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SARANRAJ JPS PUBLICATION DR. SYED WALi PEERAI

Bl. IAITHIIEYAI IAMAL/lliAM
Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
Saranraj JPS Publication,
Mylapore, Chennai, Tamil Nadu, India

© Dr. Syed Wali Peeran

Dr. Karthikeyan Ramalingam
1st Edition 2021
ISBN: 978-81-950475-4-3
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording or any information storage and retrieval system without the permission in writing from the
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Note: As new information becomes available, changes become necessary. The editors/author/contributors and the publishers have,
as far as it is possible, taken care to ensure that the information given in this book is accurate and up to date. In veiw of the possibility
of human error or advances in medical science neither the editor nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers
are strongly advised to conirm. This book is for sale in India only and cannot be exported without the permission of the publisher in
writing. Any disputes and legal matters to be settled under Chennai jurisdiction only.

Published in India
Chapter 53 Biological Clinical and Surgical Aspects of Implants
CHAPTER

67 Biological, Clinical and

Surgical Aspects of Implants

Shaesta Begum & Syed Wali Peeran

Chapter Outline:
• Fibro-osseous integration • Quality and quantity of residual bone
• Osseointegration • Lekholm and Zarb classification (1985)
• Biointegration • Bone density classification by Misch
• Other definitions of osseointegration • Quantity of residual bone jaw Bone Anatomy
• Biology of healing around implants Classification (Juodzbalys & Kubilius)
• Fibroplasia • Methods of Evaluation of Osseointegration
• Bone modelling • Criteria for evaluation of dental implants: (Albrektson
and Zarb G (1980))
• Implant bone interface
• Scope of osseointegration
• Events at Bone-Implant Interface
• Review Questions
• Key factors responsible for successful osseointegration
• Essay Questions
• Surgical considerations
• Short notes
• Anatomic considerations in placement of dental
implants • Principal references and suggested further reading

common with early materials that elicited inflammatory

One of the three mechanisms that explain the response such as acrylates, carbon, non-precious
relationship of the implant-bone interface are as follows: metals and polymers. As this type of union was unable to
♦ Fibro-osseous integration withstand normal physiological load it soon lost its
support.
♦ Osseointegration
♦ Biointegration Osseointegration:
It is defined as “a direct structural and functional
Fibro-osseous integration: connection between ordered, living bone and the
surface of a load-carrying implant”.(Brånemark P-I et al.
This concept was proposed by Charles Weiss in 1986. 1977)
According to this concept, a layer of collagenous tissue
is present between implant and bone which may act as “A direct connection between living bone and a load-carrying
an osteogenic membrane. This encapsulation was called endosseous implant at the light microscopic level.”-Branemark
‘Pseudo periodontium’.It leads to a connective tissue “Contact established without interposition of nonbone tissue
encapsulated implant in the bone. Such type of union was between normal remodeled bone and an implant entailing a
sustained transfer and distribution of load from the implant
Periodontics & Oral Implantology 1
 Implantology Section -XI

to and within the bone tissue.” -American Academy of Implant soft tissue seal formed that protects bone tissue from
Dentistry (1986) substances in the oral cavity.
“The apparent direct attachment or connection of osseous tissue The healing of the bone following implant installation is a
to an inert, alloplastic material without intervening connective complex process that involves different events in the
tissue.” - Glossary of prosthodontic terms. 8 cortical and in the cancellous compartments of the
surgical site.
“a direct structural and functional connection
Cortical bone compartment:
between organized, living bone and the surface of a load-
bearing implant without intervening soft tissue between the The surgical preparation is done in order to achieve a
implant and bone”.(Branemark) “press fit”, i.e. which means the inserted implant is slightly
wider than the canal prepared in the host bone at the
Osseointegration can be clinically definedas “the asymptomatic recipient site. In such situation,the mineralized bone
rigid fixation of an implant in bone with the ability to tissue in the periphery of the implant is compressed, the
withstand occlusal forces”. (Zarb&Albrektsson) blood vessels in the cortical portion of the canal are
“a process whereby clinically asymptomatic rigid fixation of collapsed. The nutrition to this portion of the bone
alloplastic materials is achieved and maintained in bone during gets compromised and the affected tissues most often
functional loading”. (Zarb and Albrektsson1991) become non-vital.
This concept began in the 1950s with the experiments of Hence during healing, the non-vital mineralized tissue will
Brånemark that chambers made of the metal titanium could be resorbed before new bone can form. The non-vital
become permanently incorporated with bone. That is, the lamellar bone in the cortical compartment is of
living bone could become so fused with the titanium oxide importance for the initial fixation of the implant.
layer of the implant that the two could not be separated Spongy bone compartment:
without fracture. This lead to the birth of the concept of The cancellous recipient surgical site, on the other
osseointegerated dental implants. Brånemark introduced hand, results mainly in soft tissue (marrow) injury that
the term “osseointegration” to describe this modality for initially is characterized by localized bleeding and clot
stable fixation of titanium to bone tissue.Schroeder and his (coagulum) formation. The coagulum is gradually
co-workers termed it as “functional ankylosis”. resorbed and gets occupied by proliferating blood
vessels and mesenchymal cells which forms granulation
Biointegration:
tissue.
Biointegration is the ideal outcome expected of an artificial As result of the continuous migration of mesenchymal
implant. It denotes a direct biochemical bond of the bone to cells from the surrounding marrow, the young granulation
the surface of an implant at the electron microscopic level tissue becomes replaced with provisional connective
and is independent of any mechanical interlocking system. tissue and eventually with osteoid.
This implies that the phenomena that occur at the interface In the osteoid, deposition of hydroxyapatite will
between the implant and host tissues do not induce any occur around the newly formed vascular structures.
deleterious effects such as chronic inflammatory response Hereby, immature bone, most often woven bone, is
or formation of unusual tissues. formed and sequentially osseointegration takes place.
Mechanism of osseointegration: Osseointegration, is often first established in areas
occupied by cancellous bone.
Once the implant is installed into the bone by surgical
procedure, a series of mechanical insults and injury occurs Soft tissue seal:
to both mucosa and bone. The host responds to this injury The first signs of epithelial proliferation were observed
with inflammatory reaction and initiates wound healing. representing 1–2 weeks of healing and a mature barrier
This process ultimately ensures that implant becomes epithelium was seen after 6–8 weeks. Studies have also
osseointegrated or ankylosed with bone. At the soft tissue demonstrated that the collagen fibres of the mucosa were
level, a delicate mucosal attachment is established and a organized after 4–6 weeks of healing. Thus, prior to this
time interval, the connective tissue is not properly arranged.
2 Periodontics & Oral Implantology
Chapter 67 Biological Clinical and Surgical Aspects of Implants

