Journal of Long-Term Effects of Medical Implants, 13(6)485–501 (2003)

Implant Materials, Design, and Surface

Topographies: Their Influence on
Osseointegration of Dental Implants
R. Gilbert Triplett, DDS, PhD,¹ Uwe Frohberg, DMD, MD,¹
Nikitas Sykaras, DDS, PhD,³ & Ronald D. Woody, DDS²

¹Department of Oral and Maxillofacial Surgery and Pharmacology, ²Department of

Restorative Sciences, Baylor College of Dentistry–The Texas A&M University System
Health Science Center, Dallas, Texas, USA; ³Private Practice, Athens, Greece

*Address all correspondence to R. Gilbert Triplett, Department of Oral and Maxillofacial Surgery and
Pharmacology, Baylor College of Dentistry–The Texas A&M University System Health Science Center, 3302
Gaston Avenue, Dallas, TX 75246, USA; gtriplett@tambcd.edu

ABSTRACT The purpose of this review is to describe commonly used dental implants with
reference to their material composition, design factors, and surface topographies. The review
includes a discussion of the biological principle of osseointegration and how this process of
bone–implant interaction is influenced by different implant materials, designs, and surface
characteristics.

KEY WORDS: implant surface, titanium, material composition, bone–implant interaction

Document ID# JLT1306-485–502(208) 

1050-6934/03 $5.00 © 2003 by Begell House, Inc.

