This document discusses osseointegration, the direct attachment of bone to an implant surface without intervening soft tissue. It describes the history and definitions of osseointegration as coined by Dr. Branemark. The mechanism of osseointegration involves inflammation, proliferation, and maturation phases. Factors that enhance osseointegration include implant biocompatibility, design characteristics like surface roughness, and loading conditions. Implant surface characteristics such as texture, energy, and chemistry also impact osseointegration. Moderately rough surfaces generally promote the best bone fixation.

1. OSSEOINTEGRATION
Dr P. S. Prabu MDS
Malabar Dental College & Research
Centre

2. CONTENTS
• INTRODUCTION
• HISTORY
• DEFINITIONS
• THEORIES
• MECHANISM OF OSSEOINTEGRATION
• FACTORS ENHANCINGOSSEOINTEGRATION
• FACTORS LIMITING OSSEOINTEGRATION
• CLINICAL EVALUATION OF OSSEOINTEGRATION
• CONCLUSION

3. INTRODUCTION
OSSEOINTEGRATION from latin word
OS—bone ;
Integration: “state of being combined into a complete whole”

4. • Dr. Per Ingvar Branemark, an anatomist is credited as the person who has coined the
term “osseointegration”.
• Branemark along with his team was working in the laboratory of the vital microscopy
(1952), laboratory of experimental Biology, University of Goteberg Sweden, (1960),
Institute of Applied biotechnology, Goteberg (1978).
• The main study of his group was to understand the mechanism of bone healing and
bone response to the thermal, mechanical, chemical injuries by using vital microscopy.

5. 1952 – Vital
Microscopic Studies

7. • In 1965, first human edentulous patient was treated by using the Ti screws (implants) by
reconstruction of resorbed edentulous arches using autologus tibial bone grafts.
• In May 1982 Dr. George Zarb organized the Toronto conference on osseointegration.
• Branemark presented Two stage threaded root form implant along with the 15 yrs
research work & clinical trial.
• In 1985, ADA gave its provisional acceptance for Branemark System then acceptance
under Endosseous Implant classification in August 1988.

8. DEFINITIONS
• The apparent direct attachment or connection of osseous tissue to an
inert, alloplastic material without intervening connective tissue”.- GPT 9
The process and the apparent direct connection of an exogenous materials
surface and the host bone tissues, without intervening fibrous connective
tissue. GPT 9
The interphase between alloplastic materials and the bone GPT 9

9. Structurally oriented definition :
• “Direct structural and functional connection between the ordered, living bone and the surface
of a load carrying implants”. - Branemarks and associates (1977)
• A direct connection between living bone and a load-carrying
endosseous implant at the light microscopic level.” Branemark

10. Biomechanically oriented definition :
Attachment resistant to shear as well as tensile forces- Steinmann et al (1986)
Histologically :
• Direct anchorage of an implant by the formation of bone directly on the surface of an implant
without any intervening layer of fibrous tissue. - Albrektson and Johnson (2001)
• “Contact established without interposition of nonbone tissue between normal remodeled
bone and an implant entailing a sustained transfer and distribution of load from the implant to
and within the bone tissue.” American Academy of Implant Dentistry (1986)

11. BONE PHYSIOLOGY

13. Depending on age, developmental age, localization and function, bone
consists of three tissue types that differ in collagen fibril arrangement
and mineral content.
• Woven bone
• Lamellar bone
• Bundle bone

14. WOVEN BONE
• First bone formed in response to wound healing
• Forms 30-50 µm /day
• High cellular osseous tissue
• Low mineral content, disorganised and poorly mineralized
• More pliable than mature lamellar bone , it is more forgiving of the relative
micromotion associated with interface healing
• Capable of stabilizing an unloaded implant , woven bone lacks the strength to resist
functional loads .
Carl.E .Misch

15. LAMELLAR BONE TISSUE
• Principle load-bearing tissue
• Strong , highly organized well mineralized tissue
• Makes up more than 99% of human skeleton.
• Predominant component of mature cortical and trabecular bone
• Forms relatively slow (< 1.0µm/day)
• Orientation of the collagen fibrils differs from one layer to another .
• The full strength of lamellar bone that supports an endosseus implant is not achieved
until one year post operatively- importance in treatment planning

16. COMPOSITE BONE
Formed by the deposition of lamellar bone with a woven
bone lattice
The intermediary bone formed in functional loading
Important for stabilization during the process of post
operative healing

17. FROST’S MECHANOSTAT THEORY.

18. Bundle bone
• Functional adaptation of lamellar structure to allow attachment of
tendons and ligaments
• Has perpendicular striations –sharpeys fibers
• Seen adjacent to PDL
• Mechanism of ligament and tendon attachment throughout the
body.

