Ministry of Higher

Education and Scientific

Research
Karbala University
Faculty of Dentistry

Difference between bone level and tissue

level implants
A project submitted to collage of dentistry at university of kerbala,
department of prosthodontics in partial fulfilment of the requirement for
B.D.S degree

Prepare by
Fatima Hamid Numma
Supervisor
Dr. Hassan Al-Masoudi

Dhu al-Hajjah 1444 June 2023

 Supervisor Certificate

I certify that this graduation project entitled: Difference between

bone level and tissue level implants
Was prepared by Fatima Hamid Numma, under my supervision at the
College of Dentistry/University of karbala in partial fulfilment of the
graduation requirements for the Bachelor Degree in Dentistry.

Name: Dr. Hassan Al-Masoudi

Date:

I
 Dedication

Man was found on the face of the earth, and he did not live in
isolation from the rest of mankind

And in all stages of life, there are people who deserve our thanks

The first people to be thankful are the parents. Because they have the
credit that reaches the sky;

Their existence is a reason for salvation and prosperity in this world

and the Hereafter.

To my friends to whom I testify that they are the best companions in

all matters.
To all my teachers...

I present to you my humble research ...

II
 Acknowledgments

The first to thank God Almighty and then my parents for all their efforts since I
was born for these moments.

I am pleased to thank everyone who advised me, directed me, directed me, or
contributed with me in the preparation of this research by providing me with the
required references and sources at any stage of its stages, and I especially thank
my esteemed professor (Dr. Hassan Al-Masoudi) for my support and guidance
with advice, correction, and choice of title and topic. I would also like to thank
the University of Karbala for managing the Faculty of Dentistry.

III
 Lis of contents
Certificate of the Supervisor I
Dedication II
Acknowledgments III
Lis of contents IV
List of figures V
Introduction VI
Aims of the study VII
Chapter One: Review of literature 1
1.1 The importance of dental implants in modern dentistry 1
1.2 The significance of implant-supported restorations in 4
dental prosthetics
1.3 The concept of bone level and tissue level implants 9
1.4 Dental Implant Components 11
1.5 Bone Level Implants 12
1.5.1 Characteristics and Design Principles 13
1.5.2 The interaction between bone and bone level implants 13
1.5.3 Biomechanical Considerations Associated with Bone 15
Level Implants
1.6 Tissue Level Implants 18
1.6.1 Characteristics and Design Principles 18
1.6.2 Interaction between soft tissues and tissue level 19
implants
1.6.3 The biomechanical considerations associated with 21
tissue level implants
1.7 Difference between bone level and tissue level implants 23
Chapter Two: Discussion 25
Chapter Three: Conclusions 26
3.1 Conclusions 26
References 29

IV
 List of figures

Figure (1.1): Dental Implants in Modern Dentistry 3

Figure (1.2): Full mouth dental implants 4
Figure (1.3): Different types of dental crowns 7
Figure (1.4): bridge procedure 8
Figure (1.5): Implant Supported Dentures 8
Figure (1.6): The tissue-level and Bone level 10
Figure (1.7): Components of implant 12
Figure (1.8): The basic thing that is used as a base for 17
cultivation and how it is

V
 Introduction
Dental implants have revolutionized the field of restorative dentistry, providing a
reliable and long-lasting solution for replacing missing teeth. Over the years,
various implant designs and techniques have been developed to cater to different
clinical scenarios and patient needs. Two commonly used implant types are bone
level implants and tissue level implants. Understanding the differences between
these two types is crucial for clinicians in making informed decisions during
treatment planning and achieving optimal outcomes for their patients.

In contrast, tissue level implants are placed at a level deeper within the soft tissue,
often submerging the implant head. They feature a transgingival component that
connects the implant to the prosthetic restoration. Tissue level implants distribute
occlusal forces to the surrounding soft tissues, with the load transmission
occurring mainly through the connective tissue. These implants are beneficial in
cases with compromised bone volume or when esthetic considerations are a
priority. Adequate soft tissue thickness and contours are crucial for achieving
optimal esthetic integration with tissue level implants.

The differences between bone level and tissue level implants extend beyond their
design and placement. Surgical considerations vary for each implant type, with
bone level implants being suitable for a one-stage approach in cases with
adequate bone support, while tissue level implants often require a two-stage
approach. Prosthetic options also differ, with bone level implants allowing both
screw-retained and cement-retained restorations, while tissue level implants are
predominantly used with screw-retained restorations due to their subgingival
placement [Cochran, D. L., et al, 2017].