According to Gould et al (1984), the length of At the implant site, fibres (equivalent to principal of
junctional epithelium and barrier epithelium is about periodontal ligament) run parallel to the implant surface
2mm. The height of the zone in supra-alveolar connective but do not attach to the metal body. A few weeks after
tissue is between 1 to 1.5mm. Hemidesmosomes attach implant surgery, the implant surface is connected with the
the epithelium onto the tooth/implant surface. soft tissue attachment.
Table 67.1: Healthy teeth vs Healthy dental implants
Characteristics Healthy teeth Healthy Implants
Variable: Depends on the abutment
Gingival sulcus depth 1-3mm
length and restoration margin
The barrier epithelium lies on the
implant surface.
Junctional epithelium Lies on enamel
It seems attached to titanium surfaces
by hemidesmosomes.
Complex array inserted into cemen- The collagen fiber bundles lie parallel
Gingival fibers
tum above crestal bone to the implant surface.
Similar to that of dentition. {One-piece
implant 2.55 ± 0.16 mm.Two-piece
Biologic width 2.04 mm (Average)
dental implant 3.26 ± 0.15 mm (Judgar
et al.)}
Well organized collagen fiber bundles
Connective tissue attachment-
are perpendicular to the root surface No Periodontal ligament fibers.
collagen fibers
and are inserted into the cementum
The connective tissue is comprised of Around titanium implants, it is com-
Connective tissue-composition approximately 60% collagen fibers and posed of 85% collagen fibers and 1 to
5 to 15% fibroblasts. 3% fibroblasts.
The blood supply to gingival The interface of the crestal bone and
structures is provided by large implant surface does not show the
Connective tissue-Blood supply supraperiosteal blood vessels and by vascular plexus. The number of blood
the vascular plexus of thevessels are extremely low as we close
periodontal ligament. on the titanium implant surface.
Soft periodontal ligament anchors the Lack of periodontal ligament. Ankylosis
tooth to the alveolar bone. It acts as of implant with the alveolar bone,
Mobility
a cushion and physiologic mobility makes it immobile. If there is any mobil-
exists in nature. ity of an implant, it indicates failure.
Nerve fibers are seen in histology in
Periodontal ligament is innervated and peri-implant bone. However, its role in
Proprioception
is sensitive. osseoperception phenomenon is not
completely understood.
Biology of healing around implants:
The pitch of the implant thread was engaged in the hard tissue walls in the mandible of dogs.The void between the pitch
and the body of the implant established a well-defined wound chamber and this chamber was sampled and studied after
two hours of installation up to 12 weeks of healing.

