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PRESENTED BY:
APURVA THAMPI
BONE DENSITY
Contents
•Introduction
•Bone morphology
•Bone physiology
•Influence of bone density on implant
success rates
•Aetiology of various bone density
•Bone classification schemes
•Bone density classification - Misch
•Bone density location
•Radiographic assessment of bone density
•Tactile sense - bone density
•Scientific rationale
•Effect of bone density on surgical
approach and healing
•Case studies
•Conclusion
•References
Basic bone biology in
implantology
Bone
33% organic67% inorganic
hydroxyapetite
28%
collagen
5% non
collagenous
protiens
2/25/2017
TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ;
5TH ED
4
There are 4 types of cells in bone
tissue….Osteoprogenitorcells
• Unspecialised
cells
• Develop into
osteoblasts
• Found in
periosteum,
endosteum
and in canals
of vital teeth
Osteoblasts
• Formation of
bone
• Role in
calcification
• Synthesis of
protien
Osteoclasts
• Responsible
for bone
resorption
Osteocytes
• Maintenance
of bone
• Exchange of
calcium
between bone
and ECF
TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ;
5TH ED
Can be broadly classified into :
Compact
bone
Trabecular
bone
TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ;
5TH ED
What is lamellar bone?
Structure of adult bone
Made up of layers – lamellae – thin plate of bone consisting
of collagen fibres and mineral salts
Lacunae – between each lamellae
Each lacuna consists of one osteocyte
Canaliculi spread out from each lacuna
A
B
C
Unit of bone - lamellus
Bone acquires thickness by stacking of lamellus
Between adjoining lamellae – spaces called lacunae
- Occupied by osteocytes
TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ;
5TH ED
What is woven bone?
Osteocyte in lacuna
canaliculi
Collagen fibres present in bundles – at
random
Interlaced – woven bone
All newly formed bone
Abnormal persistence of woven bone – Paget’s
disease
Compact bone VS
Trabecular bone
Osteon of compact bone
Trabeculae of spongy bone
Haversian canals
Volkmann’s canal
periosteum
osteon
canaliculi
lamellae
Lacunae containing ostecytes
Compact bone
Lamellae
arranged in
concentric
circles –
surround -
Haversian
canals
Occupied by
blood vessels
and nerves
Haversian
canal +
lamellae =
osteon or
haversian
system
Between
adjoining
osteons –
interstitial
lamellae
At the surface –
lamellae are
parallel –
circumferential
lamellae
TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ;
5TH ED
Trabecular bone
Bony plates or rods –
meshwork – trabeculae
Made of number of
lamellae
Enclose wide spaces
filled with bone marrow
– receive nutrition
Bone physiology
Calcium metabolism
Rapid influx
of calcium
from bone
fluid
Short term response
of osteoclasts and
osteoblasts
Long term
control of
bone
turnover
Normal
serum
calcium
levels –
10mg/dL
Low
calcium
level 
tetany and
death
High serum
calcium levels –
kidney stones,
dystrophic
calcification of
soft tissues
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Dec in calcium levels –
transport of ions to
osteocytes
Calciferol enhances
pumping of calcium ions
from cells into ECF
Net flux of Ca ions
PTH + calciferol +
calcitonin
Transiently
suppresses bone
resorption
Profound effect on
skeleton
PTH is the
primary regulator
– mean bone age
Important
determinant of
fragility
Instantaneous
regulation (within
seconds)
Short term
regulation
Long term
regulation
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Calcium conservation
Kidney excretes phophates by minimising loss of calcium
Renal dysfunction – high risk for osseous manipulative procedures –
renal osteodystrophy
Body spends 300mg calcium per day – recovered by absorption from
gut – depends of Vit D
Kidney is the
primary calcium
conservation
organ of the body
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Cortical bone growth and
maturation
Osseous
landmarks
for
superimpos
ition
Anterior
curvature of
the sella
turcica
Cribriform
plate
Internal
curvature of
frontal bone
Most reliable means of
determining post
adolescence growth 
essential for treatment
planning
MELSEN, BIRTE. THE CRANIAL BASE: THE POSTNATAL DEVELOPMENT OF THE CRANIAL BASE STUDIED
HISTOLOGICALLY ON HUMAN AUTOPSY MATERIAL. VOL. 32. ACTA ODONTOLOGICA SCANDINAVICA, 1974.
