MANIFESTo OF ITALIAN IMPLANTOLOGY

By Dr. Silvano U. Tramonte

In order to understand Italian Implantology, the origin and the history of implantology itself must be understood. Until 1959, implantology was a mixture of personal techniques that developed in two broad opposite directions. Their purposes were identical, but their techniques and instruments were opposite, unleashing real ideological conflicts. The two streams were juxtaosteal and endosteal. Endosteal implantology was represented by a myriad of implant shapes, attempting to achieve functional rehabilitation of patients with various degrees of edentulism, while facing many issues and with total ignorance of the procedure. These were desperate attempts, quite empirical, to make sure that the most disparate alloplastic inserts stayed in place after their insertion into the bone, replacing the function of the lost roots, while supporting a prosthetic element without unleashing flogistic reactions in the hard and soft tissues hosting them. The goal was to obtain a passive acceptance of osteoinclusion (a term proposed by Pasqualini) and an adhesive cicatrization of the soft tissues around the implants.

One of the strongest criticisms of implantology, which caused opposition from academic and scientific representatives, was that the implant would keep open a passage between the oral cavity, hosting a very rich bacterial flora, and the inside of the body, thus allowing very dangerous infections to penetrate, and spread into, the inside of the body. This question was answered in a definitive way by histological demonstrations of a biological seal capable of acting as a suitable barrier, and the total lack of inflammation symptoms in the Tramonte implants and Linkov blades periimplantar areas (Camera, Pasqualini, Tramonte 1972). However, the preconceived hostility to endosteal implantology survived for a long time.

The origins of endosteal implantology are lost in ancient times, and in endless attempts to insert the most different materials to replace lost dental elements: pieces of shell carved in the shape of teeth, pieces of bone, semiprecious stones, etc., up to the generation of real implantological attempts in recent times, that had at least the merit of identifying biotolerable materials and some rudiments of surgical techniques. Endosteal implantology ceased to be a pipedream of some unknown dentist lost in some part of the world and started to acquire the elements of scientific research, methodology and propagation, first in Italy, then, soon after, in France and Spain. So, Italy was the cradle of modern endosteal implantology (Formiggini, Zepponi, Muratori, Tramonte, Garbaccio, Mondani, to quote just its main representatives).

Immediate load was the main and constant feature of these first imaginative implantology attempts. So, immediate load represents the first distinctive differentiating element of implantology that, from that moment on, assumed a very precise territorial character, and rose to prominence as essentially an Italian phenomenon. This is because those who generated their respective implantological realities in France (Cherchève) and Spain (Perron-Andres) were students of the same teacher: the very Italian Formiggini, who is acknowledged unanimously as the father of endosteal implantology.

The first clinically predictable immediate load successes came in 1959, when the first implant specifically designed for that purpose was born. Fromthen on, its featuresare representative of any immediate load implants. This was the very Italian Tramonte implant. The features that made it so suitable and adequate for the task of supporting immediate load were: deep threads (a large difference between major and minor thread diameters) and very long pitch (large distance between thread crests). Immediately following this, reduced emergence and biological space came into practice. Finally, as a world-wide first, came the use of titanium. In fact, Stefano Tramonte was the first in the world to use titanium in clinical implantology: precisely, grade 2 Titanium.

Surgical technique anticipated the criteria of minimum invasion and atraumatic interventions so fashionable today, with flapless placements, transmucosal techniques, parallelizing the implant necks by bending and preparing them inside the mouth, bracing by immediate placement of a fixed prosthesis. Blade implants were the exception, with rather reduced flaps.

The distinctive parameters of Italian screw implants became: screw shape with a reduced shaft, of diameter smaller than 2.5 mm, deep threads, pitch larger than thread depth, emergent portion reduced to a diameter smaller than 2.5 mm, free emergent part, respect of biological space and the use of Ti2.

Among the endless copies of Tramonte implants, only Garbaccio’s bicortical implant survives, as it reached its own dignity and features. Besides these two national implants, Italian implantology widely adopted and appropriated an implant that was not Italian to start with, but became Italian, as its use spread and remained practically only in Italy: the Scialom needle implant.