Periodontics & Oral Implantology 3

 Implantology Section - XI

The stages were described based on the events at wound Contact and distant osteogenesis:
chamber. It was described under the following headings. The newly formed woven bone projected from the lateral
♦ Fibroplasia wall of the cut bony bed (appositional bone formation;
♦ Bone modelling distance osteogenesis) (Davies 1998). De novo formation
of new bone could also be seen on the implant surface, i.e.
♦ Contact and distant osteogenesis at a distance from the parent bone (contact osteogenesis)
♦ Bone remodelling (Davies 1998).
Fibroplasia: ‘Contact osteogenesis’ denotes the first step in actual
Immediately after the implant was installed, the wound osseointegration. It represents the direct contact between
chamber was occupied with bloodclot in which various the roughened surface of the implant and recently laid
leucocytes such as neutrophils erythrocytes and monocytes woven bone.
occurred in a network of fibrin. After 2 weeks of healing, woven bone formation is more
Thread of the implant is in connection with the original pronounced and in large areas there was an ongoing new
bone. The pitches on the implant threads give a mechanical formation. It was noted particularly in areas of the bone
anchorage. This is responsible for the initial or primary which were in immediate contact following surgery and
mechanical stability of the implants, two hours after initial fixation had undergone tissue resorption.The initial
installation. mechanical stability is substituted with biological stability
by the bonding of implant surface with bone.
After four days, the coagulum was replaced with
granulation tissue that contained numerous mesenchymal At 4 weeks, this newly formed mineralized bone extended
cells matrix components, and newly formed vascular from cut bone surface into the chamber all over.The central
structures (angiogenesis). A provisional connective tissue portion of chamber was filled with primary spongiosa, rich
was established. in vascularity and mesenchymal cells.
The blood clot is partially replaced by primitive granulation Bone remodelling:
tissue. After 6 to 12 weeks, the wound chamber was filled with
Bone modelling: mineralized bone. Bone tissue, including primary and
secondary osteons, could be seen in the newly formed
After 1 week of healing, the provisional connective tissue tissue and in the mineralized bone that made contact with
was rich in vascular tissue and contained numerous the implant surface.Well structured mature bone replaces
mesenchymal cells. The inflammatory cells reduced in woven bone by 12 weeks.The bone trabeculae had become
number. Cell-rich immature bone (woven bone) was reinforced by lamellar or parallel-fiber bone deposition,
seen in the mesenchymal tissues that surrounded the thus providing a structure to cope with the bearing of
bloodvessels. load.

4 Periodontics & Oral Implantology

Chapter 67 Biological Clinical and Surgical Aspects of Implants

Fig. 67.1 Factors that influence the anchorage of Implants

Implant bone interface:

♦ Bleeding.
The success of the implant is dependent on the nature of ♦ Bone trauma.
this hard tissue interface.
♦ Formation of bone debris.
The implant insertion can be compared to bone fracture
healing. They both begin with a breach in an intact skeletal ♦ Hemostasis and clot formation.
site and physical trauma. An immune response, neo- ♦ Hypoxia.
vascularization, and recruitment of skeletal progenitor cells ♦ Inflammatory reaction: These effects result in release
follows. of cytokines and growth factors and recruitment of
The immediate local effects of osteotomy and implant inflammatory cells and progenitor cells. (Shanbhag et
insertion are: al.)

Periodontics & Oral Implantology 5

 Implantology Section - XI

Events at Bone-Implant Interface: Day 3-4: A noteworthy upregulation of genes associated

Within nanoseconds of implant placement within the with inflammation can be seen and some evidence of
prepared site, a layer of water molecules form around the osteogenic differentiation can be noticed.(Shanbhag et al.)
implant. The implant surface has a significant role in this On day 3, cells around implant activate osteoblast-related
event.This layer facilitates protein and other molecules to transcription factors - Runx2 and Op.
adsorb on the implant surface. By day 4, Necrotic bone created during surgery gets
The next event is the formation of a layer of extracellular resorbed, and awell-defined interface zone is formed.
matrix proteins over the implant surface. It occurs within By day 5, there is an indication of new bone development
thirty seconds to few hours after implantation.The implant with increase in alkaline phosphatase activity. This
surface again determines the conformation, alignment and signifies the commencement of mineralization and matrix
configuration of this protein layer. remodeling.
The initial source of these proteins are blood and tissue Once activated, osseointegration follows a common
fluids at the wound location. Subsequently, proteins are biologically determined program that is subdivided into 3
derived from the cells in peri-implant region. stages:
Immediately after placement, there is platelet accumulation ♦ Incorporation by woven bone formation.
around the implants.They secrete various growth factors like
PDGF-BB, IGF-1, IGF-2, a-FGF, b-FGF, TGF, BMP, serotonin, ♦ Adaptation of bone mass to load (lamellar and
histamine and other vasoactive factors. They stimulate the parallel- fibered bone deposition)
formation of a new bone matrix. These factors help in ♦ Adaptation of bone structure to load (bone
differentiation, proliferation of osteoblasts.The factors also remodeling).
play a role in attachment of osteoblasts onto the implant By day 7 or end of first week, the adhesion of bone matrix
surface via fibronectin-mediated focal adhesion in the later onto enamel surface could be identified. The extracellular
stages. matrix is secured into the cavities on the implant surface.
Various cells interact with the implant surface through the Various studies have identified expression of such matrix
adsorbed protein layer. There is initiation of cell migration, proteins between 7 to 14 days and reported it to be a
adhesion and differentiation. It may take few hours to many dependable sign of initial osteogenic activity. A significant
days after implantation. simultaneous upregulation of several angiogenesis-related
genes was identified at day 7.
The first cells to migrate at the implant surface are
multipotent mesenchymal cells and not committed Between days 7-14,The inflammatory response is generally
osteoblasts. These multipotent cells can differentiate into downregulated. Expression of ECM proteins is a reliable
functional osteoblasts only in the presence of local oxygen indicator of early osteogenic activity and their production
tension, adequate nutrients and regulatory growth factors. and/or organization can be noticed.(Shanbhag et al.)
However, these factors are dependent on the vascular It is shown in a human model that there is induction of
supply to the implant site and physiology of the host. genes associated with osteogenesis all through the initial
Cell attachment is a complex procedure and takes place two weeks of osseointegration. By the end of two weeks,
with the help of integrins, focal Adhesion and filopodia. there is a strong transcription profile of ossification-
Cell adhesion to the rough implant surface is by Filopodia associated proteins.
(Actin-rich cell extensions). The anchorage occurs along By day 16, implant surface is well covered and extensively
precise locations in Filopodia including its tips. These integrated in a mixture of mineralized tissue, osteoid and
tips can increase in width and branch out into Foot pads dense matrix.
(localized adhesive structures).
By day 28 or completion of four weeks, the entire length and
Cell spreading is mediated by cell membrane extensions at neck of implant surface has an intimate bone contact. The
footpads. majority of tissue layer neighboring the implant is made up
6 Periodontics & Oral Implantology
Chapter 67 Biological Clinical and Surgical Aspects of Implants

