1-6 Notes For Dental Implant

DEN 003 Basic Dental Implantology
Teachers’ Guide Module #1
Name:_______________________________________________________ Class number: ______

Section: ____________ Schedule: ________________________________ Date: _____________
Lesson Title: Rationale for Dental Implants Materials:

Lesson Objectives: At the end of this module, you should be able to: Pen, pencil and highlighter
1. Determine the factors that increased need and use of implant- References:
related treatments Contemporary of Implant
Dentistry. 3rd Edition.
2. Know the clinical changes of alveolar bone after tooth extraction Carl E. Misch
and it impact on implant treatment management.
Productivity Tip: “Obstacles are those frightful things you see when you take your eyes off your goal”
- Henry Ford
A. LESSON PREVIEW/REVIEW
1) Introduction (2 mins)
The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics,
speech, and health, whether by removing caries from a tooth or replacing several teeth. What makes implant
dentistry unique is the ability to achieve this goal, regardless of the atrophy, disease, or injury of the
stomatognathic system.
2) Activity 1: What I Know Chart, part 1 (3mins)

Answer the row questions of the second column of the table below to gauge what you know
before studying the contents of the module . Write your answers on the appropriate box of the first
column. Leave the third column blank at this juncture. You will answer them when you reach Activity 4
of this module.
What I Know Questions: What I Learned (Activity 4)

1.What is the goal of modern
Dentistry?
2. It is directly related to every
indicator of tooth loss.
3. What makes implant dentistry

unique?
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This document is the property of PHINMA EDUCATION

B.MAIN LESSON
1) Activity 2: Content Notes (13 mins)
The goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics,
speech, and health, whether by removing caries from a tooth or replacing several teeth. What makes implant
dentistry unique is the ability to achieve this goal, regardless of the atrophy, disease, or injury of the
stomatognathic system. However, the more teeth a patient is missing, the more challenging this task becomes.
As a result of continued research, diagnostic tools, treatment planning, implant designs, materials, and
techniques, predictable success is now a reality for the rehabilitation of many challenging clinical situations.
The increased need and use of implant-related treatments result from the combined effect of several
factors, including
(1) aging population living longer,
(2) tooth loss related to age,
(3) consequences of fixed prosthesis failure,
(4) anatomical consequences of edentulism,
(5) poor performance of removable prostheses,
(6) consequences of removable partial dentures,
(7) psychological aspects of tooth loss and needs and desires of aging baby boomers,
(8) predictable long-term results of implant-supported prostheses,
(9) advantages of implant-supported restorations, and
(10) increased public awareness.
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EFFECTS OF AN AGING POPULATION
According to the literature, age is directly related to every indicator of tooth loss. Therefore the aging
population is an important factor to consider in implant dentistry. When Alexander the Great conquered the
ancient world, he was only 17 years old. However, life expectancy at that time was only 22 years of age. From
1000 BC to AD 1800, life span remained less than 30 years . Since 1960, the increase in life expectancy has
been more rapid than at any other time in history. In 1980, 30% of the U.S. population was older than age 45,
21% was older than 50, and 11% was older than 65. In 1995, 15 years later, all these individuals were older
than age 60. The group older than age 65 is projected to increase from 12%.
AGE-RELATED TOOTH LOSS
Single-Tooth Edentulism
The posterior regions of the mouth often require the replacement of a single tooth . The first molars
are the first permanent tooth to erupt in the mouth and, unfortunately, are often the first teeth lost as a result
of decay, failed endodontic therapy or fracture (usually after endodontics). They are important teeth for
maintenance of the arch form and proper occlusal schemes. In addition, the adult patient often has one or
more crowns, as a consequence of previous larger restorations required to repair the integrity of the tooth.
Longevity reports of crowns have yielded very disparate results. The mean life span at failure has been
reported as 3 years. Other reports range from a 3% failure rate at 23 years to a 20% failure rate at 3 years. The
primary cause of failure of the crown is caries followed by endodontic therapy.
The tooth is at risk for extraction as a result of these complications, which are the leading causes of
single posterior tooth loss in the adult . It has been estimated that a $425 crown for a 22-year-old patient will
cost $12,000 during the patient's lifetime to replace and/or repair.
Fixed Partial Dentures
The most common choice to replace a posterior single tooth is a three-unit fixed partial denture (FPD).
This type of restoration can be fabricated within 1 to 2 weeks and satisfies the criteria of normal contour,
comfort, function, esthetics, speech, and health. Because of these benefits, FPD has been the treatment of
choice for the last 6 decades. Bone and soft tissue considerations in the missing tooth site are few. Every
dentist is familiar with the procedure, and it is widely accepted by the profession, patients, and dental
insurance companies. In the United States, 70% of the population is missing at least one tooth. Almost 30% of
the 50 to 59 year olds examined in a U.S. National Survey exhibited.
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Single-Tooth Implants
A treatment option to replace a posterior single missing tooth is a single-tooth implant . For years,
patients were advised to put their desires aside and accept the limitations of an FPD. However, many feel the
most natural method to replace a tooth is to use an implant, rather than preparing adjacent teeth and joining
them together with a prosthesis. The primary reasons for suggesting the FPD were its clinical ease and
reduced treatment time. However, if this concept were expanded, extractions would replace endodontics and
dentures could even replace orthodontics. The primary reason to suggest or perform a treatment should not
be related to treatment time or difficulty of the procedure, but instead should consider the best possible long-
term solution for each individual.
Single-Tooth Implants Advantages
High success rates (above 97% for 10 years) Decreased risk of caries of adjacent teeth Decreased risk of
endodontic problems on adjacent teeth Improved ability to clean the proximal surfaces of the adjacent teeth
Improved esthetics of adjacent teeth Improved maintenance of bone in the edentulous site Decreased cold or
contact sensitivity of adjacent teeth Psychological advantage.
Partial Edentulism
The prevalence of partial edentulism is also of interest because a growing number of implants are used
in these patients. A 1988 to 1991 survey in the United States found that only 30% of these patients had all 28
teeth. Partially dentate patients had an average of 23.5 teeth, In the 1999 to 2002 follow-up survey the
average number of missing teeth was fewer than two of 28 teeth for the 20- to 39-year-old group so this
number rapidly increased to an average of pre teeth missing in adult older than age 60 Parisly edentulous
seniors older than age 50 age here lost an average of 10 teeth, with older seniors having lot: three more teeth
than the younger seniors. Stadistic for partial edentulism are similar for both men and women.
The greatest transition from an intact dental arch to a partially edentulous condition in the 1987 study
occurred in the 35- to 54-year-old group. The growth rate of this baby boomer portion of the population was
approximately 30% in 1982 and is continuing to increase, more than any other age group. For example, in
1982 the baby boomer age group (born from 1946 to 1964) increased from 39 million Americans to 79 million
in 2005. Although the number of teeth missing per patient may seem to decrease, the overall number of
missing teeth will continue to increase. Therefore the need for implant services in partially edentulous
patients will dramatically increase during the next several decades.
The most common missing teeth are molars." Partial free-end edentulism is of particular concern
because in these patients, teeth are often replaced with removable partial prostheses. This condition is rarely
found in persons younger than age 25.
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Mandibular free-end edentulism is greater than its maxillary counterpart in all age groups.
Unilateral free-end edentulism is more common than bilateral edentulism in both maxillary and
mandibular arches in the younger age groups (ages 25 to 44). About 13.5 million persons in these younger age
groups have free-end edentulism in either arch.
ANATOMICAL CONSEQUENCES OF EDENTULISM
Consequences on the Bony Structures Basal bone forms the dental skeletal structure, contains most of
the muscle attachments, and begins to form in the fetus before teeth develop. Alveolar bone first appears
when Hertwig's root sheath of the tooth bud evolves .
The alveolar bone does not form in the absence of primary or secondary tooth development. The close
relationship between the tooth and the alveolar process continues throughout life. Wolff's law (1892) states
that bone remodels in relationship to the forces applied. Every time the function of bone is modified, a
definite change occurs in the internal architecture and external configuration." In dentistry, the consequences
of complete edentulous and remaining bone volume was noted by Misch in 1922, where he described the
skeletal structure of a 90 year-old woman without teeth for several decades. Bone needs stimulation to
maintain its form and density.
Roberts et al report that a 4% strain to the skeletal system maintains bone and helps balance the
resorption and formation phenomena. Teeth transmit compressive and tensile forces to the surrounding bone.
These forces have been measured as a piezoelectric effect in the imperfect crystals of durapatite that
compose the inorganic portion of bone. When a tooth is lost, the lack of stimulation to the residual bone
causes a decrease in trabeculae and bone density in the area, with loss in external width, then height, of the
bone volume. There is a 25% decrease in width of bone during the first year after tooth loss and an overall 4-
mm decrease in height during the first year after extractions for an immediate denture.
In a longitudinal 25-year study of edentulous patients, lateral cephalograms demonstrated continued