Influence of bone
density on implant
success rates
Anterior
mandible
Anterior
maxilla
Posterior
mandible
Posterior
maxilla
Position / Arch location
Quality of
bone
dependent on
the position
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
•10% greater success rates in anterior mandible as compared to
anterior maxilla (Adell et al)
•Lower success rates in posterior mandible as compared with the
anterior mandible (Schnitman et al)
•Highest clinical failure rates – posterior maxilla – force is greater and
poor bone density
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Quality of bone
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Aetiology of various
bone density
Hormones
Vitamins
Mechanical
influences
Duration of
edentulousn
ess
Changes in bone -
adaptability
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
“Every change in the form and function of bone or of
its function alone is followed by certain definite
changes in the internal architecture, and equally
definite alteration in its external conformation in
accordance with mathematical laws”
Wolff - 1892
 Adaptive phenomena
 Alteration of mechanical forces and strain development within the bone
 density evolves as a result of mechanical deformation from microstrain
MODELLING
Independent sites of formation and
resorption
Results in change in shape and size of
bone
REMODELLING
Resorption and formation at the same
site
Replaces previously existing bone
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
The maxilla is a force distribution unit and
mandible is a force absorption unit
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
The trabecular bone in dentate mandible is
more coarse compared to the maxilla
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Anterior
mandible
Posterior
maxilla
Density change after tooth
loss.
• Initial density
• Flexure and torsion
• Parafunction before
extraction
NEUFELD JO: CHANGES IN THE TRABECULAR PATTERN OF THE MANDIBLE
FOLLOWING THE LOSS OF TEETH, J PROSTHET DENT 685-697, 1958
ORBAN B: ORAL HISTOLOGY AND EMBRYOLOGY, ED 3, ST
LOUIS, 1953, MOSBY
Based on Frosts’s mechanostat theory
50 1500 3000 10000+
Acute
Disuse
window
Adapted
window
Mild
Overload
window
Pathologic
Overload
window
Spontaneous
fracture
Stress F/A
Strain O
Strain
Acute disuse window : lowest
microstrain amount
Adapted window : ideal physiologic
loading zone
Mild overload zone : cause
microfracture; triggers an increase in
bone remodelling – more woven bone
Pathologic overload : increased
fatigue fractures, remodelling and
bone resorption
FROST, H. M. "MECHANICAL ADAPTATION. FROST’S MECHANOSTAT THEORY."
STRUCTURE, FUNCTION, AND ADAPTATION OF COMPACT BONE (1989): 179-81.
Acute disuse window
•Loses mineral density
•Disuse atrophy – modelling for new bone
inhibited
•Net loss of bone
•Microstrain – 0 – 50
•Cortical bone density decrease – 40% and
trabecular bone density decrease – 12%
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Adapted window phase
•50 – 1500 microstrain
•Equilibrium of modelling and remodelling
•“homeostatic window of health”
•18% trabecular bone and 2-5% cortical bone
•Ideally desired around an endosteal implant
Mild overload zone
•1500 – 3000 microstrain
•Greater rate of fatigue microfracture
•Bone strength and density decreases
•State of bone when endosteal implant is
overloaded
•Repair – woven bone is weaker than lamellar –
“safety range” for bone strength is reduced
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Pathologic overload zone
•Microstrains <3000 units
•Physical fracture of cortical bone
•Formation of fibrous tissue
•Marginal bone loss in implant overloading –
implant failure
Bone classification
schemes in implant
dentistry
Linkow in 1970 :
Class I
• Ideal
• Evenly spaced
trabeculae
with small
cancellated
spaces
Class II
• Less
uniformity
• Larger
cancellated
spaces
• Large marrow
filled spaces
exist
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Lekholm and Zarb in 1985:
Quality 1
•Homogenous
compact bone
Quality 2
•Thick layer of
compact bone
around a core of
dense
trabecular bone
Quality 3
•Thin layer of
cortical bone
around dense
trabecular bone
•Favorable
strength
Quality 4
•Thin layer of
cortical bone
around a coreof
low density
trabecular bone
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Misch in 1988
Bone density Description Tactile analogue Typical anatomic
location
D1 Dense cortical Oak / maple wood Anterior mandible
D2 Porous cortical and
coarse trabecular
White pine or spruce
wood
Anterior mandible
Posterior mandible
Anterior maxilla
D3 Porous cortical (thin)
and fine
Balsa wood Anterior maxilla
Posterior maxilla
Posterior mandible
D4 Fine trabecular Styrofoam Posterior maxilla
D5 type of bone exists
– most immature
bone – found in a
developing sinus
graft.
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
To be continued…
Bone density
location
Location of bone density types (%
occurance)
Bone Anterior maxilla Posterior maxilla Anterior
mandible
Posterior
mandible
D1 0 0 6 3
D2 25 10 66 50
D3 65 50 25 46
D4 10 40 3 1
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
D1 Bone
•Incresed torsion / flexure
•Div A Kennedy’s class IV
•Antr/postr mandible – lingual cortex
D2 Bone
•Partially edentulous antr/postr
mandible (premolar)
•Single tooth or 2 teeth missing
D3 Bone
•Most common in maxilla
•Also present in posterior mandible
D4 Bone
•Softest bone
•Posterior maxilla – after sinus
augmentation or iliac crest bone graft
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
• First way to identify bone density in implant site
◦ Anterior maxilla – D3
◦ Posterior maxilla - D4
◦ Anterior mandible - D2
◦ Posterior mandible – D3
D2
D3 D4
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Radiographic bone
density
IOPAR
OPGs
• Lateral cortical plates
obscure the trabecular
bone density
• More subtle changes
cannot be qualified
Correlation between Misch bone density classification
and Hounsfield units….
