Success criteria and basic

guides to osseointegration
“CONCEPT OF OSSEOINTEGRATION”

Dr. Per-Ingvar Branemark

Orthopaedic surgeon
Professor University of Goteburg, Sweden.

Threaded implant design made up of pure titanium

 Fibro – osseous
Definitions integration
Bone implant
interface
Osseointegration

Success criteria and

Success basic guides to
criteria osseointegration

Methods of Mechanism of
evaluation of osseointegration
osseointegration

Factors effecting
osseointegration
 Definitions
“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).
Bone physiology
Bone can be classified as
• Compact bone
• Spongy bone
Depending on age, developmental age, localization
and function, bone consists of three tissue types that
differ in collagen fibril arrangement and mineral
content.

Woven bone
Lamellar bone
Bundle bone
 Woven bone

• Formed by the osteoprogenitor cells in the vicinity

of blood vessels during prenatal development
,growth and healing .
• Forms 30-50 µm /day
• High cellular osseous tissue
• Low mineral content
• More pliable than mature lamellar bone , it is more
forgiving of the relative micromotion associated
with interface healing
• Capable of stabilizing an unloaded implant ,
woven bone lacks the strength to resist functional
loads .
Woven bone
 Lamellar bone tissue

• Principle load-bearing tissue

• Predominant component of mature cortical and
trabecular bone
• Forms relatively slow (< 1.0µm/day)
• Have highly organized matrix, and are densely
mineralized
• Orientation of the collagen fibrils differs from one
layer to another .
Lamellar bone
 Bundle bone

• Found in the area of ligament and tendon

attachment along the bone-forming surfaces.
• Striation are extension of sharpey’s fibers
composed of collagen bundles from adjacent
connective tissue that insert directly into the
bone
• It is formed adjacent to the periodontal ligament
of physiologically drifting teeth.
Bundle bone
 Modelling

• A surface specific activity that produces a net

change in the size and/or shape of bone .
• An uncoupled process, meaning that cell
activation(A) proceeds independently to
formation(F) or resorption(R)
• Generalized change in overall dimension of a
bone’s cortex or spongiosa
• Modelling is a fundamental mechanism of
growth , atrophy and reorientation.
 Bone Remodeling

• It is the turnover or internal restructuring of

previously existing bone .
• Coupled tissue level phenomenon
A

R/Q

F
• Remodelling cycle = 17 weeks in humans
• Remodelling includes :
1. Localized changes in individual osteons
or trabeculae
2. Turnover, hypertrophy,atrophy or
reorientation .
 Bone to implant interface
There are two basic theories

Osseointegration
(Branemark 1985)

Fibro-osseous
integration
Linkow 1976
James 1975
Weiss 1986
FIBROINTEGRATION OSSEOINTEGRATION

Vs

Concept of soft tissue Concept of Bony

anchorage Anchorage
Linkow (1970), James (1975), Branemark (1969)
Weiss (1986).
In 1986, the American Academy of Implants
Dentistry (AAID)

“Tissue-to-implant contact with healthy dense

collagenous tissue between the implant and
bone”
 Fibro-osseous integration

 Presence of connective tissue between the

implant and bone.
 Collagen fibers functions similarly to
Sharpey’s fibers found in natural dentition.
 The fibers affect bone remodeling where
tension is created under optimal loading
conditions.
Weiss concept
 Collagen fibers at the interface - peri-
implant membrane with an osteogenic
effect.
 Collagen fibers invest the implant,
originating at the trabeculae of
cancellous bone on one side, weaving
around the implant, and reinserting into a
trabeculae on the other side.
Failure of fibro-osseous theory
 No real evidence
 Forces are not transmitted through the fibers
- remodeling was not expected
 Forces applied resulted in widening fibrous
encapsulation, inflammatory reactions, and
gradual bone resorption there by leading to
failure.
 Natural teeth Implant