bone loss during this time span; a fourfold greater loss was observed in the mandible. However, because
initially the mandible height is twice that of the maxilla, maxillary bone loss is also significant in the long-term
edentulous patient.
A tooth is necessary to the development of alveolar bone, and stimulation of this bone is required to
maintain its density and volume. A removable denture (complete or partial) does not stimulate and maintain
bone; rather, it accelerates bone loss. The load from mastication is transferred to the bone surface only, not
the whole bone. As a result, blood supply is reduced and total bone volume loss occurs.
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Consequences of Bone Loss in Fully Edentulous Patients
Decreased width of supporting bone Decreased height of supporting bone Prominent mylohyoid and
internal oblique ridges with increased sore spots Progressive decrease in keratinized mucosa surface
Prominent superior genial tubercles with sore spots and increased denture movement Muscle attachment
near crest of ridge Elevation of prosthesis with contraction of mylohyoid and buccinator muscles serving as
posterior support Forward movement of prosthesis from anatomical inclination (angulation of mandible with
moderate to advanced bone loss) Thinning of mucosa, with sensitivity to abrasion Loss of basal bone
Paresthesia from dehiscent mandibular neurovascular canal More active role of tongue in mastication Effect of
bone loss on esthetic appearance of lower third of face Increased risk of mandibular body fracture from
advanced bone loss Loss of anterior ridge and nasal spine, causing increased denture movement and sore
spots during function Soft Tissue Consequences As bone loses width, then height, then width and height again,
the attached gingiva gradually decreases.
A very thin attached tissue usually lies over the advanced a trophic mandible or is absent entirely. The
increasing zones of unkeratinized gingiva are prone to abrasions caused by the overlaying prosthesis. In
addition, unfavorable high muscle attachments and hyper mobile tissue often complicate the situation. The
thickness of the mucosa on the atrophic ridge is also related to the presence of systemic disease and the
physiologic changes that accompany aging.
Conditions such as hypertension, diabetes, anemia, and nutritional disorders have a deleterious effect on the
vascular supply and soft tissue quality under removable prostheses. These disorders result in a decreased
oxygen tension to the basal cells of the epithelium. Surface cell loss occurs at the same rate, but the cell
formation at the basal layer is slowed. As a result, thickness of the surface tissues gradually decreases.
Therefore, sore spots and uncomfortable removable prostheses result. The tongue of the patient with
edentulous ridges often enlarges to accommodate the increase in space formerly occupied by teeth. At the
same time, it is used to limit the movements of the removable prostheses, and takes a more active role in the
mastication process.
As a result, the removable prosthesis decreases in stability. The decrease in neuromuscular control,
often associated with aging, further compounds the problems of traditional removable prosthodontics. The
ability to wear a denture successfully may be largely a learned, skilled performance. The aged patient who
recently became edentulous may lack the motor skills needed to adjust to the new conditions . Soft Tissue
Consequences of Edentulism Attached, keratinized gingiva is lost as bone is lost Unattached mucosa for
denture support causes increased soft spots Thickness of tissue decreases with age, and systemic disease
causes more sore spots for dentures Tongue increases in size, which decreases denture stability Tongue has
more active role in mastication, which decreases denture stability Decreased neuromuscular control of jaw in
the elderly Esthetic Consequences.
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The facial changes that naturally occur in relation to the aging process can be accelerated and
potentiated by the loss of teeth. Several esthetic consequences result from the loss of alveolar bone. A
decrease in facial height from a collapsed vertical dimension causes several facial changes. The loss of
labiomental angle and deepening of vertical lines in the area create a harsh appearance. As the vertical
dimension progressively decreases, the occlusion evolves toward a pseudo Class III malocclusion. As a result,
the chin rotates forward and creates a prognathic facial appearance .
These conditions result in a Esthetic Consequences of Bone Loss Decreased facial height Loss of
labiomentall angle Deepening of vertical lines in lip and face Chin rotates forward-gives a prognathic
appearance Decreased horizontal labial angle of lip-makes patient look unhappy Loss of tone in muscles of
facial expression Thinning of per-million border of the lips from loss of muscle tone Deepening of nasolabial
groove Increase in columella-philtrum angle Increased length of maxillary lip, so less teeth show at rest and
smiling-ages the smile Ptosis of buccinator muscle attachment-leads to jowls at side of face Ptosis of mentalis
muscle attachment-leads to "
ADVANTAGES OF IMPLANT-SUPPORTED PROSTHESES
The use of dental implants to provide support for prostheses offers many advantages, compared with
the use of removable soft tissue-borne restorations . A primary reason to consider dental implants to replace
missing teeth is the maintenance of alveolar bone . The dental implant placed into the bone serves both as an
anchor for the prosthetic device and as one of the better preventive maintenance procedures in dentistry.
Stress and strain may be applied to the bone surrounding the implant. As a result, the decrease in
trabeculation of bone that occurs after tooth extraction is reversed.
There is an increase in bone trabeculae and density when the dental implant is inserted and
functioning. The overall volume of bone is also maintained with a dental implant. Even grafts of iliac bone to
the jaws, which usually resorb without dental implant insertion within 5 years, are instead stimulated and
maintain overall bone volume and implant integration. An endosteal implant can maintain bone width and
height as long as the implant remains healthy. As with a tooth, periimplant bone loss may be measured in
tenths of a millimeter and may represent a more than twenty fold decrease in lost structure, compared with
the resorption that occurs with removable prostheses.
Advantages of Implant-Supported Prostheses
Maintain bone Restore and maintain occlusal vertical dimension Maintain facial esthetics (muscle tone)
Improve esthetics (teeth positioned for appearance versus decreasing denture movement) Improve phonetics
Improve occlusion Improve/regain oral proprioception (occlusal awareness) Increase prosthesis success
Improve masticatory performance/maintain muscles of mastication and facial expression Reduce size of
prosthesis (eliminate palate, flanges) Provide fixed versus removable prostheses Improve stability and
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retention of removable prostheses Increase survival times of prostheses No need to alter adjacent teeth More
permanent replacement Improve psychological health.
2.Activity 3: Skill-building Activities (18 mins + 2 mins checking) :
Identification Test: Identify what is being asked on the following question.
Single Tooth Implant Molars Dental Implants
Three -unit fixed partial denture (FPD) Age Modern Dentistry
Trabeculae and Density Strain and Stress Misch
Alveolar Bone
___________1. It is directly related to every indicator of tooth loss.
___________2. The most common missing teeth.
___________3. It provide support for prostheses offers many advantages, compared with the use of
removable soft tissue-borne restorations .
___________4. The most common choice to replace a posterior single tooth is,
___________5. Is to restore the patient to normal contour, function, comfort, esthetics, speech, and
health, whether by removing caries from a tooth or replacing several teeth.
___________6. There is an increase in bone___and___ when the dental implant is inserted and functioning.
___________7. It may be applied to the bone surrounding the implant.
___________8. Does not form in the absence of primary or secondary tooth development.
___________9. A treatment option to replace a posterior single missing tooth.
__________10. In dentistry, the consequences of complete edentulous and remaining bone volume in 1992
was noted by;
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Mutiple choice: Encircle the letter the bears the best answer. Check your answers after completely
answering all items by referring to Key to Correction section of this module.
1. What Implant can maintain bone width and height as long as the implant remains healthy?
A. Dental implants B. Endosteal Implant C. Single tooth D. Edentulism
2. Is the state of being Edentulous, or without natural teeth.
A. Endosteal B. Peri-implant bone loss C. Edentulism D. Trabeculation
3. It is necessary to the development of alveolar bone, and stimulation of this bone is required to maintain
its density and volume.
A. Tooth B. Keratinized Gingiva C. Muscle D. Facial esthetics
4. What is the important factor to consider in implant dentistry?
A. Age B. Age population C. Tooth D. Dental Implants
5. It serves as both as an anchor of prosthetic device and one of the preventive maintenance procedures in
dentistry?
A. Dental Implant B. Implant Dentistry C. Prosthesis D. Prosthetic
6. This condition have a deleterious effect on the vascular supply and soft tissue quality under removable
prostheses.
A. Diabetes, anemia, asthma, Bone cancer
B. Diabetes, anemia, asthma, nutritional disorders
C. hypertension, diabetes, asthma, and nutritional disorders
D. hypertension, diabetes, anemia, and nutritional disorders
7. This type of restoration can be fabricated within 1 to 2 weeks and satisfies the criteria of normal
contour, comfort, function, esthetics, speech, and health.
A. Three-unit fixed partial denture C. Acrylic denture

B. Flexible Denture D. Implant Denture
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8.It is greater than its maxillary counterpart in all age group.
A. Partial free-end edentulism

B. Unilateral free-end edentulism
C. Mandibular free-end edentulism
D. bilateral edentulism
9. The increased need and use of implant-related treatments result from the combined effect of several
factors, EXCEPT one;
A. Age Population
B. consequences of fixed prosthesis failure,
C. anatomical consequences of edentulism,
D. poor performance of removable prostheses
10. What edentulism is of particular concern because in these patients, teeth are often replaced with
removable partial prostheses. This condition is rarely found in persons younger than age 25.
A. Partial free-end edentulism
B. Mandibular free-end edentulism
C. Unilateral free-end edentulism
D. Bilateral edentulism
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3. ) Activity 4: What I Know Chart, part 2 (2 mins)

At this point, I’d like you to verify how your knowledge has changed, by reviewing the questions
in the What I Know Chart from activity 1, third column, on page 1 of this module. Write your answers to
the questions based on what you now know in the last column of the chart.
4.) Activity 5: Check for Understanding (5 mins)
1. What is the important factor to consider in implant

dentistry ?
2. It serves as both as an anchor for the prosthetic
device and one of the preventive maintenance
procedures in dentistry.
3.What implant can maintain bone width and height as
long as the implant remains healthy?
4.The state of being edentulous, or without natural teeth.
5. It occurs after tooth extraction is reversed.
SCORE:
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C. LESSON WRAP-UP
1) Activity 6: Thinking about Learning (5 mins)

A. Work Tracker
You are done with this session! Let’s track your progress. Shade the session number you just
completed.
FAQs
-
Which part of the module that
requires clarification?
1. What is Dental Implant ?
Answer: is a prosthesis that interfaces with the bone of the jaw or skull to support a dental
prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor.
2. What is the Advantages of Dental Implants?
Answer: Once a dental implant is placed successfully, it can be used just as one would a natural
tooth. The implant will blend in with the rest of the teeth. Implants are meant to be durable and long-lasting.
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KEY TO CORRECTIONS
Activity 3: Skill Building Activity:

Answer Key:
1. B 2. C 3. A. 4. B 5. A 6. D 7. A 8. C 9. A 10. A
Activity 5: Check for Understanding
Answer Key:
1. What is the important factor to consider in

implant dentistry ? Aging population
2. It serves as both as an anchor for the prosthetic
device and one of the preventive maintenance Dental Implant
procedures in dentistry.
3.What implant can maintain bone width and
height as long as the implant remains healthy? Endosteal implant
4.The state of being edentulous, or without natural

Edentulism
teeth.
5.It occurs after tooth extraction is reversed. Trabeculation
SCORE
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TEACHER-LED ACTIVITIES
{These are standard instructions for teachers.}
A. If this session happens to be a face-to-face, in-classroom learning session:
1) Collect completed work in the SAS.
2) Allocate your contact time with students to individual or small group mentoring, monitoring, and
student consultations.
3) You may administer summative assessments (quizzes, demonstrations, graded recitation,
presentations, performance tasks) during face-to-face sessions.
4) You may also explore supplementary activities that foster collaboration, provided that social
distancing is observed.
5) You may provide supplementary content via videos, etc.
It is important to remember that students who cannot make it to face-to-face, in-classroom sessions for
health and safety reasons, should not be given lower grades for missing in-class activities and should
be given alternative summative tests.
B. If this session happens to be an at-home learning session for the students:

1) Check and grade collected SAS and other input from students.
2) Schedule phone calls/virtual calls/virtual chats to individual students or small groups of students to
monitor work, provide guidance, answer questions, and check understanding.
Prepared by:
Rufino Niño K. Requina Jr. DDM, MPH

DEN 003 Basic Dental Implantology -1 Adviser
24
Teachers’ Guide Module #2 Teachers’ Guide Module #2

Lesson title: Generic Root Form component Materials:

1. Know the development of dental implant. References:
2. Identify the parts of implant fixture and its prosthetic components Contemporary of Implant
Dentistry. 3rd Edition.
Carl E. Misch
Productivity Tip: “Work Hard In Silence.Let Success Make the Noise.”
Endosteal Implant - is an alloplastic material surgically inserted into a residual bony ridge,
primarily as a prosthodontic foundation. The prefix endo means "within," and osteal means "bone."

of this module.

1. What is the oldest discipline in
dentistry?
2. Who Introduced the recent
history of Implant dentistry in
1809.
3. What is a clinical term that
implies no observable movement
of the implant.
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B.MAIN LESSON
Endosteal Implant - is an alloplastic material surgically inserted into a residual bony ridge, primarily as
a prosthodontic foundation. The prefix endo means "within," and osteal means "bone." The major
subcategory of endosteal implants covered in this text are root form implants. The term endosseous is also
used in the literature, and because the term osseous also indicates bone, either term is acceptable. However,
endosteal, periosteal, and transosteal are preferred. Many endosteal implant designs have been used in the
past, including tapered pegs, pin shapes, and plate forms. Today, an endosteal implant in the shape of a tooth
root is the design most often used in the restoration of partial or complete edentulous patients. The desire has
always been to replace missing teeth with something similar to the root of a tooth.
Implant dentistry - is the second oldest discipline in dentistry (oral surgery [exodontial] is the oldest).
Root form implant history dates back thousands of years and includes civilizations such as the ancient Chinese
who, 4000 years ago, carved bamboo sticks in the shape of pegs and drove them into the bone for fixed tooth
replacement. The Egyptians, 2000 years ago, used precious metals with a similar peg design. A skull was found
in Europe with a ferrous metal tooth inserted into a skull with a tooth peg design that dated back to the time
of Christ. Incas from Central America took pieces of sea shells and, similar to the ancient Chinese, tapped them
into the bone to replace missing teeth. In other words, history shows that it has always made sense to replace
a tooth with an implant in the approximate shape of a tooth. In reality, if the lay public were given a choice to
replace a missing tooth with an implant or to grind down several adjacent teeth and connect them with a
prosthesis to replace a missing tooth and then attempt to make the adjacent teeth look similar to the
condition prior to their preparation, the implant would be the obvious choice.
Maggiolo- introduced the more recent history of implant dentistry in 1809 with use of gold in the
shape of a tooth root. In 1887, Harris reported the use of teeth made of porcelain into which lead-coated
platinum posts were fitted. Many materials were tested, and in the early 1900s, Lambotte fabricated implants
of aluminum, silver, brass, red copper, magnesium, gold, and soft steel plated with gold and nickel. He
identified the corrosion of several of these metals in body tissues related to electrolytic action.
The first root form design that differed significantly from the shape of a tooth root was the Greenfield
latticed-cage design in 1909, made of Iridium Platinum.' This was also the first two piece implant, which
separated the abutment from the endosteal implant body at the initial placement. The surgery was designed
to use a calibrated trephine bur to maintain an inner core of bone within the implant body. The implant crown
was connected to the implant body with an antirotational internal attachment after several weeks. Reports
indicate this implant had a modicum of success. Seventy-five years later, this implant design was reintroduced
by ITI in Europe and later by Core-Vent in the United States. 10,11 Surgical cobalt chromium molybdenum
12

