BONE QUALITY

Another significant factor that affects the outcome of the implant treatment is the quality
of the bone around implants. The increase in bone density improves the mechanical
properties of the interface.
Bone quality is one of the most important factors in the successful osseointegration of
dental implants. The volume and density of bone is known to impact upon implant
success, with reduced volume and lower density increasing the risk of failure.
The classification scheme for bone quality proposed by Lekholm et al. has since been
accepted by clinicians and scientists as the standard criterion in evaluating patients for
implant placement.
Bone Quality relates to the degree of bone density present. Type is dense bone, which
provides great cortical anchorage, but limited vascularity. Type ! bone is the best bone
for osseointegration of dental implants. "t provides good cortical anchorage for primary
stability, yet has better vascularity than Type bone.
Types # and $ are soft bone te%tures with the least success in type $ bone.
Bone quality can improve around a functional osseointegrated dental implant, due to the
positive bone stimulation.
&ood cortical anchorage is necessary for immediate functional loading of dental
implants. "t is agreed that this treatment should be limited to areas of good bone quality.
Lekholm et al. suggested that 'aws with favorable bone quality will allow for good
stabili(ation of the implant fi%ture, poor bone quality give rise to instability of the fi%ture.
)affin and Berman found that only #* of Br+nemark system implants place in type , !
and # bone were lost after ,years, while in type $ bone, failure rates were #,* over the
same period. -everal long.term clinical studies have similarly demonstrated that poor
bone quality were accompanied with higher risk for implant failure.
/or the influences of the bone quality the distributions of ma%imum strains were found
near implant neck for high.density 0type and !1 bone under a%ial and lateral loadings
and low.density 0type # and $1 bone under lateral loading. /urthermore, the low.density
bone was weaker and less resistant to deformation than in any of the other configurations,
this was the reason that ma%imum strains found around the implant base for low.density
bone 0type # and $1 under a%ial loading.