19. BONE REMODELING
• It is the turnover or internal restructuring of previously existing bone .
• Constant remodeling mobilizes and redeposits calcium by coupled
resorption and formation.
• Coupling factors –chemical messages for communication

20. ULTRASTRUCTURE OF
OSSEOINTEGRATION
Soft tissue
interface
Cortical
bone
Spongy
bone

21. BONE TO IMPLANT INTERPHASE
Fibro-osseous integration supported by Linkow (1970),
James (1975), and Weiss (1986) [9],
In 1986, the American Academy of Implant Dentistry defined fibrous integration as “tissue-to-
implant contact with healthy dense collagenous tissue between the implant and bone”
In this theory, col lagen fibers function similarly to Sharpey’s fibers in natural dentition. The fibers
affect bone remodeling where tension is created under optimal loading conditions
(Weiss, 1986).
When the implant is in function the fibers closer to the implant surface gets compressed with a
corresponding tension on the fibers placed or inserting into the trabaculae
It is not accepted now as no sharpey’s fibers are present between the bones and implant so it is
difficult to transmit the loads. Therefore, bone remodeling cannot be expected to occur in fibro-
osseous integration. .

22. Osseointegration supported by Branemark (1985) [5].
• This was first described by strock as early as 1939 and more recently by Branemark et
al [2] in 1952.
• Branemark theorizes that the implant must be protected and completely out of function,
as he envisions a period of healing of at least 1 year, in which new bone is formed close
to the immobile resting implant
• Histologically defined as a direct connection between living bone and load carrying
endosseous implant at the light microscopic level

23. • Meffert, et al (1987) redefined and subdivided osseointegration into
• Ø Adaptive osseointegration : has osseous tissue approximating the surface of the
implant without apparent soft tissue interface at the light microscopic level
• Ø Biointegration: is a direct biochemical bone surface attachment confirmed at the
electron microscopic level
Fibroosseus integration osseoinegration

24. MECHANISM OF OSSEOINTEGRATION
• INFLAMMATORY PHASE
Adsorption of plasma proteins
Platelet aggregation and activation
Clotting cascade activation
Cytokine release
Nonspecific cellular inflammatory response
Specific cellular inflammatory response
Macrophage mediated inflammation

25. PROLIFERATIVE PHASE
Neovascularization
Differentiation, Proliferation and activation of cells.
Production of immature connective tissue matrix.
MATURATION PHASE
Remodeling of the immature bone matrix with coupled resorption
and deposition of bone.
Bone remodeling in response to implant loading
Physiological bone recession.

27. • Osborn and Newesley (1980) : Proposed 2 different phenomena
DISTANT OSTEOGENESIS
Distance osteogenesis refers to the
newly formed peri-implant bone
trabeculae that develop from the host
bone cavity towards the implant
surface
CONTACT OSTEOGENESIS
contact osteogenesis refers to the newly
formed peri-implant bone that develops
from the implant to the healing bone.
Relies on Migration of Differentiating
Osteogenic cell to Implant surface

28. • Davies in 1998 described the phenomenon of contact osteogenesis thoroughly
• Divided the contact osteogenesis into two distinct early phases
OSTEOCONDUCTION
Migration of differentiating osteogenic cells from the recipient host bed to implant surface
where they attach and proliferate.
De Novo bone formation
Smooth surface
Rough surface

29. • Osteoinduction :
• Phenotypic conversion of undifferentiated mesenchymal cell osteoprogenitor cell 
Bone forming cell (Osteoblast & osteocyte)
• Third tissue response is bone remodelling at the sites

30. BIOLOGICAL FIXATION OF THE IMPLANT
• A thin layer of calcified and osteoid tissue is deposited by
osteoblasts directly on the implant surface. Blood vessels
and mesenchymal cells fill the spaces where no calcified
tissue is present
• Implant surface acts as a biomimetic scaffold
• Woven and trabecular bone fill the initial gap at the implant-
bone interface.
• Arranged in a three-dimensional regular network, it offers a
high resistance to early implant loading.
• Its physical architecture including arches and bridges offers
a biological scaffold for cell attachment and bone deposition
that is biological fixation.