of osteoblasts and collagen fibers.These collagen fibers are By the end of twelve weeks, there is mature lamellar bone
arranged parallel to the implant surface. The cells, proteins in close connection with the implant surface.
of extracellular matrix and mineralized bone appear to be De novo bone formation or contact osteogenesis with the
in direct contact with the implant. The matrix of initially implant surface shows colonization of bone cells on the
formed woven bone has osteoid within it. implant followed with formation of bone matrix. This is
By six to eight weeks after surgery, the soft tissue complex similar to bone remodeling.
comprising epithelium and connective tissue develops and But in distance osteogenesis, there is absence of new bone
gets attached to the implant surface. formation on the implant surface but the bone surrounds
the implants. This is similar tohealing of cortical bones.

Fig. 67.2 Biological events that result in osseointegration.

Periodontics & Oral Implantology 7

 Implantology Section - XI

Key factors responsible for successful Implant surface characteristics:

osseointegration:
This includes
Several factors must be controlled almost simultaneously, if ♦ Micro design or surface texture: Rough surface
a predictably successful outcome is to be expected. implants favour bone anchoring and hence better
♦ Biocompatibility of implant material. osseointegration is achieved.
♦ Design characteristics of the implant. ♦ Surface chemical composition: Surfaces coated with
hydroxyapatite have shown greater interaction with
♦ Surface characteristics of the implant.
bone and hence good integration when compared to
♦ State of implantation bed. the titanium oxides alone.
♦ Surgical considerations. ♦ Surface free energy: A surface with high energy
♦ Undisturbed healing phase. exhibits high affinity for adsorption and show stronger
osseointegration. Glow discharge plasma treatment
♦ Prosthetic design and loading characteristics.
results in high surface energy as well as the implant
Implant material biocompatibility: sterilization, being conductive to tissue integration.
The most biocompatible material is commercially State of the implantation or host bed:
pure titanium (CPTi): 99.75% since it is characterized by
Implant host site should be healthy in terms of
excellent biological and good mechanical properties
vascularity and cellularity. Good bone quality with well-
resulting in long-term clinical function. It forms
formed cortex and medullary spaces with dense trabeculae.
adherent, self-repairable titanium dioxide (TiO2/ TiO)
Adequate bone quantity with available bone in reference
passivated layer of 10A0 within seconds & 100A0 within
to length, width and depth enhances the success rate of
a minute.
osseointegration.
This is followed by other bioinertceramics and
bioactive materials such as hydroxyapatite. However, Surgical considerations:
lately the degree of biocompatibility of titanium has been Strict aseptic techniques should be maintained throughout
questioned. to prevent microbial contamination which jeopardizes the
Implant design characteristics: normal healing. The preparation of implant osteotomy site
requires profuse irrigation, i.e., cooling with
It denotes the 3D construction of the implant or its
intermittent moderate speed drilling using sharp drills in
external appearance. It is of two main types – with
a gentle and least traumatic way. The critical temperature
threads or without threads on the implant surface.
for bone cells that should not be exceeded is 47oC at an
Threaded implants have been documented for long- exposure time of one minute.
term clinical function for the following reasons
Anatomic considerations in placement of dental
♦ They increase surface area, hence more functional implants:
area is available for stress load distribution
A sound knowledge of the surgical anatomy will enable to
♦ They improve the primary implant stability by avoiding choose an accurate surgical technique for each case, helps to
micro movement of the implants till osseointegration avoid anatomic hazards and appreciate surgical limitations.
is achieved. Impinging on these sites of anatomical importance will
♦ They provide great means of proprioception for the hamper the success and prognosis of the dental implants.
clinician placing the implant giving lots of information Mandible:
about the implant site.
Clinical studies have reported higher survival rates for
Modifications in the size of the threads, design and pitch of implants in the mandible compared to those in the
the threads can impact the clinical outcome maxilla, especially the posterior maxilla.
♦ Mandibular canal.
8 Periodontics & Oral Implantology
Chapter 67 Biological Clinical and Surgical Aspects of Implants