Type of
bone
Hounsfield units
D1 >1250 HU
D2 850 – 1250 HU
D3 350 - 850 HU
D4 150 – 350 HU
D5 <150 HU
SOGO, MOTOFUMI, ET AL. "ASSESSMENT OF BONE DENSITY IN THE POSTERIOR MAXILLA BASED ON HOUNSFIELD UNITS TO
ENHANCE THE INITIAL STABILITY OF IMPLANTS." CLINICAL IMPLANT DENTISTRY AND RELATED RESEARCH 14.S1 (2012): E183-E187.
Correlation between Lekholm and Zarb’s bone density
classification and bone density…
NORTON, MICHAEL R., AND CAROLE GAMBLE. "BONE CLASSIFICATION: AN OBJECTIVE SCALE OF BONE DENSITY USING THE
COMPUTERIZED TOMOGRAPHY SCAN." CLINICAL ORAL IMPLANTS RESEARCH 12.1 (2001): 79-84.
Failure in
mandible –
higher
Hounsfield
units
• Lack of
vascularisation
• Overheating
ROTHMAN, STEPHEN LG, MELVYN S. SCHWARZ, AND NEIL I. CHAFETZ. "HIGH-RESOLUTION COMPUTERIZED TOMOGRAPHY AND NUCLEAR BONE
SCANNING IN THE DIAGNOSIS OF POSTOPERATIVE STRESS FRACTURES OF THE MANDIBLE: A CLINICAL REPORT." INTERNATIONAL JOURNAL OF
Bone density –
tactile sense
Bone density Description Tactile analogue Typical anatomic
location
D1 Dense cortical Oak / maple wood Anterior mandible
D2 Porous cortical and
coarse trabecular
White pine or spruce
wood
Anterior mandible
Posterior mandible
Anterior maxilla
D3 Porous cortical (thin)
and fine
Balsa wood Anterior maxilla
Posterior maxilla
Posterior mandible
D4 Fine trabecular Styrofoam Posterior maxilla
Scientific rationale for
a bone density - based
treatment plan
Bone strength
and density
Bone elastic
modulus and
density
Bone density
and implant
bone contact
interface
Bone density
and stress
transfer
Bone density and strength
Bone density is
directly related
to the strength
of bone before
microfracture
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
1 2 43 5 6 7 8 9 10
D1D2D3D4
MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM
(NEWTOWN, PA.) 15.11 (1994): 1330-1332.
Elastic modulus and density
Directly related to the density of bone
Relates to the stiffness of the material
Amount of
strain as a
result of a
particular
amount of
stress
EM of
bone more
flexible
than Ti
Pathologic
overload
Stresses
minimized
– adapted
window
zone
Lamellar
bone at
the
interface
MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM
(NEWTOWN, PA.) 15.11 (1994): 1330-1332.
Ti - D1 bone
interface –
very little
microstrain
Ti – D4 bone
interface –
pathologic
overload
MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM
(NEWTOWN, PA.) 15.11 (1994): 1330-1332.
Bone density and bone-implant
contact percentage Area  less area = greater stress
D1 bone has greatest BIC
D2 has 65 – 75% BIC
D3 bone has 40 – 50% BIC
D5 bone has 30% BIC
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Bone density and stress transfer
Different stress contours
for different types of bone
Bone
implant
contact
Bone
density
Elastic
modulus
Crestal
bone loss
and early
implant
failure due
to increased
stress
D1 bone
Stress is of
lesser
magnitude
Highest
strains near the
crest
D2 bone
Sustains
greater strain
 intensity of
stress extends
farther apically
D4 bone
Greatest crestal
strain 
magnitude of
strain is further
apical
Adapted
window
Mild overload Implant failure
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
A nutshell….