alloy was introduced to oral implantology in 1938 by Strock (Boston, Mass.) when he replaced a single
maxillary left incisor tooth¹2 with a root form, one-piece implant that lasted more than 15 years.
Direct bone-implant- interface to titanium was initially called bone fusing and was first reported in
1940 by Bothe and coworkers. In 1946, Strock designed the first titanium, two-piece screw implant that was
initially inserted without the permucosal post. The abutment post and individual crown were added after
complete healing, The desired implant interface described by Strock was a direct bone-implant connection,
which was called ankylosis, The first submerged implant placed by Strock was still functioning 40 years later.
Branemark- began extensive experimental studies in 1952 on the microscopic circulation of bone
marrow healing. These studies led to a dental implant application in the early 1960s in which a 10-year
implant integration was established in dogs without significant adverse reactions to hard or soft tissues.
Implant clinical studies in humans with the Brånemark philosophy began in 1965, were followed for 10 years,
and were reported in 1977. The term osseointegration (rather than bone fusing or ankylosis) was defined by
Bränemark as a direct contact of living bone with the surface of an implant at the light microscopic level of
magnification. The terms bone fusing, ankylosis, and osseointegration may be interchangeable and may
address the microscopic bone implant interface. The percentage of direct bone-implant contact was not
initially addressed and has been found to be highly variable. Today, the term osseointegration has become
common in the implant discipline and describes not only a microscopic condition, but also the clinical
condition of rigid fixation.
Rigid fixation - is a clinical term that implies no observable movement of the implant when a force of 1
to 500 g is applied. The prefix osteo (e.g., osteoblast, osteotomy) also is widely used by the profession. Rigid
fixation is the clinical result of a direct bone interface but has also been reported with a fibrous tissue
interface." The osseointegration concepts of Brånemark have been promoted more than those of any other
person in recent history. The documentation of past clinical case studies, research of surgery and bone
physiology, healing of soft and hard tissues, and restorative applications from Brånemark's laboratory were
unprecedented. Adell et al published the Brånemark 15-year clinical case series report in 1981 on the use of
implants in completely edentulous jaws. Approximately 90% of the reported anterior mandibular implants
that were in the mouths of patients after the first year of loading were still in function 5 to 12 years later.
Lower survival rates were observed in the anterior maxilla. In the initial Brånemark clinical reports, no
implants were inserted into the posterior regions of the mouth, and all reported prostheses were fixed
restorations. The use of dental implants in the treatment of complete and partial edentulism has become an
integral treatment modality in restorative dentistry, 20-22
The 1988 National Institutes of Health consensus panel ondental implants recognized that restorative
procedures using implants differ from those of traditional dentistry and stressed the necessity for advanced
education. During the past 15 years, implant dentistry has become a routine method to replace teeth in a
restorative practice. Many practitioners are taught the use of a specific manufacturer's implant system, rather
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than the theory and comprehensive practice of implant dentistry. The increasing number of
manufacturers entering the field use trade names for their implant components (often unique to a particular
system), and such names have proliferated to the point of creating confusion. Several different terms or
abbreviations now exist that describe similar basic components." To make conditions worse, in the team
approach to implant treatment, the widening referral base often requires that the restoring practitioner be
knowledgeable regarding many implant systems. With the required knowledge of multiple systems and the
lack of uniformity in component names, communication is hampered among manufacturers, dentists, staff,
laboratory technicians, students, and researchers.
In addition, the incorporation of implant dentistry into the curriculum of most predoctoral and
postdoctoral programs further emphasizes the need for standardization of terms and components in implant
dentistry.
GENERIC PROSTHETIC COMPONENT TERMINOLOGY
A generic language for endosteal implants was developed by Misch and Misch in 1992. The order in
which it is presented follows the chronology of insertion to restoration. In formulating the terminology, five
commonly used implant systems in the United States were referenced. Fifteen years later, the dramatic
evolution of the U.S. implant market has resulted in changes in ninety all the implant lines and component
designs. In 2000 the U.S. market alone had to choose from more than 1300 different implant designs and 1500
abutments in various materials, shapes, sizes, diameters, lengths, surfaces, and connections. More than ever,
a common language is needed.
In pharmacology the variety of pharmaceutical components makes it impossible to list them all by
proprietary names, but a list by category of drugs is useful. Likewise, implant components still can be classified
into broad application categories, and the practitioner should be able to recognize a certain component
category and know its indications and limitations. This book incorporates a generic terminology, first
introduced by Misch and Misch for endosteal implants, that blends a continuity and familiarity of many
implant systems with established definitions from the terms of the Illustrated Dictionary of Dentistry and the
glossaries from Terms of The Academy of Prosthodontics, American Academy of Implant Dentistry, and
International Congress of Oral Implantologists. 1,2,32,33
GENERIC IMPLANT BODY TERMINOLOGY
Root form implants are a category of endosteal implants designed to use a vertical column of
bone,similar to the root of a natural tooth. Although many names have been applied, the 1988 National
Institutes of Health consensus statement on dental implants and the American Academy of Implant Dentistry
recognized the term root form. 1,22,33 The exponential growth of implant use over the last 20 years has been
paralleled by an explosion of the implant manufacturing field. There are currently more than 90 implant body
14

designs available, offering countless combinations of design features: screws, baskets, plateaus, balls,
cylinders, diameters, lengths, prosthetic connections, and surface conditions .
The most common root form design combines a separate implant body and prosthodontic abutment to
permit only the implant body placement during bone healing. A second procedure is required to attach the
implant abutment. The design and surgical philosophy is to achieve clinical rigid fixation that corresponds to a
microscopic direct bone-to-implant interface without intervening fibrous tissue occurring over any significant
portion of the implant body before the prosthetic phase of the procedure. Over the years, three different
surgical approaches have been used for the two-piece implant systems: one stage, two stage, and immediate
restoration . The two-stage surgical process places the implant body below the soft tissue, until the initial
bone healing has occurred. During a second-stage surgery, the soft tissues are reflected to attach a
permucosal element or abutment. During a one-stage surgical approach, the implant body and the permucosal
abutment above the soft tissue are both placed until initial bone maturation has occurred.
The abutment of the implant then replaces the permucosal element without the need for a secondary
soft tissue surgery. The immediate restoration approach places the implant body and the prosthetic abutment
at the initial surgery. A restoration is then attached to the abutment (out of occlusal contacts in partially
edentulous patients) at the appointment.
An implant body especially designed for one surgical method may also be selected. For example, a
permucosal element may already be attached to the implant body by the manufacturer to facilitate a one-
stage surgical approach. An implant body also may have a prosthetic abutment, which may be part of the
implant body, for the one-piece implant to be inserted and restored at the initial surgery. This was the original
concept first introduced by Strock in the 1930s. There are three primary types of root form body endosteal
implants based on design; Cylinder, Screw, or Combination.
Cylinder (press-fit) root form implants depend on a coating or surface condition to provide
microscopic retention to the bone. Most often the surface is either coated with a rough material (e.g.,
hydroxyapatite, titanium plasma spray) or a macro retentive design (e.g., sintered balls). Cylinder implants are
usually pushed or tapped into a prepared bone site. They can be a paralleled wall cylinder or a tapered
implant design.
Screw root forms are threaded into a slightly smaller prepared bone site and have the macroscopic
retentive elements of a thread for initial bone fixation. They may be machined, textured, or coated. There are
three basic screw-thread geometries: V-thread, buttress (or reverse buttress) thread, and power (square)
thread designs. Threaded implants are primarily available in a parallel cylinder or tapered cylinder design.
Micro or macro thread features, variable thread pitch, depth, and angle, as well as self-tapping features, can
be combined to create a myriad of implant designs. Combination root forms have macroscopic features from
both the cylinder and screw root forms. The combination root form designs also may benefit from microscopic
15

retention to bone through varied surface treatments (machined, textured, and the addition of coatings). Root
forms also have been described by their means of insertion, healing, surgical requirements, surface
characteristics, and interface. 28,69,70 55-68
IMPLANT BODY REGIONS
The implant body may be divided into a crest module (cervical geometry), a body, and an apex . Each
section of an implant has features that are of benefit in the surgical or prosthetic application of the implant.
An implant body is primarily designed for either surgical ease or prosthetic loading to the implant bone
interface. Years ago, the implant body was the primary design feature. A round implant permits round surgical
drills to prepare the bone. A smooth-walled cylinder implant allows the implant to be pressed or tapped into
position, similar to a nail into a piece of wood. A tapered cylinder fits into the top of the osteotomy for further
ease of placement. A cylinder implant design system offers the advantage of ease of placement, even in
difficult access locations.
The cover screw of the implant also may be attached to the implant before implant placement. For
example, in the very soft D4 bone of the posterior regions of the maxilla, the surgeon must rotate a threaded
implant design into place. Very soft bone may strip during a threaded implant insertion. This may result in lack
of initial fixation, and the implant will not be rigid. A tapered cylinder implant may be pressed by hand into
soft bone and can be initially fixated more easily. The speed of implant rotation during insertion and the
amount of apical force in implant insertion in soft bone are less relevant for a press-fit cylinder.
The cylinder system also presents some benefits for the single-tooth implant application, especially if
adjacent to teeth with tall clinical crowns.Thread extenders are needed for the screw implant placement in
these situations, as well as additional tools to insert the cover screw of the implant. In dense bone, cylinder
systems also are easier and faster to place because bone tapping is not required. Most cylinder implants are
essentially smooth-sided and bullet-shaped implants that require a bioactive or increased surface area coating
for retention in the bone. When these materials are placed on an implant, the surface area of bone contact
increases more than 30%. The greater the functional surface area of the bone implant contact, the better the
support system for the prosthesis.
A solid screw implant body design is the most commonly reported in the literature. A solid screw body
is defined as an implant of a circular cross section without penetrating any vents or holes. A number of
manufacturers provide this design (e.g., Nobel Biocare, Biomet, Zimmer, ITI, BioHorizons, LifeCore, Bio-Lok).
The thread may be V-shaped, buttress, reverse buttress, or square (power thread) in design. The V-shaped
threaded screw has the longest history of clinical use. The most common outer thread diameter is 3.75 mm,
with a 0.38-mm thread depth, and a 0.6-mm thread pitch (distance). The various body lengths usually range
from 7 to 16 mm, although lengths from 5 mm to 56 mm are available. Similar body designs are offered in a
16

variety of diameters (narrow, standard, wide) to respond to the mechanical, esthetic, and anatomical
requirements in different areas of the mouth.
A solid screw implant body permits the osteotomy and placement of the implant in dense cortical bone
as well as in fine trabecular bone. The surgery may be easily modified to accommodate both extremes in bone
density. The solid screw permits the implant removal at the time of surgery if placement is not ideal. It also
permits implant removal at the Stage II surgery if angulation or crestal bony contours are not deemed
adequate for long-term prosthesis success. The solid screw implant body may be machined or roughened to
increase marginally the functional surface area or to take advantage of biochemical properties related to the
surface coating (e.g., bone bonding or bone growth factors).
A threaded implant body is primarily designed to increase the bone-implant surface area and to
decrease the stresses at the interface during occlusal loading. The functional surface area of a threaded implant is
greater than a cylinder implant by a minimum of 30% and may exceed 500%, depending on the thread geometry. This
increase in functional implant surface area decreases the stress imposed on the implant-bone interface and is directly
related to the thread geometry.
The crest module of an implant body is that portion designed to retain the prosthetic component in a one piece
or two-piece implant system. It also represents the transition zone from the implant body design to the transosteal
region of the implant at the crest of the ridge. The abutment connection area usually has a platform on which the
abutment is seated; the platform offers physical resistance to axial occlusal loads. An antirotation feature also is
included on the platform (external hex) or extends within the implant body (internal hex, octagon, Morse taper or cone
screw, internal grooves or cam tube, and pin slots).
The implant body has a design to transfer stress/strain to the bone during occlusal loads (eg, threads or large
spheres), whereas the crest module often is designed to reduce bacterial invasion. (e.g., smoother to impair plaque
retention if crestal bone loss occurs). Its smoother dimension varies greatly from one system to another (0.5 to 5 mm).
When the crest module is smooth, polished metal, it is often called a cervical collar. A high-precision fit of the external
or internal antirotational component (flat to flat dimension) is paramount to the stability of the implant body/abutment
connection.
The prosthetic connection to the crest module is received by slip-fit or friction-fit with a butt or bevel joint. All
prosthetic connections aim at providing a precise mating of the two components tolerance. minimal Another
antirotational feature of an implant body may be flat sides or grooves along the body or apical region of the implant
body. When bone grows against the flat or groove regions, the bone is placed in compression with rotational loads. The
apical end of each implant should be flat rather than pointed. This allows for the entire length of the implant to
incorporate design features that maximize desired strain profiles.
Additionally, if an opposing cortical plate is perforated, a sharp, V-shaped apex may irritate or inflame the soft
tissues if any movement occurs (e.g., the inferior border of the mandible).
17

3. Activity 3: Skill-building Activities (18 mins + 2 mins checking) :
Root form implant Harris Restoration endosseous
Branemark within Screw root form
Direct bone implant plate forms Bone
___________1. The prefix “endo” means,
___________2. and “osteal” means,
___________3.This term is also used in the literature and because “osseous” also indicates bone.
___________4.There are many endosteal implant designs that have been used in the past, give only one;
___________5. He reported the use of teeth made of porcelain into which lead-coated platinum posts were
fitted.
___________6. It was initially called bone fusing and was first reported in 1940 by Bothe and coworkers.
___________7. He began extensive experimental studies in 1952 on the microscopic circulation of bone
marrow healing.
___________8. A category of endosteal implants designed to use a vertical column of bone, similar to the root
of a natural tooth.
___________9. It is then attached to the abutment (out of occlusal contacts in partially edentulous patients) at
the appointment.
__________10. Are threaded into a slightly smaller prepared bone site and have macroscopic retentive
elements of a thread for initial bone fixation.
18

