Bone Density:

A Key Determinant for

Clinical Success

- Dr. Tambolkar Rajeshwari A.

Introduction
Available bone describes the external
architecture & an internal architecture of
bone.

It is a determining factor in treatment

planning, implant design, surgical
approach, healing time, and initial
progressive bone loading during prosthetic
reconstruction.
CLINICAL EVIDENCE DOCUMENTS-
INFLUENCE OF BONE DENSITY ON
SUCCESS RATES
Failure rate- poor quality bone > higher quality
bone
• Adell- Ant. Mandible 10% < Ant. Maxilla.
• Schnitman – Post. Mandible > Ant. Mandible.

Bone density-
• Ant. Mandible. > Ant. Maxilla
• Ant. Mandible > Post. Mandible

Posterior maxilla- poorest bone quality & highest

failure rate.
• Jaffin and Berman –
44% poor density
• 55% - in softer bone
• 35% - poor bone
density
• Engquist – 78% - soft
bone
• Friberg – 66% in
maxilla with soft
bone.
ETIOLOGY OF VARIABLE BONE
DENSITY
Meier In 1887 - architecture of trabecular bone in the
femur.

Kulmann In 1888 - similarity between the pattern of

trabecular bone in the femur and tension trajectories
in construction beams.

Wolff In 1892 - elaborated these concepts and

published the statement: “Every change in the form
and function of bone or of its function alone is
followed by certain definite changes in the internal
architecture, and equally definite alteration in its
external conformation, in accordance with
mathematical laws.”
Modeling has independent sites of
formation and resorption and results in
the change of the shape or size of bone.

Remodeling is a process of resorption and

formation at the same site that replaces
previously existing bone and primarily
affects the internal turnover of bone.
MacMillan and Parfitt noted that the bone
is most dense around the teeth and more
dense around the teeth at the crest
compared with the regions around the
apexes

Generalized trabecular bone loss in the

jaws occurs in regions around a tooth
from a decrease in mechanical strain
Orban demonstrated a decrease in the
trabecular bone pattern around a
maxillary molar with no opposing
occlusion, compared with a tooth with
occlusal contacts on the contralateral
side.

On the left loss of trabecular bone around the

maxillary tooth. On the right trabecular bone is
much more dense around the tooth.
Bone density decrease in the jaws is related to-

- the length of time the region has been

edentulous and not loaded appropriately
- the original density of the bone
- muscle attachments
- flexure and torsion in the mandible
- parafunction before and after tooth loss
- hormonal influences
- systemic conditions.
Frost reported a model of four zones for
compact bone as
- acute disuse window
- adapted window
- mild overload zone
- the pathologic overload zone
1. Acute disuse window- (0 to 50
microstrain)

- The bone loses mineral density

- Disuse atrophy occurs because modeling for
new bone is inhibited
- Remodeling is stimulated, with a gradual net
loss of bone

Cortical bone density- 40% and trabecular

bone-12%
2. The adapted window (50 to 1500
microstrain)
- represents an equilibrium of modeling
and remodeling
- bone conditions are maintained at this
level.

histologic description- primarily lamellar or

load-bearing bone.
18% of trabecular bone and 2% to 5% of
cortical bone is remodeled each year.

Ideally desired strain around an endosteal

implant

Mori and Burr provide evidence of

remodeling in regions of bone
microfracture from fatigue damage within
the physiologic range.
3. The mild overload zone (1500 to 3000
microstrain)
- corresponds to bone modeling stimulation
and remodeling inhibition.
- the bone strength and density eventually
may decrease.

histologic description- woven or repair bone.

This may be the state for bone that has lost

density when an endosteal implant is
overloaded and changes the strain
environment
During the repair process- the woven bone
is weaker than the more mature
mineralized lamellar bone.

Therefore, although bone is loaded in the

mild overload zone, one must take care
because the “safety range” for bone
strength may be made inadequate during
the repair.
4. Pathologic overload zones
- reached when microstrains are greater
than 3000.

Cortical bone fractures occur at 10,000 to

20,000 microstrain (1% to 2%
deformation).

Begin at microstrain levels of only 20% to

40% of the ultimate strength or physical
fracture.
Woven bone is the only bone formation
observed in this zone

The crestal bone loss often evidenced

during early implant loading results from
the bone in the pathologic overload zone
The microstrain levels presented are for
cortical bone and vary in relation of each
bone density.

As the density of bone decreases, the

overall microstrain ranges increase for
the same load.
BONE CLASSIFICATION SCHEMES
RELATED TO IMPLANT DENTISTRY

In 1970 Linkow and Chercheve classified bone

density into three categories:

Class I bone structure:

Class II bone structure:
Class III bone structure:
In 1985 Lekholm and Zarb listed four bone
qualities found in the anterior regions of
the jawbone.

