‫شهداؤنا أقمار‪..

‬‬
‫ِلكّل شهيٌد حكايُة ِم ْث لي ومْث ُلك‪,‬كان لُه َب ْيت وَز ْيتونة وقلب نابض وأحالٌم ال تنتهي‪..‬‬
‫كْم َت َم نيُت أن َت ُك ون ِلي ذاكرٌة تتِس ُع ِلكّل شهيٍد وحكايته وأحالمه‪..‬‬
‫في بدايِة كّل ملخٍص ستكون " ذكُر شهيد " ‪ُ,‬س ِلَب ْت حياُتُه بغمَض ِة عْي ٍن ‪,‬ليكوَن ُح ْلُمهم هو ُحلُمنا‪,‬دماُؤ هم وقوُد شعلِة‬
‫األحياء ِلنثبت بهذا الَط ريق وُنخلص به "طريق العلم "‬
‫لم يعُد الحلُم فرديًا‪ ,‬جميُعنا على ذاِت الطريق واخالصنا هو واجٌب‬

‫الفاتحة على روحهم‪...‬‬

‫‪-----------------------------------‬‬

‫األب إبراهيم الوادي وابنه أحمد الوادي (‪ )٢٥‬عامًا‬

‫في ‪ ١٢‬اكتوبر اثناء طريقهم لتشييع جنازة ‪ ٤‬أقمار من‬
‫البلدة الذين قتلوا بدم بارد من قبل المستوطنين‬
‫تعرضوا لهجوم المستوطنين على موكب تشييع الشهداء‬
‫فرجعوا هم األقمار‪..‬‬
‫قال تعالى ‪َ ":‬و َأْن َلْيَس ِلِإل نَس اِن ِإاَّل َم ا َسَعى ۝ َو َأَّن َسْعَيُه َسْو َف ُيَر ى "‬

‫‪Bone density‬‬
‫‪Chapter 2‬‬

‫‪Clinical part‬‬
  As implant dentist , I want to place implant , now we have something called
"prosthetic driven implant dentistry ", mean what are the sequence if I want to
make treatment planning for placement of implant??
- For example : pt have missing upper teeth from canine to canine , the first step I
do is taking impression or scanning to do diagnostic wax up , why ?
To anticipate the final prosthetic design prior to any planning in my implant
procedure and from here we build up my treatment plan
 So sequence of ttt will be as following :
‫ والزم احدد انا‬, diagnostic wax up ‫ بانه اعمل‬, ‫ حيكون بهذا المكان‬prosthesis‫ بحدد كيف شكل ال‬-1
prosthetic ‫ ثم بعد هذا ال‬, screw retained or cement retained prosthesis ‫بدي اعمل‬
7 ‫ ل‬2 ‫ الموضح بالساليد من نقطة‬sequence‫ ببلش بال‬designing
‫ وكم زرعة انا بحاجة العمل‬, prosthesis‫ ثم بحدد وين أماكن الي احط فيها الزرعة تحت هاي ال‬-2
support of prosthesis ‫ وبالتالي بعمل‬replacement
3- Then determine the anticipated force factors on this prosthesis
- for example : if my pt is young , male pt and large size , so I should
anticipate this pt will produce high forces on this prosthesis , so I need to do
over engineering of the case
prosthesis‫ تاعت المريض قديش حتكون على ال‬force factor ‫أي بقدر ال‬
4- Then prior to anything I should determine the density of bone in my future
implant site (chapter topic )
‫ انا قبل ال احط الزرعة او حتى‬, 1st premolar and molar ‫يعني مثال قررت احط زرعة مكان‬
estimation of bone density of these sites by techniques we will ‫انه اعمل‬, ‫اختارها‬
modification on ttt plan according to bone density ‫ ليش؟؟ النه حنعمل‬, discuss later
prosthetic driven implant dentistry ‫ اذن هذه هي خطوات بناء خطة عالج بناء على‬
--
 Important Q: is difference in bone density lead to difference in implant success ??
ANS: routinely answer is YES ,because poor bone density or reduced bone density
surely will lead to reduction in the success rate of implant
But if I make some modifications in my treatment planning and my surgical
procedure and in healing time and in the prosthetic loading ,,the success rate in
implant in poor bone density could be comparable to that implant placed in good
bone density
: ‫ النه الهدف من هاي المحاضرة حتى نوصل الستنتاج‬, ‫ هاي النقطة الزم نفهمها‬
How I could deal with each bone density( D1 , D2 ,D3…) ?acording to :
1. Treatment planning
2. surgical procedure
3. prosthetic loading
4. healing time
5. selection of type of implant
‫ ؟؟ يعني‬differences in bone density ‫ ليش عنا‬: ‫ فسؤال مهم‬, bone density ‫ هس ندخل بمقدمة لموضوع‬
‫ ؟؟‬what are the factors affect the bone density ‫ ؟؟‬D3 ‫ وليش مكان‬D1 ‫ليش مكان فيه‬
- For example the mandible have denser bone compare to the maxilla
- One of the important factor that influence the bone density is the mechanical
influence
-The wolff law mean any change in load put on certain bone lead to change in
bone
 - for example ,change in load on mandible in lower posterior side after extract
the posterior teeth , this lead to much less bone as tooth present , mean change
internal architecture ( bone density )and affect external conformation (shape of
the bone ) )
severe ‫بصير عند المرضى‬, kennedy class 1&2 ‫ زي مثال‬, ‫يعني مريض يخلع اسنانه الخلفية ويبطل يوكل عليه‬
reduction in the bone volume ‫ أدى الى‬load ‫ النه ما في أي‬dis-use atrophy ‫ نسميه ب‬, resorption
the density will be compromised ‫وكمان‬