VI
Aims of the study

1- To compare the biomechanical characteristics of bone level and tissue level

implants.
2- To evaluate the clinical outcomes and success rates of bone level and tissue
level implants.
3- To analyze the impact of implant placement on peri-implant soft tissues.
4- To assess the prosthetic considerations and outcomes of bone level and tissue
level implants.
5- To provide evidence-based recommendations for treatment planning and
implant selection.
6- Clarification the Difference between bone level and tissue level implants

By addressing these research objectives, my study will contribute to a better

understanding of the difference between bone level and tissue level implants,
enabling clinicians to make informed decisions and enhance treatment outcomes
in implant dentistry.

VII
 Chapter One
Review of literature

1.1 The importance of dental implants in modern dentistry

Dental implants play a crucial role in modern dentistry, providing a reliable and
durable solution for the replacement of missing teeth. They have transformed the
field of restorative dentistry, offering numerous advantages over traditional tooth
replacement options like dentures or bridges [Carl E. Misch, 2008].

Dental implants have become a cornerstone of modern dentistry due to their

numerous benefits and significant impact on patients' oral health and quality of
life. They provide a long-lasting, functional, and aesthetic solution for individuals
with missing teeth [Charles A. Babbush, 2021].

Dental implants offer several key advantages compared to traditional tooth

replacement options. First and foremost, they provide superior stability and
functionality. By integrating with the jawbone through a process called
osseointegration, implants serve as a solid foundation for prosthetic restorations,
allowing patients to chew, speak, and smile with confidence.

Furthermore, dental implants help preserve oral health by preventing bone loss in
the jaw. When a tooth is lost, the underlying bone gradually deteriorates over
time. Implants mimic the natural tooth root and stimulate the surrounding bone,
preventing bone resorption and maintaining facial structure.

In addition to their functional benefits, dental implants contribute to improved

aesthetics. They closely resemble natural teeth in terms of appearance, shape, and
color, allowing for seamless integration into the smile. This can significantly

1
enhance patients' self-esteem and overall satisfaction with their dental restoration
[Charles A. Babbush, 2021].

Dental implants have emerged as a transformative advancement in modern

dentistry, revolutionizing the field of tooth replacement. Historically, missing
teeth were commonly replaced with removable dentures or fixed bridges. While
these options addressed the cosmetic and functional aspects to some extent, they
had several limitations and drawbacks.

Removable dentures often posed challenges in terms of stability, discomfort, and

difficulty in chewing certain foods. Fixed bridges, on the other hand, required the
preparation of adjacent healthy teeth for support, leading to irreversible tooth
structure loss and potential long-term complications.

The development of dental implants offered a breakthrough solution to overcome

these limitations. Dental implants are titanium or ceramic posts that are surgically
placed into the jawbone, mimicking the function of natural tooth roots. They
provide a stable foundation for prosthetic restorations, such as crowns, bridges,
or dentures.

Dental implants have gained immense popularity due to their ability to restore not
only the appearance but also the function of natural teeth. They offer superior
stability, durability, and chewing efficiency, enabling patients to enjoy a wide
range of foods without restrictions. Moreover, implants have a long lifespan,
often lasting for many years or even a lifetime with proper care and maintenance.

The scientific understanding of osseointegration, the process by which the

implant fuses with the jawbone, has played a pivotal role in the success of dental
implants. This phenomenon was first discovered by Professor Per-Ingvar
Brånemark in the 1950s, and since then, it has formed the basis of modern implant
dentistry.

2
By integrating with the surrounding bone, dental implants provide stimulation to
the jaw, preventing bone loss and preserving the integrity of the facial structure.
This not only enhances oral health but also contributes to a more youthful
appearance.

The importance of dental implants in modern dentistry is well-documented in

various scholarly publications and textbooks. One notable reference is the book
"Contemporary Implant Dentistry" by Carl E. Misch, which offers
comprehensive insights into the field of implant dentistry, including its historical
background, scientific principles, and clinical applications [Carl E. Misch,
2008].

Figure (1.1): Dental Implants in Modern Dentistry [aspire dental]

3
 Figure (1.2): Full mouth dental implants [new dental, 2022]

1.2 The significance of implant-supported restorations in dental

prosthetics
Implant-supported restorations play a pivotal role in modern dental prosthetics,
offering numerous advantages over traditional prosthetic solutions. These
restorations involve the use of dental implants as a foundation to support artificial
teeth or dental prostheses. The significance of implant-supported restorations lies
in their ability to provide improved esthetics, functionality, and long-term
stability for patients with missing teeth [Carl E. Misch,2019].

The significance of implant-supported restorations in dental prosthetics is

multifaceted and encompasses several key aspects that contribute to improved
patient outcomes.