1. What is an alloplastic material that surgically inserted into a residual bony redge, primarily as a
prosthodontic foundation?
A. Dental Implant B. Periosteal Implant C. Endosteal Implant D. Transosteal Implant
2. What is the second oldest discipline in dentistry?
A. Oral Surgery (exodentia) B. Implant Dentistry C. Endosteal Implant D. Periosteal Implant
3. Also known as dental medicine and oral medicine, and is the branch of medicine focused on the teeth.
A. Endosteal Implant B. Oral Surgery C. Implant Dentistry D.Dentistry
4. He introduced the more recent history of implant in 1809 with use of gold in the shape of a tooth root.
A. Misch B. Straumann C. Harris D. Maggiolo
5. This procedure is formally defined as the removal of teeth from the socket of the jawbone.
A. Edentulism B. Exodentia C. Oral implantology D. Implant
6. The major subcategory of endosteal implants covered in is;
A. Root form implant B. Oral implantology C. Dental Implant D. Endosteal Implant
7. He fabricated the implants of aluminum, silver brass, red copper magnesium, gold and soft steel plated
with gold and nickel.
A. Harris B. Maggiolo C. Maggiolo D. Straumann
8. The term “osseointegration” was defined by:
A. Harris B. Lambotte C. Branemark D. Straumann
9. What is a clinical term that implies no observable movement of the implant when a force of 1 to 500 is
applied.
A. Rigid fixation B. Oral fixation C. Anal fixation D. Phallic fixation
19

10. Is primarily designed to increase the bone-implant surface area and to decrease the stress at the
interface during occlusal loading.
A. Crest module B. Threaded implant body C. solid screw implant body design
D.restoration

1. What is an alloplastic material surgically inserted into

a residual bony ridge.
2. It is primarily designed to increase the bone-implant
surface area and to decrease the stresses at the interface
during occlusal loading.
3. He designed the first titanium, two-piece screw
implant that was initially inserted without the
permucosal post.
4. It was a direct contact of living bone with the surface
of an implant at the light microscopic level of
magnification.
5. Have macroscopic features from both the cylinder
and screw root forms.
SCORE:
20

C. LESSON WRAP-UP

A. Work Tracker
completed.
FAQs
-
1. What happens after dental implants are placed?
Answer: After the implant is added to your jawbone, the jawbone will begin to grow around the implant.
The implant then becomes part of your natural gum line. This process varies by person and can take anywhere
from 3 to 9 months. Once the implant is stable enough, the dentist will place an abutment on top of the implant.
2. What are the possible complications of dental implants?
Answer: The possible complications of dental implants is probably an implant that has come loose, the
jaw bone is not strong enough to hold the implant, perhaps due to bone loss from aging. Other factors can
contribute to a loose implant such as smoking, gum disease and poor hygiene. Another complication is
infection, It can become inflamed and infected, causing pain and even fever. It tend to to occur shortly after the
implant surgery takes place.
21

KEY TO CORRECTIONS

Answer Key:
1. C 2. A 3. D 4. D 5. B 6. A 7. C 8. C 9. A 10. A
Answer Key:
1. What is an alloplastic material surgically inserted into

Endosteal Implant
a residual bony ridge.
2.It is primarily designed to increase the bone-implant
surface area and to decrease the stresses at the interface Threaded implant body
during occlusal loading.
3.He designed the first titanium, two-piece screw
implant that was initially inserted without the Strock
permucosal post.
4.It was a direct contact of living bone with the surface
of an implant at the light microscopic level of Osseointegration
magnification.
5.Have macroscopic features from both the cylinder
and screw root forms. Combination root forms
SCORE:
22


Prepared by:

23

Lesson title: Applied Anatomy for Dental Implant Materials:

1. Study the anatomical structures that needs to be considered in References:
dental implant surgery and restoration. Contemporary of Implant
2. know limiting anatomical structures that largely influence the Dentistry. 3rd Edition.
dental implant treatment plan. Carl E. Misch
Productivity Tip: All the studying you are doing will be worth it in the end! Good luck!
The maxilla is pyramidal in shape with the root of the zygoma as its apex . The latter can be
palpated in the buccal vestibule of the oral cavity. It divides the facial surface of the maxilla into
anterolateral and posterolateral surfaces of the pyramid. The third surface of the pyramid is the orbital
plate of the maxilla. The base of the pyramid is the lateral wall of the nose or the medial wall of the
maxillary sinus.

of this module.

What is the third surface of the
pyramid of the maxilla?
It is the pyramidal in shape with
the root of the zygoma.
What muscle receives innervation

from the buccal and mandibular
branches of the facial nerve?
11

B.MAIN LESSON
The surgical anatomy of the maxilla and mandible provide the foundation required to safely
insert dental implants. The anatomy is also a requisite to the understanding of complications that may
inadvertently occur during surgery, such as injury to blood vessels or nerves, as well as postoperative
complication such as infection. This information also provides the operator with the confidence
needed to deal with these complications. This chapter addresses those issues important in the field of
oral implantology.
SURGICAL ANATOMY OF THE MAXILLA AS AN ORGAN
The maxilla is pyramidal in shape with the root of the zygoma as its apex. The latter can be
palpated in the buccal vestibule of the oral cavity. It divides the facial surface of the maxilla into
anterolateral and posterolateral surfaces of the pyramid. The third surface of the pyramid is the
orbital plate of the maxilla. The base of the pyramid is the lateral wall of the nose or the medial wall
of the maxillary sinus. The alveolar process of the maxilla related to the anterolateral surface carries
the incisors, the canines, and the premolars, whereas that of the posterolateral surface carries the
molars and ends as the maxillary tuberosity.
The intraoral part of the maxilla is limited by the mucobuccal fold and the orbicularis oris
muscle anteriorly and by the buccinator muscle posteriorly. The posterolateral surface of the maxilla
above the mucobuccal fold forms the anterior wall of the infratemporal fossa and is difficult to palpate.
However, the anterolateral surface of the maxilla beyond the mucobuccal fold can be palpated easily
under the skin, as can the anterior nasal spine, the anterior nasal aperture, and the frontal process of
the maxilla. Intraorally, it is possible to palpate the canine eminence, the canine fossa (distal to the
canine eminence and a common site for facial access to the maxillary sinus), the maxillary tuberosity,
and the hamular notch.
The maxilla extends as a horizontal plate medially to form the anterior two thirds of hard palate.
The horizontal plate of the palatine bone forms the posterior one third of hard palate. The palatine
bone has a vertical plate that articulates with the base of the maxilla; it also has a pyramidal process
that interposes between the maxillary tuberosity and the pterygoid processes of the sphenoid bone.
Mucosal incision at the maxillary tuberosity that extends into the hamular notch may expose the
pyramidal process of the palatine bone. Distal to this point, one may expose the medial pterygoid
muscle, which takes origin from the tuberosity and the lateral pterygoid plate of the sphenoid.
12

The medial wall of the maxilla begins at the sharp edge of the anterior nasal aperture and
extends posteriorly, with a concavity that bounds the nasal fossa and continues distal to the canine.
Once there, it forms the medial wall of the maxillary sinus and continues all the way back to the
maxillary tuberosity. The medial wall of the maxilla provides attachment to the inferior nasal concha
and to the vertical plate of the palatine bone. The opening of the maxillary sinus is found in the
medial wall of the maxilla, close to the floor of the orbit. The opening is reduced in diameter by the
uncinate process of the ethmoid bone.
The latter provides the superior and middle conchae of the lateral nasal wall. The orbital plate
of the maxilla forms the floor of the orbit and also the roof of the maxillary sinus. The infraorbital
canal carries the infraorbital nerve and vessels, and it forms a ridge that can be seen in the sinus
cavity. Muscles Attached to the Maxilla As the maxillary alveolar bone resorbs, the crest of the
residual ridge migrates toward the muscles that take their origin from the basal bone of the maxilla.
Descriptions of muscles of surgical importance to oral implantologists follow.
Orbicularis Oris Muscle
The orbicularis oris muscle originates from the mediolus at each corner of the mouth. The
muscle fibers fan out into the upper and lower lips, where they form upper and lower peripheral
portions under the skin and marginal portions under the vermilion zone of the lips. Some of the
orbicularis oris fibers attach to the ala of the nose and to the nasal septum. In the midline of the upper
lip, the peripheral portions from both sides interdigitate to create the philtrum. The marginal portions
interdigitate and create the labial tubercle. Although unattached to the bone of the maxilla, the muscle
limits the depth of the upper and lower facial vestibule. The orbicularis oris receives innervation from
the buccal and mandibular branches of the facial nerve.
Incisivus Labii Superioris Muscle
The incisivus labii superioris muscle originates from the floor of the incisive fossa of the
maxilla above the eminence of the lateral incisor and deep to the orbicularis oris. To expose the bone
of the premaxilla between the canines, a mucoperiosteal flap reflection may detach the incisivus labii
superioris. It may also detach the septalis and oblique fibers of nasalis muscle. The first is attached to
the skin of the nasal septum and the latter to the ala of the nose. These small muscles will reattach
after placement of the flap. However, if the muscles were damaged, then drooping of the septum and
flaring of the ala of the nose may result.
13

Buccinator Muscle
The buccinator muscle originates from the base of the alveolar process opposite to the first,
second, and third molar of both jaws. This muscle also takes origin from the pterygoid hamulus of the
medial pterygoid plate of the sphenoid bone and therefore bridges the gap between the maxillary
tuberosity anteriorly and the hamulus posteriorly. Extension of a subperiosteal frame design into the
pterygoid plates may interfere with the fibers of these muscles without adding too much to the
retention of the implant. When incising and reflecting the mucosa overlying the areas of the maxillary
tuberosity and hamular notch before taking impressions for maxillary subperiosteal implants, avoid
injuring the tendon of the tensor veli transact muscle, which passes around the pterygoid hamulus.
The tendon moves on an underlying bursa whenever the soft palate moves; therefore it may become
irritated by the subperiosteal frame and result in inflammation and pain. Fibers of the buccinator and
medial pterygoid muscles are also found in the area of reflection. The majority of the fibers of the
medial pterygoid muscle originate from the medial surface of the lateral pterygoid plate of the
sphenoid bone, whereas the rest of the fibers form the tuberal head, which takes origin from the
maxillary tuberosity. Near the pterygoid hamulus, a fibrous tissue raphe or, in some cases, a broad
fascialike structure is found between the transaction and the superior pharyngeal constrictor muscles.
In some cases, no raphe or fascia is found. Injury to the latter muscle should be avoided during
reflection of the mucosa, particularly on the palatal aspect of the area of the hamulus.
Levator Labii Superioris Muscle
The levator labii superioris muscle takes origin from the infraorbital margin above the
infraorbital foramen and therefore is rarely of concern to the implant surgeon. The zygomatic branch
of the facial nerve innervates this muscle.
Levator Anguli Oris (Caninus) Muscle
The levator anguli oris muscle originates in the maxilla below the infraorbital foramen. The
infraorbital nerve and vessels arise between this muscle and the levator labii superioris. In the severe
atrophic division D maxilla, the infraorbital foramen is relatively close to the crest of the ridge.
Reflection of the tissues for autogenous grafts and implant placement into sinus grafts may
approximate this region and cause parasthesia. In subperiosteal implant cases that require extensive
framework extension for retention, the operator should be aware of the location of the infraorbital
neurovascular bundle in relation to the caninus and levator labii superioris muscles. The zygomatic
branch of the facial nerve innervates the caninus muscle.
14