 This slide answer the question why mandible have denser bone than maxilla :
- Mandible have different role or function from maxilla , mandible have thick cortical
bone and dense trabecular bone while maxilla often don’t have cortical bone and
have fine trabecular bone
 Pic 1

Upper right molar with

Upper left molar with
poor bone density
good bone density
surround it
surround it

 Another application of how mechanical stresses affect the density of the bone
- Image 1 demonstrate pic of the same patient (so same hormonal issue )and the
same arch ,so why there is difference in bone density between left and right ??
Because the right molar does not have opposing tooth due to extracted opposing
lower molar ,this lead to insufficient load to maintain the bone density
WHILE the upper left molar have sufficient physiological load
 so we conclude that bone should be subjected to physiological load to maintain
its internal architecture or density and also external conformation to prevent
atrophy
window of adaption which mean load within ‫ هو ال‬window ‫اذن لو ظلينا بهذا ال‬
‫ ونمنع يصير‬bone density and external shape ‫ فانا هيك بحافظ على ال‬, physiological limit
: ‫ ولكن‬, Resorption
atrophy and reduction in density ‫ عن حد معين حيصير عنا‬load‫اذا قل ال‬.1
‫ الي رح يؤدي الى‬pathological overload ‫ عن حد معين حندخل وقتها باشي نسميه‬load ‫اذا زاد ال‬.2
Reduction in bone density and volume
strength ‫ حتى نحافظ على‬load within limit ‫اذن الزم العظم يظل عليه‬.3