31. • The early peri-implant trabecular bone formation ensures tissue anchorage that corresponds to
biological fixation of the implant.
• This begins at 10 to 14 days after surgery. Biological fixation differs from primary (mechanical) stabili
that is easily obtained during the implant insertion.
REQUIREMENTS FOR BIOLOGICAL FIXATION
• Primary stability
• Bio-mimetic implant surface
• right distance between the implant and the host bone.
It is prevalently observed in rough implant surfaces

32. FACTORS ENHANCING OSSEOINTEGRATION
• Implant material biocompatibility
• Implant design characteristic
• Implant surface characteristic
• Loading conditions
• Surgical considerations
• State of the implantation or host bed

33. • IMPLANT MATERIAL BIOCOMPATIBILITY
Chemical composition
Biological compatibility
METALS CERAMICS POLYMERS
BIOTOLERANT BIOINERT BIOACTIVE

34. Rachna Jain , Daljit KapoorThe dynamic interface: A review. J Int Soc Prev Community Dent. 2015 Sep-Oct; 5(5): 354–358

35. Biological
biocompatibility
Chemical composition
Metals Ceramics Polymers
Biotolerant Gold Polyethylene
Cobalt-chromium
alloys
Polyamide
Stainless steel Polymethylmethacrylate
Zirconium Polytetrafluoroethylene
Niobium Polyurethane
Tantalum
Bioinert Commercially pure
titanium
Aluminum oxide
Titanium alloy (Ti-
6Al-4V)
Zirconium oxide
Bioactive Hydroxyapatite
Tricalcium
phosphate
Calcium
pyrophosphate
Fluorapatite
Carbon:vitreous,
pyrolytic
Bioglass

36. Metals :
Commercially pure titanium (CPTi) : 99.75%
Titanium alloys : Ti6Al4V(90%Ti, 6% Al, 4% V)
Most biocompatible material  excellent long term
clinical function
Adherent, self repairable titanium dioxide (TiO2/
TiO) passivated layer.
It has good resistance to corrosion, and no toxicity
on macrophages or fibroblasts,
Lack of inflammatory response in peri-implant
tissues and it’s composed of an oxide layer

37. • CERAMICS
• (Calciumphosphate hydroxyapatite, Al2O3, Tricalcium phosphate)
• Makeup the entire implant
• Applied in the form of coating
• Hydroxyapatite coated implant
ADVANTAGE
• Increasing surface area,
• Decreasing corrosion rates, and accelerating bone formation via faster osteoblast
differentiation.
• Also, due to the enhanced biomechanics ha coated implants are better able to withstand
loads.
• The more organized bone pattern and higher degree of mineralization at the interface,
• As well as increased bone penetration (which improves fixation).
• The bone bonding capabilities of ha make it a very desirable surface and probably the most
reliable surface up to date.

38. POLYMERS
• Not used
• Inferior mechanical properties
• Lack of adhesion to living tissues
• Adverse immunological reaction
• Limited to
• Shock absorbing components – supra structure component

39. IMPLANT
DESIGN
CHARACTERISTIC

40. Implant Design characteristic :
Implant design refers to the three dimensional structure of the implant.
Form, shape, configuration, geometry, surface macro structure, macro
irregularities.
Cylindrical Screw shaped implants.
Threaded Non threaded.

41. Advantages of threaded implants
Threads improves the primary implant stability
avoids micromovement of the implants till
osseointegration is achieved.
V-shaped threads transfer the vertical forces in an
angulated path, and thus may not be as efficient in
stress distribution as the square shaped threads.

42. • Threaded implants provide more functional
area for stress distribution than the cylindrical
implants and pro-vide better primary
anchorage.
• Longer the length, better the primary stability.
Shorter implants (10 mm or less) are associated
with increased bone loss.