Sensory Innervation of the Maxilla
The maxillary nerve (V2) innervates the maxilla . The nerve leaves the middle cranial fossa
by passing through the foramen rotundum and appears in the pterygopalatine fossa. It exits the fossa
and passes briefly into the infratemporal fossa; from there it enters the floor of the orbit or the roof of
the maxillary sinus by passing through the infraorbital fissure.
It then exits the orbit via the infraorbital foramen. The pterygopalatine portion of the maxillary
nerve provides the descending palatine and sphenopalatine branches. The sphenopalatine nerve
enters the nasal cavity from the pterygopalatine fossa by passing through the sphenopalatine
foramen. It supplies the nasal cavity and becomes the incisive nerve that supplies the palatine
mucosa opposite to the upper six anterior teeth. The descending palatine nerve terminates as the
great palatine nerve, which supplies the mucosa of the hard palate, and the lesser palatine nerves,
which supply the mucosa of soft palate.
These sensory nerves also carry parasympathetic fibers from the sphenopalatine ganglion that
innervate the mucous glands of the palate. The infratemporal portion of V2 branches into the
posterior alveolar nerve and zygomatic nerve. The latter divides into the zygomaticofacial and
zygomaticotemporal cutaneous nerves. The posterior superior alveolar nerve supplies the buccal
gingiva, buccal alveolar bone, second and third molars, and two roots of first molar. The infraorbital
portion of V2 gives rise to anterior superior alveolar and occasionally middle superior alveolar nerves.
These nerves run in bony grooves in the facial wall of the maxillary sinus under the Schneiderian
membrane.
The nerves supply the sinus wall and the premolars; the canine, lateral, and central incisor on
the same side; and also the central incisor at the contralateral side. The infraorbital nerve exits the
maxilla at the infraorbital foramen and supplies cutaneous branches to the lower eyelid, side of the
nose, and upper lip. Implantologists often need to block V2 or several of its branches. Luckily these
can be achieved by an intraoral route. V2 can be reached via the great palatine foramen and
descending palatine canal, or via the pterygomaxillary fissure by following the slope of the
posterolateral surface of the maxilla into the pterygopalatine fossa.
Posterior Superior Alveolar (Dental) Nerve
The nerve arises within the pterygopalatine fossa, courses downward and forward, passing
through the pterygomaxillary fissure, and enters the posterior aspect of the maxilla. It runs between
the bone and the lining of the maxillary sinus. This nerve supplies the sinus, the molars, the buccal
15

gingiva, and the adjoining portion of the cheek; it may be injured during a sinus augmentation with a
lateral approach. Clinically this does not appear to be of major consequence.
Infra-orbital Nerve
This nerve is a continuation of the main trunk of the maxillary division. It leaves the
pterygopalatine fossa by passing through the inferior orbital fissure to enter the floor of the orbit. It
runs in the infraorbital groove and then in the infraorbital canal. The nerve exits the orbit through the
infraorbital foramen to give cutaneous branches to the lower eyelid, the ala of the nose and the skin,
and the mucous membrane of the lip and cheek.The infraorbital foramen is located between the
levator labii superioris muscle, which takes origin above the foramen, and the levator anguli oris
(caninus) muscle, which takes origin below the foramen. This foramen and neurovascular contents
are within 5 to 10 mm of an extremely resorbed maxilla. When applying onlay grafts, which expose
the entire maxilla, the implant dentist must be very aware of this situation. Fixation screws or implants
may cause paresthesia when inserted through the graft and into this structure.
Subperiosteal implants designed for an atrophied maxilla should not extend into the site of the
infraorbital nerve and vessels. In some cases of maxillary sinus disorder, the site of the infraorbital
foramen becomes tender, probably as a result of inflammation of the infraorbital nerve. This is an
important diagnostic test for possible postoperative involvement after sinus augmentation procedures.
Middle Superior Alveolar (Dental) Nerve
This branch of the infraorbital nerve is given off as the infraorbital nerve passes through the
infraorbital groove. The middle superior alveolar nerve runs downward and forward in the lateral wall
of the sinus to supply the maxillary premolars. This region is routinely violated for the lateral approach
to sinus grafts, with apparently no consequence.
Anterior Superior Alveolar (Dental) Nerve
This branch of the infraorbital nerve arises within the infraorbital canal. It initially runs laterally
within the sinus wall and then curves medially to pass beneath the infraorbital foramen. It turns
downward to supply the maxillary anterior teeth. A nasal branch passes into the nasal cavity to supply
the mucosal lining of a portion of the nasal cavity. Before elevation of nasal mucosa and placement of
grafts, this nerve must be anesthetized. The infraorbital nerve block or V2 block anesthesia is
suggested. Implant dentists must also anesthetize this branch before placement of implants in the
incisor region. The anterior, middle, and posterior superior alveolar nerves intermingle to form the
superior dental plexus. The posterior, middle, and anterior superior alveolar nerves run in the facial
wall of the maxillary sinus between its lining membrane and the bone.
16

During antrostomy procedures to augment the floor of the sinus, the operator should be aware
of these structures, which are present even in the absence of teeth. Palatine Nerve The greater
(anterior) and lesser (posterior) palatine nerves supply the hard and soft palate, respectively. They
exit the pterygopalatine fossa through the superior opening of the descending palatine canal, travel
downward, and enter the oral cavity by way of the greater and lesser palatine foramina. The greater
palatine nerve runs forward in a groove on the inferior surface of the hard palate to supply the palatal
mucosa as far forward as the incisor teeth. Here the nerve communicates with the nasopalatine nerve.
The nerve supplies the gingiva, mucous membrane, and glands of the hard palate. The greater
palatine artery and vein accompany the nerve during its course in the hard palate. As the maxillary
alveolar process atrophies, it shifts to the palate and brings the crest of the ridge closer to the groove
where the greater palatine neurovascular bundle is found. The restoring dentist should be aware that
an incision too palatal to the crest of the ridge in the atrophied maxilla might injure these vital
structures. This foramen is entered for a V2 block anesthesia. One may find it by taking a blunt
instrument and pressing firmly along the alveolar palatal bone angle. The instrument will depress over
the foramen when in the correct position.
Nasopalatine (Sphenopalatine) Nerve
The nasopalatine nerve leaves the pterygopalatine fossa through the sphenopalatine
foramen located in the medial wall of the fossa. It enters the nasal cavity and supplies portions of the
lateral and superior aspects of the nasal cavity. The longest branch reaches the nasal septum, where
it turns downward and forward, traveling on the surface of the septum. While on the septum it forms a
groove on the vomer bone. The nerve supplies the nasal mucosa, descends to the floor of the nose
near the septum, passes through the nasopalatine canal, and then exits onto the hard palate through
the incisive foramen. The latter opening is deep to the incisive papilla.
The nerve communicates with the greater palatine nerve. The incisive nerve should be
anesthetized before elevation of the mucosa of the floor of the nose for subnasal grafts or implants
that engage the nasal floor in the incisor region.
Arterial Supply to the Maxilla
The majority of arterial blood supply comes from the maxillary artery, which is one of the
terminal branches of the external carotid artery. The artery starts deep to the neck of the mandibular
condyle (mandibular portion) and then proceeds either superficial or deep to the lateral pterygoid
muscle (pterygoid portion). It then branches close to the pterygomaxillary fissure, where one branch
enters the fossa (pterygopalatine portion). The other branch, called the infraorbital artery, enters the
floor of the orbit via the infraorbital fissure; it proceeds in the infraorbital canal and exits on the face by
passing through the infraorbital foramen.
17

Branches of the maxillary artery are as follows:
1. Mandibular portion: deep auricular, tympanic, middle meningeal, and inferior alveolar arteries
2. Pterygoid portion: deep temporal, lateral pterygoid, medial pterygoid, and masseteric arteries
3. Pterygopalatine portion: posterior superior alveolar, descending palatine, and sphenopalatine

arteries
4. Infraorbital portion: anterior and middle superior alveolar, palpebral, nasal, and labial arteries
supplemental arterial blood supply reaches the maxilla via two branches from the cervical portion of
the facial artery (ascending palatine and tonsillar arteries), two dorsolingual arteries from the lingual
artery, and the ascending pharyngeal branch of external carotid artery.
All the collateral circulation reaches the maxilla from the area of the soft palate. During
orthognathic surgery to correct maxillary prognathism, the surgeon often cuts the posterior, middle,
and anterior superior alveolar arteries, as well as the descending palatine arteries, without
compromising the blood supply to the maxilla because of the presence of supplemental blood supply
from the branches mentioned previously. It is important to note that the maxillary artery supplies
blood to the bone of the mandible via its inferior alveolar artery and its branches to the muscles of
mastication.
Detaching the masseter and medial pterygoid muscles without reattaching it could result in
necrosis of the ramus of the mandible. In addition, all the arterial branches mentioned previously arise
from the external carotid; therefore bilateral arteriosclerosis of the carotids, which is common in old
age and in uncontrolled diabetic patients, may compromise the blood supply to the maxilla and could
result in delay of healing after insertion of implants or bone grafting to the area. More detailed
consideration of applied anatomy of the arterial supply to both the maxilla and mandible is presented
at the end of this chapter.
Drainage of the Maxilla
The veins follow the arteries and carry the same names. The maxilla drains into the maxillary
vein. The latter communicates freely with the pterygoid plexus of veins and then joins the superficial
temporal vein to form the posterior facial vein within the parotid gland. Infection from the maxilla may
follow the maxillary vein to the pterygoid plexus veins and then to the cavernous sinuses via emissary
veins, causing infected cavernous sinus thrombosis. Adequate arterial supply and healthy venous
drainage are essential for bone regeneration and remodeling of bone grafts.
18

Lymphatic Drainage
The maxilla, including the maxillary sinuses, drains its lymphatics into the submandibular
lymph nodes. In addition, the posterior portion of the maxilla and soft palate drain into the deep facial
lymph nodes, part of the deep cervical nodes. Palpation of lymph nodes is an essential part of the
physical examination of the head and neck.
SURGICAL ANATOMY OF THE MANDIBLE
The clinician should be familiar with the anatomical features of dentulous and edentulous
mandibles, not only from radiographs but also from physical examination . The symphysis, inferior
border, premasseteric notch, gonial angle, lateral pole of condyle, and coronoid process are all
palpable under the skin. Intraoral palpable features of the mandible from the facial surface include the
external oblique ridge and retromolar triangle, with the coronoid process at its tip, the external oblique
ridge bordering it laterally, and the internal oblique ridge bordering it medially. The latter is called the
temporal crest because this is the site for insertion of the medial tendon of the temporalis muscle.
The mental foramen can be located at the midpupillary line at the apices of the premolars.
From the lingual aspect, palpate the internal oblique ridge and torus mandibularis at the premolar
region. Reflection of mucoperiosteal flap beyond the mucobuccal fold facially exposes the mentalis
muscles lateral to the midline, the mental foramen with the mental neurovascular bundle, the
depressor labii inferioris and triangularis close to the inferior border in the premolar region, the
transaction at the base of the alveolar process opposite to the molars, and the temporalis tendons at
the anterior border of the ramus.
An atrophied edentulous mandible loosens the alveolar process, and the crest of the ridge may
be found at the same level as the external and internal oblique ridge. It is possible to palpate the
superior genial tubercles with its genioglossus muscle attachment. Reflection of the mucoperiosteal
flap after midcrest incision may expose the mental neurovascular bundle, which is abnormally located
at or occasionally lingual to the crest of the ridge. The transact muscle may loose its attachment to
the external oblique ridge, whereas the mylohyoid may rise above the level of the ridge.
The lingual nerve, which has a close relationship to the alveolar bone of the third molar in the
dentulous mandible, may run close to the crest of the edentulous ridge; in some cases it may be
found under the retromolar pad. Muscle Attachment to the Mandible The loss of teeth begins a
cascade of events that leads to alveolar bone loss in width and height. As the mandibular alveolar
bone resorbs, the residual ridge migrates toward many of the muscles that originate or insert on the
mandible . The origin, insertion, innervation, and function of the muscles of surgical importance to the
implant dentist are discussed.
19