4
These include:

1. Enhanced Esthetics: Implant-supported restorations offer a natural and

aesthetic solution for replacing missing teeth. Unlike traditional removable
dentures, implant-supported restorations provide a stable and lifelike
appearance, closely resembling natural teeth in color, shape, and contour. This
contributes to increased patient satisfaction and confidence in their smile.

2. Improved Functionality: Dental implants act as artificial tooth roots that

integrate with the jawbone, providing a strong and stable foundation for the
restoration. This stability allows patients to experience improved chewing
efficiency and bite strength, restoring their ability to eat a wide range of foods
comfortably. With implant-supported restorations, patients can regain the full
function of their natural teeth, leading to improved oral health and overall
well-being.

3. Preservation of Adjacent Teeth: Unlike traditional dental bridges, which rely

on adjacent teeth for support, implant-supported restorations do not require
the alteration or preparation of neighboring healthy teeth. By preserving the
integrity of adjacent teeth, implant-supported restorations promote better
long-term oral health and reduce the risk of complications associated with
traditional bridge placement.

4. Bone Preservation: When a tooth is lost, the underlying jawbone tends to

undergo gradual resorption. However, dental implants mimic natural tooth
roots, stimulating the surrounding bone through a process called
osseointegration. This helps preserve the bone structure and prevent bone loss,
maintaining the integrity of the facial structure and supporting adjacent teeth.

5. Long-Term Durability: Implant-supported restorations have a high success

rate and offer long-term durability. With proper oral hygiene and regular dental

5
 check-ups, these restorations can last for many years, providing a cost-
effective and reliable solution for tooth replacement.

6. Psychological and Emotional Benefits: The impact of tooth loss extends

beyond the physical aspects. Missing teeth can significantly affect a person's
self-confidence and social interactions. Implant-supported restorations help
restore a patient's smile, improving self-esteem and psychological well-being.
This leads to a better quality of life and increased social confidence.

By providing improved esthetics, functionality, bone preservation, and long-term

durability, implant-supported restorations have revolutionized dental prosthetics.
They offer patients a reliable and long-lasting solution for tooth replacement,
enhancing oral health, appearance, and overall quality of life [Carl E.
Misch,2019].

There are 3 common implant supported restorations used in modern dental

work:

1- Dental crowns – A dental crowncan be built to match the surrounding teeth,

and attached to the dental implant to restore a single missing tooth. This is the
most common type of dental implant, which is why the term “dental implant” is
often used synonymously with an implant-supported dental crown [Dr. Lisa M.
Skutak].

A dental crown is a solution for the teeth to cover and protect them when they are
broken. They are designed to look just like the natural tooth, and we specialize in
restorative dentistry that offers crowns as part of the service. A dental crown is
supposed to last up to twenty years if you look after them well, and there are a
range of dental crown types that you can choose from. The options can include
[Category, 2020]:

6
 • Porcelain
• Stainless Steel
• Gold
• Metal
• Hybrid Crowns
• Resin

Figure (1.3): Different types of dental crowns [Category, 2020]

2- Dental bridges – This type of bridge is similar to the conventional fixed

bridge. The difference is that rather than retainer crowns being placed over your

natural teeth, they’re placed over dental implants [Smith, 2013].

7
 Figure (1.4): bridge procedure [Australian Dental Association, 2020]

3- Implant supported Dentures – Dental implants can be used to support

permanent dentures, replacing either the upper arch, lower arch, or both arches of
teeth. This has a number of advantages compared to traditional dentures. Implant
supported dentures don’t need to be removed, they don’t slip, and they look and
feel more natural [Dr. Lisa M. Skutak].

Figure (1.5): Implant Supported Dentures [the ivory dental clinic]

8
1.3 The concept of bone level and tissue level implants
Bone level and tissue level implants are two distinct types of dental implants
commonly used in modern implant dentistry. Bone level implants are designed to
be placed at or slightly below the level of the alveolar bone, whereas tissue level
implants are positioned at a deeper level within the soft tissues [Carl E. Misch,
Randolph Resnik, 2020].

Bone level implants, as the name suggests, are designed to be placed at or slightly
below the level of the alveolar bone. These implants are typically positioned such
that the implant-abutment interface is at or just below the crestal bone level. This
type of implant design aims to achieve a stable connection with the bone,
promoting osseointegration and ensuring long-term implant success. By
maintaining a close proximity to the bone, bone level implants provide excellent
support for the prosthetic restoration.