♦ Anterior loop of mandibular canal. The position of the nerve can be accurately assessed
♦ Anterior extension of mandibular canal. using computed tomography which can give minute cross
sections.
♦ Mental foramen.
Surgical considerations:
♦ Submandibular fossa.
♦ Lingual inclination of alveolar ridge. Any trauma to the vascular bundle can cause haemorrhage,
visibility impairment and increased potential of fibrous
Dental implant should be placed about 2 mm superior to tissue formation at the surface of the implant. Most
the roof of the alveolar canal leaving a 2 mm safety zone important, patient experiences altered nerve sensation in
between an implant and the coronal aspect of the nerve. form of anaesthesia, paraesthesia or hyperesthesia.
(Greenstein and Tarnow) The inserted implant should be
invested by 1 mm of bone both bucally and lingually. Mental foramen:

Mandibular canal: The most distal portion of the implant is ideally placed
2-3mm anterior to the mental foramen to avoid injury to
On a panoramic radiograph, entry of the inferior alveolar the nerve.
nerve into ramus can be well identified because the lingual
is a cortical bone and canal has a cortical lining and also the The mental nerve and vessels emerge from mental foramen.
mental foramen can be appreciated. The antero-posterior position of the mental foramen
is variable;it may be far forward as the apex of the first
The position of the mandibular nerve must be ascertained. premolar to as far distal as below the mesial root of first
On a panoramic view, the location of the canal in reference molar. The vertical position of the foramen is usually found
to the crest of the ridge is dependent on the bucco-lingual more coronal and facial than the mandibular canal.
position of the mandibular canal. If the nerve canal
proceeds along the lingual aspect of the mandibular The average distance from inferior border was 12mm with
body, the canal will be projected more superior towards a range 9 to 15mm. The opening of the mental foramen
the crest. When the nerve canal proceeds towards the faces upward and distally. The average distance from the
foramen on the buccal of the mandibular body, it will midline is 2.2 cm and the distance between the foramina is
be projected more inferior in relationship to the crest. 44mm. This can be variable. (41mm to 45.8mm)

Zone of safety: Surgical considerations:

The safety zone for surgery is a minimum of 2mm of space
between the coronal border and the implant apex, to avoid
any injury to the mandibular canal or its contents. It can be
determined by clinical or radiographic methods using two
lines.
Mental foramen may be a problem because its location
is not constant. It is important to identify location by
radiographs and palpation before grafting procedures or
extensive flap reflection. Surgical trauma to the mental
nerve can produce paraesthesia of the lip.

♦ Line A is drawn corresponding to the posterior plane In partially or totally edentulous jaws, the disappearance of
of occlusion, at the level of residual crestal ridge on the alveolar process of the mandible brings the mandibular
the site of implant engagement. canal and the mental foramen closer to the superior
border. When these patients are evaluated for implants,
♦ Line B is drawnat the most superior aspect of the the location of the mental foramen must be determined to
mental foramen, and it is parallel to line A. avoid injury.
♦ Both the Lines A and B are joinedwith a perpendicular
Based on the distance between the two mental foramina
line C. This length of line C corresponds to the safe
on the opposing sides, the number of implants to be
zone in the mesial half of the first molar.This zone of
placed can be determined. A minimum required distance
safety typically includes the middle and distal half of
between implant and mental nerve is 5 mm from anterior
mandibular first molar along with the mesial half of
or bony foramen.
mandibular second molar.

Periodontics & Oral Implantology 9

 Implantology Section - XI

Submandibular fossa: Table 67.2: Minimum Required Distance Between

It is concavity present in the inner side of the body of the Implant And Indicated Structure In Maxilla
mandible below the mylohyoid ridge in first to third molar Buccal plate surface 1.0 mm
region. The facial artery and its lateral loop are found in Lingual plate surface 1.0mm
this depression.
Maxillary sinus 1.0mm
Surgical considerations:
Incisive canal Avoid midline of maxilla
The lingual aspect of the body of the mandible should
be palpated as well as evaluated using CT scan before Nasal cavity 1.0mm
osteotomy preparation. The clinician should also be knowledgeable about
The perforation of the lingual plate occurs because of the following that could affect the implant placement,
the significant undercut under the mylohyoid muscle. This including
perforation can occur due to angulation of the implant. Teeth:
After the drill penetrates the lingual plate, it can proceed
quickly several millimetres beyond the lingual cortex and ♦ Roots of the teeth adjacent to the dental implant
partially cut the facial artery. This leads to life-threatening sites.
haemorrhage, in the floor of the mouth and tongue followed ♦ Implants should be placed at a minimum distance of
by respiratory obstruction. 1.5mm from an adjacent natural tooth.
Lingual inclination of alveolar ridge: ♦ Adjacent Implants: Adjacent implant surfaces should
be at a minimum distance of 3 mm.
The anterior mandible is often angled to the lingual after Available bone:
the initial labial resorption of the bone, or often after
resorption of the residual ridge. ♦ Bone quality and bone quantity.