Finally, the blade implant, by Linkov first, then Pasqualini, but now in declining use, enjoyed a wide popularity. Even Tramonte produced its own blade, that enjoyed a broad success, but was abandoned when the use of reduced implants and multi-type electrowelded implantology was perfected. Intraoral electrowelding (elettrosincristallizzazione) was the latest totally Italian invention, thanks to the Mondani intraoral welder.

Besides the typically Italian implants, a totally original and typically Italian implantology was developing: the immediate load electrowelded implantology.

The Italian school of endosteal implantology was the sole and dominant implantology until the appearance of the Swedish school of endosteal implantology, twenty years later, which was based on instruments and concepts completely opposed to those of the Italian school: deferred load, narrow and fine threads, double surgery, etc. In the following table the main features of the two implantological schools are summarized, once strongly different and divided. As time passed, the concepts and principles of Italian implantology have prevailed more and more, to the point of spreading broadly at the end of the 1990s, causing radical changes in the Swedish implantology school, that has openly welcomed principles and concepts it rejected and fought for decades, up to a few years earlier.

Features / Italian school / SwedishSchool
THREAD / Broad / Narrow
DISTANCE BETWEEN THREAD TURNS / Large / Reduced
EMERGENCE / Reduced / Large
BIOLOGICAL SPACE / Yes / No
TITANIUM / Gr.2 / Gr.2/4/5
TRANSMUCOSAL / Yes / No
IMMEDIATE LOAD / Yes, compulsory / No
IMMEDIATE BRACING / Yes / No
PARALLELIZATION / Immediate by bending / Deferred by connection
INVASIVENESS / Low / Important
TRAUMATICITY / Low / Important
FLAPPING / Not usually, just in case of need / Yes, compulsory
EMERGENCE / Free / Fixed
ADAPTABILITY / Greatest / Non-existent
SURGICAL RECONSTRUCTIONOF ATROPHIC SITES / Avoided / Necessary
PRE-IMPLANTAR OSTEOPLASTY / No / Yes
PHYSIOLOGICAL PERIIMPLANTAR BONE LOSS / No / Yes
PERIMPLANTITIS / Statistically insignificant / Statistically important (unverified data)
ESTHETICS / Always good / Good only in optimal conditions
HYGIENIC PROSTHESES / Yes / No
VERSATILITY / High / Low
BONE QUALITY / D1-D2-D3-D4-D5 / D1-D2
ADAPTABILITY AND THERAPEUTIC EASE OF HANDLING / Maximum / Non-existent

If today there are many common points between the Italian and the Swedish implantology schools, the reason is that the Swedish school adopted systematically the principles that were the features of the Italian school since its inception. Before embracing them, the Swedish school labeled them as damning defects, and used them to reject Italian immediate load implantology. In fact, as long as immediate load was the prerogative of the Italian school, it was considered anti-scientific, quacky and causing fibrous integration, in other words a clinical, conceptual and histological failure.

Let’s see what the typical, exclusive, and unique elements of Italian implantology have been for the past 50 years, used only by Italian implantology, fought and criticised forever by all those who nowadays are inspired by it:

INSTRUMENTS

IMPLANTS

All implants feature free emergence: a fixed emergence point does not exist, and the surgeon is free to sink them at will, depending on the mucosal thickness and the coronal thread position.

All implants present reduced emergence: this is never greater than 2.5 mm (not even in cases of shaft diameters up to 4 mm, introduced by Tramonte in more recent times).

All implants are customizable: i.e. adaptable to the residual bone tissue of the patient. It is always possible to parallelize the emerging necks by bending them. Non only that, Italian school implants are modifiable in their structure and morphology to adapt them to the different needs of each clinical case: placements out of crest and moving the neck into the crest, building bipeds and tripods, realization of complex implant structures in cases of advanced electrowelded implantology, “S” implants. The “S” implant, protected by trademark, is the extreme evolution of the Italian school concepts. Besides, screw and needle implants present an elasticity coefficient closer to the one of bone.

