International Journal Dental and Medical Sciences Research

Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

Osseointegration – A Dynamic Process

Dr. Harsha Hardiya1, [Link] Saha2, [Link] Kumari3
1
Post graduate student, Department of Prosthodontics, Crown and Bridge and Implantology, College of Dental
Science and Hospital, Indore
2
Professor and Head, Department of Prosthodontics, Crown and Bridge and Implantology, College of Dental
Science and Hospital, Indore
3
Post graduate student, Department of Prosthodontics, Crown and Bridge and Implantology, College of Dental
Science and Hospital, Indore

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Submitted: 01-03-2021 Revised: 09-03-2021 Accepted: 12-03-2021
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ABSTRACT:The efficacious replacement of lost implant. After a period of 3 to 6 months, woven
natural teeth by tooth root analogues i.e. implants is bone is reintegrated by lamellar bone which acquire
a prime attainment in the field of dentistry, this sufficient strength for load bearing. This bone
immensely depends on adequate integration of healing process is termed as osseointegration.
these implants within the bone. This bone-implant Development of this interface is convoluted and
integration is known as osseointegration. The involves diverse factors. These incorporate not only
science of osseointegration has become an accepted implant related factors and surface chemistry but
and proven treatment for edentulism. This paper also surgical technique and bone factors.[3]
reviews the concept of osseointegration.
KEY WORDS: Implants, osseointegration, bone- II. OSSEOINTEGRATION CAN BE
implant interface, bone denstity, Implant stability DEFINED AS:
“A direct connection between living bone and a
I. INTRODUCTION load-carrying endosseous implant at the light
Dental implants are used as treatment microscopic level.” –Branemark
modality for missing teeth owing to the fact that 1. The apparent direct attachment or connection of
they function as artificial roots onto which a osseous tissue to an inert, alloplastic material
prosthesis may be anchored. [1] The utmost without intervening fibrous connective tissue;
compelling and important advancements in 2. The process and resultant apparent direct
dentistry by Professor Per- Ingvar Branemark and connection of an exogenous material’s surface and
his colleagues was the discovery of the host bone tissues, without intervening fibrous
osseointegration and its application to clinical connective tissue present;
dentistry.[2] A poorly organized woven bone is 3. The interface between alloplastic materials and
formed that have a somewhat low inherent strength bone. -G.P.T. 9
at the interface immediately after insertion of an

III. HEALING OF DIFFERENT BONE DENSITIES[4]:

Bone density Location Features Ideal healing Bone-
time implant
contact
D1 bone Anterior The cortical 3-4 months 80%
(Compact cortical bone) mandible bone
requires
greater
healing
time
because of
poor blood
circulation
compared
with
trabecular
bone.
DOI: 10.35629/5252-0302186191 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 186
 International Journal Dental and Medical Sciences Research
Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

Healing
occurs by
formation
of lamellar
bone
interface
D2 bone (Thick compact to Anterior and The 4 months 70%
porous cortical bone on the posterior excellent
crest and coarse trabecular mandible blood
bone within) supply of
trabecular
bone and
rigid initial
fixation
permits
adequate
bone
healing.
D3 bone Anterior The actual 6 months 50%
(Thin porous cortical bone maxilla implant
on the crest fine trabecular interface
bone within) develops
more
rapidly than
D2 bone.
D4 bone Posterior The healing months <25%
(Fine trabecular bone) maxilla and
progressive
bone
loading
sequence
for D4 bone
requires
more time
than any
other three
types D1,
D2 and D3.