On the other hand, tissue level implants are placed at a deeper level within the
soft tissues. These implants are positioned in a way that allows the soft tissues to
heal and form a cuff or collar around the implant. The collar acts as a barrier
between the implant and the oral environment, providing protection and
minimizing the risk of complications such as peri-implantitis. Tissue level
implants are commonly used when there is inadequate bone support or when the
primary stability of the implant is compromised.

By understanding the differences between bone level and tissue level implants,
clinicians can make informed decisions in treatment planning. Factors such as the
patient's bone quality, esthetic requirements, and clinical considerations influence
the choice between these implant types. Additionally, the specific clinical
indications and contraindications for bone level and tissue level implants are
discussed in the referenced chapter, providing valuable insights for practitioners.

9
Overall, the concept of bone level and tissue level implants revolves around their
respective positioning in relation to the bone and soft tissues. The choice between
these implant types depends on various factors, and a thorough understanding of
their characteristics and clinical implications is essential for successful implant
dentistry [Carl E. Misch, Randolph Resnik, 2020].

Figure (1.6): The tissue-level and Bone level [Dr Minoru Sanda,, 2022]

10
1.4 Dental Implant Components

Components of Bone Level Implants:

1. Implant Fixture: This component is surgically placed into the jawbone and
serves as the artificial root of the implant. It is typically made of
biocompatible materials such as titanium or titanium alloy.

2. Abutment: The abutment is attached to the implant fixture and acts as a

connector between the implant and the prosthetic restoration. It is often
made of metal or ceramic and provides support and stability for the dental
crown or bridge [Carl E. Misch, 2008].

Components of Tissue Level Implants:

1. Implant Fixture: Similar to bone level implants, tissue level implants also
consist of an implant fixture that is surgically inserted into the jawbone. It
serves as the anchor for the implant restoration.

2. Transmucosal Element: Unlike bone level implants, tissue level implants have
an additional component called the transmucosal element. This component
emerges through the gum tissue, allowing for direct attachment of the
prosthetic restoration. It is designed to maintain the health and stability of the
soft tissues surrounding the implant [Carl E. Misch, 2008].

11
 Figure (1.7): Components of implant [Nikos Mattheos,2020]

1.5 Bone Level Implants

Bone level implants are a type of dental implant used in implant-supported
restorations. They play a crucial role in modern dentistry, offering a reliable
solution for replacing missing teeth. Unlike tissue level implants, bone level
implants are designed to be placed at the level of the bone crest, facilitating a
closer proximity between the implant and the underlying bone. This positioning
allows for optimal stability, osseointegration, and long-term success of the
implant restoration [Charles A. Babbush, et al, 2020].

12
1.5.1 Characteristics and Design Principles

Bone level implants possess specific characteristics and design principles that
distinguish them from other implant types. They are typically composed of
biocompatible materials, such as titanium or titanium alloys, known for their
favorable biocompatibility and osseointegration properties. The implant body is
designed with threads and a tapered shape, facilitating primary stability during
placement and enhancing the mechanical engagement with the surrounding bone.

Furthermore, bone level implants often incorporate advanced surface

modifications, such as sandblasting, acid etching, or incorporation of micro- or
nano-scale features. These surface treatments promote faster and more
predictable osseointegration, ensuring the long-term success of the implant.

The design principles of bone level implants prioritize achieving a secure and
stable connection with the surrounding bone. This is achieved through the use of
prosthetic components, such as abutments and implant-supported restorations,
which are securely attached to the implant body. The goal is to create a functional
and aesthetic restoration that mimics the natural dentition, ensuring patient
satisfaction and oral health [Charles A. Babbush, et al, 2020].

1.5.2 The interaction between bone and bone level implants

The interaction between bone and bone level implants is a crucial aspect to
consider in implant dentistry. The success of osseointegration, the process by
which the implant fuses with the surrounding bone, directly affects the long-term
stability and function of the implant.

Bone level implants are designed to be placed at or slightly below the crestal bone
level. This positioning allows for a direct interface between the implant surface
and the bone, promoting optimal bone-to-implant contact (BIC). The primary
goal is to achieve a strong and stable connection between the implant and the
13
bone, ensuring the transfer of occlusal forces and providing long-term support for
the prosthetic restoration.

Several factors influence the interaction between bone and bone level implants.
Implant surface characteristics, such as roughness and topography, play a
significant role in promoting osseointegration. Numerous studies have
demonstrated that rough surfaces enhance BIC and promote faster and more
robust bone healing compared to smooth surfaces [Buser, D., et al, , 2012],
[Cochran, D. L., et al, 2017]. Therefore, implant designs incorporating rough or
modified surfaces are commonly used in bone level implants to facilitate
osseointegration.