Each bone density has different strengths
Bone density affects elastic modulus
Density differences result in difference in BIC
Different stress-strain distribution at a B-I interface
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Effect of bone
density on treatment
planning
Modifications in treatment
plan
Prosthetic
factors
Implant
surface
condition
Implant
number
Need of
progressive
loading
Implant
design
Implant
size
CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH,
3RD EDITION
Aim : decrease strain in the bone thereby decrease microfracture  increase SA
Dense cortical D1 Bone
Analogous to oak or
maple wood
Almost all dense cortical
bone
Mostly seen in anterior
mandible and sometimes
in posterior mandible
Advantages/disadvantages of D1
bone
Highly mineralized
Excellent bone
strength
Best implant bone
contact
Less force
transmission to apical
thirds
Implant crown ratio>1
Less blood supply – not
regenerative
Easily overheated
Implant height limited
to less than 12mm
Prior to osteotomy…
Amount of heat generated by each drill is directly
related to the bone removal by each drill
First drill – 2mm diameter
Rotational speed – 2000rpm
Intermittent pressure  “bone dances”
Osteotomy preparation in D1 bone
•Ext/Int irrigation
•Intermittent pressure
•Pause 3-5mins
•New drills
•Incremental drill
sequence
Overheating
•Primarily from
periosteum
•Minimal reflection
•Precise approximation
Blood supply
•Greater width
•Greater height
•Slower speed used
Final
osteotomy drill
•Short of full osteotomy
depth
•Allows passive implant
fit
•Removed drill
remnants
Bone tap
•Unthread ½ turn to
relieve internal
stresses
Final implant
placement •Slower healing rate
•5 months to achieve
mature interface
healing
•3-4 months
•May use immediate
loading
Stage II
recovery
D2 bone Dense-to-thick porpus cortical
and carse trabeculae
Hounsfield values – 750-1250
units
Analogous to spruce or white pine
wood
Occurs mostly in anterior
mandible and posterior mandible
Ideal implant dimension – 4mm
diameter ; 12 mm height
Advantages/disadvantages
Excellent implant
surface healing
Secure initial
rigid interface
Intrabony blood
supply
Osteotomy preparation in D2 bone
Rotation of drill – 2500 rpm
Ext/int irrigation used
Pause every 5-10 seconds – pumping motion
Drill sequence similar to D1 bone
Crestal bone drills should be used – reduce mechanical trauma
Bone tap – engages lateral or apical cortical bone
Healing
Excellent
blood supply
Initial rigid
fixation
Lamellar
bone interface
< 60% - 4
months
healing
interval
Abutment
placement
may
commence
D3 bone
Thinner porous cortical bone
Hounsfield values – 375 – 750 HU
Analogous to balsa wood
Found in anterior maxilla and anterior mandible/maxilla
Ideal implant dimension – 4X12
Roughened implant body – acid etched or resorbable blast media
Advantages/ disadvantages
Time and difficulty
for preparation is
minimal
Blood supply is
excellent
Highest survival
rate
Disadvantages of D3 bone
Bone anatomy
• Anterior maxilla is narrow
Osteotomy
• Lateral perforation
• Oversize by mistake
• Apical perforation
BIC
• 50%
Implant placement
• One time
• In level with crestal bone
Implant design
•TPS or Hydroxyapatite coated
•Costly
•Threaded
•Greater SA
•Press fit
Healing
•6 months
•Progressive loading more important than D1 or D2
D4 bone
Least density – no
cortical crestal bone
Found in posterior
molar region
Analogous to stiff
Styrofoam
Ideal Implant height –
14 mm (min 12 mm)
Disadvantages
Difficult to obtain rigid fixation
Rotating drills not to be used apart from pilot drill
Osteotomes may be used to compress osteotomy site
Cortical bone in the opposite landmark to be engaged (if any)
Increase number of implants to improve load distribution
No cantilever advocated
Summary
Densities vary depending of the location of edentulous ridge and the period of
edentulousness
D1 is the strongest bone - 10 times greater than D4
Minimum of 12mm height of implant required for initial stability
Additional bone healing and incremental loading will improve bone density
Conclusion
Bone remodels in relationto the forces excerted upon it – density varies
References
Textbookof human histology , Inderbir Singh ; 5th ed
Contemporary implant dentistry, Carl E Misch, 3rd edition
Orban B: Oral histology and embryology, ed 3, St Louis, 1953, Mosby
Melsen, Birte. The cranial base: the postnatal development of the cranial base
studied histologically on human autopsy material. Vol. 32. Acta Odontologica
Scandinavica, 1974.
Neufeld JO: changes in the trabecular pattern of the mandible following the loss of
teeth, J Prosthet Dent 685-697, 1958
Frost, H. M. "Mechanical adaptation. Frost’s mechanostat theory." Structure,
function, and adaptation of compact bone (1989): 179-81
Sogo, Motofumi, et al. "Assessment of bone density in the posterior maxilla based on
Hounsfield units to enhance the initial stability of implants." Clinical implant
dentistry and related research 14.s1 (2012): e183-e187.
Norton, Michael R., and Carole Gamble. "Bone classification: an objective scale of
bone density using the computerized tomography scan." Clinical oral implants
research 12.1 (2001): 79-84.
Misch, C. E., and M. W. Bidez. "Implant-protected occlusion: a biomechanical
rationale." Compendium (Newtown, Pa.) 15.11 (1994): 1330-1332.