Strain distribution of the alveolar bone with 13 i!lant and with "an"ellous
bone t#!e $ under a%ial loadin&' The a%iu strains
(ere found around i!lant base in the "an"ellous bone'
http233bme.ntu.edu.tw3abc34.34..4.pdf
BONE AN) TISSUE *+A,TIN* NEE)S
Bone and tissue grafting aims to regenerate missing bone and attachment around teeth
sub'ected to long.standing periodontal disease. "n addition, if a tooth has disease, one can
restore or regenerate bone prior to the placement of bridges or implants.
Guided Tissue Regeneration (GTR) refers to procedures that attempt
to regenerate lost periodontal structures 0bone, periodontal ligament, and connective
tissue attachment1 that support our teeth. This is accomplished using biocompatible
membranes, often in combination with bone grafts and3or tissue stimulating proteins.
Guided Bone Regeneration (GBR) refers to procedures that attempt to
regenerate bone prior to the placement of bridges or, more commonly, implants. This is
accomplished using bone grafts and biocompatible membranes that keep out tissue and
allow the bone to grow.
Bone grafting is the procedure of choice for treating deteriorating bone material and
especially for preparing dental implant sites that can lead to successful replacement of
missing teeth, despite the loss of bone mass. Bone grafting procedures were used to
create the required bone structure for the implants.
The combination of the implant and the minimally invasive technique has shown to
dramatically reduce or eliminate the post.operative pain, swelling and bruising oft.times
associated with dental implant placement.
Sinus lift (bone grafting)
"n some individuals there is inadequate bone in the upper molar region for dental implant
placement. This inadequacy can be corrected by a grafting procedure called a 5sinus lift5
or sinus elevation procedure.
Conventional sinus lift
The conventional sinus lift requires the elevation of a large gum flap in order to e%pose
the bone on the side of the upper 'aw. A window is then made and pushed inward to
allow the addition of bone to the top half of the implant.
6e%t, bone is added to the pocket and around the top of the implant as shown below
After addition of the bone, the gum flap is then sewn back in place.
Again, it is the gum flap which causes the pain, swelling and bruising associated with the
sinus lift, not the grafting itself. "n addition, patients undergoing this procedure must not
create pressure within the sinus post operatively for appro%imately one month. "t is
therefore imperative that patients refrain from blowing their nose and must snee(e with
their mouths open for about one month after this type of surgery in order to avoid damage
to the graft.
Minimally invasive sinus lift
The minimally invasive sinus lift procedure differs widely from the conventional
procedure.
After the graft is in'ected, the implant is simply screwed into place.
-welling, bruising or pain is not anticipated since there are no sutures or flaps involved in
this minimally invasive technique. 7qually important is that snee(ing and blowing of the
nose is not an issue when this minimally invasive procedure is employed.
Complex Bone Graft Surgery
The loss of critical 'awbone material, for both upper and lower 0ma%illary and
mandibular, respectively1 can occur for a number of reasons or
causes.
8sing 0autogenous1 bone eliminates a large number of possible
tissue re'ection problems that can routinely occur in certain
types of grafting surgeries. 8sing a person9s bone, via chin
block or ramus grafts, both are simply used to take bone where
there is abundance and move it to where it is needed to provide
volume for supporting an implant. :.rays are used to evaluate
the e%istence of bone deterioration issues. ;hoto, shows mini.
titanium screws that are holding in new grafts in # different locations. There are ! screws
for each block of bone added.
use of -lasa +i"h -rotein 0;<;1 as a method for utili(ing
Bone .or!ho&eni" -roteins 0B=;1 to speed up healing,
promote growth of new tissues and decreasing healing time
during pre.implant site development.
>eficient areas are a result of disuse atrophy, and surgical bone
loss. These sites are e%posed, roughened up to promote bleeding
which is needed to wet the new bone and promote uptake of
nutrition for the newly added bone material.
The ascending ramus or area of bone behind the wisdom teeth
is another site where bone can be harvested and used to create
width and height for new implant placement procedures.
>eminerali(ed free(e dried bone and bovine bone can be used
in special applications that eliminates the use of artificial
fillers that some implant specialists often use.
<eflecting the gums under the lower teeth e%poses the
mental nerves, and allows the dentist to see the proposed
si(e of an area for bone harvesting once these anatomical
sites are identified, small perforations are made to outline
the grafting margins.
Then the dots are connected, the appropriate si(ed area of
needed bone is removed.
-mall holes are then drilled in the bone for small titanium
screws that affi% the bone to the desired surgical site.
The sectioned mandibular graft, ready for removal will insure adequate bone for the new
site.
This is a painless procedure, with bone filling in the area,
through self.regeneration, in a few short months.
There is no pain, during or after the procedure, according to several patients that have
undergone the procedure.
-light bruising and swelling is normal post operative sequel, but are short in duration.
Titanium screws are small and will be removed at the ne%t stage
of surgery during implant placement. The screw holes will also
fill in with newly generated bone, over time.
The key to long term successful implant placement is having
enough bone to hold the implants during function.
+I)*E )E,I/IEN/IES01A+) AN) SO,T TISSUE
Ridge deficiencies
-evere alveolar deficiencies can prevent ideal implant placement. =anagement of
osseous defects often necessitates autogenous bone grafting.
?lassification of Alveolar <idge >efects
Alveolar rid&e defe"ts "an be "lassified into three &eneral "ate&ories2
/lass I @ Buccolingual loss of tissue with normal ridge height in an apico.
coronal dimension
/lass II @ Apico.coronal loss of tissue with normal ridge width in a
buccolingual dimension
/lass III @ ?ombination buccolingual and apico.coronal loss of tissue
resulting in loss of normal height and width
http233www.worlddent.com3!AAA3AB3articles3levine.%mlCpageD!
The management of alveolar ridge deficiencies poses a challenge for tooth replacement
with dental implants.
The replacement of missing hard and soft tissues is critical not only to the esthetic
outcome but also to the biomechanical support of the prosthesis. The development of
anterior guidance may contribute to the generation of unfavorable moment forces on
ma%illary anterior implants. This is especially true when the volume of the alveolar
deficiency is replaced by the prosthesis instead of considering ridge augmentation.
<idge augmentation techniques available for implant placement in the anterior ma%illa
include nasal floor elevation, bone spreading, bone grafting, guided bone regeneration,
and3or combinations of these procedures. The morphology of an osseous defect is an
important consideration in the selection of an augmentation method
&uided bone regeneration 0&B<1 techniques have been used during implant placement or
staged with implant placement after bone formation.

Ehen implants are placed
simultaneously with guided bone regeneration, the best results are obtained when treating
circumferential or vertical dehiscent type defects, with less predictable osseous gains
found in a hori(ontal dimension.
The staged technique of implant placement following bone regeneration has the
advantages of
01 A larger available osseous surface contributing to bone formationF
0!1 Allowing improved implant alignmentF
0#1 ;ermitting better initial stability of the implantF
0$1 "ncreased maturation of the new bone with probable improved apposition to the
implant surface. Buser et al have suggested that the staged approach be used for treating
large bone defects and the simultaneous approach used for smaller defects. The staged
technique has the disadvantage of a long healing period before implant placement 0G
months1 and a poorer bone quality of the regenerated tissue, unless corticocancellous
autologous bone grafts are used beneath the membrane.
-tudies suggest that membranous bone grafts show less resorption than endochondral
bone grafts. Although cancellous grafts revasculari(e more rapidly than cortical grafts,
cortical membranous grafts revasculari(e more rapidly than endochondral bone grafts
with a thicker cancellous component.
Soft Tissue Management
The recipient site must be completely healed before graft placement. -oft tissue surgery
is completed at least B weeks before grafting. Beveled incisions slightly distant from the
ridge crest and divergent releasing incisions remote to the defect facilitate closure and
maintain an adequate blood supply. "ncisions e%tended too far palatally are avoided due
to possible postoperative epithelial sloughing.
?omplete flap coverage and tension.free wound closure are essential for successful graft
incorporation. Before graft placement, the periosteum at the base of the facial flap is
carefully incised with tissue scissors and3or a scalpel blade to allow stretching of the
mucosa and tension.free adaptation of the wound margins.
;rocedures to enhance graft coverage will usually result in a reduction in keratini(ed
mucosa over the ridge crest and a loss of vestibular depth. Hccasionally tissue grafts may
be necessary. The attached mucosa may be repositioned facially at second.stage surgery.
http233www.osteomedcorp.com3;ages3?linicalArticles.asp%CidD#
Soft-Tissue ssessment
-oft.tissue assessment is most important in the diagnostic evaluation for implant
restoration in the esthetic (one. The e%isting gingival position of the failing tooth must
first be evaluated. Appro%imately to ! mm of facial gingival recession may result
following tooth removal and immediate implant placement.