IV. THEORY OF OSSEOINTEGRATION repair.[6] Osseointegration follows a common,

There are two theories concerning the bone-implant biologically determined program, once activated.
interface : Three stages of osseointegration are as follows:
1. Fibro-osseous integration proposed up by 1. Incorporation by woven bone formation;
Linkow (1970), James (1975), and Weiss 2. Adaptation of bone mass to load (lamellar and
(1986).[5] parallel fibered bone deposition);
2. Osseointegrationsupported by 3. Adaptation of bone structure to load (bone
Branemark(1985).[4] This was first described remodeling).
by Strock in early 1939 and later by
Branemark et al in 1952.
VI. IMPLANT TISSUE INTERFACE
V. STAGES OF OSSEOINTEGRATION The tissue-titanium-implant interface may be
Osseointegration is activated by any lesion divided into three main zones.
of the pre-existing bone matrix, as direct bone 1. Implant and bone interface
healing, occurs in defects. Growth factors and non- 2. Implant connective tissue interface
collagenous proteins are set free when the matrix is 3. Implant epithelial interface
exposed to extra cellular fluid and activate bone
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 International Journal Dental and Medical Sciences Research
Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

[Link] FACTORS FOR SUCCESSFUL IMPLANT OSSEOINTEGRATION

(ALBREKTSSON, 1983)[7]:
1)IMPLANT 1. Metals like commercially pure (c.p)
BIOCOMPATIBILITY: titanium and possibly tantalum are well accepted
in bone as they are self-repairing and corrosion
resistant to oxide layer.

2. Metals like cobalt-chrome-molybdenum

alloys, stainless steels & titanium alloys are less
well tolerated by bone.

3. Ceramics and aluminum oxides due to

insufficient documentation and very less clinical
trials are less commonly used.
2) IMPLANT DESIGN: 1. Threaded implants provide more
functional area for stress distribution than the
cylindrical implants and provide better primary
anchorage.

2. 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.

3. Longer the length, better the primary

stability.

4. Wide diameter implants transmit less

stress on crestal bone than narrow implants.

5. Platform-switching concept also

preserves the marginal bone loss. This design uses
a narrow diameter abutment over a wide diameter
implant which provide a biomechanical advantage
by shifting the stress concentration area away from
the cervical bone-implant interface.
1. Surface topography relates to the
3) IMPLANT SURFACE: orientation of surface irregularities and degree of
roughness of the surface.

2. Advantages of increased surface

roughness

a. Increased surface areas of the implant to

bone so increased bone at implant surface.

b. Increased biomechanical interaction with

bone of the implant.

3. Smooth surfaces result in unacceptable

bone cell adhesion and clinical failure.
4) STATE OF THE HOST 1. Previous irradiation: - relative
BED: contraindication. However some delay is
preferable before implant placement.

2. Low ridge height and resorption and

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 International Journal Dental and Medical Sciences Research
Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

Osteoporosis: - an indication for ridge

augmentation with bone grafts before / during
implant placement.

3. Infection

4. Bone quality: - As stated by Branemark et

al. and Misch, D1 and D2 bone densities shows
good initial stability and better osseointegration
while D3 and D4 shows poor prognosis.
5)SURGICAL 1. Optimum surgical procedure to promote
CONSIDERATIONS: regenerative type of the bone healing rather than
reparative type of the bone healing (Erickson
R.A.)

2. Drilling technique – graduated protocol

(more drills)

3. Irrigation – copious amount of 0.9 %

NaCl
a. -To prevent bone tissue necrosis

4. Slow drill speed (less than 2000 rpm with

irrigation).

5. A moderate power used at implant

insertion

VIII. FACTORS AFFECTING OSSEOINTEGRATION[8]

Factors enhancing osseointegration Factors inhibiting osseointegration
Macrogeometry of the implant body Excessive implant mobility and
micromotion
Titanium coating on Co-Cr metal implant NSAIDS especially selective COX-2
inhibitors, warfarin and heparins
Laser Lithography Radiation
Transcription factor Sp7 Rheumatoid arthritis, Osteoporosis
Bone source augment to socket Smoking
Mechanical stability and loading conditions Advanced age, nutritional deficiency
applied on the implant and renal insufficiency

Effects of drugs such as simvastatin and Effects of drugs such as cyclosporin

bisphosphonates A, methotrexate and cis-platinum

IX. TECHNIQUES FOR SURFACE MODIFICATION OF IMPLANTS

There are numerous methods used to amend the surface topography of dental implants. These may be
subtractive or additive processes

DOI: 10.35629/5252-0302186191 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 189
 International Journal Dental and Medical Sciences Research
Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