Lingual or Medial Attachments Mylohyoid Muscle
The mylohyoid muscle is the main muscle of the floor of the mouth. It takes origin from the
entire length of the mylohyoid lines on the medial aspect of the mandible bilaterally. The most
posterior fibers of the mylohyoid insert into the body of the hyoid bone, whereas the other fibers meet
in the midline to form a median raphe that extends from the mandible to the hyoid bone. The
structures above the mylohyoid muscle are sublingual or intraoral in location, and the structures
below the mylohyoid muscle are extraoral or subcutaneous.
With a severely resorbed residual ridge, the origin of the mylohyoid muscle approximates the
crest of the ridge, especially in the posterior mandible. In these cases surgical manipulation at the
crest of the ridge may injure the mylohyoid muscle. A mandibular periosteal reflection for
subperiosteal implant often reflects this muscle to the second molar region. The substructure of the
implant then has a permucosal site in the first molar area and a lingual primary strut above and below
the mylohyoid muscle. Surgical manipulation of the tissue of the floor of the mouth may lead to
edematous swelling of the sublingual space (above the mylohyoid muscle), swelling of the
submandibular space (below the mylohyoid muscle), or both.
Ecchymosis resulting from blood accumulation may occur subcutaneously and/or

submucosally. In some cases, infection may start and spread lingually and lead to an abscess or
cellulitis either sublingually (intraoral) or submandibularly (extraoral), depending on the site of origin of
the infection in relation to the origin of the mylohyoid muscle. Extensive bilateral cellulitis of the
sublingual spaces may push the tongue backward or compress the pharynx, which may result in
airway obstruction and necessitate a tracheotomy or cricothyroidotomy to maintain the airway.
Functionally, the mylohyoid muscle raises the hyoid bone and floor of the mouth, or it can depress the
mandible if the hyoid bone is fixed. The mylohyoid nerve that innervates the muscle is a motor branch
of the inferior alveolar nerve. The latter is a branch of the mandibular nerve (V3).
Genioglossus Muscle
The genioglossus muscle forms the bulk of the tongue. It takes origin from the superior
genial tubercle. The anterior fibers insert into the dorsal surface of the tongue from the root to its tip,
and the posterior fibers insert into the body of the hyoid bone. The genioglossus muscle is the main
protruder of the tongue. The genial tubercles, particularly the superior pair, may be located near the
crest of the alveolar ridge in Divisions C to D atrophic mandible. During the elevation of the lingual
mucosa and before making an impression for a subperiosteal implant, one should be aware of the
20

origin of this structure to avoid causing injury during the procedure. A portion of this muscle may be
reflected from the genial tubercle. However, the muscle should not be completely detached from the
tubercle, because this may result in retrusion of the tongue and possible airway obstruction. A branch
of the hypoglossal nerve (cranial nerve XII) supplies the genioglossus.
Medial Pterygoid Muscle
The majority of the fibers of the medial pterygoid muscle take origin from the medial surface of
the lateral pterygoid plate of the sphenoid bone. A small slip of muscle originates from the tuberosity
of the maxilla. The muscle inserts on the medial surface of the angle of the mandible. The medial
pterygoid muscle bounds the pterygomandibular space medially. This space is entered when an
inferior dental nerve block is administered. Furthermore, during surgical procedures medial to the
medial tendon of the temporalis muscle, such as in preparation for the insertion of unilateral
subperiosteal implant, the pterygomandibular space is usually involved. Infection of this space is
dangerous because of its proximity to the parapharyngeal space and the potential for spread of the
infection to the mediastinum. Surgical exposure of tissue posterior to the maxillary tuberosity may
also involve the medial pterygoid muscle because a portion of the muscle takes origin from the
maxillary tuberosity. However, the numbers of fibers originating from the tuberosity are few in
comparison with the fibers from the medial surface of the lateral pterygoid plate. A branch of the
mandibular division (V3) of the trigeminal nerve innervates the muscle.
Lateral Pterygoid Muscle
Although the lateral pterygoid muscles rarely are involved in surgery for implants, their
possible action in mandibular flexure or adduction during opening, as well as the effect of this
phenomenon on subperiosteal implants or prosthetic full-arch splitting of mandibular implants in the
molar region, warrants their consideration. The lateral pterygoid muscle consists of superior and
inferior heads. The superior head takes origin from the infratemporal surface and crest of the greater
wing of the sphenoid bone (roof of the infratemporal fossa), whereas the inferior head takes origin
from the lateral surface of the lateral plate of the pterygoid process of the sphenoid bone. The fibers
of the superior head run downward to insert on the anterior band of the temporomandibular joint (TMJ)
disk (about 15% of its fibers) and the pterygoid fovea on the neck of the mandible. The fibers of the
inferior head run upward to insert on the pterygoid fovea and also and median collateral ligament of
the TMJ disk. Because on the medial pole of the condyle, median capsule, of the angulation of the
lateral pterygoid muscles, many authors believe that the mandibular flexure causing alteration in the
mandibular arch width, and sometimes pain in patients with a full-arch subperiosteal implant or
prosthetic splint, may be caused by contraction of the lateral pterygoid muscles. The muscles
21

normally function in protraction of the mandible and are innervated by a branch of the mandibular
nerve (V3).
Temporalis Muscle
The temporalis is a fan-shaped muscle of mastication. It takes origin from the temporal fossa
and inserts into the coronoid process of the mandible and the anterior border of the ramus as far
inferiorly as the last molar at the site of the retromolar fossa. The muscle has two tendons that insert
into the mandible. The superficial tendon is located laterally and the deep tendon is inserted medially.
The temporalis tendons and their associated fascia project anteromedially and inferiorly and serve as
a common point for attachment for the temporalis, masseter, and medial pterygoid muscles, as well
as for the transaction and superior pharyngeal constrictor muscles.
The long buccal nerve and vessels are also located in this area. This temporalis tendon-fascial
complex extends into what is traditionally called the retromolar triangle. Surgical exposure of the
mandibular ramus medially would involve this tendon-fascial complex, with its contents of muscle
fibers, nerves, and vessels, and may lead to transaction and postoperative pain. Incisions placed on
the anterior ascending ramus for subperiosteal implants or harvesting bone from the external oblique
and ramus should be inferior to the insertion of the two tendons of the temporalis muscle. The
temporalis muscle is a powerful elevator and retractor of the mandible and, like all the major
muscles of mastication, is innervated by a branch of V3.
Buccal or Facial Muscle Attachments Mentalis Muscle
The external surface of the mandible in the midline presents a ridge indicative of the location of
the symphysis menti . The ridge leads inferiorly to a triangular elevation known as the mental
protuberance. The base of the triangle is raised on either side into the mental tubercles. The mentalis
muscles take origin from the periosteum of the mental tubercles and the sides of the mental
eminence and insert into the skin of the chin and superiorly interdigitate with the orbicularis oris of the
lower lip. Above the mentalis origin, the incisivus muscles take origin from small fossae called the
incisivus fossae. Complete reflection of the mentalis muscles for the purpose of extension of a
subperiosteal symphyseal intraoral graft may result in implant or "witch's chin," probably caused by
the failure of muscle reattachment. If the muscle is completely detached to expose the symphysis,
then an elastic bandage is applied externally to the chin for 4 days to help in the reattachment of the
muscle.
Another approach attached to bone and reflect the distal portion. The is to incise the muscle
and leave a proximal portion distal and proximal portions should be approximated with resorbable
sutures before suturing the mucosa. The mentalis muscle receives its nerve supply from the
marginal (mandibular) branch of the facial nerve.
22

Buccinator Muscle
The fibers of the transaction muscle (cheek muscle) take origin from the lateral surfaces of the
alveolar processes of the maxilla and the mandible in the area of the molars, the maxillary tuberosity,
the pterygoid hamulus, the pterygomandibular raphe, and the retromolar fossa of the mandible. The
insertion of the muscle is complex. The upper and lower fibers of the transaction blend with the fibers
of the orbicularis oris at the upper and lower lips. The central fibers decussate at the modiolus before
they insert into the orbicularis oris.
The modiolus is the site of crossing and intermingling of fibers from the transaction muscle with
fibers from the elevator and depressor muscles of the angle of the mouth. The modiolus forms a
palpable node inside the angle of the mouth opposite the upper first premolar tooth. The parotid duct
opposite the maxillary second molar pierces the transaction muscle. The buccopharyngeal fascia,
which is a part of the visceral fascia of the neck, covers the muscle. Lateral to the fascia is the buccal
pad of fat.
Some patients wearing lower subperiosteal implants complain of episodic swelling and pain at
the site of origin of the transaction muscle, particularly after periods of heavy mastication or bruxism.
Incision of these swellings does not usually yield exudate or purulence. The condition responds well
to heat application, transactionary drugs, and rest. Although the cause for this condition is not known,
one may speculate that myositis of a detached transaction muscle may cause it. The process of
muscle reattachment to the implant surface or to a new site should be investigated. The buccal
branch of the facial nerve innervates the muscle.
Masseter Muscle
This strong muscle of mastication covers the lateral surface of the ramus and angle of the
mandible. The masseter has a dual origin from superficial and deep heads. The superficial head
takes origin from the anterior two thirds of the lower border of the zygomatic arch. The deep head
originates from the posterior one third of the zygomatic arch and the entire deep surface of the arch.
The muscle inserts into the outer surface of the ramus of the mandible from the sigmoid notch to the
angle. However, the muscle can be deflected easily during surgery to expose the bone for the ramus
extension needed for lateral support of a subperiosteal implant. The space between the masseteric
fascia and the muscle is a potential surgical space, known as the masseteric space, into which an
infection may spread, causing myositis and trismus. The masseter is one of the main elevators of the
jaw. The masseteric nerve provides the innervation of the muscle and is a branch of the mandibular
division (V3) of the trigeminal nerve. Innervation of the Lower Jaw and Associated Structures
23

Inferior Alveolar (Dental) Nerve
This nerve arises as a branch of the mandibular nerve (V3) in the infratemporal fossa. It
appears at the inferior border of the inferior head of the lateral pterygoid muscle, courses downward,
and enters the mandibular foramen on the medial aspect of the ramus. Before the nerve enters the
mandibular foramen, it gives numerous sensory branches that innervate the mandibular bone. These
small nerves are in association with small vessels in neurovascular channels. The inferior dental
nerve can run as one unit through the mandibular canal until it reaches the premolar region, where it
divides into the mental and the incisive nerves. The mental nerve exits the canal through the mental
foramen. In an excessively resorbed ridge, the mental foramen, with its contents of mental nerve and
vessels, can be found on the crest of the ridge. When making an incision or reflection of the mucosa
in this area, avoid injury to these vital structures. Knowledge of the position of the inferior dental canal
in vertical and buccolingual dimensions is of paramount importance during site preparation for
implants.
The potential use of reconstruction techniques on computed tomographic scans and magnetic
resonance imaging may increase clinicians' ability to locate the inferior dental canal precisely within
the jawbone. Much less expensive techniques using panoramic cross-sectional tomographic imaging
are also available. In some cases the inferior dental nerve may divide into two or three rami that
occupy separate canals as the nerve travels in the mandible to supply the bone. These variations can
be determined by conventional radiographic techniques, and the operator should modify the surgical
approach and type of implant to avoid injury to the portion of the nerve that exits the foramen. Injury
to the portion of the inferior alveolar nerve that remains in the atrophied bone and does not innervate
soft tissues is of far less consequence. The nerves in the bone, when in contact with an implant, may
account for the rare but occasional observation of tenderness, even though the implant is rigid and
appears healthy. In addition, the fibrous tissue around these nerves may cause an increase in the
amount of fibrous tissue around an implant that is inserted in contact with these structures.
Lingual Nerve
The lingual nerve is a branch of the mandibular nerve that is given off in the infratemporal
fossa. It appears at the inferior border of the inferior head of the lateral pterygoid muscle anterior to
the inferior alveolar nerve. It passes downward and forward between the ramus of the mandible and
the medial pterygoid muscle. The nerve enters the oral cavity above the posterior edge of the
mylohyoid muscle close to its origin at the third molar region. Because the nerve lies just medial to
the retromolar pad, incisions in this region should remain lateral to the pad, and the mucosal
reflection should be done with the periosteal elevator in constant contact with bone to prevent injury
to the nerve. The nerve proceeds on the surface of the hyoglossus muscle and then crosses the duct
of the submandibular gland medially to enter the floor of the mouth and the tongue.
24

While in the infratemporal fossa, the nerve is joined by the chorda tympani nerve, which is a
branch of cranial nerve VII. The chorda tympani nerve carries taste fibers from the anterior two thirds
of the tongue and parasympathetic preganglionic fibers to the submandibular autonomic ganglion.
The ganglion is connected to the lingual nerve on the surface of the hyoglossus muscle. The
postganglionic neurons from the submandibular ganglion supply the submandibular and sublingual
salivary glands. The branches of the lingual nerve in the oral cavity carry sensory information from the
lingual mucosa, the mucosa of the floor of the mouth, and the anterior two thirds of the
tongue.Improper reflection of a lingual mucoperiosteal flap may injure the lingual nerve and produce
ipsilateral paresthesia or anesthesia of the innervated mucosa, loss of taste, and reduction of salivary
secretion. The extent of involvement depends on the degree of injury to the nerve. Nerve to the
Mylohyoid.
The mylohyoid motor branch of the inferior dental nerve is given off just before the nerve
enters the mandibular foramen. This branch descends in a groove on the medial surface of the
mandibular ramus and then appears in the submandibular triangle at the posterior border of the
mylohyoid muscle. The nerve supplies the mylohyoid muscle and then proceeds on its surface with
the submental artery (branch of the facial artery) until it reaches the anterior belly of the digastric
muscle, which it also supplies. Because the nerve is so closely related to the ramus of the mandible,
surgical intervention in this area may lead to injury of this important motor nerve.
Long Buccal Nerve
This nerve is a sensory branch of the mandibular division of the trigeminal nerve and is
distributed to the skin and mucous membrane of the cheek and the buccal transact opposite the
mandibular molar region. The nerve courses between the two heads of the lateral pterygoid muscle,
then precedes medial to, or sometimes within, the medial temporalis tendon to gain access to the
surface of the buccinator muscle.
The nerve supplies the skin of the cheek and runs down to the level of the external oblique
ridge, penetrates the buccinator, and spread its branches under the cheek mucosa, alveolar mucosa,
and attached gingivae opposite to molar teeth. The implantologist who is planning to access the
ramus for the purpose of excising a block graft should be aware of the buccal nerve and avoid injuring
it. In addition, surgical manipulation in this area (e.g., during insertion of a subperiosteal implant) may
injure this nerve.
25