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 
I. INTRODUCTION
Since their introduction over 40 years ago, dental
implants have changed the practice of dentistry. Im-
plants have revolutionized our concept of replacing
missing teeth and have become an established treat-
ment modality supported by many scientific stud-
ies. Implants provide support for single teeth, fixed
partial or complete dentures, and removable partial
or complete dentures. They also serve as anchorage
devices for orthodontic appliances and for extraoral
prostheses to reconstruct craniofacial defects. Their
latest application is in the area of distraction osteo-
genesis, where they serve as distraction devices during
the process of new bone formation.
A multitude of different implant systems have been
introduced for use in many oral and maxillofacial in-
dications.¹ Oral implants can be classified based on
their insertion technique as subperiosteal implants,²
ramus frame implants,³ transosseous implants,⁴ and
endosseous implants.⁵ Over the years, only endosseous
implants have proven to be highly predictable. The
success of endosseous implants is directly related to
the principle of osseointegration, a process of implant–
bone interaction that finally leads to its end product,
bone-to-implant anchorage. Osseointegration is a
predictable process and is influenced by a number of
factors. Implant-related variables critical in osseointe-
gration include implant material, design, and surface
characteristics. Patient-related variables determining
implant success or failure include bone quality, medi-
cal status, smoking, irradiation, and parafunctional
habits. Surgical technique, operator experience, and
implant-loading design are additional success–failure
criteria that influence the survival rate of endosseous
implants.⁶ The aim of this article is to outline how
implant material, design, and surface characteristics
influence the process of bone–implant interaction.
II. DEFINITIONS OF OSSEOINTEGRATION
The concept of osseointegration was introduced by
Brånemark et al. in the 1960s.⁷ Osseointegration is a
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R. G. TRIPLETT ET AL.
biological concept. Since its introduction, the term has
been defined and redefined from different viewpoints,
the common denominator being an inanimate metal-
lic structure anchored long-term in living bone under
functional loading. The host response to implants
inserted in living bone involves a series of events at
cellular and molecular levels, ideally leading to an
intimate apposition of bone to implant surface.
Albrektsson et al.⁸ defined osseointegration as
“direct functional and structural connection be-
tween living bone and the surface of a load-bearing
implant.” Steineman et al.⁹ looked at osseointegration
as “a bony attachment with resistance to shear and
tensile forces.” Zarb and Albrektsson¹⁰ provided a
more clinical definition and described osseointegra-
tion as “a process in which a clinically asymptomatic
rigid fixation of alloplastic material is achieved and
maintained in bone during functional loading.” The
term osseointegration is not limited to describing
initial bony implant anchorage but is presently in-
terpreted as a clinical descriptor of implant survival.
Throughout the period of implant loading, the sur-
rounding living bone is undergoing continuous active
remodeling and adaptation with direct ongrowth to
the implant surface.
III.A. Implant Material
The biomaterials used for manufacturing dental im-
plants include metals, ceramics, carbons, polymers,
and combinations of these.¹¹ Any biomaterial selected
for dental implant fabrication must meet the basic
criteria of biocompatibility and biofunctionality. A
biocompatible material is chemically and biologically
compatible with living bone, thus enhancing the pro-
cess of osteoconduction, or ongrowth of bone to its
surface. A biofunctional material exhibits specific
physical properties that allow the implant to func-
tion under the maximum amount of occlusal loading
without damaging the surrounding living tissues.
Polymers are softer and more flexible than the
other classes of biomaterials. They also present with
low mechanical strength, which makes them prone
Journal of Long-Term Effects of Medical Implants
 IMPLANT MATERIALS, DESIGN, AND SURFACES
to mechanical fractures during function under high
loading forces. Polymeric materials have very little