Subtractive processes Additive processes

Acid etching HA coating
Alkaline etching TCP coating (Tri Calcium
Sand blasting Phosphate)
Sand blasting + Acid etching Zirconia coating
Grit blasting Titanium sintering
Titanium blasting Titanium plasma spray
Laser lithography Anodization
Sintered implants

X. METHODS OF EVALUATION OF head that percusses the implant a total of 16

OSSEOINTEGRATION times. The entire measuring procedure takes
Invasive methods - Which interferes with about 4 s.
osseointegration process of implant 5. Resonance frequency analysis: It measures
1. Histomorphometric: This is attained from a implant stability and bone density at distinct
dyed specimen of the implant and peri-implant time points using vibration and structural
bone by evaluating theperi-implant bone principle analysis. The implant stability
quantity and bone-implant contact (BIC). quotient (ISQ) ranges between 40 and 80, the
2. Precise measurement is an advantage, but, it is higher the ISQ, the higher the implant stability.
not desirable for long-term studies. It is used in
the nonclinical studies and experiments due to XI. NEWER METHODS TO ASSESS
the invasive and destructive procedure. IMPLANT STABILITY
3. Tensional test:It was beforehand measured 1. Implatest conventional impulse testing
by detachingthe implant plate from the Conventional impulse testing of an
supporting bone. Bränemark amended it by implant requisites fastening an accelerometer with
applying the lateral load to the implant fixture. associated wires and connectors to the implant,
4. Push-out/pull-out test : It assesses the healing manifesting it with a calibrated hammer, and then
proficiency at the bone implant interface. It recording and explicating the data.
estimates interfacial shear strength by applying Implatest is operator independent
load parallel to the implant-bone interface. It is (independent of the direction or position of test
assessed during the healing period. The push- application on the implant) and data can be
out and pull-out tests are at most useful for garnered in seconds. It incorporates all of the
nonthreaded cylinder type implants, characteristics of a conventional impulse test into a
considering that most of clinically available compact, portable, self-contained probe.[9]
fixtures are of threaded design.
5. Removal torque analysis :It is considered 2. Electro-mechanical impedance method
stable if the reverse or unscrewing torque of Analyses the electro-mechanical
implant is >20 Ncm. Nonetheless, the impedance of piezoelectric materials (work as both
drawback is that the process of sensors and actuators) which is directly associated
osseointegration may fracture under the with the mechanical impedance of the host
applied torque stress at the time of abutment structure.[10]
connection implant surface. Piezoelectric zirconatetitanate (PZT) is
Non-invasive methods - which does not interfere combined to the monitored structure and begins to
with osseointegration process vibrate after applying a voltage in 1 V in the kHz
1. Percussion test: An osseointegrated implant range. Furthermore, transition of structural
produce a ringing sound on percussion while characteristics such as damping, mass distribution,
an implant that has undergone fibrous would impact the reading electrical admittance of
integration makes a dull sound. PZT as read by impedance analyzer.
2. Radiographs
3. Reverse torque test: A reverse or unscrewing 3. Micro motion detecting device
torque is enforced to examine implant stability A customized loading device which
at the time of abutment connection. Implants comprise of a digital micrometer and a digital force
are removed that rotate under the applied gauge (range of 10–2500 N) used to regulate
torque and are considered failures. implant micromotion. The forces were achieved by
4. Periotest: It is a device which is an electrically turning a dial, which controlled the height ofthe
driven and electronically monitored tapping force gauge. This dialed in force was applied to the
DOI: 10.35629/5252-0302186191 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 190
 International Journal Dental and Medical Sciences Research
Volume 3, Issue 2,Mar-Apr 2021 pp [Link] ISSN: 2582-6018

abutment via a lever. The digital micrometer was persistent precision in the surgical procedures
placed tangent to the crown of the abutment and involved in installing the titanium fixtures.
detected the displacement after the load
application.[11] REFERENCES
[1]. Sumiya Hobo. Osseointegration and occlusal
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DOI: 10.35629/5252-0302186191 |Impact Factorvalue 6.18| ISO 9001: 2008 Certified Journal Page 191