Therefore, a hopeless tooth
with a free gingival margin to ! mm more coronal to its contralateral counterpart is
more favorable.
A hopeless tooth with free gingival margin positioned at the same level or more apical
than its contralateral counterpart is not favorable because of the ensuing apical resorption
that occurs with wound healing. 8nder these conditions, orthodontic e%trusion of the
failing tooth prior to e%traction is recommended.

The e%trusion of the tooth will result in
the development of both soft and hard tissue in a more coronal position. This allows the
implant platform to be positioned where it can be managed prosthetically and during
post.treatment supportive maintenance care. This method of tissue regeneration can
compensate for the hard. and soft.tissue deficiencies to create a harmonious soft.tissue
level as well as additional bone.
6e%t in the soft.tissue assessment is to evaluate the gingival scallop and gingival biotype.
&ingival scallop has been categori(ed as flat, scalloped, and pronounced scallop. Teeth
with a normal or pronounced gingival scallop and a thin biotype are more prone to
gingival tissue recession and interpro%imal tissue loss following tooth e%traction. This is
less likely to occur on teeth with a flat gingival scallop and a thick biotype. "t may be
optimal to e%tract the hopeless tooth, perform hard. and soft.tissue grafting, and place the
implant three to si% months later.
The final parameter in the soft.tissue assessment is the height of the interdental papilla.
"nterdental papilla height is determined by the position of the underlying osseous crest
and the height of the interpro%imal contact area. &reater this distance, the greater the risk
of tissue loss following e%traction and immediate implant placement. This tissue is often
difficult to re.establish, especially for the thin3scalloped periodontium. The provisional
restoration must support appro%imately # mm of unsupported soft tissue with gentle
pressure that e%erts laterally to support the full height of the interdental papilla.
!ard-Tissue ssessment
/or immediate implant.supported restorations, the facial free gingival margin is
supported by the e%isting facial bone of the failing tooth, and the interpro%imal gingival
tissue is determined by the interpro%imal bone level of the ad'acent tooth.
6ormal relationship from the free gingival margin to the underlying osseous crest was
found to have a facial dimension of # mm and an interpro%imal dimension of $., mm. "f
the facial gingival levels are harmonious between the hopeless tooth and the ad'acent
tooth, and the distance to the osseous crest is # mm or more, orthodontic e%trusion prior
to e%traction would allow for a more favorable esthetic result. "f the interpro%imal height
to the osseous crest is greater than $., mm, soft.tissue loss can be e%pected following
implant placement and restoration. "f this distance is greater than $., mm, the patient
needs to be aware that prosthetic compromise may be needed to close the interpro%imal
space.
The shape and position of the hopeless tooth also need to be evaluated in the diagnostic
assessment for immediate implant placement. -quare.shaped teeth may have a more
favorable esthetic outcome than ovoid or triangular.shaped teeth because the
interpro%imal contact is longer and more tooth structure fills the interdental space.
Labial alveolar bone and the overlying soft tissue are often thin when teeth are positioned
too far facially. 7%traction and immediate implant placement may result in perforation, or
e%tensive loss of the labial bone and the collapse of the gingival architecture. "n this case,
ridge augmentation and preservation procedures prior to implant placement may result in
a more favorable esthetic outcome.

/"&2
A2 Tooth has a hopeless prognosis.
B2 Hn e%traction, there is a perforation of the labial plate.
A B /
) E ,
/2 The e%traction site was augmented for ridge preservation, and graft material with a
&ore.Te% augmentation material membrane was used to e%pand the osseous volume of
bone.
E0,2 -i% months later, the ridge has been augmented with good radiographic bone
density.
Hn the other hand, lingual tooth position often results in thicker labial bone and gingival
tissue. A hopeless tooth in this position is more favorable for immediate implant
placement due to less likelihood of damage during e%traction and implant placement. "n
addition, soft.tissue loss may be minimi(ed, and there would be less chance of a gingival
discrepancy in the final restoration.
?onclusion
The restorative team must have a thorough understanding of the osseous and soft.tissue
profiles associated with a failing tooth to decide if immediate implant placement will
achieve the desired esthetic result. "n situations where immediate implant placement is
not possible, ridge preservation needs to be performed to minimi(e tissue loss. This will
minimi(e the corrective augmentation procedures necessary to obtain an esthetic result
with delayed implant placement.