histological changes in the ‫ لدراسة‬model ‫ عمل‬frost ‫ في عنا عالم اسمه‬, ‫لنفهم الموضوع اكثر‬ 
cortical bone according to the amount of the mechanical stress applied to the bone
stress applied to the bone ‫ حسب كمية ال‬zones 4 ‫فبناء على دراسته قسم التغييرات الى‬
Stress load Zone Description
0-50 micro strain Acute dis use window Insufficient
load ,insufficient
remodeling , no internal
turn over weak and
atrophy bone , external
shape and bone density
become less
50-1500 micro Adapted window -This is what we want ,
strain /physiological zone and the load we want
‫هون معنيين يظل العظم ضمن هذا‬ implant subjected to (not
‫النطاق من القوى‬ less or more )
-In this window of load ,
bone maintain external
form and internal
architecture and density ,
the bone will be strong
enough to resist the
load , the bone will have
internal normal turn over
-Histologically it is strong
bone ,called lamellar
bone (organized and
sufficiently mineralized
and strong bone )
1500-3000 micro Mild over load window -The bone still maintain
strain the external shape but
the internal density will
be reduced
-The bone histologically
will be weaker , less
mineralized , more
susceptible to resorption
-Still the bone not
resorbed , but is more
suspectable to resorb if
load increase above
3000 micro strain
-histologically the bone
enter woven bone
(immature , less
mineralized , weak
bone )
Beyond 3000 Enter pathological -here bone resorption
micro strain overload window occur
lower ‫فمثال اذا صورنا زرعة ب‬-
excessive ‫ عليها‬6
‫حنالقي العظم ذايب‬, loading
‫حواليها‬
‫ العظم لسا‬mild overload ‫في‬-
‫ بس صار‬resorption ‫ما صار‬
‫اكثر عرضة انه يصير‬
‫زاد‬stress ‫ لو‬resorption
bone ‫وغالبا بصير‬-
‫ اذا كان‬resorption
associated with plaque
accumulation (bacteria ,
poor OH with overload
accelerate bone loss
around implant )
‫ لهيك بس نسلم التركيبة النهائية ع‬-
‫الزرعة بنكون معنيين بتزبيط‬
‫االطباق بحيث نتجنب يصير‬
overloading on implant
 In adapted window , there is bone turnover , or bone remodeling
bone density ‫يعني العظم بتجدد ليظل محافظ على‬
  Here we enter critical zone , we might loss implant if we don’t intervene to reduce
the load , or to control plaque accumulation (we said previously , poor OH +
overload = accelerate the bone resorption and loss around implant )
-----------------------------------
So until here , we understand how the bone response to mechanical stress , this affect on
our ttt planning and designing of occlusal scheme of final implant restoration
 D2 : thick cortical bone
with coarse trabeculated
bone

D1 : dense D3 : thinner cortical

cortical bone and bone with fine to
minimal coarse trabeculated
trabeculated bone
bone

D4 : NO cortical
bone and all
bone are fine
trabeculated
bone

 D5 introduced by misch , is grafted bone , for example I do sinus lifting and

put bone graft , the bone graft in initial placement is D5 (immature with
insufficient mineralization )
soft ‫ واجيت افتح بعد شهرين حالقي العظم كثير كثير‬, bone graft ‫ وحطيت‬sinus lifting ‫فمثال عملت‬
not ready to replace an implant ‫وبكون‬

 D1 is not common , if it is present , it will be in atrophied anterior mandible

 Maxilla have D2 in anterior maxilla
 The patient have missing single tooth as upper 1st molar ..lower 5 etc
usually single missing or 2 adjacent missing teeth have D2 either in maxilla
or mandible
 ‫‪ In the anterior mandible , it is very rare to find D4 ,BUT I could fine D4 if I did‬‬
‫‪osteoplasty‬‬
‫أحيانا في ‪ ant mandible‬بنعمل ‪ , cutting of crestal bone anteriorly‬لكي احصل على ‪more‬‬
‫‪ , width of the bone‬فانا اذا قصيت ال ‪ cortical bone‬من فوق فممكن ممكن في حالة ‪atrophied‬‬
‫‪ mandible‬االقي عنده ‪ D4‬لكنه ‪rare cases‬‬