application in implant dentistry and were only used
to fabricate shock-absorbing components placed be-
tween the implant and the suprastructure.¹² This ele-
ment has been eliminated in most implant systems.
Carbon biomaterials have been used both as
a coating for titanium alloy implants and for the
fabrication of carbon implants. Carbon surfaces are
easily contaminated during implant insertion, and
these implants must be handled very carefully. The
material properties of carbons have prohibited their
wide use. Carbons are very brittle materials that have
no mechanical deformability compared to the more
malleable metals and alloys.
Aluminum oxide, bioglasses, hydroxyapatite (HA),
and tricalcium phosphate ceramics are also very
brittle implant biomaterials. Hydroxyapatite, trical-
cium phosphate, and aluminum oxide ceramics are
currently used as plasma-sprayed coatings onto a
metallic core.¹³ Implants made entirely from alumi-
num oxide or bioglass ceramics are stiff and pressure
resistant but less resistant to bending stresses than are
the metals. Implant shape and design are important
factors to consider in ceramic implants in order to
avoid mechanical fracture. Both polycrystalline and
single-crystal aluminum–ceramic implants have been
marketed, but these systems have not become widely
accepted.¹⁴¹⁵ There is direct bone apposition to poly-
crystalline aluminum oxide ceramic implants, and the
bone–implant interface is maintained during func-
tional loading.¹⁶ Single-crystal aluminum–ceramic
implants have been found to be encapsulated in
connective tissue with no signs of osseointegration.
Commercially pure (CP) titanium and its alloy ti-
tanium-6aluminum-4vanadium (Ti-6Al-4V) are the
two major metals used in implant manufacturing.¹⁷
Titanium is a lightweight metal that is resistant to
corrosion and chemical attack. It can be easily milled
and shaped while retaining its modulus of elastic-
ity and mechanical strength. Commercially pure
titanium is classified in 4 grades based on its oxygen
content. Grade 4 contains the greatest amount of
oxygen (0.4%). The stoichiometric composition rec-
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ommended for dental implants consists of 99.75%
titanium, 0.05% iron, 0.1% oxygen, 0.03% nitrogen,
0.05% carbon, and 0.012% hydrogen.¹⁸ The titanium
implant surface is either machined smooth or rough-
ened by sand- or gritblasting, acid-etching, plasma-
sprayed coatings, or the addition of powder spheres.
Regardless of its surface topography, commercially
pure titanium instantaneously forms a highly reactive
surface layer of titanium oxide. This oxide surface is
a dynamic interface, which leads to the apposition
and ongrowth of mineralized bone matrix. The ini-
tial oxide thickness of 2–6 nm before implantation
will increase two to three times during the biological
process of bone–implant interaction and will change
constantly under loading conditions.¹⁹ The initial
oxide surface not only increases in thickness but also
changes its chemical composition by incorporating
calcium, phosphorus, and sulfur.²⁰ Another sign of
this dynamic tissue–biomaterial interaction is the
release and accumulation of metallic ions into the
surrounding living tissues where they can stay locally
or be spread systemically.²¹ So far there have been no
reports that oral and maxillofacial implants can induce
toxic levels of metal ions that are hazardous to the
health of the implant recipient.
During the processes of implant site preparation
and implant insertion, a thin layer of bone will be-
come necrotic. The host response to this initial trauma
includes inflammation, repair, and remodeling. Pro-
teins, lipids, and other biomolecules are immediately
absorbed to the implant surface, as gaps between the
implant and bone are filled with blood. The healing
process starts with the replacement of the necrotic
bone and the hematoma by rapidly formed woven
bone within two weeks. This woven bone undergoes
remodeling and resorption before newly differenti-
ated osteoblasts produce mature lamellar bone tissue
around the implant, leading to anchorage. Lamellar
bone tissue does not bind directly to the titanium
oxide surface but rather to an afibrillar interfacial zone
composed of glycoproteins and proteoglycans.²² This
amorphous zone mediates the adhesion of osteoblasts,
osteoid, and mineralized matrix to the oxide layer.
The final deposition of mineralized bone matrix oc-
 