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Bone density ppt

  • 2. Contents •Introduction •Bone morphology •Bone physiology •Influence of bone density on implant success rates •Aetiology of various bone density •Bone classification schemes •Bone density classification - Misch •Bone density location •Radiographic assessment of bone density •Tactile sense - bone density •Scientific rationale •Effect of bone density on surgical approach and healing •Case studies •Conclusion •References
  • 3. Basic bone biology in implantology
  • 4. Bone 33% organic67% inorganic hydroxyapetite 28% collagen 5% non collagenous protiens 2/25/2017 TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ; 5TH ED 4
  • 5. There are 4 types of cells in bone tissue….Osteoprogenitorcells • Unspecialised cells • Develop into osteoblasts • Found in periosteum, endosteum and in canals of vital teeth Osteoblasts • Formation of bone • Role in calcification • Synthesis of protien Osteoclasts • Responsible for bone resorption Osteocytes • Maintenance of bone • Exchange of calcium between bone and ECF TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ; 5TH ED
  • 6. Can be broadly classified into : Compact bone Trabecular bone TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ; 5TH ED
  • 7. What is lamellar bone? Structure of adult bone Made up of layers – lamellae – thin plate of bone consisting of collagen fibres and mineral salts Lacunae – between each lamellae Each lacuna consists of one osteocyte Canaliculi spread out from each lacuna A B C Unit of bone - lamellus Bone acquires thickness by stacking of lamellus Between adjoining lamellae – spaces called lacunae - Occupied by osteocytes TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ; 5TH ED
  • 8. What is woven bone? Osteocyte in lacuna canaliculi Collagen fibres present in bundles – at random Interlaced – woven bone All newly formed bone Abnormal persistence of woven bone – Paget’s disease
  • 10. Osteon of compact bone Trabeculae of spongy bone Haversian canals Volkmann’s canal periosteum osteon canaliculi lamellae Lacunae containing ostecytes
  • 11. Compact bone Lamellae arranged in concentric circles – surround - Haversian canals Occupied by blood vessels and nerves Haversian canal + lamellae = osteon or haversian system Between adjoining osteons – interstitial lamellae At the surface – lamellae are parallel – circumferential lamellae TEXTBOOKOF HUMAN HISTOLOGY , INDERBIR SINGH ; 5TH ED
  • 12. Trabecular bone Bony plates or rods – meshwork – trabeculae Made of number of lamellae Enclose wide spaces filled with bone marrow – receive nutrition
  • 15. Rapid influx of calcium from bone fluid Short term response of osteoclasts and osteoblasts Long term control of bone turnover Normal serum calcium levels – 10mg/dL Low calcium level  tetany and death High serum calcium levels – kidney stones, dystrophic calcification of soft tissues CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 16. Dec in calcium levels – transport of ions to osteocytes Calciferol enhances pumping of calcium ions from cells into ECF Net flux of Ca ions PTH + calciferol + calcitonin Transiently suppresses bone resorption Profound effect on skeleton PTH is the primary regulator – mean bone age Important determinant of fragility Instantaneous regulation (within seconds) Short term regulation Long term regulation CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 17. Calcium conservation Kidney excretes phophates by minimising loss of calcium Renal dysfunction – high risk for osseous manipulative procedures – renal osteodystrophy Body spends 300mg calcium per day – recovered by absorption from gut – depends of Vit D Kidney is the primary calcium conservation organ of the body CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 18. Cortical bone growth and maturation Osseous landmarks for superimpos ition Anterior curvature of the sella turcica Cribriform plate Internal curvature of frontal bone Most reliable means of determining post adolescence growth  essential for treatment planning MELSEN, BIRTE. THE CRANIAL BASE: THE POSTNATAL DEVELOPMENT OF THE CRANIAL BASE STUDIED HISTOLOGICALLY ON HUMAN AUTOPSY MATERIAL. VOL. 32. ACTA ODONTOLOGICA SCANDINAVICA, 1974.
  • 19. Influence of bone density on implant success rates
  • 20. Anterior mandible Anterior maxilla Posterior mandible Posterior maxilla Position / Arch location Quality of bone dependent on the position CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 21. •10% greater success rates in anterior mandible as compared to anterior maxilla (Adell et al) •Lower success rates in posterior mandible as compared with the anterior mandible (Schnitman et al) •Highest clinical failure rates – posterior maxilla – force is greater and poor bone density CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 22. Quality of bone CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 24. Hormones Vitamins Mechanical influences Duration of edentulousn ess Changes in bone - adaptability CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 25. “Every change in the form and function of bone or of its function alone is followed by certain definite changes in the internal architecture, and equally definite alteration in its external conformation in accordance with mathematical laws” Wolff - 1892
  • 26.  Adaptive phenomena  Alteration of mechanical forces and strain development within the bone  density evolves as a result of mechanical deformation from microstrain MODELLING Independent sites of formation and resorption Results in change in shape and size of bone REMODELLING Resorption and formation at the same site Replaces previously existing bone CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 27. The maxilla is a force distribution unit and mandible is a force absorption unit CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 28. The trabecular bone in dentate mandible is more coarse compared to the maxilla CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 29. Anterior mandible Posterior maxilla Density change after tooth loss. • Initial density • Flexure and torsion • Parafunction before extraction NEUFELD JO: CHANGES IN THE TRABECULAR PATTERN OF THE MANDIBLE FOLLOWING THE LOSS OF TEETH, J PROSTHET DENT 685-697, 1958
  • 30. ORBAN B: ORAL HISTOLOGY AND EMBRYOLOGY, ED 3, ST LOUIS, 1953, MOSBY
  • 31. Based on Frosts’s mechanostat theory 50 1500 3000 10000+ Acute Disuse window Adapted window Mild Overload window Pathologic Overload window Spontaneous fracture Stress F/A Strain O Strain Acute disuse window : lowest microstrain amount Adapted window : ideal physiologic loading zone Mild overload zone : cause microfracture; triggers an increase in bone remodelling – more woven bone Pathologic overload : increased fatigue fractures, remodelling and bone resorption FROST, H. M. "MECHANICAL ADAPTATION. FROST’S MECHANOSTAT THEORY." STRUCTURE, FUNCTION, AND ADAPTATION OF COMPACT BONE (1989): 179-81.
