osseointegration /cosmetic dentistry courses

Endosseous osseointegrated dental implant
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

Contents :
Historical reviewHistorical review
Development of concept of osseointegrationDevelopment of concept of osseointegration
DefinitionsDefinitions
Scope of osseointegrationScope of osseointegration
Fibrointegration Vs OsseointegrationFibrointegration Vs Osseointegration
Ultra structure of osseointegrationUltra structure of osseointegration
Biology of OsseointegrationBiology of Osseointegration

Mechanism of osseointegration
 Contact osteogenesis vs distant osteogenesis
Anchorage mechanism or Bonding mechanism
 Biomechanical bonding
 Biochemical bonding

Key factors responsible for successful
osseointegration
Success criteria of implants
Clinical evaluation of osseointegration

Invasive methods

Non invasive methods
Failure and loss of osseointegration
Conclusion
References

HISTORICAL REVIEWHISTORICAL REVIEW

500 BC – Etruscan population

600 AD – Mayan population
“First evidence of use of implants”

1700 – John hunter → “Transplantation”
Transmission of various diseases

1809-Maggiolo
Gold roots
1939-Strock
Vitallium screw

1943 - Dahl 1948 - Goldberg and Gershkoff
Subperiosteal implant

Consistent failures :
1960 – Linkow Blade vent implant

 Inflammatory reaction
 Gradual bone loss
 Fibrous encapsulation

“CONCEPT OF OSSEOINTEGRATION”
Dr. Per-Ingvar Branemark
Orthopaedic surgeon
Professor University of Goteburg, Sweden.
Threaded implant design made up of pure titanium.

Integrated titanium fixture
1952 vital microscopic studies
(Bone marrow of rabbit fibula)
“Osseointegration”
Optical chamber
(Bone marrow of rabbit fibula)

Integrated titanium fixture
Repair of major mandibular and tibial defects.
Clinical Study
Development of procedures for rehabilitation of edentulism :

Experimental study in dogs

Subperiosteal and
Soft tissue
reaction
Use of titanium fixtures
Transosseous
First experimental study

Two stage procedure

Evidence for osseointegration
Macroscopic level
Histological level
Radiological level

Intact bone to
implant surface
Intact bone to
implant surface

Basic research 1952 to 1965 → 13-15 year extensive research
1965 → First clinical evidence of implant insertion
“Edentulous human patient for resorbed edentulous ridge”

DefinitionsDefinitions
“The apparent direct attachment or connection of osseous tissue to
an inert, alloplastic material without intervening connective tissue”.
- GPT 8
Structurally oriented definition :
“Direct structural and functional connection between the ordered,
living bone and the surface of a load carrying implants”.
- Branemark and associates (1977)

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)

Clinically :
Ankylosis of the implant bone interface.
-Schroeder and colleagues 1976
“functional ankylosis”
“It is a process where by clinically asymptomatic rigid fixation
of alloplastic material is achieved and maintained in bone during
functional loading”
- Zarb and T Albrektson 1991

Biomechanically oriented definition :
“Attachment resistant to shear as well as tensile forces”
- Steinmann et al (1986).

Scope of osseointegration in dentistry
1) Prosthetic rehabilitation of missing teeth
Complete edentulous maxilla and mandible rehabilitation.
Removable prosthesisFixed prosthesis

Single tooth replacementPartial dental loss 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.

 “ Fibrous integration as tissue to implant contact with
interposition of healthy dense collagenous tissue between the
implant and bone”.
 “Direct bone to implant interface without any intervening
layer of fibrous tissue”.
FIBROINTEGRATION
Vs
Concept of Bony
Anchorage
Branemark (1969)
Concept of soft tissue
anchorage
Linkow (1970), James (1975),
Weiss (1986).
OSSEOINTEGRATION

Fibro-Osseousintegration :
“Pseudoligament”, “Periimplant ligament”, “Periimplant
membrane”.
Hypothesis – Collagen fibers function similar to the sharpeys
fibers in the natural dentition.
Fact : The histological difference between the sharpeys fibers and
collagen fibers around the implant.