Oblique and horizontal Parallel, irregular,

group of fibers complete encapsulation

Uniform distribution of load Difficult to transmit the

(Shock absorber) load

Failure : Inability to carry adequate loads

- Infection
Parallel fiber Complete fiber
arrangement encapsulation
Fibrosseousintegration Osseointegration
 Osseointegration
American Academy of Implant Dentistry (AAID)
defined it as "contact established without
interposition of non-bone tissue between normal
remodeled bone and an implant entailing a
sustained transfer and distribution of load from the
implant to and within the bone tissue"
Mechanism of Osseointegration
• Healing process may be primary bone healing or
secondary bone healing.

• In primary bone healing, there is well organized

bone formation with minimal granulation tissue
formation – ideal

• Secondary bone healing may have granulation

tissue formation and infection at the site, prolonging
healing period. Fibrocartilage is sometimes formed
instead of bone - undesirable
 Blood between the
fixture and bone

Blood clot
Phagocytic
PMNL
cells
Procallus ( contains
fibroblast)

Callus (contains
osteoblast)
Remodelling

Bone
 Bone tissue response

 Mechanism of integration: (Davies - 1998)

 Mechanism of integration: (Osborn and

Newesley – 1980)
Mechanism of integration: (Osborn and
Newesley – 1980)
 Contact osteogenesis
 Distance osteogenesis
• Distance Osteogenesis • Contact Osteogenesis
A gradual process of bone The direct migration of
healing inward from the bone-building cells
edge of the osteotomy through the clot matrix to
toward the implant. Bone the implant surface.
does not grow directly on Bone is quickly formed
the implant surface. directly on the implant
surface.
Mechanism of integration: (Davies -
1998)
Contact osteogenesis :
 Early phases of osteogenic cell migration
(Osteoconduction)
 De novo bone formation
 Bone remodeling at discrete sites.
 Osteoconduction
“Osteoconduction” refers to the migration of
differentiating osteogenic cells to the proposed site.

Migration of the connective tissue cells will occur

through the fibrin that forms during clot resolution.

The migration of cells through a temporary matrix

such as fibrin - retraction of the fibrin scaffold.

Implant design can have a profound influence on

osteoconduction by maintaining the anchorage of
the temporary scaffold
 De novo bone formation

Differentiating osteogenic cells, which reach

the implant surface initially, secrete a
collagen-free organic matrix that provides
nucleation sites for calcium phosphate
mineralization
Noncollagenous bone proteins - Osteopontin
and bone Sialoprotein
 Bone bonding in de novo bone
formation

Bonding of de novo bone will occur by the fusion,

or micromechanical interlocking of the biologic
cement line matrix with the surface reactive
layer of the substratum.
 Bone remodeling

During the long-term phase of peri-implant healing,

it is only through those remodeling osteons that
actually impinge on the implant surface that de
novo bone formation will occur at these specific
sites on the transcortical implant
Stages of Osseointegration

According to Misch there are two stages in

osseointegration, each stage been again
divided into two substages. They are:
Surface modeling
Stage 1: Woven callus (0-6 weeks)
Stage 2: Lamellar compaction (6-18 weeks)
Remodeling, Maturation
Stage 3: Interface remodeling (6-18 weeks)
Stage 4: Compacta maturation (18-54 weeks)
 Stage 1: Woven callus

• 0-6 weeks of implantation.