  • 32. Acute disuse window •Loses mineral density •Disuse atrophy – modelling for new bone inhibited •Net loss of bone •Microstrain – 0 – 50 •Cortical bone density decrease – 40% and trabecular bone density decrease – 12% CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 33. Adapted window phase •50 – 1500 microstrain •Equilibrium of modelling and remodelling •“homeostatic window of health” •18% trabecular bone and 2-5% cortical bone •Ideally desired around an endosteal implant
  • 34. Mild overload zone •1500 – 3000 microstrain •Greater rate of fatigue microfracture •Bone strength and density decreases •State of bone when endosteal implant is overloaded •Repair – woven bone is weaker than lamellar – “safety range” for bone strength is reduced CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 35. Pathologic overload zone •Microstrains <3000 units •Physical fracture of cortical bone •Formation of fibrous tissue •Marginal bone loss in implant overloading – implant failure
  • 36. Bone classification schemes in implant dentistry
  • 37. Linkow in 1970 : Class I • Ideal • Evenly spaced trabeculae with small cancellated spaces Class II • Less uniformity • Larger cancellated spaces • Large marrow filled spaces exist CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 38. Lekholm and Zarb in 1985: Quality 1 •Homogenous compact bone Quality 2 •Thick layer of compact bone around a core of dense trabecular bone Quality 3 •Thin layer of cortical bone around dense trabecular bone •Favorable strength Quality 4 •Thin layer of cortical bone around a coreof low density trabecular bone CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 39. Misch in 1988 Bone density Description Tactile analogue Typical anatomic location D1 Dense cortical Oak / maple wood Anterior mandible D2 Porous cortical and coarse trabecular White pine or spruce wood Anterior mandible Posterior mandible Anterior maxilla D3 Porous cortical (thin) and fine Balsa wood Anterior maxilla Posterior maxilla Posterior mandible D4 Fine trabecular Styrofoam Posterior maxilla
  • 40. D5 type of bone exists – most immature bone – found in a developing sinus graft. CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 43. Location of bone density types (% occurance) Bone Anterior maxilla Posterior maxilla Anterior mandible Posterior mandible D1 0 0 6 3 D2 25 10 66 50 D3 65 50 25 46 D4 10 40 3 1 CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 44. CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 45. D1 Bone •Incresed torsion / flexure •Div A Kennedy’s class IV •Antr/postr mandible – lingual cortex D2 Bone •Partially edentulous antr/postr mandible (premolar) •Single tooth or 2 teeth missing D3 Bone •Most common in maxilla •Also present in posterior mandible D4 Bone •Softest bone •Posterior maxilla – after sinus augmentation or iliac crest bone graft CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 46. • First way to identify bone density in implant site ◦ Anterior maxilla – D3 ◦ Posterior maxilla - D4 ◦ Anterior mandible - D2 ◦ Posterior mandible – D3 D2 D3 D4 CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 48. IOPAR OPGs • Lateral cortical plates obscure the trabecular bone density • More subtle changes cannot be qualified
  • 49. Correlation between Misch bone density classification and Hounsfield units…. Type of bone Hounsfield units D1 >1250 HU D2 850 – 1250 HU D3 350 - 850 HU D4 150 – 350 HU D5 <150 HU SOGO, MOTOFUMI, ET AL. "ASSESSMENT OF BONE DENSITY IN THE POSTERIOR MAXILLA BASED ON HOUNSFIELD UNITS TO ENHANCE THE INITIAL STABILITY OF IMPLANTS." CLINICAL IMPLANT DENTISTRY AND RELATED RESEARCH 14.S1 (2012): E183-E187.
  • 50. Correlation between Lekholm and Zarb’s bone density classification and bone density… NORTON, MICHAEL R., AND CAROLE GAMBLE. "BONE CLASSIFICATION: AN OBJECTIVE SCALE OF BONE DENSITY USING THE COMPUTERIZED TOMOGRAPHY SCAN." CLINICAL ORAL IMPLANTS RESEARCH 12.1 (2001): 79-84.