Implant macrodesign, including thread design and shape, also influences the
interaction between bone and bone level implants. The design and configuration
of implant threads affect the mechanical engagement with the bone, providing
initial stability and facilitating osseointegration. Appropriate thread design
enables effective force distribution and stress transfer within the surrounding
bone, enhancing long-term implant stability.

The quantity and quality of the surrounding bone are crucial factors in the
interaction between bone level implants and the bone. Adequate bone density and
volume are essential for achieving primary stability during implant placement and
subsequent osseointegration. Insufficient bone quantity may require pre-implant
augmentation procedures, such as bone grafting or guided bone regeneration, to
optimize the bone-implant interface [Esposito, M., et al., 2015].

In summary, the interaction between bone and bone level implants is a complex
process that involves the surface characteristics, macrodesign, and the quality of
the surrounding bone. Understanding these interactions is crucial for clinicians in
selecting appropriate implant designs, optimizing treatment planning, and
ensuring long-term stability and success of dental implants.

14
1.5.3 Biomechanical Considerations Associated with Bone Level Implants

Bone level implants play a crucial role in providing stable and long-lasting
support for dental restorations. Several biomechanical factors must be considered
to ensure successful outcomes in terms of implant stability, load distribution, and
preservation of surrounding bone and soft tissues.

1. Implant Design: The design of bone level implants affects their biomechanical
behavior. The implant body's length, diameter, and thread design contribute to
primary stability and load distribution. A tapered design can provide increased
primary stability and enhance bone-to-implant contact (BIC) for optimal
osseointegration. The choice of implant material, such as titanium or zirconia,
also influences the mechanical properties and clinical performance of bone
level implants [Jaffin RA, Berman CL, J Periodontol. 1991].

2. Load Distribution: Proper load distribution is critical to minimizing stress on

the implant and surrounding bone. An ideal occlusal scheme, including the
arrangement and occlusal contacts of the prosthetic restoration, should be
considered. Axial or vertical loading is preferable over oblique or lateral
loading, as it reduces the risk of implant failure and bone resorption. Prosthetic
components, such as abutments and screw joints, must be carefully selected to
ensure load transfer and distribution without compromising the implant-bone
interface [Wennerberg A et al, 2008].
3. Implant-Bone Interface: The implant-bone interface is critical for the
transmission of mechanical forces and ensuring long-term stability. Achieving
a strong implant-bone interface involves factors such as implant surface
characteristics, implant-abutment connection, and bone quality. Surface
treatments, such as sandblasting, acid-etching, or plasma spraying, enhance
the surface roughness and promote bone apposition, leading to improved
biomechanical bonding [Dohan Ehrenfest, D. M et al, 2018]. Additionally,
the selection of an appropriate implant-abutment connection type, such as

15
 internal or external hexagon, influences the load distribution and resistance to
rotational forces. Bone quality assessment is crucial for determining the
appropriate implant size and achieving adequate primary stability
[Geminiani, A., Ercoli, C, et al, 2019].
4. Implant Loading Protocols: Implant loading protocols involve the timing and
distribution of functional loads on the implant. Immediate or early loading
protocols have gained popularity, allowing for faster restoration and improved
patient satisfaction. However, careful consideration of bone quality, implant
stability, and prosthetic factors is necessary to determine the suitability of
early loading protocols. Delayed loading protocols provide additional time for
osseointegration and may be preferred in cases with compromised bone
quality or implant stability [Albrektsson, T., et al, 2020].

In conclusion, the biomechanical considerations associated with bone level

implants involve stress distribution, implant design, implant-bone interface, and
implant loading protocols. Optimizing these factors is crucial for achieving long-
term implant success, minimizing complications, and ensuring favorable
biomechanical performance.

The following figure shows the basic thing that is used as a base for cultivation
and how it is:

16
Figure (1.8): The basic thing that is used as a base for cultivation and how
it is [DR-MEDIC STOM et al.]

17
1.6 Tissue Level Implants

Tissue level implants are a prominent type of dental implant widely used in
modern implant dentistry. These implants are designed to establish a stable
connection between the implant and the soft tissues surrounding the implant site.
By focusing on the interaction with the peri-implant soft tissues, tissue level
implants offer unique advantages and considerations compared to other implant
designs [Babbush, C. A, et al, 2021].

1.6.1 Characteristics and Design Principles

Tissue level implants are designed to maintain a closer proximity to the soft
tissues surrounding the implant site. Unlike bone level implants, tissue level
implants do not penetrate as deeply into the bone. Instead, they are placed at a
level that allows for a submucosal position, with the implant-abutment interface
positioned at or just above the soft tissue level. This design allows for a direct
connection between the implant and the soft tissues, promoting a stable soft tissue
seal and favorable esthetic outcomes.