Screw shaped implants:

  • Broad thread
  • Large distance between thread crests (large pitch)
  • Free and reduced emergence
  • Grade 2 titanium

The original screw-shaped implants of the Italian school of implantology are exclusively Tramonte and Garbaccio.

Needle implants:

Adopted by Italians, they were invented by the French Scialom.

From the beginning, they have been part of the Italian school protocol and they are used officially only in Italy.

Blade implants:

Blade implants are American, adopted by the Italian school but widely used in America. They have produced international literature and famous copies in Italy, by Pasqualini and Tramonte.

ORAL WELDER (SINCRISTALLIZZATRICE)

Invented by Mondani, it is an integral and exclusive element of the Italian school instrument set. Its use is compulsory in its protocol. So far, it has not been adopted by any other implantological schools.

GRADE 2 TITANIUM

Introduced by one of the most important representatives of the school, the use of titanium spread rapidly worldwide, but especially in its higher grades, which are more suitable for the mechanical features and needs of buried implants, and selected for them. Grade 2 titanium, instead, is a unique feature of Italian school implants, chosen because it can be bent to parallelize and move the implant necks, and customized by modifying implant structures (“S” implant), to realize autonomous implant units, made of two or more implants suitably placed to build bipeds, tripods or quadripods, whose necks are bent and joined by oral welding to obtain a single neck.

BIOMECHANICS

1.These implants dissipate the largest forces inside the medullar bone, thanks to their large threads, reduced emergence and machined emergence surface, and on the internal corticals, thanks to bicorticalism.

2.In Italian implantology the useful work surface is composed by single threads and by the macromechanical lock produced between threads, while in Swedish implantology it is the global surface composed by microthreads and surface microporosity.

3.Italian implantology seeks the lack of parallelism of implant bodies to increase the polygonal base surfaces, trying to place the load axis inside these surfaces (bipeds, tripods in implant units or complex structures).

4.Italian screws are usable with excellent results in all bone qualities, from D1 to D5.

BIOPHYSIOLOGY

1.The good physiological response of the periimplantar tissues, due to the mentioned emergence profiles, absence of prosthetic connection, respect of biological space sizes, and prostheses more respectful of receiving tissue, has been shown from 1972 by undisputable histological research (Camera, Pasqualini 1972).

2.Italian school implants stimulate the deep bone, improving its medullar structure.

3.Recently, all the advantages of surface treatments have been acquired, by introducing them on Italian school implants.

SURGICAL TECHNIQUES

Transmucosal

Since the beginning, Italian school implants are placed preferably flaplessly. Flapping is reserved for the most complex cases.

Multi type implantology

Represented by screw and needle implants, bipods and tripods, implant structures in advanced implantology, modified implants, etc.

Compulsory immediate load

It is true that implantology could not avoid immediate load up to 1959. With the introduction of titanium (1964), and the new implant design (1963), Italian implantology has attained clinical success with percentages over 90%, and unequivocally binds its name to successful immediate load. Immediate load now moves from an approach ruled by good luck to a predictable and reliable one, ruled by rational choices, an undisputable certainty.

Parallelization by bending

The introduction of Ti2 (1964) led very rapidly to exploiting its malleability to transfer to screw shaped implants the fundamental feature of needle implants: the creation of an implant adapted to the receiving site during the surgical phase. From there evolved the angled implants typical of the Italian school, copied recently by the Swedish school with the name “all on four/six”, the crossing implants used for the non-surgical bypass of the IAN, especially the “S” implants.

Immediate bracing of implants by electrowelding

One of the basic factors in the success of immediate load, forever acknowledged as such, is the immediate implant bracing done by acrylic ferrules, realized in various ways, or the placement of sufficiently rigid, reinforced provisionals, immediately or a few hours later. The introduction of the oral welder (Mondani, 1978) made the bracing process much more practical and scientific, as well as extremely predictable. The pioneers of immediate load understood immediately that implants had to be steadied in some way to allow bone osteogenesis to start in an ankylosing and effective way, but up to the arrival of the Mondani “welder” this was left to the skill and resourcefulness of the implantologist. Electrical welding is the final event in the surgical procedure.