Quality 1
Quality 2
Quality 3
Quality 4
Following the protocol results in 10% difference in
implant survival between Quality 2 and Quality 3
bone and 22% lower survival in the poorest bone
density.
failure rate site
Jaffin and 55% in Quality 4 bone
Berman
Engquist 78% in Quality 4 bone
Friberg 66% in soft bone with severe
resorption
Johns 3% type III bone
28% type IV bone
Weng 20% in the posterior maxilla
Higuchi a greater in the posterior maxilla
This surgical, prosthetic, and implant
design protocol does not render similar
results in all bone densities.

The amount of crestal bone loss also has

been related to stress and bone density.
MISCH BONE DENSITY
CLASSIFICATION

D5 bone- A very soft bone, with incomplete

mineralization
Determination of Bone Density

The bone density may be determined by-

1. tactile sense during surgery

2. the general location
3. radiographic evaluation.
1. TACTILE SENSE
To communicate more broadly to the
profession the tactile sense of different
bone densities, this classification compares
materials of varying densities.

Drilling and placing implants into-

D1 bone - oak or maple wood.
D2 bone - white pine or spruce.
D3 bone - balsa wood.
D4 bone - Styrofoam.
2. LOCATION

Misch described four bone densities found in

the edentulous regions of the maxilla and
mandible.

D1 bone
D2 bone
D3 bone
D4 bone
A review of the literature, blended with a survey of
200 completely and partially edentulous
consecutive patients, found that the location of
different bone densities may be superimposed
with the different regions of the mouth.
D1 type-

D1 bone - mandible about 8% of the time.

D1 bone - twice often in the anterior mandible (6%
versus 3%).

As the bone is reduced in volume to C minus

height (C−h), especially in the anterior
mandible, D1 bone will occur with greater
frequency and may reach 25%, whereas D3 will
be less and be reduced to less than 10%.
The C−h mandible often exhibits an increase in
torsion or flexure in the anterior segment between
the foramens during function. This increased
strain causes the bone to increase in density.

D1 bone may be encountered in the anterior

Division A mandible of a Kennedy Class 4 partially
edentulous patient with a history of parafunction
and recent extractions.

One also may observe D1 bone when the angulation

of the anterior implant may require the
engagement of the lingual cortical plate in a
Division A bone volume.
D2 type-

- Observed most commonly in the

mandible.
- Anterior mandible consists D2
bone 2/3 time.
- Posterior mandible consists D2
bone ½ time.
- Maxilla presents D2 bone less
often than mandible.
- About 1/4 of patients have D2
bone in the partially edentulous
patient’s anterior and premolar
region
- Edentulous spans with single-
tooth or two-tooth have D2 bone.
D3 type-
- Common in the maxilla.
- More than ½ of the patients have D3 bone in
maxilla.
- Anterior maxilla has D3 bone about 65% of the
time & ½ patients have posterior maxillas with
D3 bone.
- Almost ½ posterior mandibles also have D3 bone
& about 25% of the anterior edentulous
mandibles have D3 bone.
D4 type-
- Most often in the posterior maxilla (about 40%)
- Almost 2/3 patients have D4 bone.
- The anterior maxilla has D4 bone less than 10%
of time more often after an onlay iliac crest bone
graft.
- The mandible has D4 bone in less than 3% of the
patients.
- D4 bone is usually in a Division B bone.
Generalizations for treatment planning can be
made prudently, based on location.

It is safer to err on the side of less dense bone

during treatment planning, so the prosthesis will
be designed with slightly more, rather than less,
support.

Therefore the initial treatment plan before

computed tomographic (CT) radiographic scans
or surgery suggests the anterior maxilla is
treated as D3 bone, posterior maxilla as D4 bone,
anterior mandible as D2 bone, and posterior
mandible as D3 bone.
RADIOGRAPHIC BONE
DENSITY
Computed tomography (CT) produces axial images
& has 260,000 pixels, and each pixel has a CT
number related to the density of the tissues
within the pixel.

- Higher the CT number denser the tissue.

The Misch bone density classification may be
evaluated on the CT images to a range of
Hounsfield units:
BONE STRENGTH AND DENSITY

Bone density is related directly to the strength of

bone

A tenfold difference in bone strength was observed

from D1 to D4 bone.

D2 bone exhibited 47% to 68% greater ultimate

Bidez and Misch performed three-dimensional,
finite stress analyses on bone volumes of Division
A, B, and C minus width patients.

Each model reproduced the cortical and

trabecular bone material properties of the four
densities described.
INFLUENCE OF BONE DENSITY ON LOAD
TRANSFER
The bone density influences the amount of bone in
contact with the implant surface at first &
second stage surgery.