• Woven bone is formed at implant site.
• Primitive type of bone tissue and characterized
Random, felt-like orientation of collagen
fibrils
Numerous irregularly shaped osteocytes
Relatively low mineral density
Stage 2: Lamellar compaction

• 6th week of implantation and continues till

18th week.
• The woven callus matures as it is replaced
by lamellar bone.
• This stage helps in achieving sufficient
strength for loading.
Stage 3: Interface remodeling

• This stage begins at the same time when

woven callus is completing lamellar
compaction.
• During this stage callus starts to resorb, and
remodeling of devitalized interface begins.
• The interface remodeling helps in
establishing a viable interface between the
implant and original bone.
Stage 4: Compact bone maturation

• This occurs form 18th week of implantation

and continues till the 54th week.
• During this stage compact bone matures by
series of modeling and remodeling processes.
• The callus volume is decreased and interface
remodeling continues.
Johansson & Albrektsson

• Fibrous tissue interface 1 month

• 50% bone-implant interface 3 month
• 65% 6 month
• 85% 1 year
Factors Effecting
Osseointegration
Six different factors known to be
important for the establishment of a
reliable, long-term osseous anchorage
of an implanted device

 Implant biocompatibility
 Design characteristics
 Surface characteristics
 State of the host bed
 Surgical technique and
 Loading conditions
Implant Biocompatibility

 Chemical interaction determined – properties of

surface oxide
 Commercially pure (c.p.) Titanium and Titanium
alloy (Ti -6AL-4V)
 Documented long term function
 Covered with adherent, self- repairing oxide
layer
 Excellent resistance to corrosion – high
dielectric constant
 Load bearing capacity
Other metals
 Niobium, tantalum
 Cobalt chrome molybdenum alloys
 Stainless steels
 Ceramics - calcium phosphate
hydroxyapatite (HA) and various types of
aluminium oxides
Biocompatible - insufficient documentation and
very less clinical trials - less commonly
used.
Grouping of hard tissue replacement materials
according to their compatibility to bony tissue

Degree of Characteristics of Materials

Compatibility Reactions of Bony Tissue

Biotolerant Implants separated from Stainless steels: CoCrMo

adjacent bone by a soft and CoCrMoNi alloys
tissue layer along most of the
interface: distance
osteogenesis

Bioinert Direct contact to bony tissue Alumina ceramics, zirconia

contact osteogenesis ceramics, titanium,
tantalum, niobium, carbon.

Bioactive Bonding to bony tissue: Calcium phosphate-

bonding osteogenesis containing glasses, glass-
ceramics, ceramics,
titanium (?)
 Implant Design (Macrostructure)
Threaded or screw design implants
 Promote osseointegration
 More functional area for stress distribution
than the cylindrical implants.
 Minimal - <0.2 mm/year bone loss

Cylindrical implants
 Press fit root form implants depend on
coating or surface condition to provide
microscopic retention and bonding to the
bone
 Bone saucerization ?
 Non threaded Threaded

•Tendency for slippage •No slippage tendency

•Bonding is required •No bonding is required
Functional surface area per unit length of implant
may be modified by the three thread geometry
parameters

• Thread shape
• Thread pitch
• Thread depth
Grooves on the threads of all implants and
on the collars, whereever appropriate.
 Increase surface area
 Increase area for bone-to-implant contact
Implant Surface (Microstructure,
Surface Topography)
“The extent of bone implant interface is
positively correlated with an increasing
roughness of the implant surface”
Roughened surface

 Greater bone to implant contact at
histological level
 Micro irregularities - cellular adhesion.
 High surface energy - improved cellular
attachment.
• Roughness parameter (Sa)
0.04 –0.4 m - smooth
0.5 – 1.0 m – minimally rough
1.0 –2.0 m – moderately rough
 2.0 m – rough

• Wennerberg (1996) – stated that moderately

rough implants developed the best bone fixation.