Surgical consideration: ♦ Alveolar bone deformities.

In an attempt to place implants in the long axis of the
missing tooth often results in a lingual perforation of
the mandible especially in the canine region, which is the
most common site for life-threatening haemorrhage.
Other causes include a tear in the lingual periosteum during
elevation or handling of the flap.
Surgical considerations of maxilla:
The anatomical structures that influence implant placement
include
♦ Maxillary sinus.
♦ Nasal cavity.
♦ Incisive foramen.
♦ Palatine and pterygoid vessels.
♦ Canine fossa.
Quality and quantity of residual bone:
The quality of the bone in an edentulous area has a prime
influence on treatment planning, implant design, surgical
approach, and healing up to implant loading.
♦ Bone density and volume may be precisely determined
prior to surgery by a computed tomography scan
accompanied by Hounsfield values of the bone.
♦ The bone quality is commonly evaluated during
surgery.
♦ Bone tissue assessment in implant tissue has two
primary functions.
– Diagnostic tool-Helps in assessing the sufficiency
of bone tissue for dental implant placement.
– Prognostic tool-Helps in predicting the success or
failure of dental implant.

10 Periodontics & Oral Implantology

Chapter 67 Biological Clinical and Surgical Aspects of Implants

Lekholm and Zarb classification (1985): ♦ Quality III: A thin layer of cortical bone surrounding
dense trabecular bone of favorable strength, normally
Bone Quality refers to the amount and topographic found in the anterior maxilla but can also be seen in
relationship of cortical and cancellous bone. the posterior mandible and the posterior maxilla.
(Jaffin&Berman)
♦ Quality IV: A thin layer of cortical bone surrounding
Bone quality is classified as: a core of low-density trabecular bone, it is very soft
♦ Quality I: Composed of homogenous compact bone, bone and normally found in the posterior maxilla. It
usually found in the anterior mandible can also be seen in the anterior maxilla.
♦ Quality II: A thick layer of compact bone surrounding This classification offers a subjective, nonspecific technique
a core of dense trabecular bone, usually found in the to determine bone density. The primary drawback of this
posterior mandible classification is that it does not provide quantitative data
about bone quality and density.

I II III IV

Fig 67-3: Classification of bone quality

Bone density classification by Misch:
Misch defined four density groups in all regions of the jaw.
The regions of the jaw are divided into
1. Anterior maxilla – second premolar to second
premolar
2. Posterior maxilla – molar region,
3. Anterior mandible – first premolar to first premolar
4. Posterior mandible – second premolars and molars

Fig 67-4: Classification of bone density

Dense Cortical (D-1) bone:

D1 bone type is composed of all dense and homogenous Histologically is composed of dense lamellar bone with
cortical bone. It exhibits greater strength than any other complete haversian systems.
bone type.This is present in 4% of anterior and 2% of The CT images have a range of > 1250 Hounsfield unit.
posterior mandible. This is called oak or maple like.

Periodontics & Oral Implantology 11

 Implantology Section - XI

Advantages: Disadvantages:
♦ Since it is highly mineralized, able to withstand heavy ♦ Use of threaded implants
occlusal loads. ♦ Progressive loading not required
♦ Heals with little interim bone formation, ensuring
excellent bone strength while healing. Thin porous cortical and fine trabecular
bone (D3):
♦ It shows greatest bone-implant contact of more than
80%, hence greater success. This is composed of thinner porous cortical bone on
♦ Fewer stresses transmitted to apical third, hence the crest and fine trabecular bone within the ridge. The
short implants can better withstand higher loads tactile feeling when preparing this bone density is similar
compared to other bone densities. to compressed balsa wood.
Disadvantages: The bone: implant contact is approximately 50%. It may
be found in anterior maxilla and posterior regions of the
♦ This bone type has fewer blood vessels and hence
mouth.
depends on periosteum for its nutrition.
♦ Capacity of regeneration is impaired due to poor On CT, reformatted images may have a range of 375-750
blood circulation. Hounsfield units.