  • 51. Failure in mandible – higher Hounsfield units • Lack of vascularisation • Overheating ROTHMAN, STEPHEN LG, MELVYN S. SCHWARZ, AND NEIL I. CHAFETZ. "HIGH-RESOLUTION COMPUTERIZED TOMOGRAPHY AND NUCLEAR BONE SCANNING IN THE DIAGNOSIS OF POSTOPERATIVE STRESS FRACTURES OF THE MANDIBLE: A CLINICAL REPORT." INTERNATIONAL JOURNAL OF
  • 53. Bone density Description Tactile analogue Typical anatomic location D1 Dense cortical Oak / maple wood Anterior mandible D2 Porous cortical and coarse trabecular White pine or spruce wood Anterior mandible Posterior mandible Anterior maxilla D3 Porous cortical (thin) and fine Balsa wood Anterior maxilla Posterior maxilla Posterior mandible D4 Fine trabecular Styrofoam Posterior maxilla
  • 54. Scientific rationale for a bone density - based treatment plan
  • 55. Bone strength and density Bone elastic modulus and density Bone density and implant bone contact interface Bone density and stress transfer
  • 56. Bone density and strength Bone density is directly related to the strength of bone before microfracture CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION 1 2 43 5 6 7 8 9 10 D1D2D3D4
  • 57. MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM (NEWTOWN, PA.) 15.11 (1994): 1330-1332.
  • 58. Elastic modulus and density Directly related to the density of bone Relates to the stiffness of the material Amount of strain as a result of a particular amount of stress EM of bone more flexible than Ti Pathologic overload Stresses minimized – adapted window zone Lamellar bone at the interface MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM (NEWTOWN, PA.) 15.11 (1994): 1330-1332.
  • 59. Ti - D1 bone interface – very little microstrain Ti – D4 bone interface – pathologic overload MISCH, C. E., AND M. W. BIDEZ. "IMPLANT-PROTECTED OCCLUSION: A BIOMECHANICAL RATIONALE." COMPENDIUM (NEWTOWN, PA.) 15.11 (1994): 1330-1332.
  • 60. Bone density and bone-implant contact percentage Area  less area = greater stress D1 bone has greatest BIC D2 has 65 – 75% BIC D3 bone has 40 – 50% BIC D5 bone has 30% BIC CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 61. Bone density and stress transfer Different stress contours for different types of bone Bone implant contact Bone density Elastic modulus Crestal bone loss and early implant failure due to increased stress D1 bone Stress is of lesser magnitude Highest strains near the crest D2 bone Sustains greater strain  intensity of stress extends farther apically D4 bone Greatest crestal strain  magnitude of strain is further apical Adapted window Mild overload Implant failure CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 62. A nutshell…. Each bone density has different strengths Bone density affects elastic modulus Density differences result in difference in BIC Different stress-strain distribution at a B-I interface CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION
  • 63. Effect of bone density on treatment planning
  • 64. Modifications in treatment plan Prosthetic factors Implant surface condition Implant number Need of progressive loading Implant design Implant size CONTEMPORARY IMPLANT DENTISTRY, CARL E MISCH, 3RD EDITION Aim : decrease strain in the bone thereby decrease microfracture  increase SA
  • 65. Dense cortical D1 Bone Analogous to oak or maple wood Almost all dense cortical bone Mostly seen in anterior mandible and sometimes in posterior mandible
  • 66. Advantages/disadvantages of D1 bone Highly mineralized Excellent bone strength Best implant bone contact Less force transmission to apical thirds Implant crown ratio>1 Less blood supply – not regenerative Easily overheated Implant height limited to less than 12mm
  • 67. Prior to osteotomy… Amount of heat generated by each drill is directly related to the bone removal by each drill First drill – 2mm diameter Rotational speed – 2000rpm Intermittent pressure  “bone dances”
  • 68. Osteotomy preparation in D1 bone •Ext/Int irrigation •Intermittent pressure •Pause 3-5mins •New drills •Incremental drill sequence Overheating •Primarily from periosteum •Minimal reflection •Precise approximation Blood supply •Greater width •Greater height •Slower speed used Final osteotomy drill
  • 69. •Short of full osteotomy depth •Allows passive implant fit •Removed drill remnants Bone tap •Unthread ½ turn to relieve internal stresses Final implant placement •Slower healing rate •5 months to achieve mature interface healing •3-4 months •May use immediate loading Stage II recovery
  • 70. D2 bone Dense-to-thick porpus cortical and carse trabeculae Hounsfield values – 750-1250 units Analogous to spruce or white pine wood Occurs mostly in anterior mandible and posterior mandible Ideal implant dimension – 4mm diameter ; 12 mm height
  • 71. Advantages/disadvantages Excellent implant surface healing Secure initial rigid interface Intrabony blood supply
  • 72. Osteotomy preparation in D2 bone Rotation of drill – 2500 rpm Ext/int irrigation used Pause every 5-10 seconds – pumping motion Drill sequence similar to D1 bone Crestal bone drills should be used – reduce mechanical trauma Bone tap – engages lateral or apical cortical bone
  • 73. Healing Excellent blood supply Initial rigid fixation Lamellar bone interface < 60% - 4 months healing interval Abutment placement may commence
  • 74. D3 bone Thinner porous cortical bone Hounsfield values – 375 – 750 HU Analogous to balsa wood Found in anterior maxilla and anterior mandible/maxilla Ideal implant dimension – 4X12 Roughened implant body – acid etched or resorbable blast media
  • 75. Advantages/ disadvantages Time and difficulty for preparation is minimal Blood supply is excellent Highest survival rate
  • 76. Disadvantages of D3 bone Bone anatomy • Anterior maxilla is narrow Osteotomy • Lateral perforation • Oversize by mistake • Apical perforation BIC • 50% Implant placement • One time • In level with crestal bone Implant design •TPS or Hydroxyapatite coated •Costly •Threaded •Greater SA •Press fit Healing •6 months •Progressive loading more important than D1 or D2
  • 77. D4 bone Least density – no cortical crestal bone Found in posterior molar region Analogous to stiff Styrofoam Ideal Implant height – 14 mm (min 12 mm)
  • 78.