Natural teethNatural teeth ImplantImplant
Oblique and horizontalOblique and horizontal
group of fibersgroup of fibers
Parallel, irregular,Parallel, irregular,
completecomplete
encapsulationencapsulation
Uniform distribution ofUniform distribution of
load (load (Shock absorberShock absorber))
Difficult to transmitDifficult to transmit
the loadthe load
Failure : Inability to carry adequate loads - Infection

Parallel fiber
arrangement
Complete fiber
encapsulation

Fibrosseousintegration Osseointegration

ULTRASTRUCTURE OF OSSEOINTEGRATION
Soft tissue
interface
Cortical
bone
Spongy
bone

Biology of Osseointegration (Branemark)

Mechanism of osseointegration
PhasePhase TimingTiming Specific occurrenceSpecific occurrence
11.. InflammatoryInflammatory
phasephase
Day 1-10Day 1-10 Adsorption of plasma proteinsAdsorption of plasma proteins
Platelet aggregation and activationPlatelet aggregation and activation
Clotting cascade activationClotting cascade activation
Cytokine releaseCytokine release
Nonspecific cellular inflammatoryNonspecific cellular inflammatory
responseresponse
Specific cellular inflammatorySpecific cellular inflammatory
responseresponse
Macrophage mediated inflammation.Macrophage mediated inflammation.

2.2. Proliferative phaseProliferative phase Day 3 - 42Day 3 - 42 NeovascularizationNeovascularization
Differentiation, ProliferationDifferentiation, Proliferation
and activation of cells.and activation of cells.
Production of immatureProduction of immature
connective tissue matrix.connective tissue matrix.

3.Maturation3.Maturation
phasephase
AfterAfter
day 28day 28
Remodeling of the immature bone matrixRemodeling of the immature bone matrix
with coupled resorption and deposition ofwith coupled resorption and deposition of
bone.bone.
Bone remodeling in response to implantBone remodeling in response to implant
loadingloading
Physiological bone recession.Physiological bone recession.

Contact osteogenesis vs distant osteogenesis
Osborn and Newesley (1980) : Proposed 2 different phenomena
Distant osteogenesis

Contact osteogenesis

Contact Osteogenesis
Relies on Migration of
Differentiating Osteogenic cell
to Implant surface
Undifferentiated
Perivascular connective cells
Differentiating Osteogenic cells

Key factors responsible for
successful osseointegration
Implant material
biocompatibility
Loading
conditions
Implant design
characteristic
Implant surface
characteristic
State of the implantation or
host bed
Surgical
considerations

IMPLANT
MATERIAL
BIOCOMPATIBILITY

Implant materials
Metals Ceramics Polymers
Chemical composition
Biological compatibility
Bio inertBio tolerant Bio active

BiologicalBiological
biocompatibilitybiocompatibility
Chemical compositionChemical composition
MetalsMetals CeramicsCeramics PolymersPolymers
BiotolerantBiotolerant GoldGold PolyethylenePolyethylene
Cobalt-chromiumCobalt-chromium
alloysalloys
PolyamidePolyamide
Stainless steelStainless steel PolymethylmethacrylatePolymethylmethacrylate
ZirconiumZirconium PolytetrafluoroethylenePolytetrafluoroethylene
NiobiumNiobium PolyurethanePolyurethane
TantalumTantalum
BioinertBioinert Commercially pureCommercially pure
titaniumtitanium
Aluminum oxideAluminum oxide
Titanium alloy (Ti-Titanium alloy (Ti-
6Al-4V)6Al-4V)
Zirconium oxideZirconium oxide
BioactiveBioactive HydroxyapatiteHydroxyapatite
TricalciumTricalcium
phosphatephosphate
CalciumCalcium
pyrophosphatepyrophosphate
FluorapatiteFluorapatite
Carbon:vitreous,Carbon:vitreous,
pyrolyticpyrolytic
BioglassBioglass

Metals
Commercially pure titanium (CPTi) : 99.75%
Most biocompatible material → excellent long term clinical function
Adherent, self repairable
titanium dioxide (TiO2/
TiO) passivated layer.
(10A0
within seconds,
100A0
within a minute.)