‫‪Now we should applied what we study clinically‬‬

‫اشربوا مي واذكروا هللا‬

‫‪ ‬اول تيكنيج هي ال ‪ , general location‬يعني مثال ال ‪ post maxilla‬انا الزم اعاملها قبل ال اشوف‬
‫االشعة او اعمل جراحة ‪,‬رح أتوقع انها تكون ‪ , D4‬احنا حكينا انه ‪ Post maxilla‬ممكن يكون ‪D3 or‬‬
‫‪ D4‬ولكن بنروح للجانب األقل كثافة ‪ ,‬فبدل ما احكي حيكون ‪ D3‬ال بقول غالبا حيكون ‪ , D4‬النه ال‬
‫‪ modifications‬الي حعملها ب ‪ D4‬اكثر من ‪ D3‬من ناحية ‪surgery‬‬
‫‪ -‬كمان ال ‪ anterior maxilla‬احتمال نالقي ‪ , D3 or D2‬نفرض انه حنالقي ال ‪poorer density‬‬
‫وهو ‪ D3‬وهيك بعتبره‬
 D2 ‫ اتعامل معه على افتراض انه‬, D2/D3 ‫ احتمال‬, Post mandible ‫ كمان ال‬-
D2 ‫ بعتبرها‬D1/D2 ‫ احتمال‬, ant mandible ‫ كمان ال‬-
using tactile ‫ هو‬more objective accurate ‫ الطريقة ال‬, roughly ‫ كل هاد هو تقدير‬
sensing during surgery
‫ فحسب‬, suitable site for implant ‫ عشان احضر ال‬bite drill ‫ نسميه ال‬first drill ‫ لما ادخل ال‬-
Sensation or strength or resistance during drilling , I could estimate the ‫ال‬
bone density
- If I could classify the bone density in the first drill and can do modification in
subsequent drills

‫شجر الصنوبر‬

In space , I
feel
 3rd

technique is radiographic evaluation , this mean use CT medical scaning , by

using house field unite ( where I put curser the bone density appear on
screen )

 House field unit in minus or zero mean we enter in air or soft bone =D5
 Very high number as 3000 , there is high possibility to be enamel or root
fracture
  This number are accurate only in CT medical , but in implant it is enough to
use CBCT due to much less radiation and sufficient to evaluation regarding
implant dentistry (radiation as low as possible and enough for implant )
- But CBCT don’t give me accurate estimation of HU regarding bone density,
but provide me with rough HU estimation of bone density
‫ بقدرش احكي او اجزم انه‬, HU = 850 ‫يعني ممكن احط مؤشر الماوس على نقطة معينة يعطيني انه‬
rough estimation ‫ يعني تعطيني‬, D3 &D4 ‫ بس بقدر أقول ما بين‬, D3
structure is very dense ‫ بعرف انه هاد ال‬HU=2000 ‫او اعطتني‬
‫ الخ‬, fluid ‫ او‬soft tissue‫ بعرف انه بال‬, HU = minus ‫او كان ال‬
 Newer machine and newer software might give me better estimation , but we
still consider CBCT as rough estimation for bone density

)BIC(

 Now we will start with clinical application , why should we be very cautious
when dealing with different bone density ? why I should use different drilling
protocol when I make drilling in D4 ?why I cant deal with D4 as D1 ??what
factor affected by bone density ??
 The first thing we should know that bone density affect the bone strength ,
elastic modulus ….(mention in slide above ), for all these factors , I should do
modifications in ttt planning and surgical protocol ,prosthetic protocol and
healing time according to the differences in bone density
 Increase in bone density  increase in strength of the bone
- For example :
For D2 ( either cortical or trabeculated )=5.38 mega pascal
For D4 =1.7 mega pascal

 More denser bone higher elastic modulus , for example :