Maxillary nerve Zycomatic Branch Orbital plate of the maxilla

Medial wall of maxilla orbicularis oris muscle incisivus superioris labii muscle
Latter Levator labii superioris muscle Maxilla
Posterolateral surface
___________1. Is a pyramidal in shape with the root of the zygoma as its apex.
___________2. The third surface of the pyramid is;
___________3. It is the surface of maxilla above the mucobuccal fold forms the anterior wall of the
infra-temporal fossa and is difficult to palpate.
___________4. Innervates the maxilla.
___________5. It is a branch of the facial nerve innervates the caninus muscle.
___________6. Begins at the sharp edge of the anterior nasal aperture and extends posteriorly.
___________7. It provides the superior and middle conchae of the lateral nasal wall.
___________8. Originates from the floor of the incisive fossa of the maxilla above the eminence of the lateral
incisor and deep to the orbicularis oris.
___________9. Originates from the modiulos at each muscle.
__________10. Takes the origin from the infra-orbital margin above the infra-orbital for-amen and therefore
is rarely of concern to the implant surgeon.
26

1. It divides the facial surface of the maxilla into anterolateral and posterolateral surfaces of the pyramid.
A. Mandibular B. Maxilla C. Maxillary sinus D. Maxillary nerve
2. Has a vertical plate that articulates with the base of the maxilla.
A. Anterolateral B. Posterolateral C. Palatine bone D.maxilla
3. The openingof the maxillary sinus is found in the;
A. Medial wall of maxilla

B. Interal nasal wall of maxilla
C. Middle wall of maxilla
D. Anterior wall
4. Forms the floor of the orbit and also the root of the maxillary sinus.
A. Incisivus labii superior B. Posterolateral C. Orbital plate D. Orbicularis oris
5. Originates in the maxilla below the infra-orbital for-amen.
A. Levator labii superior B. Orbicularis oris C. Incisivus labii superior
D. Levator labii superior Levator anguli oris muscle
6. It leaves the middle cranial fossa by passing through the for-amen rotundum and appears in the
pterygopalatine fossa.
A. Nerve B. maxillary nerve C. orbital plate D. Infra-orbital
7. This nerve is a continuation of the main trunk of the maxillary division.
A. Infra-orbital nerve B. Posterior nerve C. Anterior nerve D. Middle nerve
8. This nerve leaves the pterygopalatine fossa through the spenopalatine for-amen located in
the medial wall of the fossa.
A. Middle nerve B. Infra-orbital nerve C. Nasopalatine nerve D. Anterior nerve
27

9. Is a fan- shaped muscle of mastification.
A. Lateral Pterygoid muscle

B. Temporalis muscle
C. Genioglosses muscle
D. Medial Pterygoid muscle
10. Branch of the mandibular nerve that is given off in the infra-temporal fossa.
A. Inferior Alveolar nerve

B. Long Buccal nerve
C. Masseter muscle
D. Lingual nerve

1. What is one of the main elevators of the jaw ?
2. It was originates from the modiolus at each corner of the mouth.
3. It leaves the pterygopalatine fossa through the sphenopalatine foramen

located in the medial wall of the fossa.
4. It is the result from blood accumulation may occur subcutaneously
and/or submucosally.
5. What nerve is a sensory branch of the mandibular
division of the trigeminal nerve and is distributed to the skin and mucous me
mbrane of the cheek and the buccal transact opposite the mandibular molar
region.
SCORE:
28

C. LESSON WRAP-UP

A. Work Tracker
completed.
FAQs
-
1. What is the difference between the mandibular molars and maxillary molars?
Answer: Maxillary molars are located in the upper jaw while mandibular molars are placed in
the lower jaw.
2. What do maxilla and mandible roles in our facial skeleton?
Answer: The lower jaw (mandible) supports the bottom row of teeth and gives shapes to the lower
face and chin while the upper jaw (maxilla) holds the upper teeth, shapes the middle of the
face, and supports the nose.
29

KEY TO CORRECTIONS

Answer Key:
1. B 2. C 3. A 4. C 5. D 6. A 7. A 8. C 9. B 10. D
Answer Key:
1.What is one of the main elevators of the jaw ? Masseter
2.It was originates from the modiolus at each corner of the

mouth. Orbicularis oris muscle
3.It leaves the pterygopalatine fossa through the
sphenopalatine foramen located in the medial wall of the Nasopalatine Nerve
fossa.
4.It is the result from blood accumulation may occur
Ecchymosis
subcutaneously and/or submucosally.
6. What nerve is a sensory branch of the mandibular division
Long Buccal Nerve
of the trigeminal nerve and is distributed to the skin and m
ucous membrane of the cheek and the buccal transact
opposite the mandibular molar region.
SCORE:
30


Prepared by:

31
Teachers’ Guide Module #2 Teachers’ Guide Module # 4

Lesson title: Bone Physiology,Metabolism and Biomechanics Materials:

1. Thoroughly review the knowledge on bone physiology, References:
metabolism and biomechanics and relate its importance to dental Contemporary of Implant
implantology. Dentistry. 3rd Edition.
2. Understand the mechanism of bone healing and bone integration Carl E. Misch
around the dental implant that would provide dental implant body
and restoration stability and support.
Productivity Tip: Work as hard as you can and then be happy in the knowledge you have done anymore.
(1) Introduction (2 mins)
Bone is a dynamic structure that is adapting constantly to its environment. Because the skeleton is the
principal reservoir of calcium, bone remodeling (physiologic turnover) performs a critical life support role in
mineral metabolism. Collectively, bones are essential elements for locomotion, antigravity support, and life
sustaining functions such as mastication.
(2) Activity 1: What I Know Chart, part 1 (3mins)

of this module.

1.What is a vital mineralized issue
and are unique morphologic
organs?
2.What is the first bone formed
relatively immature?
3.Where can we found the

primary metabolic calcium
reserves of the body?
11

B.MAIN LESSON
Consistent success with implant-supported prostheses requires a thorough knowledge of the

physiology, metabolism and biomechanics of bone as a tissue, and bones as musculoskeletal organs. Bone is a
vital mineralized issue and bones are unique morphologic organs, composed of calcified and soft tissues that
provide structural and metabolic support for a wide variety of interactive functions. Understanding the clinical
manipulation of bone begins with an appreciation of the fundamental genetic and environmental mechanisms
of osseous development and adaptation.
The genome codes for growth factors, ischemic agents, vascular induction/invasion mechanisms, and
mechanically induced inflammation. These biological mechanisms interact with the physical factors of
diffusion limitation and mechanical loading to produce bone morphology . Fundamental principles control the
quality and quantity of bone that directly and indirectly supports stomatognathic function. A firm grasp of the
modern concepts of bone physiology, metabolism, and biomechanics is an essential prerequisite for
innovative clinical practice. These principles are an objective basis for designing a realistic treatment plan that
has a high probability of meeting the esthetic and functional expectations of the patient.
Bone- is a dynamic structure that is adapting constantly to its environment. Because the skeleton is the
principal reservoir of calcium, bone remodeling (physiologic turnover) performs a critical life support role in
mineral metabolism. Collectively, bones are essential elements for locomotion, antigravity support, and life
sustaining functions such as mastication. Mechanical adaptation of bone is the physiologic basis of
stomatognathic reconstruction with implant-supported prostheses. A detailed knowledge of the dynamic
nature of bone physiology and biomechanics is essential to enlightened clinical practice.
OSTEOLOGY In defining the physiologic basis of orthodontics, the initial consideration is bone
morphology (osteology) of the complex. via the systematic study of a personal collection of more than 1000
human skulls, Spencer Atkinson provided the modern basis of craniofacial osseous morphology as it relates to
the biomechanics of stomatognathic function. A frontal section of an adult skull shows the bilateral symmetry
of bone morphology and functional loading . Because the human genome contains genes to pattern the
structure of only half of the body, the contralateral side is a mirror image. Consequently, normal development
of the head is symmetrical. Thus unilateral structures are on the midline, and bilateral structures are
equidistant from it.the vertical components of the cranium tend to be loaded in compression (negative stress),
and the horizontal components are loaded in tension (positive stress).
From an engineering perspective, the internal skeletal structure of the mid face is similar to that of a
ladder: vertical rails loaded in compression connected by rungs loaded in tension. This is one of the most
efficient structures for achieving maximal compressive strength with minimal mass in a composite material.
12

Differential Osteology of the Maxilla and Mandible Although equal and opposite functional loads are delivered
to the maxilla and mandible, the maxilla transfers stress to the entire cranium, whereas the mandible must
absorb the entire load. Consequently, the mandible is much stronger and stiffer than the maxilla.
A midsagittal section through the incisors and a frontal section through the molar region show the
distinct differences in the osseous morphology of the maxilla and mandible. The maxilla has relatively thin
cortices that are interconnected by a network of trabeculae. Because it is loaded primarily in compression, the
maxilla is structurally similar to the body of a vertebra. The mandible, however, has thick cortices and more
radially oriented trabeculae . The structural array is similar to the shaft of a long bone and indicates that the
mandible is loaded predominantly in bending and torsion.
This biomechanical impression based on osteology is confirmed by in vivo strain gauge studies in
monkeys. Hylander2,3 demonstrated substantial bending and torsion in the body of the mandible associated
with normal masticatory function . A clinical correlation consistent with this pattern of surface strain is the
tendency of some humans to form tori in the areas of maximal bending and torsion . The largest tori are on
the side on which the individual habitually chews (preferential working side).
Temporomandibular Articulation
The temporomandibular joint (TMJ) is the principal adaptive center for determining the intermaxillary
relationship in all three planes of space. shows optimal skeletal development consistent with normal
morphology of the TMJ. shows aberrant skeletal and dental relationships consistent with degeneration of the
fossa and mandibular condyle (i.e., the enlarged mushroom shape of the condylar process, the roughened
topography of the articulating surfaces, the loss of articular cartilage and subchondral plate).
Progressive degeneration or hyperplasia of one or both mandibular condyles may result in substantial
intermaxillary discrepancies in the sagittal, vertical, and frontal dimensions. Adaptation of the TMJ allows for
substantial growth change to occur without disturbing the intermaxillary relationship of the dentition (e.g.,
Class I occlusion remains Class I). In the adult years the intermaxillary relationship continues to change but at a
slower rate. The face lengthens and may rotate anteriorly as much as 10 mm over the adult lifetime. The
mandible adapts to this change by lengthening and maintaining the intermaxillary dental relationship .
However, if the TMJs of an adult undergo bilateral degenerative change, whether symptomatic or not,
the mandible can decrease in length, resulting in a shorter, more convex face . Within physiologic limits, the
TMJ has remarkable regenerative and adaptive capabilities allowing for spontaneous recovery from
degenerative episodes . Unlike other joints in the body, the TMJ has the ability to adapt to altered jaw
structure and function. After a subcondylar fracture, the condylar head is pulled medially by the superior
pterygoid muscle and resorbs. If the interocclusal relationship is maintained, a new condyle forms from the
medial aspect of the ramus and assumes normal function.
13

Unilateral subcondylar fractures usually result in regeneration of a new functional condyle with no
significant deviation of the mandible. However, about one fourth of subcondylar fractures result in a
mandibular deviation toward the injured side, resulting in an asymmetrical Class II malocclusion with a midline
deviation. Another sequela of mandibular trauma is internal derangement such as a unilateral closed lock (a
condyle distally displaced relative to the disk). If the range of motion is reduced in a growing patient, the
compromised function may inhibit mandibular growth, resulting in a cant of the occlusal plane. Progressive
dysfunction and pain may ensue, particularly when associated with occlusal trauma. Reestablishing normal
bilateral function allows the compromised condyle or condyles to adapt favorably.
BONE PHYSIOLOGY
The morphology of bone has been well described, but its physiology is elusive because of the technical
limitations inherent in the study of mineralized tissues. Accurate assessment of the orthodontic or orthopedic
response to applied loads requires time markers (bone labels) and physiologic indexes (DNA labels,
histochemistry, and in situ hybridization) of bone cell function. Systematic investigation with these advanced
methods has defined new concepts of clinically relevant bone physiology.
Specific Assessment Methodology Physiologic interpretation of the response to applied loads requires
the use of specially adapted methods, as follows:
•Mineralized sections are an effective means of accurately preserving structure and function
relationships.
•Polarized light birefringence detects the preferential orientation of collagen fibers in the bone matrix.
•Fluorescent labels (e.g., tetracycline) permanently mark all sites of bone mineralization at a specific
point in time (anabolic markers).
•Microradiography assesses mineral density patterns in the same sections.
•Autoradiography detects radioactively tagged precursors (e.g., nucleotides, amino acids) used to mark
physiologic activity.
•Nuclear volume morphometry differentially assesses osteoblast precursors in a variety of osteogenic

tissues,
•Cell kinetics is a quantitative analysis of cell physiology based on morphologically distinguishable

events in the cell cycle (i.e., DNA synthesis [S] phase, mitosis, and differentiation-specific change in nuclear
volume).
14