Steinman (1988) referred this layer as Biologically inert
On Histological investigation → intimate contact
between the titanium surface and the periimplant
bone.
(Branemark 1977, Alberktsson et al 1984)
Chemical purity, surface cleanliness - Osseointegration

Titanium alloys : Ti6Al4V(90%Ti, 6% Al, 4% V)
Johanson (1992) - Cp titanium higher torque removal values than
Ti6Al4V screw 23 vs 16 N/cm.
- Higher bony contacts 59 vs 50% after 3 months
implant insertion
Experimental investigation at 3, 6 and 12th
months
Significantly stronger bone reaction to Cp Ti
Retarded bone formation around the Ti6Al4V→ leaked out Al
ion competing with calcium during early stage of calcification
causing osteomalacia

Tantalum and Niobium : High degree of
osseointegration
 There was evidence of exaggerated macrophage
reaction compared to Cp titanium.

CERAMICS
(Calciumphosphate hydroxyapatite, Al2O3, Tricalcium phosphate)
• Makeup the entire implant
• Applied in the form of coating
• Hydroxyapatite coated implant
• Gottlander 1994 – short term and longterm reaction
Short term reaction – Positive, enhanced interfacial bone formation
Long term reaction – Cp titanium 50-70% more interfacial bone
compared to HA coated.
• Hahn J (1997) HA coated implant – 97.8%(6 yrs) clinical success.

Matter of concernMatter of concern
HA coating loosening – macrophage activation and
bone resorption
Beisbrock & Edgertson – Microbial adhesion,
Osseousbreakdown, coating failure.

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

IMPLANT
DESIGN
CHARACTERISTIC

Implant Design characteristics :
Implant design refers to the three dimensional structure of the
implant.
Form, shape, configuration, geometry, surface macrostructure,
macro irregularities.
Cylindrical Screw shaped implants.

Threaded Non threaded.

“Precision fit in the vital bone” → Osseointegration
Cylindrical implants / press fit implants :
Severe bone resorption
Lack of bone steady state – micro movements
Alberktsson 1993 – continuing bone saucerization of 1mm -first
year, 0.5mm anually and thereafter increasing rate of resorption
upto 5 year follow up.

Threaded implants
Documentation for long term clinical
function.
Alteration in the design, size and pitch of
the threads can influence the long term
osseointegration.

Advantages of threaded implants
More functional area for stress load distribution than the
cylindrical implants.
Threads improves the primary implant stability avoids
micro movement of the implants till osseointegration
is achieved.

Non threaded
Tendency for slippage
Bonding is required
 No slippage tendency
 No bonding is required
Threaded

IMPLANT SURFACE
CHARACTERISTIC

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

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

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

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

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

Machined / turned surfaces : gold standard.
Moderately rough implant surfaces
• Roughness parameter (Sa)
0.04 –0.4 µm - smooth
0.5 – 1.0 µm – minimally rough
1.0 –2.0 µm – moderately rough
> 2.0 µm – rough
: For faster & firmer bone integration
0

 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 µm will – soft tissue
→no bone cell adhesion → clinical failure.
 Moderately rough surface more bone in
contact with implant → better osseointegration.

• 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 µm will – soft tissue →no bone
cell adhesion → clinical failure.
Moderately rough surface more bone in contact with
implant → better osseointegration.

Carlsson et al 1988, Gotfredsen (2000) – positive correlation
between increasing surface roughness and degree of implant
incorporation (osseointegration).
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

Machined / turned surface
SEM x 1000 SEM x 4700
Cp Titanium
Surface roughness profile 5 µm

Titanium plasma sprayed coating (TPS)
The first rough titanium
surface introduced
Coated with titanium powder
particles in the form of
titanium hydridePlasma flame spraying technique

 6-10 times increase
surface area. (Steinmann
1988, Tetsch 1991)
Roughness Depth profile of about 15µm

Hydroxyapatite coatings
HA coated implant bioactive
surface structure – more rapid
osseous healing comparison
with smooth surface implant.
↓
Increased initial stability
Can be Indicated
- Greater bone to implant
contact area
- Type IV bone
- Fresh extraction sites
- Newly grafted sites
SEM 100X

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 NaOH, Aq. Nitric acid,
hydrofluoric acid.
Decrease in contact angle by 100
– better
cell attachment.
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

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 300SEM x 70

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.
Charge affects the hydrophilic and hydrophobic
characteristic of the surface.
A hydrophilic / easily wettable implant surface :
Increases a initial phase of wound healing.
Fact : Increase surface energy would disappear
immediately after implant placement

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.