Smooth surface < 0.2 m will – soft tissue no

bone cell adhesion  clinical failure.
Moderately rough surface more bone in contact
with implant  better osseointegration.
 Surface treatments
• Turned surface
• Sandblasted surface
• Acid etched surface
• Titanium plasma spray
• Sandblasting and surface
etching
• Hydroxyapatite coatings
• Anodized surface
 Bone – implant contact area
Surface treatment 1 month 3 months 6 months

Machined/ 42% 44%

truned
Machined/ sandblasted 54%

Machined/ acid etched 42% 51% 49%

Sandblasted 58% 52%

and acid etched
72% 68%
Oxidized 35% 43%
Titanium plasma-sprayed 52% 78%

Hydroxyapaptite 79%
Ion implantation 68% 61%
Laser treated 38%
State of the host bed

Ideal host bed

Healthy and with an adequate bone stock
 Bone height
 Bone width
 Bone length
 Bone density

Undesirable host bed states for implantation

 Previous irradiation
 Ridge height resorption
 Osteoporosis
 Implant bed - Bone Quality
According to Lekholm and Zarb,1985

• Quality I
composed of homogenous compact
bone found in the lower anterior

• Quality II

Thick layer of cortical bone surrounding

dense trabecular bone found in the lower
posterior
• Quality III
Thin layer of cortical bone surrounding dense
trabecular bone – upper anterior and upper &
lower posterior region

• Quality IV
Very thin layer of cortical bone surrounding
a core of low-density trabecular bone
- very soft bone found in the
upper anterior and posterior
• Branemark system (5 year documentation)
• Mandible – 95% success
• Maxilla – 85-90% success
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
Selection of implant
• D1 and D2 – conventional threaded implants
• D3 and D4 – HA coated or Titanium plasma coated
implants
 Surgical Considerations
 Promote regenerative type of the bone
healing rather than reparative type of the
bone healing.
 The critical time/ temperature - bone tissue
necrosis - 47° for one minute.
 Recommendations
 Slow speed
 Graded series
 Adequate cooling
 Bone cutting speed of less than 2000 rpm
 Tapping at a speed of 15 rpm with irrigation
 Using sharp drills
 The optimal torque threshold – 35 N/cm.
 Implant should gently engage the bone in order
to avoid too much pressure at the bone
interface which could jeopardize healing
 Surgical skill / technical excellence
 Loading conditions
 Progressive or two stage loading
 Immediate or one stage or
nonsubmerged loading
 Progressive or two stage loading

Branemark et al to accomplish osseointegration

considered the following prerequisites
 Countersinking the implant below the crestal
bone
 Obtaining and maintaining a soft tissue covering
over the implant for 3 to 6 months
 Maintaining a non loaded implant environment
for 3 to 6 months
• Delayed loading:
- Two-stage surgical protocol
- One-stage surgical protocol

• Immediate loading:
1. Immediate occlusal loading (placed
within 48 hours)

2. Immediate non-occlusal loading (in

single-tooth or short-span
applications)

3. Early loading (within two months)

 • 677 subjects - 2,349 delayed-loaded dental
implants

• 178 patients - 477 immediate-loaded implants

• Unadjusted 1-year survival estimates for the

delayed and immediate loading groups were 95.5%
and 90.3%

• Immediate loading, current tobacco use, maxillary

implants, and shorter implants were associated
with failure

Susarla SM. Delayed versus immediate loading of implants: survival

analysis and risk factors for dental implant failure. J Oral Maxillofac surgery.
2008 ;66(2):251-5
Frost’s mechanostat theory
 Systemic factors

• Active chemotherapy

• Type 2 (late-onset) diabetes: This is

especially the case where this is not well
controlled

• Treatment by an operator with limited

surgical experience.
 Osteotomy

Clot formation Alteration in protein synthesis

Formation of bone
Formation of collagen
matrix

Bone apposition and Osteoblasts

mineralization Alkaline phosphatases

Maintenance of
Bone remodelling
osseointegration

Valero AM, Ferrer García JC, Ballester AH, Rueda CL. Effects of diabetes
on the osseointegration of dental implants. Med Oral Patol Oral Cir Bucal
2007;12:E38-43
• Patients who were smokers at the time of implant
surgery had a significantly higher implant failure
rate (23.08%) than non-smokers (13.33%)

• Short implants and implant placement in the

maxilla were additional independent risk factors for
implant failure.