43. IMPLANT SURFACE
CHARACTERISTIC

44. Implant surface characteristics
Topographic properties
Implant surface texture
& roughness
Physical properties
Surface energy and charge
Physiochemical properties
Implant surface chemistry

45. Orientation of irregularities on the surface
Degree of roughness of the surface
Orientation of irregularities may give :
-Isotopic surface and anisotropic surface
Wennerberg (1996) Ivanoff (2001) : Better bone fixation
(osseointegration) will be achieved with implants with an enlarged
isotropic surface as compared to implant with turned anisotropic
surface structure.
Surface topography

46. 1) Turned surface/ machined surface
2) Acid etch surface - HCl and H2SO4
3) Blasted surface – TiO2 / Al2O3 particles
4) Blasted + Acidetch surface
- Al2O3 particles & HCl and H2SO4
- Tricalcium phosphate & HF & NO3
Different machining process results in different surface topographies

47. 5) Hydroxyapatite coated surface (HA)
6) Titanium plasma sprayed surface (TPS)
7) Oxidized surface
8) Doped surface
9) Nanosized hydroxyapatite coated surfaces

48. Additive surface treatment :
Titanium plasma spraying (TPS) hydroxyapatite (HA) coating
Substractive surface treatment :
Blasting with titanium oxide / aluminum oxide and acid etching
Modified surface treatment :
Oxidized surface treatment
Laser treatment
Ion implantation

49. MACHINED / TURNED SURFACES
Moderately rough implant surfaces
Roughness parameter
0.04 –0.4 m - smooth
0.5 – 1.0 m – minimally rough
1.0 –2.0 m – moderately rough
> 2.0 m – rough
: For faster & firmer bone integration

50. • Wennerberg (1996) – moderately rough implants developed the best
bone fixation as described by peak removal torque and bone to
implant contact.
• In vivo studies
Smooth surface < 0.2 m will no bone cell adhesion  clinical
failure.
Moderately rough surface more bone in contact with implant 
better osseointegration.

51. TITANIUM PLASMA SPRAYING
• Plasma spraying a powder form of molten droplets
• at high temperatures pof 15000℃
• An argon plasma associated with a nozzle to provide very
high velocity 600m /sec molten particles of titanium powder(.05 to 0.1mm)
projected on to a metal or alloy substrate
• Increases surface area upto 600%
• Total load bearing capability by 25% to 30%
• Porous surface in the range 150 to 400 𝜇𝑚
• Grater advantage in sogter bone
• Disadvantage – Detachment of titanium after implant insertion

52. Advantages of moderately rough surface :
Faster osseointegration, retention of the fibrin clot,
osteoconductive scaffold, osteoprogenator cell migration.
Increase rate and extent of bone accumulation  contact
osteogenesis
Increased surface area renders greater osteoblastic proliferation,
differentiation of surface adherent cells.
Increased cell attachment growth and differentiation.
Increased rough surfaces :
Increased risk of periimplantitis
Increased risk of ionic leakage / corrosion

53. HYDROXYAPETITE COATING
• Was introduced by degroot
• Plasma spraying of small particles of crystalline ha ceramic powders
• A powdered crystalline hydroxyaapetite is introduced and melted hot high velocity region of plasma gun
• And propelled on to the implant as a partially melted ceramic
• Ha coated implant bioactive surface structure – more rapid osseous healing comparison with smooth
surface implant.
• Increased initial stability
• More penetration of the bone – advantage in areas of limited bone contact
• Gap healing is enhanced
• The corrosion rate of metal is reduced

54. Hydroxyapatite coatings
Can be Indicated
- Greater bone to implant
contact area
- Type IV bone
- Fresh extraction sites
- Newly grafted sites
SEM 100X

55. ADVANTAGES OF COATED SURFACES
• Increased surface area
• Increased roughness for initial stabilty
• Stronger bone –implant interphase
ADDITIONAL ADV OF HA COATING
• Faster healing bone interphase
• Increased gap healing between bone and ha
• Stroger interphase than TPS
• Less corrosin of metal
DISAVANTAGES
• Flaking cracking or scaling on insertion
• Increased plaque retention when above bone
• Increased bacteria and nidus for infection
• Complication of treatment of failing implants
• Increased cost

