BONE DENSITY

a key determinant for treatment planning

in
IMPLANT DENTISTRY
 OUTLINE:
 INTRODUCTION
 EVOLUTION OF IMPLANTOLOGY
 BONE DENSITY
 MODELLING & REMODELLING

 BIOMECHANICS OF BONE DENSITY

 STRESS vs STRAIN MECHANISM
 F R O S T ’ S M O D E L O F PAT T E R N F O R C O M PA C T B O N E
 C ATA G O R I E S O F M E C H A N I C A L A D A P TAT I O N O F B O N E

 D I F F E R E N T C L A SS I F I C AT I O N O F B O N E D E N S I T Y
 LINKOW’S 1970
 LEKHOLM & ZARB’S 1985
 CARL MISCH’S

 W H E R E D O W E F I N D D I F F. B O N E Q U A L I T I E S ? ?
 LO C AT I O N W I S E D I S T R I B U T I O N
 C L I N I C A L C O N S I D E R AT I O N S
 OUTLINE
 CAN WE ASSESS BONE DENSITY THROUGH RADIOGRAPH??
 CT SCAN & HOUNSFIELD’S UNITS

 WHY BONE DENSITY IS SIGNIFICANT??

 BONE STRENGTH
 ELASTIC MODULOUS
 BIC
 LOAD DISTRIBUTION

 C L I N I C A L T I P S A N D B O N E D E N S I T Y A S A M O D I F I E R I N T R E AT M E N T P L A N N I N G
 NO. OF IMPLANTS
 SIZE OF IMPLANTS
 S U R FA C E C H A R A C T E R I S T I C S
 PROGRESSIVE LOADING
 P R O S T H E T I C C O N S I D E R AT I O N

 O SS E O D E N S I F I C AT I O N ( B O N E S P R E A D I N G ) – N OV E L A P P R OA C H
 R AT I O N A L E & S C O P E

 C O N C L U S I O N / TA K E H O M E P O I N T S
“IF YOU FAIL TO PLAN, YOU ARE
PLANNING TO FAIL”

- BENJAMIN FRANKLIN
 EVOLUTION OF IMPLANTOLOGY

BONE DRIVEN PROSTHETIC DRIVEN BIOMECHANICAL PERSPECTIVE

BONE DENSITY GENERTED FORCES

 BONE AS A DYNAMIC TISSUE
GROUND SBUSTANCE
WHAT MAKES IT HARD BUT ELASTIC? FIBERS
CELLS
• PTH
FUNCTIONS: • CALCITONIC
• BONE MODELLING • VIT. D3
• BONE REMODELLING • GROWTH FACTORS
Osteoblast OsteoClast • STRESS
• MINERALIZATION

“EVERY CHANGE IN THE FORM & FUNCTION OF BONE IS FLOOWED BY CERTAIN DIFINITE
CHANGES IN THE INTERNAL ARCHITECTURE.”
- WOLFF 1892
 BIOMECHANICS OF BONE DENSITY

• WHAT IS STRESS??
FORCE
STRESS
AREA

• WHAT IS STRAIN??
CHANGE in length
STRAIN
AREA

ALVEOLAR BONE DENSITY EVOLVES

AS A RESULT OF MECHANICAL
DEFORMATION FROM MICROSTRAIN
 FROST’S MODEL OF REMODELING PATTERN FOR
COMPACT BONE UNDER STRESS

Four zones for bone related to Mechanical

adaption to strain before spontaneous
fracture.

1. ACUTE DISUSE WINDOW

2. ADAPTED WINDOW
3. MILD OVERLOAD WINDOW
4. PATHOLOGIC OVERLOAD
WINDOW
 CLASSIFICATION OF BONE DENSITY
 ACCORDING TO LINKOW 1970:
IDEAL
 CLASS I BONE STRUCTURE: EVENLY SPACED
TRABECULAE WITH SMALL CANCELLATED SPACES

 CLASS II BONE STRUCTURE: SLIGHLTY LARGER

SATISFACTORY

CANCELLATED SPACE WITH LESS UNIFORMITY OF

OSSEOUS PATTERN

 CLASS III BONE STRUCTURE: LARGE, MARROW LOOSE FITTING

FILLED SPACES EXIST B/W BONE TRABECULAE
 ACCORDING TO LEKHOLM & ZARB
1985:

QUALITY 1 QUALITY 2 QUALITY 3 QUALITY 4

 ACCORDING TO MISCH 1988:

D1 D2 D3 D4
WHERE DO WE FIND DIFF. TYPE OF BONE QUALITIES?
 CAN WE ASSESS BONE DENSITY
THROUGH RADIOGRAPH??
 PERIAPICAL & PANORAMIC
RADIOGRAPHS

 TOMOGRAPHIC RADIOGRAPHS- CT/CBCT


CORRELATION B/W CT HOUNSFIELD UNITS & MISCH
BONE DENSITY CLASSIFICATION

D1 >1250 HOUNSFIELD UNITS

D2 850-1250 HOUNSFIELD UNITS
D3 350-850 HOUNSFIELD UNITS
D4 150-350 HOUNSFIELD UNITS
D5 <150 HOUNSFIELD UNITS
 SO WHY BONE DENSITY IS IMPORTANT??

BONE DENSITY ~ BONE STRENGTH

BONE STRENGTH IS RELATED TO BONE MINERALIZATION.

BONE TYPE STRENGTH SCALE HEALING TIME (WAITING PERIOD)

D1 9-10 3-4 MONTHS
D2 7-8 3-4 MONTHS
D3 3-4 5-6 MONTHS
D4 1-2 5-6 MONTHS

Bone is 60% mineralized at 4 months after implant surgery

BONE DENSITY ~ ELASTIC MODULOUS

• the amount of strain (changes in INTERNAL

STRUCTURE) as a result of a particular amount of
stress.
• STIFFNESS OF THE MATERIAL

MICROSTRAIN
STRSS ON IMPLANT IS ELASTIC
CONDITION-
IMPLANT MORE RIGID MODULOUS OF
PATHOLOGIC
PROSTHESIS THAN BONE BONE IS LOW
OVERLOAD

IMPLANT FAILURE
BONE DENSITY ~ BIC ( BONE TO IMPLANT CONTACT )

MECHANICAL DISTRIBUTION &

STABILITY TRASMISSION OF FORCES
TO THE BONE
FORCE
STRESS
AREA

Bone density BIc (%)

Less the area of BIC, D1 85
greater will be the stress
D2 65-70
D3 40-50
D4 < 30