Minnesotta: Churcill- Livingstone; 2013. P95-99

39. Bischof M, Nedir R, Segre S-M, Benard J-P, Samson J. Implan stability measurement of delayed and immediately loaded implans during healing. A clinical RFA study with SLA ITI implans. Clinical Oral Implan Research.

2004;15(5):529-39.

40. Guler AU, Sumer M, Duran I, Sandikci EO, Telcioglu NT. Resonance frequency analysis of 208 Straumann dental implans during the healing period. J Oral Implanol. 2013;39(2):161-7.

41. Glauser R, Sennerby L, Meredith N, Rée A, Lundgren A, Gottlow J, et al.

Resonance frequency analysis of implans subjected to immediate or early functional occlusal loading. Successful vs. failing implans. Clin Oral Implans Res. 2004;15(4):428-34.

42. Liu Y, Sun H, Zhu C, Deng F. The predictive value of resonance frequence analysis using Ostell ISQ during early healing of immediately restored implans in the aesthetic zone. Clinical Oral Implan Research. 2014:546 43. Ostell. Ostell ISQ : Taking Measurement with Ostell ISQ.2013.

44. Ostell. Ostell ISQ: Your guide to optimal implan loading decision. 2013.

45. Bonadio C. Macaca fascicularis: Long tailed macaque 2000 [Available from:

http://animaldiversity.org/accounts/Macaca_fascicularis , accesed 14 June 2016)

(33)

46. European-Commision. Animals used for scientific purposes 2015 [Available from:http://ec.europa.eu/environment/chemicals/lab_animals/3r/alternative_e n.htm , accesed 14 June 2016]

47. Miyata T, Kobayashi Y, Araki H, Ohto T, Shin K. The influence of controlled occlusal overload on peri-implan tissue. Part 3: A histologic study in monkeys. Int J Oral Maxillofac Implans. 2000;15(3):425-31.

48. Newman M, Takei H, Klokkevold P, Carranza F. Carranza's Clinical Periodontology. 11 ed. Missouri: Elsevier Saunder; 2011.p 626

(34)

Lampiran 1 Surat Keterangan Persetujuan Protokol No IPB PRC-15-B006

(35)

(36)

Lampiran 2 Hasil Uji Statistik

(37)

(38)

Tabel hasil uji normalitas

Kontak oklusal

Kolmogorov-Smirnov^a Shapiro-Wilk

Statistic df Sig. Statistic df Sig.

STABILITAS bulan pertama ringan .385 3 . .750 3 .000

bulan pertama normal .385 3 . .750 3 .000

bulan kedua tanpa

kontak .385 3 . .750 3 .000

bulan kedua ringan .385 3 . .750 3 .000

bulan kedua normal .385 3 . .750 3 .000

a. Lilliefors Significance Correction

b. STABILITAS is constant when kontak oklusal = baseline tanpa kontak. It has been omitted.

c. STABILITAS is constant when kontak oklusal = baseline ringan. It has been omitted.

d. STABILITAS is constant when kontakoklusal = baseline normal. It has been omitted.

e. STABILITAS is constant when kontakoklusal = bulan pertama tanpa kontak. It has been omitted.

Tabel hasil uji Kruskal – Wallis nilai stabilitas implan pada Periode Baseline

kontakoklusal N Mean Rank

STABILITAS baseline tanpa kontak 3 5.00

baseline ringan 3 5.00

baseline normal 3 5.00

Total 9

Test Statistics^a,b

STABILITAS

Chi-Square .000

df 2

Asymp. Sig. 1.000

a. Kruskal Wallis Test

b. Grouping Variable:

kontakoklusal

(39)

Tabel hasil uji Kruskall-Wallis nilai stabilitas implan pada periode bulan pertama antar kontak oklusal

kontakoklusal N Mean Rank

STABILITAS bulan pertama tanpa

kontak 3 7.00

bulan pertama ringan 3 6.00

bulan pertama normal 3 2.00

Total 9

STABILITAS

Chi-Square 6.788

df 2

Asymp. Sig. .034

b. Grouping Variable: kontak oklusal

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antara bulan pertama tanpa kontak dan bulan pertama ringan

kontakoklusal N Mean Rank Sum of Ranks

kontak 3 4.00 12.00

bulan pertama ringan 3 3.00 9.00

Total 6

Test Statistics^b

STABILITAS

Mann-Whitney U 3.000

Wilcoxon W 9.000

Z -1.000

Asymp. Sig. (2-tailed) .317 Exact Sig. [2*(1-tailed Sig.)] .700^a a. Not corrected for ties.