56. Sand blasting Acid etch
The objective
Sand blasting – surface roughness
(substractive method)
Acid etching – cleaning
SEM 1000X SEM 7000X
Lima YG et al (2000), Orsini Z et al (2000).
Acid etching with 1% HF and 30% NO3
after sand blasting – increase in
osseointegration by removal of aluminium
particles (cleaning).
Wennerberg et al 1996. superior bone fixation and bone adaptation

57. SLA IMPLANTS (Straumann)
(Sand blasted Large grit Acid etchedManufactured by large grit sand blasting with .25- .5mm
corundum particles at 5 bar
Subsequent acid etching with HCl / H2SO4 at high temperatures generating an active
surface area with equal roughness and enhanced cell adhesion
The roxolid implant is developed by this method

58. By large grit-blasting (354–500 μm), followed by etching in hydrochloric, sulfuric,
Hydrofluoric, and oxalic acid and finalized by a proprietary neutralizing technique
The FRIADENT plus surface exerts dynamic changes in wettability.
Upon contact to extracellular matrix proteins, the initial hydrophobic surface shifts to a hydrophilic state,
exhibiting a water contact angle of 0°
The FRIADENT plus surface (DENTSPLY Implants,
Mannheim, Germany)

59. Laser induced surface roughening
Eximer laser – “Used to create roughness”
Regularly oriented surface roughness configuration compared
to TPS coating and sandblasting
SEM x 300
SEM x 300
SEM x 70

60. Discrete Crystalline Deposition (DCD)
Nanotite and its successor the 3i T3 dental implant
(BIOMET 3i, palm beach gardens, FL, USA),
The osseotite surface (BIOMET 3i, palm beach gardens,
FL, USA)
• Calcium phosphate (CaP) particles of 20–100 nm are deposited on a double acid-
etched surface by a sol-gel process named Discrete Crystalline Deposition (DCD)
• These CaP particles make up roughly 50% of the surface area and exert a higher
adhesive force to the implant surface than former techniques of CaP deposition
•
• Bacterial adhesion to the NanoTite surface has been shown to be lower compared to
the predecessor Osseotite surface

61. TiUnite (Nobel Biocare Holding AG, Zürich, Switzerland)
implants.
• The implant surface is electrochemically modified by anodic oxidation to
increase the thickness of the tio2 layer from 17–200 nm in conventional
titanium implants to 600–1000 nm
• Anodic oxidation might be effectively transferred to the implant’s neck in
order to create a tight soft tissue seal.
• Nanostructured titanium surfaces generated by anodic oxidation have been
shown to propagate adhesion, proliferation, and extracellular matrix
deposition of human gingival fibroblasts

62. Evaluation of response of osteoblasts done by Sammons etal (2005).journal of clinical oral implants
Thay compared
Anodized- Nobel BiocareTiUnite Ra =.76𝜇𝑚
Blasted and acid etched(Dentsply Friadent DPS,
Ra=2.41𝜇𝑚𝐷𝑒𝑛𝑡𝑠𝑝𝑙𝑦𝐹𝑅𝑖𝑎𝑑𝑒𝑛𝑡 𝑃𝑙𝑢𝑠 2.75, 𝑆𝑡𝑟𝑎𝑢𝑚𝑎𝑛𝑛𝑛 𝑆𝐿𝐴, 𝑅𝑎 = 2.935𝜇𝑚)
Plasma Sprayed (Dentsply FriadentTPS,Ra =3.5𝜇𝑚)
Acid etched (3i osseotite Ra =.86𝜇𝑚
Turned (Nobel Biocare Mk III Ra =.81𝜇𝑚
The rate of cellular spreading was significantly increased in surfaces combining blasting and
acid etching.

63. Physical characteristic :
•Physical characteristic refers to the factors such as surface energy and charge.
Hypothesis : A surface with high energy high affinity for adsorption  show
stronger osseointegration.
Baier RE (1986) – Glow discharge (plasma cleaning) results in high surface energy as
well as the implant sterilization, being conductive to tissue integration.
Parithimarkalaignan S, TV Padmanabhan. Osseointegration: An Update. J Indian Prosthodont Soc. 2013 Mar; 13(1): 2–6.