curs in two directions. Bone grows directly from the
osteotomy site to the surface of the implant. Bone
formation also takes place along the biomaterial and
extends from the implant toward the healing bone.²³
The end product of this dynamic biological process is
direct bone anchorage to an implant body.
III.B. Implant Design
The design of medical implants depends on a number
of factors necessary for long-term success and must be
in concert with physiology, anatomy, and biomateri-
als. Key factors that influence the design of implants
include (1) biomaterial, (2) three-dimensional finite
element analysis, (3) machining, and (4) surface treat-
ment such as etching, blasting, and coating. Implant
design refers to three-dimensional structure of the
implant with all the elements and characteristics
that compose it. Form, shape, configuration, surface
macrostructure, and macro-irregularities are terms
that have been used to describe various aspect of the
three-dimensional structure.²⁴
Dental implants are constructed from biocom-
patible materials that can be formed into configura-
tion and placed within a fixed amount of available
bone and project through the integument (mucous
FIGURE 1. Examples of numerous threaded dental im-
plants with both smooth and rough surfaces.
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R. G. TRIPLETT ET AL.
or skin).²⁵ If functional forces are placed on the
implant within its physiological limits of health, a
normal clinical and histological result can be obtained.
Within limited magnitude of functional loading, good
osseous adaptation can be demonstrated histologically
around many implant configurations. Implant design
must choose the configuration that will function most
efficiently in a limited, fixed amount of available
bone, transmitting maximal functional forces while
maintaining the site in a healthy physiological state.
The ideal configuration should provide an implant
attachment (abutment) with the greatest margin of
functional safety to enhance the prognosis of the
planned prosthetic device.
Most implants designed to function in the osseo-
integrated mode of tissue integration are generally
round in their cross-section dimension. Endosseous
dental implants exist in a wide variety of designs, with
the long-term objective being uncomplicated function
of the prosthetic replacement through osseointegra-
tion of the implant bone interface (Fıgs. 1 and 2).
The prosthetic interface is an important aspect of
implant design. It is the level at which the super-
structure or the abutment connects to the implant
body. This interface can be either external or internal.
External connections include the hexagonal (hex), the
octagonal (octa), and the spline, with its interdigitat-
FIGURE 2. Nonthreaded (press fit) implants including HA-
coated and titanium plasma spray-coated surfaces.
Journal of Long-Term Effects of Medical Implants
 IMPLANT MATERIALS, DESIGN, AND SURFACES
ing projections and slots. The internal connections
include the morse taper interface, the internal hexa-
gon, and the internal octagon. Dental implants are
also categorized into threaded and nonthreaded cyl-
inders. The nonthreaded implants are considered to
be “press-fit” implants. Currently, threaded implants
dominate the implant market because of their ability
to provide initial implant stability in a predictable
manner. The threads are used to maximize the initial
contact, improve stability, and enlarge the implant
surface area. The threads favor dissipation of the
interfacial stresses. ²⁶ ²⁷
A major factor limiting long-term implant main-
tenance is excessive load transmitted to the implant
from the prosthesis. Fınite element analysis allows
design engineers/scientists to understand how to
modify load transfer by improving implant design.
Comparative analysis of implant systems and configu-
rations can be used to predict the range of forces that
will be created and ultimately to design the implant to
function within physiological acceptable limits.
Three-dimensional finite element analysis also al-
lows the analysis and modification of surface texture
to enhance the prognosis of the implant. Comput-
erized models of living bone and implants inserted
within the bone have been constructed to aid in the
analysis of implant configuration design.²⁸
A finite element is a geometric shape such as a
pyramid, trapezoid, rhomboid, or cube. These ele-
ments can be used as building blocks to create a
model of anything, including bone or an implant.
One commonly used element shape is the cube. Each
cube has eight points, or nodes, and extending from
each node are x,y,z coordinate axes. When viewing
a computer model of a finite-element system, the
x,y,z axes are designed to show the perspective from
which the total or specific region of the model is
being observed.
In a combined finite element model of an implant
placed in bone, stress and strain under conditions of
tension, compression, and shear are all calculated
based on the mechanical properties of each of the
materials being modeled. An implant within bone
can be modeled to contain a discontinuous zone for
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a slip (frictionless) condition, or a continuous zone
for a no-slip (adherent) condition at the interface to
act as parameters for calculation to better understand
the biomechanical environment of osseointegration
and osseopreservation. The implant can be loaded
vertically, horizontally, or in any lateral direction and
magnitude, with a variety of characters and for any
duration. The stress and strain that pass through the
implant interface and within the implant at every
node of every element can be calculated as a function
of direction, magnitude, rate, and duration of applied
load. These models allow the measurement of forces
along the entire implant interface as they pass to the
modeled opposing bone or peri-implant interface,
which reacts in an equal and opposite manner.
To be useful, computerized results are correlated
with histological and radiographic findings around
functioning implants to understand how clinical func-
tion (in vivo) causes what is theoretically predicted
by three-dimensional finite element analysis. Design
improvements have already led to the development
of implants with reduced areas of stress concentra-
tion and improved stress transfer homogenizations
across the interface. These improvements favorably
affect the long-term bone maintenance at each point
in the implant surface.²⁴
The parallel wall cylindrical root form implants
threaded versus smooth (nonthreaded) have domi-
nated the implant market for the past 20 years and
have provided impressive long-term clinical results.
These results are based primarily on data from im-
plants placed into dense bone in the anterior man-
dible. The initial stability of implants can be remark-
ably decreased, however, in poor-quality bone, thereby
jeopardizing the osseointegration process.²⁹ Implant
design has recently focused on a tapered cylindrical
configuration so that the surrounding bone is com-
pressed with insertion of the implant. As a result, the
implant is stable in its final position because of this
press fit concept (compression). The induced (osseo)
compression is a function of the relationship between
the drill/tap and the implant geometry. Local com-
pression of the bone can be increased by altering the
surgical technique by selecting a final drill size smaller
 