♦ Delicate and minimal periosteal reflection along with A roughened implant body or the once with hydroxyapatite
a precise closure of periosteum and overlying tissues coatings may prove successful. Greater diameter implants
is indicated to help recover blood supply should be used as there is bone spreading.
Advantages:
Dense to thick porous cortical bone and coarse
trabecular bone (D2): ♦ Implant osteotomy preparation time and difficulty
is minimal – for each drill size, it is less than 10
This is composed of a combination of dense to porous seconds
cortical bone on the crest and coarse trabecular bone ♦ Crest module drill and bone tap not required
on the inside. The D2 bone trabeculae are 40% to 60%
stronger than D3 trabeculae. The density is similar to ♦ Blood supply is excellent for healing, intraosseous
spruce or white pine wood. bleeding during osteotomy helps cool the site.
Disadvantages:
This occurs most frequently in anterior mandible followed
by posterior mandible and in anterior maxilla for a single ♦ In anterior such bone type is narrower, hence
missing tooth. osteotomy can lead to lateral or apical perforation.
On CT reformatted images may have a range of 850-1250 ♦ With thin crestal cortical bone, greater is the risk to
Hounsfield units load during healing.
Advantages: ♦ Healing periods is longer upto 6 months.
♦ Provides excellent implant interface healing. Usually Fine trabecular bone (D4):
referred to as the ideal bone. This hasvery little density and little or no cortical crestal
♦ The cortical bone on the crest or the lateral portions bone. It is the opposite spectrum of D1 bone. Most
of the implant site provide secure initial rigid surface common location is the posterior molar region of maxilla
in long term edentulous patient or in an augmented ridge
♦ Intrabony blood supply allows bleeding during
in height and width by bone substitutes or in a sinus graft.
osteotomy which helps to control overheating.
♦ Excellent healing with bone implants interface of The tactile sense is similar to stiff, dense Styrofoam or soft
more than 70% balsa wood. The bone implant contact is often less than
25%.
12 Periodontics & Oral Implantology
Chapter 67 Biological Clinical and Surgical Aspects of Implants

A CT scan with reformatted images shows < 375 Hounsfield space from the neighboring tooth and 3mm from a nearby
units.
Advantage:
♦ The bone spreading is easiest.
Disadvantages:
♦ Bone trabeculae are sparse, so initial fixation is a big restoration.
challenge.
♦ The initial drill is the only drill to be used since
chances of perforation are very high
♦ Additional implants may be necessary to improve
implant loading distribution.
♦ Large diameter implants with roughened or
hydroxyapatite coating is mandatory to improve the
amount of bone-implant contact.
♦ Undisturbed healing for longer periods of more than
6-9 months is required.
implant.
Available bone angulation:
It is the angle between the occlusal plane and the
implant body. It should be perpendicular to the plane of
occlusion and parallel to the long axis of the prosthodontic
Crown height space:
It is the vertical distance from the crest of the ridge to
occlusal plane.
Divisions of available bone:
1. Division A (Abundant bone):
2. Division B (Barely sufficient bone)
3. Division C (Compromised bone)
4. Division D (Deficient bone)

Quantity of residual bone: Dimensions of Division A

♦ Width > 6mm
Residual bone or available bone designates the amount of
♦ Height >12mm
bone in the edentulous area planned for implantation. It is
calculated based on its length, width, height, angulation and ♦ Mesiodistal length > 7mm
crown height space. ♦ Angulation of occlusal load < 25 degrees
Available bone height: ♦ Crown height space < 15mm
An orthopantomogram is widely used to assess the available Dimensions of Division B
bone height. It is measured from the crest of edentulous
This type of bone offers sufficient bone height, but the
alveolar ridge to the opposing landmark.
available bone width can be classified into B+ and B-w (B
Anteriorly in maxilla, measured from crest of the alveolar minus width)
ridge to the maxillary nares. In mandible, from the crest of
♦ Width 2.5 to 6 mm
the alveolar ridge to the inferior border of the mandible.
* B+: 4 to 6 mm
Posteriorly, in maxilla, from the crest of the ridge to floor
of the sinus. In the mandible, from the crest to the ridge to * B-w: 2.5 to 4mm
the mandibular canal. ♦ Height >12 mm.
Available bone width: ♦ Mesiodistal length >6mm
It is measured as the width between the buccal and lingual ♦ Angulation < 20 degrees
cortical plates at the crest of planned location for implant ♦ Crown height space < 15mm
placement. The minimal width required is one mm of bone
Dimensions of Division C:
between the implant and the cortical plates.
This type is deficient in one or more dimensions. If there is
Available bone length:
only deficient bone width, then it is C-w (C minus w) and
It denotes the mesio-distal length of available bone in an if the bone height is reduced, then it is C-h (C minus h).
edentulous region. There should be a minimum of 1.5mm