64. Implant surface chemistry :
• Chemical alteration  increases bioactivity  increase implant
bone anchorage.
Chemical surfaces :
• Ceramic coated – hydroxyapatite (HA), Calcium phosphate
• Oxidized/anodized surfaces with electrolytes containing
phosphorous, sulfur, calcium, magnesium and flouride.
• Alkali + Heat treatment.
• Ionization, implantation of calcium ion, floride ions
• Doped surfaces with the BONE stimulating factors / growth
factors.

65. Anchorage Mechanism or Bonding Mechanism in
Osseointegrated implants :
Biomechanical bonding
In growth of bone into small surface
irregularities of implant surface  three
dimensional stabilization
Seen in :
• Machined / turned screw implant
• Blasted /Acid etch surface  moderately
rough implant surface.

66. Surface roughness at the micrometer level / nanometer level
Wennerberg and Albrektsson, surface roughness can be
divided into four categories:
 Smooth surfaces: sa value <0.5 μm (e.G. Polished
abutment surface).
 Minimally rough surfaces: sa value 0.5 to <1.0 μm (e.G.
Turned implants).
 Moderately rough surfaces: sa value 1.0 to <2.0 μm (e.G.
Most commonly used types).
 Rough surfaces: sa value ≥2.0 μm (e.G. Plasma sprayed
surfaces).
Parithimarkalaignan S, TV Padmanabhan. Osseointegration: An Update. J Indian Prosthodont Soc. 2013 Mar; 13(1): 2–6.

67. Enhancing of Osseointegration with Propolis-Loaded TiO2 Nanotubes in Rat
Mandible for Dental Implants by Somdanith N etal, Materials (Basel). 2018 Jan;
11(1): 61.
TiO2 nanotubes (TNT) formation is beneficial for improving bone cell–material
interaction and drug delivery for Ti dental implants. Among the natural drugs to
be installed in TNT, selected propolis has antibacterial and anti-inflammatory
properties. It is a resinous natural product which is collected by the honeybees
from the various types of plants with their salivary enzymes.
This study concludes that TNT loaded with a propolis (PL-TNT-Ti) dental implant
has the ability to improve osseointegration.

68. BONE FACTOR
• Bone quality  bone with well
formed cortex and densely
trabaculated medullary spaces
• Bone quantity  Refers to the
dimension of available bone in
reference to length, width and
depth.
Initial implant stability

69. •Factors compromising the bone quality
Infection
Irradiation
Heavy smoking
Branemark system (5 year documentation)
Mandible – 95% success
Maxilla – 85-90% success
Aden et al (1981) – 10% greater success rate in anterior
mandible compared to anterior maxilla.
Difference in bone
composition

70. LIKHOM AND ZARB CLASSIFICATION 1985
Class I :
Jaw consist almost
exclusively of
homogeneous
compact bone
Class II :
Thick compact
bone surrounds
highly trabecular
core
Class III :
Thin cortical
bone surrounds
highly trabecular
core
Class IV :
Thin cortical
bone surrounds
loose, spongy
core
D1 D2 D3 D4
MISCH CLASSIFICATION 1988

71. HEALING OF DIFFERENT BONE DENSITIES :
D1 bone:
a. D1 bone is usually found in anterior mandible.
b. Poor blood circulation- more healing time
c. Healing occurs by formation of lamellar bone interface (forms slowly at 0.6 microns per day)
rather than woven bone (forms rapidly at 80 to 50μm/day) after the initial trauma. Therefore, for
complete regeneration of vital bone in this dense structure, 5 months healing time may be
required.
d. Excellent load bearing capacity
e. Bone-implant contact (BIC) =80
Nindal S. Osseointegration in Dental Implants: A Literature Review Indian Journal of Applied Research
4(7):411-413 ·

72. D2 bone
a. Usually found in anterior and posterior mandible.
b. The excellent blood supply of trabecular bone and rigid initial fixation permits adequate bone healing
within four months.
c. BIC = 70%
D3 bone
a. Usually found in anterior maxilla
b. The time frame for automatic healing is approximately 6 months. The actual implant interface develops
more rapidly than D2 bone; however the extended time per-mits the regional acceleratory phenomenon (RAP)
from implant surgery to stimulate the formation of more trabecular bone. More advanced bone mineralization
in extra 2 months also increases its strength before loading.
Nindal S. Osseointegration in Dental Implants: A Literature Review Indian Journal of Applied
Research 4(7):411-413 ·