than recommended or by placing a tapered implant
into a cylindrical site.³⁰³¹
Modification of the implant threads and shape
of the implant body are aimed at maximizing ini-
tial contact, improving implant stability, enlarging
implant surface areas, and improving dissipation of
interfacial stresses.²⁶²⁷³⁰⁴⁰ Thread depth, thickness,
pitch, face angle, and helix angle are varying geomet-
ric parameters that determine the functional thread
surface and affect the biomechanical load distribution
of the implants.³⁹ Thread thickness and thread face
angle determine the shape of the thread, which can
be V-shaped, square, or reverse buttress.³⁹⁴⁰
Recently, some manufacturers (Nobel Biocare,
Gothenburg, Sweden, and Paragon, Encino, Cali-
fornia) introduced the concept of double- or triple-
threaded implants, which are faster to thread into the
osteotomy site, generate less heat upon placement,
provide increased initial stability, and require more
torque for placement and thus tighter contact with
bone. These are indicated primarily for Type III and
IV cancellous bone. A number of additional features
have been employed by implant design engineers
to accentuate or replace the effect of threads. These
include perforations of various shapes and dimen-
sions, vents, ledges, grooves, flutes, and indentations.
The implant can be solid or hollow, with a parallel,
tapered/conical, or stepped shape/outline and a flat,
round, or pointed apical end.
III.C. Implant Surface Topography
The initial studies conducted by Brånemark et al.⁷⁴¹
and Schroeder et al.⁴² using commercially pure tita-
nium implants showed that implant anchorage with
direct bone contact can be achieved in the dense cor-
tical bone of the mandible (osseointegration). The
percentage of bone–implant contact necessary to cre-
ate sufficient anchorage to permit successful implant
function as a load-bearing device over time remains
unclear. Orthopedic implants with varying porous
surfaces have been studied widely since 1960s.⁴³⁴⁴
In many studies the use of implants with various sur-
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R. G. TRIPLETT ET AL.
face treatments have been demonstrated to result in
higher torque removals and higher percentage direct
bone–implant contact when compared with smooth
turned titanium surfaces.⁴⁵⁴⁶ Similar studies have also
shown high percentages of bone–implant contact and
greater values of maximum shear strength for HA-
coated implants when compared with uncoated or
grit-blasted titanium implants.⁴⁵
The quality of implant surfaces is one of the six
factors described by Albrektsson et al.⁸ that influence
wound healing of implantation site and subsequently
effect osseointegration. The overall objective of sys-
tematic modifications of selective surface properties
of an implant is to affect the biological consequences.
Some surface properties are directly related to each
other, and chemical composition including contami-
nation, impurities, and roughness influences these
properties and may change the osseous response to
the implant surface, thereby decreasing osseointegra-
tion.⁴⁶⁴⁷
It is therefore difficult to isolate and modify a single
parameter without influencing others. A sophisticated
surface modification can be masked by contamination
because material surfaces generally are very reactive
with the environment, and sources of contamination
are common and difficult to avoid. Examples of po-
tential contamination sources are lubricant, residue
from machining, detergents and surfactant residues
from the cleaning procedure, organic films and cor-
rosion products from sterilization/autoclaving, and
dissimilar metals transferred during the surgical pro-
cedures.⁴⁷⁴⁸ These factors should be kept in mind
when considering the various surface topographies
to be discussed. Simply increasing roughness alone
without biological validation of improved implant
stability and osseointegration may not improve im-
plant performance.
Wennerberg and et al.⁴⁹⁵⁰ have suggested that
smooth be used to describe abutments, whereas the
term minimally rough (0.5–l µm), intermediately rough
(1–2 µm), and rough (2–3 µm) be used (apart from
porous surfaces for implanted surfaces). However, in
the majority of literature reports, based on the aver-
age surface roughness (Sa), surfaces with an Sa ≤ 1 µm
Journal of Long-Term Effects of Medical Implants
 IMPLANT MATERIALS, DESIGN, AND SURFACES
FIGURE 3. Commercially pure machined implant surface
from Noble Biocare dental implant.
are considered smooth, and those with Sa > 1 µm are
described as rough. Machined (turned) CP titanium is
a smooth surface with an Sa value of 0.53–0.96 µm⁵¹
(depending on the manufacturing protocols, grade
of the material, and shape and sharpness of the cut-
ting tools). Circumferential parallel lines of 0.1 µm
in depth/width, perpendicular to the long axis of the
implant, are a common finding in machined surfaces
(Fıg. 3). Surface topography can produce orientation
and guide locomotion of specific cell types and has the
ability to directly affect cell shape and function.⁵²⁵⁵
Plasma spray-coating is one of the most common
methods for surface modification. Plasma spraying is
used for the application of both Ti or HA on metallic
cores with a coating thickness of 10–40 µm for Ti ⁵⁶
and 50–70 µm for HA. Thickness depends on par-
ticle size, speed and time of impact, temperature, and
distance from the nozzle tip to the implant surface
area. The surface roughness value (Ra) for Ti plasma
spray is 1.82 µm, and for HA plasma spray, Ra = 1.59
to 2.94 µm (Fıg. 4).⁵¹
Blasting with particles of various diameters is an-
other frequently used method of surface alteration.
In this approach, the implant surface is bombarded
with particles of aluminum oxide (A1₂0₃) or titanium
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FIGURE 4. Titanium plasma spray (TPS)-coated implant
surface demonstrating the roughness and increased sur-
face area for bone apposition compared with the smooth
machined surface implant (Steri-Oss Replace implant,
Nobel Biocare).
oxide (TiO₂), and by abrasion, a rough surface is pro-
duced with irregular pits and depressions. Roughness
depends on particle size, time of blasting, pressure,
and distance from the source of particles to the im-
plant surface. There seems to be a strong tendency
for surface roughness to increase as the particle size
increases. Blasting a smooth Ti surface with (A1₂0₃)
particles of 25 µm, 75 µm, or 225 µm produces sur-
faces with roughness values of 1.16–1.20, l.43, and
l.94–2.20, respectively.⁵⁰⁵⁷
Chemical etching is another process by which
surface roughness can be increased. The metallic
implant is immersed into an acidic solution, which
erodes its surface, creating pits of specific dimensions
and shape. Concentration of the acidic solution, time,
and temperature are factors determining the result of
chemical attack and microstructure of the surface. In
1996, an implant was marketed that had its surface
etched with a mixture of hydrochloric acid/sulfuric
acid (HCI-H₂SO₄) solution (Fıg. 5). Resistance to
torque removal was found to be four times greater
with this acid-etched surface than with a machined
 