D2 =107 MPa
D4 =35 MPa
 Q: how the elastic modulus affect stress transfer ??
 - Most implants nowadays made from titanium alloy , if we have titanium
implant inside the bone , this titanium implant have higher elastic modulus
when compared even with D1  more difference ‫ فرق كبير‬in elastic modulus
between implant and surrounding bone , this will lead to more micro-strain
differences and more stresses applied to this bone
‫هذا االختالف‬, load ‫ فلما تتعرض الزرعة لل‬, ‫هس بسبب هذا االختالف الكبير بين العظم والزرعة‬
‫ اعلى‬micro strain ‫ عشان هيك كل ما كان‬, stress shielding ‫ يسمى بال‬, overload ‫حيولد‬
‫ اعلى‬stresses ‫كل ما كان‬
‫ رح نحكي عنهم كمان شوي‬modification of factors ‫شو الحل؟؟ اعمل‬
 (Google) Stress-shielding effects arise from shear stresses due to the
difference of material properties between bone and the implant
  More denser bone  higher BIC  higher surface area
: D4 ‫ ووحدة جوا ال‬D1 ‫وحدة جوا ال‬, ‫ تخيلوا انه في عنا زرعتين‬
- D4 have fine trabecular bone ,so have spaces , no bone , so surface area
around D4 is less than surface area around D1
forces
stress‫ كلما زادت ال‬surface area ‫ فكلما قلت ال‬, area ‫ هو ال‬stress ‫واحنا بنعرف تعريف ال‬ -
‫ واكل وتعرضوا‬, upper molar and other lower molar ‫نفترض انه مريض عنده زرعتين وحدة‬ -
lower molar surrounding ‫ هس احنا بنعرف انه ال‬, ‫ نيوتن‬50 = ‫الزرعتين لنفس القوة نقول‬
stress on ‫فبالتالي ال‬, ‫ اعلى‬surface area ‫ فبالتالي ال‬, bone is denser than upper
forced applied to each implant‫ مع انه نفس كمية ال‬upper molar will be higher
crown either upper or lower
 If I put implant in D4 bone in upper molar site  stress distribution will reach
lower apical area
- but if implant put in D2 bone stress will transfer to more coronal area
- more denser bone stresses transfer more coronally ,while less dense
transfer more apically
 one of important modification is treatment planning( ‫اول اشي بخطر ببالي عدد‬
‫ ) الزرعات‬, for example :
- pt have missing upper 4 ,5,6 and lower 4,5,6  I decide to put bridge 3 unit
for upper and lower to replace 4 5 6 in both arch , but how many implant I
need ??
-usually (we talk in general ), 2 implant2 is enough to replace 4 6 in lower
arch , while in upper less dense bone we need 3 implants to replace 4 5 6
-this difference is due to reduction in the bone density which affect
strength , elastic modulus ,BIC , stress transfer so I should do modification
 in general : in poor bone density , we need to over engineering the case , for
example increase number of implant
 according to stress equation : to decrease the stress : increase surface area
OR decrease forces
 Q : what is the most important technique to increase BIC ?the best way is
increasing number of the implants  second technique is increase size or
width or diameter of the implant  third factor is increasing length of the
implant (effect of increasing length is lesser than effect of increasing width )
final factor is select the implant design that maximize the surface area (as
thread square design )
 Micro design : make distance between threads less  make more surface
area
+Micro design according to surface treatment of the implant
 Another factor to reduce stresses on less dense bone by reduction of the
amount of forces
- We can't control the biting forces of the patient , because it is determine by
patient's factors as patient's muscles
1- But we can control occlusal design (occlusal scheme )of my final
prosthesis , avoid any cantilever prostheses
maxilla and ‫ (ما فهمت الجملة )لكن بحاالت ال‬merely???---- ‫ يستخدم‬cantilever ‫هو ال‬
cantilever ‫ يفضل ما نستخدم ال‬, poor density bone
2- Another technique is reduction of buccolingual
dimension of final implant prosthesis to reduce
applied forces  decrease stress load
 So the first important factor is treatment planning modification , the 2nd
important factor is the surgical procedure
: D4 ‫فمثال في‬, D4 ‫ مثل ما بتعامل مع‬drilling ‫ في‬D1 ‫ يعني مش من المنطق اتعامل مع‬-
It is recommended in D4 to drill undersize osteotomy , for example I want
to put implant of 5 mm width  the last drill should be just 4 mm ,why ?
Because the bone is very elastic in D4 bone , so when I put the implant in
small size , I will compress the bone

- Another surgical technique called Osseo-densification of the bone , it is

specific technique of drilling rather than cutting bone  it will densify the
bone , there is special driller prepare the osteotomy hole not by cutting , but
rather by densification

- Or instead of using drill , I can use osteotome manually , not drill , these
osteotome are same do densification of bone not cutting
outside ‫يعني بجمع العظم على الجوانب خالل الحفر بدل ما انه اجمعه‬
 Osteotome

 Q ; does D1 need modification ?