73. D4 bone
a. Usually found in posterior maxilla
b. The healing and progressive bone loading sequence for D4 bone requires more time than any
other three types D1, D2 and D3. Time is needed not only to allow the bone to remodel at the surface
but also required for more advanced bone mineralization and increased
strength. Hence eight months of undisturbed healing period is suggested
Fugazzotto P. A et al. , demonstrated the efficacy of cylinder implant used in D4 bone.
It was documented that implant success rates were much lower in D4 bone than in D1, D2
and D3.
Nindal S. Osseointegration in Dental Implants: A Literature Review Indian Journal of
Applied Research 4(7):411-413 ·

74. IMPLANTATION BED / HOST BED
•Objective  Healthy implant host site
•Nature of the host site - vascularity
- cellularity (osteogenic potential)
Two Factors
•Patient Considerations - Age
•History of proposed host bed
-Previous irradiation
- Infection
- History of smoking
- Advanced ridge resorption
- Osteoporosis or osteoporotic like bone lesion

75. Age :
Old age
Extreme young age - Relative contraindication to insertion of
implants.
Infrapositioning of implant because of alveolar growth
 Wait till the completion of growth
 Maxillofacial deformities : implant placement is delayed until
the child is at puberty.

76. Smoking and osseointegration :
• History of smoking may affects the healing response in
osseointegration.
• Lower success rates with oral implants
• Mechanism behind
Vasoconstriction
Reduced bone density
Impaired cellular function
• Mean failure rates in smoker is about twice than in non smoker.

77. Previous irradiation
Need not be an absolute contraindication for the insertion of oral implants.
Preferable that some delay is allowed before an implant is inserted into a
previously irradiated bed.
10–15 % poorer clinical results must be anticipated after a therapeutical
dose of irradiation.
Because of vascular damage, at least in part. One attempt
Increase the healing conditions in a previously irradiated bed is by using
hyperbaric oxygen, as a low oxygen tension definitely has negative effects
on tissue repair

78. Hyperbaric oxygen therapy (HBO) :
• HBO  Elevates the partial pressure of oxygen in the tissues.
• Granstrom G (1998)  HBO can counteract some of the
negative effect from irradiation and act as a stimulator for
osseointegration.
• Role of HBO in osseointegration
– Bone cell metabolism
- Bone turnover
- Implant interface and the capillary
network in the implant bed (angiogenesis)

79. SURGICAL
CONSIDERATIONS

80. Objective:
Minimum tissue violence – osseointegration
 Controlled surgical technique
 Surgical skill / technical excellence
• Profuse irrigation for continuous / Adequate cooling
•Use of well sharpened drills and use of graded series of drills
 Violent surgical techniques
the critical time/temperature relationship for bone tissue
necrosis is around 47 °C applied for 1 min.

81. I
M
P
L
A
N
T
L
O
A
D
I
N
G

82. Loading condition
Objective : “No loading while healing”  successful
osseointegration.
Movement of the implant within the bone – fibrous tissue
encapsulation rather than osseointegration.
Premature loading
leads to implant
movement
The end result
“Soft tissue
interface”
“Bony interface”

83. Branemark, Albrektson – two stage implant insertion.
First stage – Installation of fixture into bone
Second stage – Connection of abutment to the fixtures
Maxilla 6 months
Mandible 3 months
Misch – Progressive / Gradual loading
Different Philosophies regarding Loading conditions
Suggested in
Softer bone
less number of implants to be used

84. Immediate functional loading protocol
Clinical trials successful osseointegration
(95-100% success rate- Completely edentulous patients)
 Bone quality is good
Functional forces are controlled
More favourable in mandible compared to maxilla
Over loading – Stress concentration, undermining bone
resorption without apposition (Branemark 1984)
To decrease the bio mechanical load
Prosthetic design considerations
Cantilever length may be shortened or eliminated
Narrow occlusal table
Minimizing the offset load
Increasing the implant number
Use of wider implant with D4 bone compared to D1 & D2