FIGURE 5. Acid-etched roughened surface of Steri-Oss
Replace implant.
surface,⁵⁸ and in a prospective multicenter study in
which implants were loaded for 0–36 months, the
total success rate was 93.7%.⁵⁹
Another modification was sandblasting with
the addition of acid-etching (SLA), (Straumann,
Waldenburg, Switzerland).⁶⁰ This surface is pro-
duced by a large-grit (250–500 µm) blasting pro-
cess, followed by etching with hydrochloric–sulfuric
acid.⁶¹ The average Ra for the acid-etched surface
is 1.3 µm, and for the sandblasted and acid-etched
surface, Ra = 2.0 µm (Fıg. 6).⁶⁰ Increased removal
torque values of the sandblasted and acid-etched
surface, as compared to the acid-etched surface,⁶⁰
and bone–implant contact values of 60–70% provide
the basis for a 6-week healing period protocol for
the former surface type.⁴⁵
Porous sintered surfaces are produced when
spherical powders of metallic or ceramic material
become a coherent mass with the metallic core of
the implant body. Lack of sharp edges is what dis-
tinguishes these from rough surfaces. Porous surfaces
are characterized by pore size, shape, volume, and
depth, which are affected by the size of spherical
particles and the temperature and pressure condi-
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R. G. TRIPLETT ET AL.
FIGURE 6. Roughened surface implant treated by sand-
blasting and acid etching (ITI Straumann SLA implant).
This appears to provide significantly more surface area
than the acid- etched surface alone.
tions of the sintering chamber.⁶² Pore depth depends
on the size of the particles (44–150 µm) and their
concentration per unit area, as well as on the thick-
ness of the applied coating (usually 300 µm). A pore
depth of 150–300 µm appears to be the optimal size
for bone ingrowth and maximum contact with the
walls of the pore.⁶²⁶⁴ Pore shape does not seem to
influence the biological result, whereas pore volume
(% porosity) is important and must be carefully con-
trolled to maintain the strength of the coating and,
at the same time, have adequate porosity for bone
ingrowth.⁶⁵ Story et al.⁶⁶ reported that a decrease of
9% in porosity resulted in a 12% decrease in bone
ingrowth at 12 weeks after implantation in the ca-
nine mandible, and implant topology together with
porous distribution can influence trabecular bone
adaptation.⁶⁷
Clinical trials of porous-coated implants demon-
strated a survival rate of 95% at 4 years and reported
advantages of the implant design, which included the
ability to use shorter endosseous lengths because of
the threefold increase in the surface area compared to
Journal of Long-Term Effects of Medical Implants
 IMPLANT MATERIALS, DESIGN, AND SURFACES
FIGURE 7. Porous surface implant created by anodic oxi-
dation (Ti-Unite surface of a Nobel Biocare implant).
a machined implant.⁶⁸ In the future, porous-coated
implants could be impregnated with growth factors
and act as delivery vehicles because of increased sur-
face volume.⁶⁹ A new approach to surface preparation
has been developed that combines a well-defined tita-
nium oxide layer with a high degree of porosity. It is
postulated that such a porous oxide with well-known
chemistry and adequate surface area and topography
may facilitate improved short- and long-term stability
in suboptimal bone.
The method used for preparing the porous oxide
surface is anodic oxidation, which is an electro-
chemical method that results in the growth of the
oxide film. The properties (thickness, microstructure,
composition) of the oxide will depend on different
process parameters such as electrolyte composition,
anodic potential, current, temperature, and electrode
geometry. The oxide surface of this Ti-Unite im-
plant (Nobel Biocare) has a surface gradient along
the implant axis with respect to the oxide thick-
ness and increases continuously from the coronal
to the apical end of the implant. The surface area is
increased 95% compared with the ideal flat surface
(Fıg. 7).⁷⁰
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IV. DISCUSSION
There is controversy concerning bone growth and
osteogenesis associated with dental implants as to
whether bone grows from the osteotomy walls toward
the implant surface or along the implant material as
well.²⁵ Some investigators maintain that new bone
grows from the periosteal and endosteal osteogenic
tissue toward the implant surface,⁷¹⁷² while others
maintain that distances and contact osteogenesis
can both occur.²³ Differences in implant design may
affect the pattern of healing response. Porous coated
implants provide the space and volume for cell mi-
gration and attachment and thus support contact os-
teogenesis. In the case of threaded implants, where a
tight fit does not allow colonization of its surface by
osteogenic cells, osseointegration will proceed from
newly created osteotomy wall.⁷³
Regardless of the order in which bone is produced
when healing is completed and the implant becomes
stably anchored in bone, the nature interface exhibits
certain characteristics that can be evaluated clinically
and histologically.⁷⁴ There are numerous in vivo and in
vitro studies designed to offer insight into the process
of osseointegration and the structure of the developed
interface.⁷⁵⁷⁶ The two methods most often used to
assess the quality of the osseointegrated interface are
biomechanical tests and histomorphometric analysis.
Several studies have been reviewed in an attempt to
identify those factors that influence the successful
osseointegration of dental implants. Four types of
biomechanical test are reviewed: pull-out, push-out,
torque measurement, and resonant frequency analysis
(Table 1).
IV.A. Pull-Out Test
The interfacial attachment strength of HA-coated
cylindrical implants with four designs (grooved,
threaded, dimpled, and smooth) were tested in both
axial pull-out and torsion.⁷⁷ Implants 4 × 10 mm were
implanted in canine mandibles for 15 weeks. Reported
stress values were estimated by dividing the failure
  R. G. TRIPLETT ET AL.