- D1 might lead to failure of implant (despite having higher strength , elastic
modulus , BIC..) , but the problem of D1 bone have very few spongy bone ,
which mean small blood vessels , and one of the most important factor for
success of implant and osteointegration is sufficient blood supply (initial
step is blood supply )
- And because of this , we need to do modification ,especially in surgery to
prevent necrosis inside the bone and gain successful osteointegration
: D4 ‫ طيب شو هي هاي التعديالت؟؟عكس الي حكيناه ل‬-
‫ ممكن‬, ‫ مم‬4 ‫ يعني زرعة عرضها‬, oversizing osteotomy ‫ بعمل‬, undersizing ‫يعني بدل‬-1
undersizing ‫ اذا كانت متوفرة يعني ما بددي اعمل‬3.9 ‫ او‬mm 3.8 ‫ ل‬drill ‫أوصل باخر‬
‫ النه مش معنية‬, drilling ‫ خالل‬cold saline ‫ ب‬good irrigation ‫ضروري ومهم جدا يكون في‬-2
healing ‫ وال يوجد تروية كافية ل‬over heating ‫ابدا يصير عندي‬
‫ النه‬, countersink drill ‫ مثل‬specific ‫ واحيانا بنتستخدم أدوات‬very sharp new drill ‫استخدام‬-3
‫ اكثر‬overheating ‫ بكون عندي‬dull ‫ فكل ما كانت األداة‬, dense ‫العظم‬
 (Google ):the Countersink drills are made for use in cases where dense bone
is encountered to ensure passive fit of the implant neck into the surgical site
 4-i should use sequential drill , for example when I decide to put 5 mm width
implant of maxilla I should start with bite drill = 1.7 mm then 2 mm, 3mm ,
4mm and finally put implant with 5 mm diameter , this if the bone less density
-dense bone as D1 for example , we start with bite drill = 2 mm , then 2.3
mm,2.6 mm,3mm,3.3mm,4mm,4.3mm
‫ما بقدر اروح من‬, sequentially ‫ فاحنا بنمشي‬,‫ مم‬5 ‫ بنكمل لحتى ما نوصل ل‬mm 4.3 ‫واذا عنا اكثر من‬
over heating and ‫ لحتى ما يصير عنا‬very delicate ‫ النه بدنا نمشي شوي شوي بالعظم‬, 3 ‫ ل‬2
pressure necrosis due to implant insertion
good initial stability ‫ انه بعطيني‬D1 ‫كل هاد حتى لو كانت من مزايا ال‬

 3rd factor of modification is healing time ,:

- This mean we need to wait more time in D4 for osteointegration than D1
healing time
- D1 & D2 , I can do immediate loading while poor density bone as D4 , I
should wait more time until osteointegration occur
poor density bone ‫ في‬immediate loading ‫ال ينصح بتاتا انه اعمل‬

 The 4th factor is the loading protocol :

- In D4 , we avoid do immediate loading , and prefer do progressive bone
loading to achieve gradual increasing in the bone density , this mean when
I put implant in poor density bone , and wait until implant is ready for ‫تركيب‬
,it preferable to start with temporary prosthesis as acrylic type prosthesis
rather than start immediately with zirconia or other type of metal
prosthesis , why ?
Because acryl have less impact force  stress applied by it will be less
final ‫ بعديها بروح ل‬, ‫ شهر‬temporary ‫ بقعد بال‬, ‫فهيك الستريس تدريجيا تنتقل على العظم‬
permanent zirconia or metal crown