85. METHODS OF EVALUATION OF OSSEOINTEGRATION
Invasive method
•Histological section
•By using torque gauges
•TEM (transmission electron microscopy)
•Pullout test
•Histomorphometric

86. Non-invasive methods :
•Radiographs
•Periotest
•Reverse torque

87. RESONANCE FREQUENCY ANALYSIS
•Uses an L shaped trandducer screwed to an implant or abutment
•Transducer beam excited over a range of frequencies 5 to 15 KHZ
•Four generations
•1.measuring element transducer
•2.frequency response analyzer
•3.battery driven , precallibrated from the manufacturer(osstellTM,ossteell AB
(1-lowest stability, 100- highest stability)
4.Wireless with a metal rod or peg attached to implant by screw connection.peg has a
small magnet at its top.The peg vibrates in two directions – one in the highest frequency
mode and other in the lowest frequency mode.

88. CRITERIA FOR IMPLANT SUCCESS
1. Individual unattached implant is immobile when tested
clinically.
2. No evidence of peri implant radiolucency is present as
assessed on an undistorted radiograph.
3. Mean vertical bone loss is less than 0.2 mm after 1st year
of service.
4. No persistent pain, discomfort or infection.
5. A success rate of 85% at the end of a 5-year observation
period and 80% at the end of a 10-year period are mini-
mum levels of success

89. RECENT ADVANCES

90. Hydrophilic Implants
SLActive dental implants (Straumann Holding AG, Basel,
Switzerland),
• The degree of hydrophilicity has been enhanced by
rinsing under nitrogen protection and storage in saline
solution.

91. Photofunctionalization
• Uv treatment of dental implant surfaces enhances bioactivity and osseointegration
• By altering the titanium dioxide on the surface.
• Uv treatment reduces the degree of surface hydrocarbon and increases surface energy and wettability
• Promoting interactions of cells and proteins to the implant on a molecular level, uv light is believed to
enhance the osteoconductivity

92. Extracellular Matrix Proteins
Dental implants coated with extracellular matrix proteins
have shown a positive effect on peri-implant bone
formation in preclinical studies
Anti bacterial peptides
peri-implantitis is the main cause of long-term implant failure
GL13K has been derived from a defense protein found in saliva and
has proven biocompatibility and antibacterial function on titanium discs in a Porphyromonas gingivalis model
Human beta defensins (HBDs) are peptides that convey antibacterial effects on epithelial borders

93. Drug Coatings
HA coatings have been successfully used as local drug delivery systems.
• Statins inhibit the HMG-CoA reductase and are prescribed in dyslipidemia.
• When incorporated in the implant surface, statins have been claimed to trigger the local
liberation of BMPs, thus promoting osseointegration
• Bisphosphonates antiresorptive drugs to treat osteoporosis
• Peter et al. demonstrated in a rat model that implants with a Zolendronate containing HA
coating yield a higher peri-implant bone density and promote increased mechanical fixation.
• In an osteoporotic rat model, Stadlinger et al. demonstrated increased BIC and a higher level
of bone mineralization of Zolendronate loaded implants

94. FAILURE OF OSSEOINTEGRATION
• Sign and symptoms
1. Horizontal mobility beyond 0.5 mm or any clinically observed vertical
movement under less than 500 gm force
2. Rapid progressive bone loss regardless of the stress reduction and
periimplant therapy .
3. Pain during percussion or function
4. Continued uncontrolled exudate in spite of surgical attempts at
correction.

95. 5. Generallised radiolucency around an implant
6. More than one half of the surrounding bone is lost around an implant
7. Implant insertion in poor position, making them useless for prosthetic
support

96. SUMMARY
• osseointegration is a term to describe a direct
bone to implant interface observed in
experimental and clinical investigations. This
bony interfacial reaction differed from that with
intervening fibrous tissue, regarded as an
inevitable result when a metal device is inserted
in bone.
• An initial necrotic border zone is nevertheless
inevitable around a dental implant. This necrotic
border zone must heal with highly differentiated
bone tissue instead of fibrous tissue if proper
bone integration is to ensue.