The percentage of bone contact- cortical bone

>trabecular bone.

The very dense bone of a C−h resorbed anterior

mandible (D1) or of the lateral cortical bone of a
Division A anterior mandible provides the
highest percentage of bone in contact with an
endosteal implant.
The sparse trabeculae of posterior maxilla (D4) offer
less areas of contact with the body of the implant.

Consequently, greater implant surface area is required

to obtain a similar amount of bone implant contact in
soft bone compared with denser bone quality found
around an anterior mandibular implant.

Crestal bone loss and early implant failure after

loading- excess stress at the implant-bone interface.
A range of bone loss has been observed
with similar loads on the implant.

This phenomenon is explained by the

evaluation of finite element analysis of
stress contours in the bone.
As a result of the correlation of bone strength and
bone-implant contact, when a load is placed on
an implant, the stress contours in the bone are
different for each bone density.
In D1 bone, most stresses are
concentrated around the implant near
the crest, and the stress is of lesser
magnitude.
D2 bone, with the same load, sustains a
slightly greater crestal stress and the
intensity of the stress extends farther
apically, along the implant body.

D2 bone has an
intermediate stress
intensity around the
implant.
D4 bone exhibits the greatest crestal stresses,
and the magnitude of the force of load on the
implant proceeds farthest apically along the
implant body.

D4 bone has a higher

stress intensity around
the implant and even
extends to the zone
around the threads.
As a result, the magnitude of stress may remain
similar and give one of the following three
different clinical situations, based on bone
density:

(1) physiologic bone loads and no bone loss,

(2) pathologic bone loads and crestal bone loss, or
(3) severe pathologic loads and implant failure.

Therefore to re-equilibrate the equation, the

dentist should modify treatment plans for each
bone density.
TREATMENT PLANNING

Bone density is an implant treatment plan

modifier in several ways:

prosthetic factors
implant size
implant design
implant surface condition
implant number
progressive loading.
Prosthesis design-One way of reducing
biomechanical loads on implants

- cantilever length may be shortened or

eliminated, narrower occlusal tables designed,
and offset loads minimized.
- Rp4 restorations- permit the patient to remove
the restorations at night.
- RP-5 prostheses- permit the soft tissue to share
the occlusal force.
- Night guards and acrylic occlusal surfaces
distribute and dissipate parafunctional forces on
an implant system.
Direction of force-
- load directed along the long axis of the implant
body decreases the amount of stress in the crestal
bone region so the angle of load on the implant
body should be more axial.

Functional area-
- Stress can be reduced by increasing the functional
area

No. of implants-
-Increasing implant number is an excellent way to
reduce stress by increasing functional loading area.
-Three implants rather than two may decrease
applied implant moment torque in half and bone
Macrogeometry-

- Increased macrogeometry to decrease stress.

- D4 bone benefits from relatively longer implants
for initial fixation and early loading compared
with other bone densities.
- The minimum bone height for initial fixation and
healing-
minimum bone height
for initial fixation and
healing
D1 10mm
D2 12mm
D3 14mm
- pathologic overload of bone most often occurs
over crestal region
- width of the implant may decrease stress by
increasing the surface area which may reduce
the length requirement.
- For every 0.5-mm increase in width, there is an
increased surface area between 10% and 15%.
- width is more significant than length for an
implant design.
- D4 bone often requires wider implants compared
with D1 or D2 bone
Implant design- The implant design affects the
magnitude of stresses and their impact on the
bone-implant interface.
A D4 implant should have the greatest design
surface area
D1 implant should be designed for easy surgical
placement.

Thread design- Thread design with more threads

has more surface area
-D4 implant body should have more and deeper
threads than a D1 implant body.
Surface condition-

in D4 bone Hydroxyapatite coatings are strongly

suggested and have resulted in improved short-
term survival rates compared with titanium
alone.

After 1 to 2 years the mechanical load on the

implant is more critical to the amount of bone
contact than the coating on the implant body.
Progressive bone loading-

- Provides for a gradual increase in occlusal loads,

separated by a time interval to allow the bone to
accommodate.
- Over time, progressive loading changes the
amount and density of the implant-bone contact.
- This increases the density of bone at the implant
interface and improves the overall support
system mechanism.
- The softer the bone, the more important the
progressive loading
 SUMMARY
A key determinant for clinical success is the
diagnosis of bone density around an
endosteal implant. The strength of bone is
related directly to bone density. Factors such
as the amount of bone contact, the modulus
of elasticity, and axial stress contours around
an implant are affected by the density of
bone. As a consequence, the treatment plan,
which includes implant number and size,
should be modified as stress factors increase
or bone density increases.
Thank you