TABLE 1. Biomechanical Studies of the Bone–Implant Interface

Observation Biomechanical Biomechanical

Model Implant type Ref.
time result test
Goat mandible and Cylindrical 4 x 11 mm TPS 2–24 wks 50–1000 N Pull-out 79
maxilla
Canine mandible Cylindrical 3/3.3/4 x 4/8/15 mm HA 15 wks 130–282 MPa Pull-out 78
Canine mandible Threaded/cylindrical 4 x 10 mm HA 15 wks 5.1–5.6 MPa Pull-out 77
Canine femur Cylindrical 6 x 13 mm Ti alloy, HA 4,12 mos 0.1–11.7 MPa Push-out 80
Rabbit femur Cylindrical 2.8 x 6 mm HA, Al2O3 3 mos 3–15 MPa Push-out 83
Canine femur Cylindrical 10 x 10 mm HA, Glass 12 wks 0.24–3.84 MPa Push-out 82
ceramic
Rabbit tibia and femur Threaded 3.75 x 4 mm cpTI 6 wks, 3,6 20–37 Ncm Torque 85
mos
Rabbit tibia Threaded, Cylindrical 3.75 x 10 mm 3,12 wks 20–117 Ncm Torque 87
cpTi machined, blasted, HA
Rabbit femur Threaded 3.25 x 4 mm cpTi, 2 mos 1.8–36.1 Ncm Torque 58
machined, acid etched
Miniature pig maxilla Threaded 3.75 x 10 mm, 4 x 8 mm 4,8,12 wks 46–227 Ncm Torque 60
TPS, acid etched
Rabbit femur and tibia Threaded 3.75 x 6 mm cpTi 12 wks 10–60 Ncm Torque 86
machined blasted

load by the total implant surface area and ranged from
4.61 to 6.85 MPa. In a similar study, Block et al.⁷⁸ re-
corded interfacial strength values of 130 to 282 MPa.
In this study, longer and wider implants exhibited the
highest absolute pull-out force but the lowest force
per unit area. Kraut et al.⁷⁹ performed pull-out tests
on titanium plasma-sprayed cylindric, 4 × 11 mm
implants placed 2–24 weeks. They reported pull-out
forces of 50 to 1000 Ncm with the observation of a
time-dependent increase in force.
IV.B. Push-Out Test
implant. Push-out tests of HA-coated implant range
from 3.21 to 15 MPa, depending on implant dimen-
sions, bone quality and configuration, and cystallinity
of the HA coating.⁸⁰⁸³ Wong et al.⁸⁴ reported that
push-out failure load was correlated with average
surface roughness. Hydroxyapatite-coated implants
exhibited higher surface coverage by bone and in-
creased failure loads. Push-out and pull-out tests are
indicated for cylindric press-fit nonthreaded implants,
whereas threaded implants are more effectively tested
with the counter-torque or reverse-torque test and
resonance frequency analysis.

The proper use of push-out tests requires that both
the coronal and apical ends of the implant must be
free of bone contact. The coronal portion accepts the
applied push-out force, and the apical end must be
exposed to allow smooth and free extrusion of the
IV.C. Torque
Sennerby et al.⁸⁵ reported removal torque values
(RTV) of 35.6 Ncm for 3.75 × 4 mm screw-shaped
machined term implants that were implanted for

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 IMPLANT MATERIALS, DESIGN, AND SURFACES
6 months. Grit-blasting of machined 6 × 3.75-mm
threaded implants with 25-µ A1₂O₃ or TiO₂ re-
sulted in RTV of 24.9–26.5 Ncm in the tibia of the
rabbit.⁸⁶ A comparison of two implant designs and
three surface treatments found increased RTV with
time. Specifically, at 12 weeks the RTV for threaded
HA-coated, TiO₂ blasted, and machined implants
were 117, 45, and 32 Ncm, respectively.⁸⁷ Buser et
al.⁶⁰ compared the acid-etched surface with the sand-
blasted and acid-etched surface at 4, 8, and 12 weeks
of healing. Results revealed a corresponding RTV for
the acid-etched surface of 62.5, 87.6 and 95.7 Ncm
at the 4, 8, and 12 weeks of healing. The RTV for the
sandblasted/acid-etched surface were 109.6, 196.7,
and 186.8 Ncm, respectively.
IV.D. Resonance Frequency Analysis
Recently, resonance frequency analysis has been used
to measure implant stability and functional implant
stiffness in bone.³⁴³⁶ This technique is sensitive to
marginal bone changes because any bone loss will be
detected by a decrease in the resonance frequency.
Studies used in the RFA have shown that the degree
of stability is determined by the density of the bone,
the surgical technique used, and the design of the
implant.³⁰³⁵ Resonance frequency analysis values
are lower in soft bone qualities when compared with
denser bone but increase with time, as bone apposi-
tion and stiffness increase under function. According
to Friberg et al.,³⁵ in some instances, the primary
stability is so high that any further increase cannot
be expected, which is why direct loading protocols
may be applied. RFA measurements are being used
to compare stability and improvement in stability in a
wide variety of investigations involving osteointegra-
tion and implant stability. Measurement of implant
stability quotients (ISQ) shown by the values of 1–100
ISQ is based on resonancy frequency of the transducer
on a scale of 3500 Hz (0 ISQ) to 8500 Hz (100 ISQ).
The higher ISQ value corresponds to higher stability.
This approach is a significant improvement over the
previously used methods of pull-out tests, push-out
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
tests, and torque evaluations. In cases of tapered
implants, resonance frequency analysis has shown
significantly higher values for tapered implants than
for parallel body implants.⁸⁸
IV.E. Histomorphometry
Histomorphometric analysis of bone–implant in-
terfaces has been performed in various ways and
considering various parameters. This has resulted in
a wide spectrum of reported values (Table 2). Histo-
morphometric analyses of bone–implant interface is
often presented as a percentage of total implant length
and a percentage of three consecutive “best threads”
length.⁸⁹ Depending on bone quality, the ratio of
cortical versus cancellous bone and the length of the
implant, significant differences may exist between “to-
tal length” and “three best threads” results.⁸⁵ Implant
design (threaded versus cylindrical,⁹⁰⁹¹ solid versus
hollow⁹²⁹³), implant material,⁹⁴ surface treatment,⁹⁵⁹⁶
healing time, and loading conditions are some of the
parameters influencing the analytic approach. Thread
volume fill and number of cells in contact with the
implant surface are two other variables frequently
reported in histomorphometric studies.⁸⁵⁸⁶⁹⁷
The histologic and biomechanical evaluation of
dental implants can represent the combined/additive
effect of many variables and can be presented in many
different ways. Reporting the biomechanical results of
implants with various lengths and diameters in vari-
ous units (N, MPa, Ncm, Nm) and in absolute force
values or stress values (absolute force value divided by
the implant surface) creates confusion for comparative
evaluations. For this reason, complete description and
identification of the test/study conditions should ac-
company any data reports, and critical judgment must
be exercised when fair comparisons are attempted.²⁵
IV.F. Clinical Correlation
As extremely important and necessary as these stud-
ies appear to be for the ultrastructural evaluation of
  R. G. TRIPLETT ET AL.