BIOLOGICAL RESPECT

Biological respect of receiving tissues always was a specific and exclusive feature of Italian implantology, pursued with every available means since the early 1960s:

Large biological space area: free emergence has always been a feature of Italian implants, which guaranteed from the beginning suitable spaces for epithelial adhesion.

Minimal invasiveness and autramaticity: the maximum diameter of bone perforation is 2.25 mm even for implants of 6 mm diameter. This guarantees a minimal disruption to the bone and epithelial tissues housing the shaft, while the threads open their own way simply by cutting, moving and compacting the spongious tissue trabeculae without removing any tissue. Even in the case of implants with shaft diameter increased to 4 mm, the insertion perforation remains with a 2.25 mm diameter.

Flapless surgery: this has always been the dominant feature of Italian immediate load, adopted by other schools only recently.

Very limited noxious load: the implant noxious load is its capacity to produce damages. The higher such load, the more frequent are the productions of mucus, periimplantitis, periimplantar bone resorptions, etc.

BIOLOGICAL SAVINGS AND REDUCTION OF BIOLOGICAL COSTS

Since its inception, a basic feature of Italian implantology has been respect of the patient’s biological nature. This principle is expressed by:

  • reducing tissue damages by using very limited surgeries, thanks to flapless procedures
  • perforations of very limited diameters, thanks to the use of reduced shafts even with implants with broad threads (this means that in order to insert a 6 mm implant, a perforation of only 2.25 mm is necessary, realizing an absolutely outstanding saving of bone tissue)
  • reducing any post-surgery complications (the lighter the surgery, the less frequent and important are its complications)
  • developing surgical techniques aimed at exploiting only the bone present, without any osteoplastic interventions on crests, augmentation, distraction, sinus lift, etc.

Let’s calculate the reduction in the removed bone volume with the same useful implant diameter. The surface of a circle of  2.25 mm (this is the diameter of the insertion hole of an Italian implant with a 5 mm major thread ) is 3.97 mm2, while the surface of a circle of  5 mm (this is the diameter of the insertion hole of a buried implant with a 5 mm major thread) is 19.6 mm2. It is clear that there is a huge difference between the two surfaces, which becomes scary when this value is used to calculate the whole volume of the perforation. To clarify, an implant with a major thread  of 5 mm, a shaft  2.25 mm and a length of 10 mm requires a space of 39.7 mm3, while one of  5 mm thread and shaft needs 196 mm3. Or, if you prefer, 0.0396 cc versus 0.196 cc. For the  2.25 mm implant we do not consider the threaded part, because the thread is self-tapping, does not remove bone but is limited to compacting trabeculae, determining a sort of hardening of the material surrounding the implant.

A remarkable biological saving is obtained also by a biocompatible evolution in the course of time, with absence of flogistic phenomena in bone and mucosal tissues, periimplantar resorptions, etc. Also, the possibility of building respectful and hygienic prostheses further respects the tissue, therefore saves it. Another rather exclusive aspect of these implants is the possibility of managing failures with a limited cost.

By failures, we mean the loss of an implant or the need to remove it. If we add to the preceding calculations one millimeter of periimplantar bone wear, we obtain that for a  2.25 mm implant the residual bone hole is 82.9 mm3, or 0.0829 cc, while the one left by a  5 mm implant is 282.2 mm3, or 0.282 cc, a scary well. Apart from a biological damage, there is a time-related damage and, obviously, an economic damage. In the first case it is sufficient to wait a few weeks to reinsert an implant, or a larger implant can be inserted immediately, in the second case a bone reconstruction procedure is necessary, to avoid a vertical bone loss, then an implant can be placed after a few months, a few more months are necessary to wait for osteointegration, then one can proceed to prosthetic rehabilitation.

Further points ensuring a maximized biological saving are:

  • Absence of reconstructive surgery
  • Absence of preimplantar osteoplasty
  • Absence of “physiological bone resorption”
  • Absence of periimplantitis

GENERAL FEATURES

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