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.
Based on :
• Design characteristic → Macrostructure
(Threads, vent, slots)
• Surface characteristic → Microstructure.
(Chemical surface treatmentwww.indiandentalacademy.comwww.indiandentalacademy.com

Surface roughness at the micrometer level / nanometer level
Requirement :
Minimum size of
•50-100µm cavities or pores
→ complete bone tissue
(ground substance + cellular
components + Haversian
system)
• 1-10µm for calcified bone
ground substance.
? At nanometer level - no experimental evidence
Some investigators – nanometer size rough surface can carry proper
load. www.indiandentalacademy.comwww.indiandentalacademy.com

Biochemical bonding
Seen with certain bioactive implant
surfaces like :
• Calcium phosphate coated implant surfaces
• HA coated implant surfaces
• Oxidized/ anodized surfaces
Bone bonding / Bonding osteogenesis
Biointegration :
•“Strong chemical bond may develop between the host bone
and bioactive implant surfaces and such implants are said to be
biointegrated”. www.indiandentalacademy.comwww.indiandentalacademy.com

Doped surfaces that contain various types of bone growth factors or
other bone-stimulating agents may prove advantageous in
compromised bone beds. However, at present clinical documentation
of the efficacy of such surfaces is lacking : BMP = Bone
morphogenetic protein.
Doped surfaces

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

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

•Factors compromising the bone quality
Infection ,Irradiation & Heavy smoking
Schnitman et al (1988) – lower success rate in posterior mandible
compared to anterior mandible
- posterior maxilla higher failure rates.

LEKHOLM 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

According to Branemark and Misch
D1 and D2 bone → initial stability / better osseointegration
D3 and D4 → poor prognosis
D1 bone – least risk
D4 bone - most at risk

Jaffin and Berman (1991) – 44% failure in type IV bone
Selection of implant
D1 and D2 – conventional threaded implants
D3 and D4 – HA coated or Titanium plasma coated implants

Osteopromotion :
Procedure to enhance the formation of bone
approximating the implant surface :
• Bone regeneration techniques (using PTFE membrane)
• Bone growth factors like PDGF, IGF, PRP, TGF-B1 →
stimulates osteoprogenator cells, enhance the bone growth.

 Stefini CM et al (2000) recommend to apply PDGF and IGF on
the implant surfaces before placing into cervical bed. This method
showed better wound healing and rapid osseointegration.

Indications :
1) Localized ridge augmentation prior to implant placement
2) Treatment of periimplant bone defect.
Exposed implant
surface
PTFE membrane Regeneration of bone
Increased bone to implant contactwww.indiandentalacademy.comwww.indiandentalacademy.com

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

Age :
Old age – no poorer result.
Extreme young age - Relative contraindication to insertion of
implants.
Infrapositioning of implant because of alveolar growth
Wait till the completion of growth.

 Bone anchored hearing aids
Maxillofacial deformities : implant placement is delayed
until the child is at puberty.
Only in selected cases
ex: Ectodermal dysplasia
Anterior part of the jaw + over denture therapy.
2-3 year old child.www.indiandentalacademy.comwww.indiandentalacademy.com

Smoking and osseointegration :
• History of smoking affect 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.

Radiation therapy and osseointegration :
• Jacobson (1985) previous irradiation – relative contraindication
for implant placement.
• Expected success rate 10-15% lower than the non irradiated
patients.
Number of factors to be considered :
• Dose and fraction of irradiation
• Timing from radiotherapy to implant surgery
• Anatomic region in which the implant to be inserted
• Loading factors and handling of the soft tissue.
• Johnson (1987) Surgical risk → 1m before and 6m after,
Low risk → 6m to 1.5 yr
Increased risk → there after.

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)

SURGICAL CONSIDERATIONS

 Violent surgical techniques
Objective:
Minimum tissue violence – osseointegration
Controlled surgical technique
Surgical skill / technical excellence

Use of well sharpened drills and use of graded series of drills
• Profuse irrigation for continuous / Adequate cooling
Parameters :

Slow drill speeds
Proper drill geometry
Intermittent drilling
Eriksson R.A :
Drill speed < 2000 rpm, tapping at 15 rpm.
Cooling during tapping and insertion of screw
Others
Cooling the irrigants
Using internally irrigated drills
Violent surgical technique
Frictional heat / overheating → increased temperature
rise in bone → wide zone of necrosis → fibrous tissue,
primary failure of osseointegration.