DeLuca S, Habsha E, Zarb GA. The effect of smoking on

osseointegrated dental implants. Part I: implant survival. Int J
Prosthodont 2006;19(5):491-8
Methods of Evaluation
of
Osseointegration
 Implant stability
 Stability is a requisite characteristic of
osseointegration.

 Initial stability is a function of the

 Bone quality,
 Implant design and
 Surgical technique.

 During the osseointegration healing and maturation

process , the initial stability changes with increases
in bone- to –implant contact and osseous
remodeling.
 Rigid fixation
 Absence of observed clinical mobility.
 First clinical criterion to be evaluated.
Scale A healthy implant movesDescription
less than 73 microns –
appears as zero clinical mobility .
0 Absence of clinical mobility with 500g in any
 The goal for root form implants should be rigid
direction
fixation and IM status 0
1 Slight detectable horizontal movement

2 Moderate visible horizontal mobility up to 0.5 mm

3 Sever horizontal movement greater than 0.5 mm

4 Visible moderate to sever horizontal and any

visible vertical movement
 Invasive Methods
 Histological sections (10 microns sections)
 Histomorphometric – To know the percentage
of bone contact
 Transmission electron microscopy
 By using Torque gauges
 Non-Invasive Methods
 Percussion test
 Tapping with a metallic instruments
Ringing sound- osseointegrated.
Dull sound - fibrous integration.
 Radiographs
 Perio-test
 Checks mobility and damping system.
 Normal values - 5 to +5 PTV
 Dynamic modal testing
 Resonance frequency analysis
Harvard success criteria
• The dental implant must provide functional
service for 5 years in 75% of cases
 Subjective criteria
• Adequate function
• Absence of discomfort
• Improved aesthetics
• Improved emotional and psychological
wellbeing
 Objective criteria
• Bone loss no greater than 33% of vertical length of
implant

• Good occlusal balance and vertical dimension

• Gingival inflammation amenable to treatment

• Mobility of less than 1mm in any direction

• Absence of symptoms of infection

• Absence of damage to surrounding structure

• Healthy connective tissues

 Success rates
Implants Percentage

Subperiosteal 39 - 90

Staple 95

Vitreous carbon 50

Blade 65 - 90

Osseointegrated 80 - 100
Possible criteria for success

• Mobility
• Peri-implant radiolucency
• Marginal bone loss
• Sulcus depth
• Gingival status
• Damage to adjacent teeth
• Violation of maxillary sinus , mandibular
canal or floor of nasal cavity
• Appearance
• Length of service
Condition for application of criteria
• Only osseointegrated implants should be evaluated
with these criteria.

• The criteria apply to individual endosseous

implants.

• At the time of testing, the implants must have been

under a functional load.
• Implants that are beneath the mucosa and in a
state of health in relation to the surrounding
bone should preferably not be included in the
evaluations but reported as complications.

• Complications of an iatrogenic nature that are

not attributable to a problem with material or
design should be considered separately when
computing the percentage of success
Revised criteria - Albrektsson

• Individual implant is immobile clinically

• No evidence of peri-implant radiolucency is

present as assessed on an undistorted
radiograph.

• Mean vertical bone loss is less than 0.2 mm

annually after the first year of service.
• No persistent pain, discomfort, or infection is
attributable to the implant.

• Implant design does not preclude placement of

a crown or prosthesis with an appearance that
is satisfactory to the patient and dentist.

• By these criteria, a success rate of 85% at the

end of a 5-year observation period and 80% at
the end of a 10 year period are minimum levels
for success.
 Implant quality Clinical conditions
scale
Success (optimum a) No pain or tenderness upon
health) function

b) 0 mobility

c) 2 mm radiographic bone loss

from initial surgery

d) No exudates history

Misch CE et al. Implant Success, Survival, and Failure: The International

Congress of Oral Implantologists (ICOI) Pisa Consensus Conference. Implant
Dent 2008;17:5–15
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