The design principles of tissue level implants focus on achieving and maintaining
a healthy soft tissue architecture around the implant. The implant collar is
typically wider, providing a platform for the soft tissues to adapt and form a stable
cuff around the implant. This design facilitates the integration of the implant with
the surrounding tissues and enhances esthetics [Arun K. Garg, 2019].

some additional characteristics and design principles of tissue level implants

[Carl E. Misch, 2014]:

1. Emergence Profile: Tissue level implants are designed to create a natural

emergence profile that mimics the contour of a natural tooth. The emergence
profile refers to the way the implant emerges through the soft tissues, creating

18
 a smooth transition from the implant to the surrounding gum tissue. This helps
to achieve optimal esthetics by ensuring a natural-looking emergence of the
restoration.

2. Tissue Stability: Tissue level implants prioritize the stability and health of the
peri-implant soft tissues. The design aims to promote a tight seal between the
implant and the soft tissues to prevent bacterial infiltration and maintain peri-
implant health. The wider collar and the submucosal placement of the implant-
abutment interface contribute to the stability of the soft tissues and reduce the
risk of tissue recession.

3. Soft Tissue Attachment: Tissue level implants facilitate a close and strong
attachment of the soft tissues to the implant surface. The implant surface is
usually treated with specific micro- or nano-textures to enhance the soft tissue
adhesion, promoting a stable soft tissue seal around the implant. This
attachment is essential for maintaining long-term peri-implant health and
stability.

4. Esthetics: Tissue level implants are designed with a focus on achieving

optimal esthetic outcomes. By maintaining the implant-abutment interface at
or just above the soft tissue level, tissue level implants provide more flexibility
in creating natural-looking gingival contours and achieving harmonious
gingival architecture around the restoration. This design consideration is
particularly important in anterior regions where esthetics play a crucial role.

1.6.2 Interaction between soft tissues and tissue level implants

The interaction between soft tissues and tissue level implants plays a crucial role
in the success and longevity of implant-supported restorations. Tissue level
implants are designed to place the implant-abutment interface at or slightly above
the soft tissue level, allowing for a more harmonious relationship between the
implant components and the surrounding soft tissues.

19
One key aspect of the soft tissue-implant interaction is the establishment of a
healthy and stable soft tissue seal around the implant. This soft tissue seal acts as
a barrier against bacterial infiltration and contributes to the prevention of peri-
implant diseases, such as peri-implant mucositis and peri-implantitis. The quality
and maintenance of this seal are influenced by various factors, including implant
design, surface characteristics, and surgical techniques employed during implant
placement.

The emergence profile, or the contour and shape of the soft tissues around the
implant, is another important aspect of the soft tissue-implant interaction. Tissue
level implants, with their placement at or slightly above the soft tissue level, allow
for a more natural emergence profile to be achieved. This facilitates the creation
of an esthetically pleasing restoration, particularly in the anterior regions of the
mouth where the appearance of the gingival tissues is critical.

Furthermore, the preservation of the peri-implant soft tissue architecture is vital

for long-term implant success. The maintenance of an adequate volume and
height of the peri-implant soft tissues contributes to the esthetics and stability of
the restoration. Soft tissue augmentation techniques, such as connective tissue
grafts or free gingival grafts, may be required in cases where the soft tissue
architecture needs enhancement or correction.

Several studies have investigated the interaction between soft tissues and tissue
level implants. For instance, a study by Schulte et al. (2017) compared the peri-
implant soft tissue response between bone level and tissue level implants. The
findings demonstrated that tissue level implants exhibited superior peri-implant
soft tissue health and stability compared to bone level implants, with better
preservation of peri-implant papillae and less soft tissue recession [Schulte W,
Lukas D et al. 2010].

20
Another study by Canullo et al. (2020) evaluated the influence of implant neck
design on peri-implant soft tissue dimensions and health. The results indicated
that tissue level implants, with their placement at or above the soft tissue level,
promoted better preservation of soft tissue height and improved esthetic outcomes
compared to bone level implants [Canullo L et al, 2020].

In conclusion, the interaction between soft tissues and tissue level implants is a
critical factor in achieving successful implant-supported restorations. The
establishment of a healthy and stable soft tissue seal, the creation of a natural
emergence profile, and the preservation of peri-implant soft tissue architecture
are key considerations. Tissue level implants have demonstrated advantages in
terms of soft tissue response and esthetic outcomes. However, further research
and long-term clinical studies are necessary to validate these findings and
optimize soft tissue-implant interactions.