TABLE 2. Histomorphometric Studies of the Bone–Implant Interface

Bone–implant
Model Implant type Observation time Ref.
contact
Canine mandible Threaded Ti 5–24 mos 50–65% 94
Threaded Ceramic 41%
Canine mandible Threaded cpTi 4 mos 42–70% 105
Baboon mandible and Threaded cpTi, alloy 3 mos 40% 106
maxilla Threaded HA 62%
Baboon mandible Cylindrical HA 6 mos 67% 107
Canine mandible Cylindrical TPS 3 mos 48% 91
Canine mandible Threaded Ti 3 mos 46% 92
Cylindrical TPS 55%
Cylindrical HA 71%
Rhesus monkey Porous 74 mos 64–67% 96
mandible
Human biopsies Threaded cpTi 1–16 yrs 43–100% 108
Human biopsies Threaded cpTi 8–20 mos 34–93% 95
Canine mandible Threaded hollow cpTi 15 and 36 mos 52–78% 109
Monkey mandible Threaded cpTi 18 mos 11–73% 110

the bone–implant interfacial zone, they offer very V. CONCLUSIONS

little help for the clinical judgment of success-
ful osseointegration. Differences between healing
rates in animal models and humans, variance of
bony sites and implant parameters, and variabil-
ity of biomechanical tests and conditions prevent
direct correlation of these histomorphometric and
biomechanical results to the prediction of clinical
results. For this reason, in addition to the criteria for
success proposed by Zarb and Albrektsson,⁹⁸ other
noninvasive methods have been developed that al-
low objective assessment of the osseointegration
process. Radiographic evaluation,⁹⁹ tapping the
implant with a metallic instrument and assessing
the emitted sound,¹⁰⁰ resonance frequency measure-
ments,¹⁰¹ stability measurement with the Periotest
instrument (Siemens, Erlangen, Germany),¹⁰² rota-
tional stiffness produced upon impact,¹⁰³ and reverse
torque application¹⁰⁴ are suggested clinical methods
for monitoring successful implant placement and
osseointegration.
The wide variety and constant evolution of dental
implant design, correlated with scientific finding and
research studies, reflect the attempts of investigators to
successfully incorporate an artificial structure within
a biological system. Clinicians must have knowledge
of the cellular and molecular events that lead to os-
seointegration, because such knowledge is essential
to relate clinical findings with basic mechanisms. It
is evident that implants should be carefully selected,
balancing the research information on their properties
with the intended treatment plan. Clinical judgment
of bone quality and quantity, implantation site, and
biomechanics of the implant and type of final restora-
tion are important considerations in evaluating the
properties and features of an implant system. Better
understanding of molecular biology and biomaterials
science will generate dental implants with properties
and features that will provide an enhanced biological
response and improve clinical results.²⁵

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 IMPLANT MATERIALS, DESIGN, AND SURFACES
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