(40)

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antara bulan pertama tanpa kontak dan bulan pertama normal

Kontak oklusal N Mean Rank Sum of Ranks

kontak 3 5.00 15.00

bulan pertama normal 3 2.00 6.00

Total 6

STABILITAS

Mann-Whitney U .000

Wilcoxon W 6.000

Z -2.121

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antara bulan pertama ringan dan bulan pertama normal

Kontak oklusal N Mean Rank Sum of Ranks STABILITAS bulan pertama

ringan 3 5.00 15.00

bulan pertama

normal 3 2.00 6.00

Total 6

STABILITAS

Mann-Whitney U .000

Wilcoxon W 6.000

Z -2.023

(41)

Tabel hasil uji Kruskall-Wallis nilai stabilitas implan pada periodebulan kedua antar kontak oklusal

Kontak oklusal N Mean Rank

STABILITAS bulan kedua tanpa

kontak 3 7.00

bulan kedua ringan 3 6.00

bulan kedua normal 3 2.00

Total 9

STABILITAS

Chi-Square 6.054

df 2

Asymp. Sig. .048

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antarabulan kedua tanpa kontak dan bulan kedua normal

Kontak oklusal N Mean Rank Sum of Ranks

kontak 3 5.00 15.00

bulan kedua normal 3 2.00 6.00

Total 6

STABILITAS

Mann-Whitney U .000

Wilcoxon W 6.000

Z -2.023

(42)

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antara bulan kedua tanpa kontak dan bulan kedua ringan

kontakoklusal N Mean Rank Sum of Ranks

kontak 3 4.00 12.00

bulan kedua ringan 3 3.00 9.00

Total 6

STABILITAS

Mann-Whitney U 3.000

Wilcoxon W 9.000

Z -.745

Tabel hasil uji Post Hoc Mann Whitney nilai stabilitas implan antara bulan kedua ringan dan bulan kedua normal

Kontak oklusal N Mean Rank Sum of Ranks STABILITAS bulan kedua

ringan 3 5.00 15.00

bulan kedua

normal 3 2.00 6.00

Total 6

STABILITAS

Mann-Whitney U .000

Wilcoxon W 6.000

Z -2.023

b. Grouping Variable: kontakoklusal

(43)

Tabel hasil uji Friedman perbedaan nilai stabilitas implan dengan kontak oklusal tanpa kontak antara yang diukur saat baseline, bulan pertama, dan bulan kedua.

Ranks

Mean Rank

baseline 1.00

Tanpa kontak bulan

pertama 2.00

Tanpa kontak 2bulan 3.00

Test Statistics^a

N 3

Chi-Square 6.000

df 2

Asymp. Sig. .050 a. Friedman Test

Tabel hasil uji Friedman perbedaan nilai stabilitas implan dengan kontak oklusal ringan antara yang diukur saat baseline, bulan pertama, dan bulan kedua.

Ranks

Mean Rank

baseline 1.00

Ringan bulan

pertama 2.00

Ringan bulan

kedua 3.00

N 3

Chi-Square 6.000

df 2

(44)

Tabel hasil uji Friedman perbedaan nilai stabilitas implan dengan kontak oklusal normal antara yang diukur saat baseline, bulan pertama, dan bulan kedua.

Ranks

Mean Rank

baseline 1.33

Normal bulan

pertama 1.67

Normal bulan

kedua 3.00

N 3

Chi-Square 5.600

df 2