1.6.3 The biomechanical considerations associated with tissue level implants

Biomechanical considerations play a crucial role in the success and longevity of

dental implants. Tissue level implants, characterized by their design that allows
the implant platform to be at the level of soft tissue, present specific
biomechanical factors that must be carefully evaluated.

One of the primary biomechanical considerations with tissue level implants is the
distribution of occlusal forces. Since the implant platform is positioned closer to
the soft tissue, the transfer of occlusal forces to the underlying bone is influenced
by the resilience and compressibility of the soft tissue. Studies have shown that
the presence of a thicker soft tissue biotype can enhance the stress distribution
and absorption capacity around tissue level implants [Korfage, A et al, 2012].
This emphasizes the importance of evaluating the patient's soft tissue biotype and
its impact on the biomechanical behavior of tissue level implants.

21
Another critical consideration is the emergence profile and its effect on functional
and esthetic outcomes. The emergence profile refers to the contour and shape of
the implant-supported restoration emerging from the soft tissue. It plays a
significant role in the distribution of forces and preservation of peri-implant
tissues. Research has demonstrated that optimizing the emergence profile can
lead to improved load distribution and reduced stress concentrations, contributing
to long-term implant success [Tarnow, D. P et al, 2000].

Furthermore, the interplay between implant length and diameter should be

carefully assessed. Tissue level implants typically have a shorter length compared
to bone level implants, which may affect their load-bearing capacity and
resistance to bending forces. A study by Geng et al. (2011) evaluated the effect
of implant length and diameter on stress distribution and concluded that
increasing the implant length enhanced stress distribution along the implant and
reduced the risk of mechanical complications [Geng et al, 2011].

The choice of prosthetic components, including the abutment and crown, also
influences the biomechanics of tissue level implants. Studies have investigated
the impact of different abutment materials and designs on stress distribution and
found that material selection and the presence of anti-rotational features can
significantly affect the biomechanical behavior of tissue level implants.
Additionally, the restoration's occlusal scheme and the occlusal contacts should
be carefully designed to minimize excessive forces on the implant and
surrounding tissues, promoting long-term stability [Misch, C. E., 2008]

In summary, the biomechanical considerations associated with tissue level

implants encompass the distribution of occlusal forces, soft tissue biotype,
emergence profile, implant dimensions, and prosthetic components. A
comprehensive understanding of these factors is essential for treatment planning
and achieving favorable functional and esthetic outcomes.

22
1.7 Difference between bone level and tissue level implants

1. Implant Design and Placement [Chrcanovic BR, et al, 2018]:

• Bone Level Implants: These implants are designed to be placed at or

slightly below the crestal bone level. They have a transmucosal component
that connects the implant to the prosthetic restoration.

• Tissue Level Implants: These implants are placed at a level deeper within
the soft tissue, often submerging the implant head. They have a
transgingival component that connects the implant to the prosthetic
restoration.

2. Biomechanical Considerations [Brånemark PI, et al, 2004]:

• Bone Level Implants: The primary load transmission occurs at the bone-
implant interface due to their placement closer to the crestal bone. They
provide high stability and distribute occlusal forces primarily to the bone.

• Tissue Level Implants: These implants distribute occlusal forces to the

surrounding soft tissues. The load transmission occurs mainly through the
connective tissue, resulting in reduced stress on the bone.

3. Surgical Considerations [Buser D, et al, 2002]:

• Bone Level Implants: The surgical procedure involves placing the implant
at or slightly below the crestal bone level, allowing for easy access during
prosthetic rehabilitation. This technique is commonly used in cases with
adequate bone volume.
• Tissue Level Implants: The surgical procedure involves placing the implant
deeper within the soft tissue, requiring a two-stage approach. This
technique is beneficial in cases with compromised bone volume or esthetic
considerations.

23
4. Soft Tissue Management [Buser D, et al, 2002]:
• Bone Level Implants: The position of the implant head relative to the soft
tissue level can impact esthetics. Proper soft tissue management
techniques, such as gingival contouring and emergence profile
development, are crucial for achieving optimal esthetic outcomes.
• Tissue Level Implants: Due to their subgingival placement, tissue level
implants rely on the soft tissue architecture for esthetic integration.
Adequate soft tissue thickness and contours are essential for achieving
optimal esthetics.
5. Clinical Outcomes: [Buser D, et al, 2012]
• Bone Level Implants: Studies have shown high long-term survival rates
and excellent osseointegration for bone level implants. They offer
predictable outcomes, especially in cases with sufficient bone support.
• Tissue Level Implants: Tissue level implants have shown comparable
success rates to bone level implants, particularly in cases with
compromised bone volume or esthetic demands. Proper soft tissue
management is critical for achieving favorable esthetic outcomes.
6. Prosthetic Options: [Buser D, et al, 2012]
• Bone Level Implants: Bone level implants allow for both screw-retained and
cement-retained restorations. The transmucosal component provides easy
access for prosthetic procedures and maintenance.
• Tissue Level Implants: Tissue level implants are predominantly used with
screw-retained restorations due to their subgingival placement. The
transgingival component allows for adequate soft tissue integration and
healing.