Critical temperature for bone necrosis
• Previously 560
to 700
for 1 min.
• 560
C critical temperature for bone necrosis → Irreversible bone
damage.
• Recently 47 0
C for 1 min.
Denaturation of alkaline phosphate enzyme → inhibition of
Alkaline Ca synthesis → Loss osseointegration (Erickson 1986,
Albrektsson 1984)

Insertion torque
 Insertion torque is high – removal torque is low.
Poor osseointegration
 High torque if used → stress / compression in bone
 Holding power of implant will fall.
45 N/cm
Moderate torque should be used

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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”

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

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

Success criteria of implants
Schuitman and Schulman criteria (1979)
1) The mobility of the implant must be less than 1mm when
tested clinically.
2) There must be no evidence of radiolucency
3) Bone loss should be less than 1/3rd
of the height of the
implant
4) There should be an absence of infection, damage to structure
or violation of body cavity, inflammation present must be
amneable to treatment.
5) The success rate must be 75% or more after 5 years of
functional service.

Albrektson and Zarb G (1980)
1) The individual unattached implant should be immobile when
tested clinically
2) The radiographic evaluation should not show any peri - implant
radiolucency
3) Vertical bone loss around the fixtures should be less than
0.2mm annually after first year of implant loading.
4) The implant should not show any sign and symptom of pain,
infection, neuropathies, parastehsia, violation of mandibular
canal and sinus drainage.
5) Success rate of 85% at the end of 5 year observation period and
80% at the end of 10 year service.
6) Implant design allow the restoration satisfactory to patient and
dentist. - Smith and Zarb (1989)

METHODS OF EVALUATION OF OSSEOINTEGRATION
Invasive method
• Histological section
• By using torque gauges
•Pullout test
• Histomorphometric

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

•Resonance frequency analysis
•Impulse testing

References :
1.Osseointegration in clinical dentistry – Branemark, Zarb,
Albrektsson
2.Osseointegration and occlusal rehabilitation – Sumiya
Hobo
3.Contemporary Implant Dentistry – Carl E.Misch
4.Endosseous implants for Maxillofacial reconstruction –
Block and Kent
5.Implants in Dentistry –Block and Kent
6.Dental and Maxillofacial Implantology – John. A.
Hobkrik, Roger Watson

6.Endosseous Implant : Scientific and Clinical
Aspects – George Watzak
7.Optimal Implant Positioning and Soft Tissue
management – Patrik Pallaci
8.Osseointegration in craniofacial reconstruction-
T. Albrektssson.
9.Osseointegration in desntistry : an introduction :
Philip Worthington, Brein. R. Lang, W.E.
Lavelle.

Schroeder et alSchroeder et al.,(1981).The reactions of bone, connective.,(1981).The reactions of bone, connective
tissue, and epithelium to endosteal implants with titanium-tissue, and epithelium to endosteal implants with titanium-
sprayed surfaces.sprayed surfaces. Journal of Maxillofacial Surgery 9,15-Journal of Maxillofacial Surgery 9,15-
25.25.
Adell et alAdell et al.,(1981). A 15 year study of osseointegrated.,(1981). A 15 year study of osseointegrated
implants in the treatment of edentulous jaw.implants in the treatment of edentulous jaw. InternationalInternational
journal of Oral Surgery 6,387-399.journal of Oral Surgery 6,387-399.
Zarb & SymingtonZarb & Symington (1983).Osseointegrated dental implants:(1983).Osseointegrated dental implants:
preliminary report on a replication study.preliminary report on a replication study. Journal ofJournal of
prosthetic dentistry 50,271-279.prosthetic dentistry 50,271-279.
Albrektsson et alAlbrektsson et al.,(1986).The long-term efficacy of currently.,(1986).The long-term efficacy of currently
used dental implants: a review and proposed criteria forused dental implants: a review and proposed criteria for
success.success. International journal of Oral and MaxillofacialInternational journal of Oral and Maxillofacial
ImplantsImplants 1,11-25.1,11-25.

Johansson & AlbrektssonJohansson & Albrektsson. (1987) Integration of screw implants. (1987) Integration of screw implants
in the rabbit. A 1- year follow-up of removal of titaniumin the rabbit. A 1- year follow-up of removal of titanium
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