  • 79. Disadvantages Difficult to obtain rigid fixation Rotating drills not to be used apart from pilot drill Osteotomes may be used to compress osteotomy site Cortical bone in the opposite landmark to be engaged (if any) Increase number of implants to improve load distribution No cantilever advocated
  • 80. Summary Densities vary depending of the location of edentulous ridge and the period of edentulousness D1 is the strongest bone - 10 times greater than D4 Minimum of 12mm height of implant required for initial stability Additional bone healing and incremental loading will improve bone density
  • 81. Conclusion Bone remodels in relationto the forces excerted upon it – density varies
  • 82. References Textbookof human histology , Inderbir Singh ; 5th ed Contemporary implant dentistry, Carl E Misch, 3rd edition Orban B: Oral histology and embryology, ed 3, St Louis, 1953, Mosby Melsen, Birte. The cranial base: the postnatal development of the cranial base studied histologically on human autopsy material. Vol. 32. Acta Odontologica Scandinavica, 1974. Neufeld JO: changes in the trabecular pattern of the mandible following the loss of teeth, J Prosthet Dent 685-697, 1958 Frost, H. M. "Mechanical adaptation. Frost’s mechanostat theory." Structure, function, and adaptation of compact bone (1989): 179-81
  • 83. Sogo, Motofumi, et al. "Assessment of bone density in the posterior maxilla based on Hounsfield units to enhance the initial stability of implants." Clinical implant dentistry and related research 14.s1 (2012): e183-e187. Norton, Michael R., and Carole Gamble. "Bone classification: an objective scale of bone density using the computerized tomography scan." Clinical oral implants research 12.1 (2001): 79-84. Misch, C. E., and M. W. Bidez. "Implant-protected occlusion: a biomechanical rationale." Compendium (Newtown, Pa.) 15.11 (1994): 1330-1332.

Editor's Notes

  1. Ordered composite of organic and inorganic matrix Osseous matrix – osteoid – collagen fibers in ground substance – organic Viscous gel of water and glycoprotein complexes
  2. Implantology is a bone manipulative therapy and favourable calcium metabolism is a important consideration It is a process by which mineral equilibrium is maintained at 10mg/dL When calcium is needed, bone structure is sacrificed
  3. Involves preservation of skeletal mass – problem – inadequate bone mass in reconstructive dentistry
  4. Maxilla and mandible have different biomechanical functions Mandible – dentate – outer cortical bone is denser and thicker, trabeculae are coarse and dense Maxilla – strain transferred to the zygomatic arch and palate –bone away from brain and orbit – thin cortical plate and fine trabecular
  5. When teeth are present, the outer cortical plate is thicker and the trabecular bone is more coarse and dense Bone is most dense around the teeth
  6. Bone exhibits adaptive phenomena – alteration of mechanical stress and strain environment within the host bone Greater the magnitude of stress, greater the strain observed – affects the overall density of bone
  7. Interestingly, a astronaut aboard the Russian Mir space station lost 12% of his bones in 111 days
  8. D1 bone is never observed in maxilla and rarely in mandible
  9. D1 – increase torsion or flexure on the bone may cause the bone to undergo strain and convert to D1 bone
  10. Kirkos and Misch established correlation b/w density of bine and hounsfeild units
  11. In a scale of 1 – 10, D1 id 9/10. D2 is 7-78 D3 is 3-4 – 50% weaker D4 is 1-2 – 10 times weaker than D1 bone
  12. Initial bone density – mechanical immobilization – after healing – permits distribution and transmission of forces
  13. Whenever stress is present, deformation or strain is produced Strain – relative deformation of an object subjected to stress
  14. Dependent on the periosteum for blood supply and nutrients - minimal reflection indicated – precise closure Overheating – less performance of the drills ; progress with more difficulty – implant failure
  15. TPS – titanium plasma spray
  16. Implnat of choice – wide diameter, HA coated