Periodontics & Oral Implantology 13

 Implantology Section - XI

One more category is C-a (C minus a) where the available interface exceeding 150µm will impair differentiation of
bone is adequate in height and width, but the angulation is osteoblasts in early healing period.
greater than 30 degrees regardless of implant placement. Premature loading leads to implant movement resulting in
♦ Width (C-w bone): 0 to 2.5mm soft tissue interface rather than a bony interface.
♦ Height (C-h bone) < 12mm Other factors to decrease the biomechanical load
♦ Angulation of occlusal load (C-a bone) >30 degrees includes
♦ Crown height space > 15mm ♦ Shortening or elimination of cantilever length
Dimensions of Division D: ♦ Use of narrow occlusal table,
♦ Severe atrophy ♦ Minimizing the offset load,
♦ Basal bone loss ♦ Increasing the implant number and
* Flat maxilla ♦ Use of a wider implant with D4 bone compared to
D1 & D2
* Pencil thin mandible
♦ > 20mm crown height JAW BONE ANATOMY CLASSIFICATION
Undisturbed healing phase:
(Juodzbalys & Kubilius):
Conditions optimal for bone formation must be It classifies the edentulous jaw segment into three types
maintained. Pre-osteoblasts, derived from primary (Types I to III) based on anatomical and radiographic
mesenchymal cells depend on a favourable oxidation- jawbone quantity and quality. It is proposed to help in
reduction (redox) potential of the environment. treatment planning.
Thus, a proper vascular supply and oxygen tension are Classification system of the jaw bone anatomy in endosseous
needed. If oxygen tension is poor, the primary stem cells dental implant treatment. H = height; W = width; L = length;
may differentiate into fibroblasts, form scar tissue and lead RVP = Alveolar ridge vertical position; ME BPH = Mesial
to implant failure. interdental bone peak height; DI BPH = Distal interdental
bone peak height; MC = mandibular canal; IAN = inferior
Prosthetic design and Loading conditions: alveolar nerve; MSR = maxillary sinus region (all linear
measurements are expressed in mm).
Ideally, there should be no loading while healing to achieve
successful osseointegration. Micro movements at the

14 Periodontics & Oral Implantology

Chapter 67 Biological Clinical and Surgical Aspects of Implants

Methods of Evaluation of Osseointegration:

They are of two types

Invasive methods
•Histological section.
•Histomorphometry.
•By using torque gauges.
•Pullout test.
•Push out test.
Non-Invasivemethods
•Radiographs.
•Stability measurement with Periotest.
•Reverse torque.
•Resonance frequency analysis.
•Impulse testing.
•Computer-assisted linear analysis.

Fig. 67.5: Classification system of the jawbone anatomy in endosseous dental implant treatment. (Juodzbalys &
Kubilius).
Periodontics & Oral Implantology 15
 Implantology
Criteria for evaluation of dental implants: (Albrektson and Review Questions:
Zarb G (1980))
♦ The individual unattached implant should be immobile
when tested clinically.
♦ The radiographic evaluation should not show any
peri - implant radiolucency.
♦ Vertical bone loss around the fixtures should be Short notes:
less than 0.2mm annually after first year of implant
loading.
♦ The implant should not show any sign and symptom
of pain, infection, neuropathies, parastehsia, violation 5. What is the scope of osseointegeration?
of mandibular canal and sinus drainage.
♦ Success rate of 85% at the end of 5 year observation
reading:
period and 80% at the end of 10-year service.
♦ Implant design allows the restoration satisfactory to
patient and dentist. - Smith and Zarb (1989)
Scope of osseointegration:
1. Prosthetic rehabilitation of missing teeth
• Complete edentulous maxilla and mandible
rehabilitation.
• Partial dental loss/replacement.
• Single tooth replacement.
2. Anchorage for the maxillofacial prosthesis
• Auricular Prosthesis.
• Ocular Prosthesis.
• Nasal prosthesis.
3. For rehabilitation of congenital and developmental
defects
• Cleft palate.
• Ectodermal dysplasia.
4. Complex maxillofacial defect rehabilitation.
5. Orthodontic anchorage.
16 Periodontics & Oral Implantology
Section - XI
Essay Questions:
1. Discuss the biologic aspects of dental implant.
2. Describe the available quantity and quality of alveolar
bone and its relationship with dental implantology.
3. Write a brief note on implant bone interface.
4. What are the criteria of success of dental implant?
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♦ Albrektsson T, Zarb G. Worthington P. Eriksson A.R.:
The Long-Term Efficacy of Currently Used Dental
Implants: A Review and Proposed Criteria of Success;
Int Journal of Max Imp 1986; 1, 11-25.
♦ Albrektsson.T, Br˚anemark.P.-I, Hansson.H.-A,
Lindstrom.J, “Osseointegrated titanium implants:
requirements for ensuring a long-lasting, direct bone-
to-implant anchorage in man,” Acta Orthopaedica
1981: 52, 2, pp. 155–170.
♦ Al-Sabbagh M.Complications in implant dentistry.
Dent Clin North Am. 2015 Jan;59(1): xiii-xv. doi:
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♦ Ayse Gulsahi (2011). Bone Quality Assessment
for Dental Implants, Implant Dentistry - The Most
Promising Discipline of Dentistry, Prof. Ilser Turkyilmaz
(Ed.), ISBN: 978-953-307-481-8, InTech, Available
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dentistry-the-most-promising-discipline-of-dentistry/
bone-qualityassessment-for-dental-implants
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