24
 Chapter Two
Discussion

Bone level implants are dental implants that are placed at or below the crest of
the alveolar bone. They are designed to achieve stability and osseointegration,
and they are typically placed using a two-stage surgical procedure. Bone level
implants offer excellent stability, promote optimal bone-to-implant contact, and
are preferred for cases where achieving esthetic outcomes is crucial.

Tissue level implants, on the other hand, are dental implants that are placed above
the crest of the alveolar bone. They focus on preserving the soft tissue architecture
around the implant and are typically placed using a one-stage surgical technique.
Tissue level implants allow for easier manipulation of the gingival tissues,
simplify the treatment process, and are advantageous for maintaining gingival
health.

In summary, bone level implants are placed at or below the bone level,
emphasizing stability and osseointegration, while tissue level implants are placed
above the bone level, focusing on preserving and manipulating the gingival tissue.
The choice between these implant types depends on factors such as anatomical
characteristics, esthetic requirements, and clinician preferences.

25
 Chapter Three
Conclusions

3.1 Conclusions

Through the comprehensive analysis of bone level and tissue level implants, it
becomes evident that these two implant types possess distinct characteristics,
clinical considerations, and outcomes. Bone level implants are designed to be
placed at or slightly below the crestal bone level, offering high stability and
primarily distributing occlusal forces to the surrounding bone. On the other hand,
tissue level implants are placed deeper within the soft tissue, relying on the
connective tissue for load transmission and providing favorable esthetic
integration.

Further research in this field is warranted to explore additional aspects, such as

long-term esthetic outcomes, comparative studies on bone level and tissue level
implants in specific clinical scenarios, and advancements in implant design and
techniques. By continuing to expand our knowledge and understanding of these
implant types, we can further refine treatment protocols and improve patient
outcomes in the field of implant dentistry.

In conclusion, the difference between bone level and tissue level implants lies in
their design, placement, biomechanical considerations, surgical approaches,
prosthetic options, and clinical outcomes. This knowledge equips dental
professionals with valuable insights to tailor treatment plans, select the
appropriate implant type, and optimize treatment outcomes for their patients.

26
In conclusion I Suggestions some point to anyone who has a project related
to a research topic

1. Conduct a comprehensive literature review: Begin your project by conducting

a thorough literature review on bone level and tissue level implants. This will
help you gather relevant information, understand the current state of research,
and identify any gaps or controversies in the field.

2. Define clear research objectives: Clearly define the objectives of your project.
What specific aspects of bone level and tissue level implants do you want to
investigate? Are you focusing on clinical outcomes, patient satisfaction,
esthetics, or other factors? Defining your research objectives will guide your
project and ensure a focused approach.

3. Compare anatomy and biomechanics: Explore the anatomical and

biomechanical differences between bone level and tissue level implants.
Investigate how their respective designs and placement affect load
distribution, stress on surrounding tissues, and long-term stability.

4. Analyze clinical considerations: Examine the clinical considerations

associated with bone level and tissue level implants. Discuss indications and
contraindications for each type, surgical techniques, prosthetic options, and
the impact on treatment planning. Highlight any unique considerations or
challenges specific to each implant type.

5. Evaluate clinical outcomes: Investigate and compare the clinical outcomes of

bone level and tissue level implants. Assess parameters such as
osseointegration, implant stability, complications, success rates, and long-
term survival. Consider factors like esthetics, soft tissue management, and
patient satisfaction in your evaluation.

27
6. Discuss emerging trends and advancements: Explore any emerging trends or
advancements related to bone level and tissue level implants. Investigate
recent research, technological innovations, and novel approaches that may
influence the field. Discuss potential future directions and advancements that
may impact the use and selection of implant types.

7. Provide recommendations for clinical practice: Based on your findings,

provide recommendations for clinical practice. Summarize the advantages and
disadvantages of bone level and tissue level implants in different scenarios.
Offer insights on appropriate implant selection, treatment planning, and
techniques to optimize patient outcomes.

8. Consider limitations and future research: Acknowledge the limitations of your

study and identify areas for future research. Highlight any unanswered
questions or areas that require further investigation to enhance the
understanding of bone level and tissue level implants.

28
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