• Finite element modeling is an engineering method of calculating stresses and strains in all materials,
including living tissue
• Microelectrodes inserted in living tissue such as the periodontal ligament (PDL) can detectelectrical
potential changes associated with mechanical loading,
•Backscatter emission is a variation of electron microscopy that assesses relative mineral density at the
microscopic level in a block specimen.
•Microcomputed tomography is an in vitro imaging method for determining the relative mineral
density of osseous tissue down to a resolution of approximately 5 μm (about the size of an osteoblast nucleus).
•Microindentation testing is a method for determining the mechanical properties of bone at the
microscopic level.
Classification of Bone Tissue
Orthodontic tooth movement involves a cytokinemediated bone adaptation response similar to wound
healing therefore, tooth movement is a good experimental model for understanding the types of bone formed
during the postoperative bone modeling and long-term remodeling response to bone manipulative therapy.
The first bone formed is relatively immature woven bone .
Woven bone
Is compacted to form composite bone (primary ostons) and subsequently is remodeled to lamellar
bone. To appreciate the biologic mechanism of bone healing and adaptation, the practitioner must have
knowledge of bone types. Woven bone varies considerably in structure; it is realtively weak, disorganized, and
poorly mineralized.Woven bone is not found in the adult skeleton under normal, steady state conditions;
rather, it is compacted to form composite bone, remodeled to lamellar bone, or rapidly resorbed if
prematurely loaded. The functional limitations of woven bone are an important aspect of orthodontic
retention, as well as postoperative healing of implants and orthognathic surgery segments. However, it serves
a crucial role in wound healing ;
(1) rapidly filling osseous defects;
(2) providing initial continuity for fractures, osteotomy segments, and endosseous implants; and
(3) strengthening a bone weakened by surgery or trauma. The first bone formed in response to wound
healing is the woven type.
15

Lamellar Bone
Lamellar bone, a strong, highly organized, well mineralized tissue, makes up more than 99% of the
adult human skeleton. When new lamellar bone is formed, a portion of the mineral component
(hydroxylapatite) is deposited by osteoblasts during primary mineralization . Secondary mineralization, which
completes the mineral component, is a physical process (crystal growth) that requires many months. Within
physiologic limits, the strength of bone is related directly to its mineral content. The relative strengths of
different histologic types of osseous tissue are such that woven bone is weaker than new lamellar bone, which
is weaker than mature lamellar bone. Adult human bone is almost entirely of the remodeled variety:
secondary osteons and spongiosa. The full strength of lamellar bone that supports an endosseous implant is
not achieved until about 1 year postoperatively. This is an important consideration in planning the functional
loading of an implant-supported prosthesis.
Composite Bone
Composite bone is an osseous tissue formed by the deposition of lamellar bone within a woven bone
lattice, a process called cancellous compaction. This process is a rapid means of producing relatively strong
bone in a short period. Composite bone is an important intermediary type of bone in the physiologic response
to functional loading, and it usually is the predominant osseous tissue for stabilization during the early process
of postoperative healing. When the bone is formed in the fine compaction configuration, the resulting
composite of woven and lamellar bone forms structures known as primary osteons. Although composite bone
may be high-quality, load-bearing osseous tissue, it is eventually remodeled into secondary 7,30 osteons.
Bundle Bone
Bundle bone is a functional adaptation of lamellar structure to allow attachment of tendons and
ligaments. Perpendicular striations, called Sharpey's fibers, are the major distinguishing characteristics of
bundle bone. Distinct layers of bundle bone usually are seen adjacent to the PD along physiologic bone
forming surfaces. Bundle bone is the mechanism of ligament and tendon attachment throughout the body.
First-generation blade implants were thought to form a ligamentous attachement to bone, which was deemed
a pseudoperiodontium. However, histologic studies could not demonstrate any bundle bone attaching fibrous
conective tissue to bone at the interface. Because the fibrous tissue encapsulation had no physiologic role, it
was actually scar tissue, which was equivalent to a nonunion in a failed facture repair.
SKELETAL ADAPTATION: MODELING AND REMODELING
Skeletal adaptation to the mechanical environment is achieved through changes in
(1) bone mass, (3) matrix organization, and
(2) geometric distribution (4) collagen orientation of the lamellae

16

In addition to these adaptive mechanisms that influence bone formation, the mechanical properties of
osseous structures change as a result of maturation, function, aging, and pathologic processes.
A few physiologic and pathologic examples are;
(1) secondary mineralization, (3) fatigue damage, and
(2) mean bone age, (4) loss of vitality (pathologic hypermineralization).
Trabecular and cortical bone
These grow, adapt, and turn over by means of two fundamentally distinct mechanisms: modeling and
remodeling. In bone modeling, independent sites of resorption and formation change the form (shape, size, or
both) of a bone. In bone remodeling, a specific, coupled sequence of resorption and formation occurs to
replace previously existing bone. The mechanism for internal remodeling (turnover) of dense compact bone
involves axially oriented cutting and filling cones. From an orthodontic perspective the biomechanical
response to tooth movement involves an integrated array of bone modeling and remodeling events.
Bone modeling is the dominant process of facial growth and adaptation to applied loads such as
headgear, rapid palatal expansion, and functional appliances. Modeling changes can be seen on cephalometric
tracings, but remodeling events, which usually occur at the same time, are apparent only at the microscopic
level. True remodeling usually is not imaged on clinical radio graphs, but can be detected with clinical
scintillation scans. Constant remodeling (internal turnover) mobilizes and redeposits calcium by means of
coupled resorption and formation: bone is resorbed and redeposited at the same site. Osteoblasts, osteoclasts,
and possibly their precursors are thought to communicate by chemical messages known as coupling factors.
Transforming growth factor ß is thought to be a coupling factor.
CORTICAL BONE GROWTH AND MATURATION
Enlow sectioned human skulls and histologically identified areas of surface apposition and resorption.
The overall patterns of bone modeling ("external remodeling") helped define the mechanisms of facial growth.
Although the method could not distinguish between active and inactive modeling sites, it was adequate for
determining the overall direction of regional activity in the maxilla and mandible. This method of osseous
topography was a considerable advance in the understanding of surface modeling of facial bones. age, Melsen
used micro radio graphic images of mineralized sections to extend the capability of the osseous topography
method. Patterns of primary and secondary mineralization identified active appositional sites and provided a
crude index of bone formation rates. Through the systematic study of autopsy specimens of 126 normal males
and females from birth to 20 years of the most stable osseous structures in the anterior cranial base of
growing children and adolescents were defined anatomically . This research established that the three most
stable osseous landmarks for superimposition of cephalometric radiographs, and these are the following:
17

(1) the anterior curvature of the sella turcica,
(2) the cribriform plate, and
(3) the internal curvature of the frontal bone
In effect, this research established the gold standard for reliable superimposition on the anterior
cranial base. This information is valuable for implantologists because a superimposed tracing of serial
cephalometric radiographs is the most reliable means for determining when postadolescent growth is
complete. The latter is essential for treatment planning implant placement during the late adolescent and
early adult periods.
Roberts et al introduced simultaneous use of multiple fluorochrome labels and microradiography to

assess modeling and remodeling patterns over extended periods of time. Noorda applied these methods for a
three-dimensional assessment of subcondylar growth of the mandible of adolescent rabbits. Twenty-week-old
rabbits (early adolescents) were labeled every 2 weeks with a rotating series of six different
multifluorochrome labels for 18 weeks. Cross sections of the subcondylar region were superimposed on
original, oldest-labeled, and newest-labeled bone according to fluorescent time markers . Because all three
sections were at the same relative level at a point in time, superimposition on original (unlabeled) bone and
the oldest labeled bone provided an index of the relative amounts of bone resorbed and formed as the
mandible grew superiorly . This method provides the most accurate assessment to date of cortical bone drift
overtime.
The major mechanism of the increase in inter-ramal width during adolescent growth in rabbits is lateral
drift of the entire subchondral region. The Noorda study also produced important quantitative data on the
rates of surface modeling (apposition and resorption) of primary bone . During the last 18 weeks of growth to
adult stature, the surface apposition rate decreased from more than 25 um per day to less than 5 um per day .
The secondary osteon census peaked at about 8 to 10 weeks . Therefore under conditions of relatively
rapid growth, primary cortical bone is remodeled to secondary osteons in about 2 months. Remodeling
therefore is a time-dependent maturation of primary cortical bone. There is little long-term documentation of
the bone remodeling response to functional loading of implant supported restorations. The same methods
used for defining the growth and development of the rabbit mandible would provide valuable new
information for the field of implantology.
Cutting and Filling Cones The rate at which cutting and filling cones progress through compact bone is
an important determinant of turnover. The progression is calculated by measuring the distance between
initiation of labeled bone formation sites along the resorption arrest line in longitudinal sections. Using two
fluorescent labels administered 2 weeks apart in adult dogs, the velocity was 27.7 ± 1.9 µm per day (mean ±
18

SEM [standard error of the mean], n = 4 dogs, 10 cutting and filling cones sampled from each). At this speed,
evolving secondary osteons travel about 1 mm in 36 days.
Newly remodeled secondary osteons (formed within the experimental period of the dog study)
contained an average of 4.5 labels (administered 2 weeks apart); the incidence of resorption cavities is about
one third the incidence of labeled osteons. These data are consistent with a remodeling cycle of about 12
weeks in dogs compared with 6 weeks in rabbits and 17 weeks in humans. This relationship is useful for
extrapolating animal data to human applications. More recent experimental studies have shown that new
secondary osteons may continue to fix bone labels for up to 6 months, indicating that terminal filling of the
lumen is slow. Traumatic or surgical wounding usually results in intense but localized modeling and
remodeling responses. After an osteotomy or placement of an endosseous implant, callus formation and
resorption of necrotic osseous margins are modeling processes; however, internal replacement of the
devitalized cortical bone surrounding these sites is a remodeling activity.
In addition, a gradient of localized remodeling disseminates through the bone adjacent to any invasive
bone procedure. This process, called regional acceleratory phenomenon, is an important aspect of
postoperative healing. Modeling and remodeling are controlled by an interaction of metabolic and mechanical
signals. Bone modeling is largely under the integrated biomechanical control of functional applied loads .
However, hormones and other metabolic agents have a strong secondary influence, particularly during periods
of growth and advanced aging. Paracrine and autocrine mechanisms, such as local growth factors and
prostaglandins, can override the mechanical control mechanism temporarily during wound healing.
Remodeling responds to metabolic mediators such as parathyroid hormone (PTH) and estrogen, primarily
varying the rate of bone turnover .
Bone scans with "Te-bisphosphate, a marker of bone activity, indicate that the alveolar processes, but
not the basilar mandible, have a high remodeling rate. Uptake of the marker in alveolar bone is similar to
uptake in trabecular bone of the vertebral column. The latter is known to remodel at a rate of about 20% to
30% per year compared with most cortical bone, which turns over at a rate of 2% to 10% per year.43
Metabolic mediation of continual bone turnover provides a controllable flow of calcium to and from the
skeleton. Structural and Metabolic Fractions The structural fraction of cortical bone the relatively stable outer
portion of the cortex; the metabolic fraction is the highly reactive inner aspect .
The primary metabolic calcium reserves of the body are found in trabecular bone and the endosteal half of
the cortices. Analogous to orthodontic wires, the stiffness and strength of a bone are related directly to its
crosssectional area.
Diaphyseal rigidity quickly is enhanced by adding a circumferential lamella at the periosteal surface.
Even a thin layer of new osseous tissue at the periosteal surface greatly enhances bone stiffness because it
increases the diameter of the bone. In engineering terms, cross-sectional rigidity is related to the second
19

moment of the area. The same general relationship of round wire diameter and stiffness (strength) is well
known to orthodontists. The rigidity of a wire increases as the fourth power of diameter.
Therefore when a relatively rigid material (bone or wire) is doubled in diameter, the stiffness increases
16 times. The addition of new osseous tissue at the endosteal (inner) surface has little effect on overall bone
strength. Structurally, the long bones and mandible are modified tubes-an optimal design for achieving
maximal strength with minimal mass, Within limits, loss of bone at the endosteal surface or within the inner
third of the compacta has little effect on bone rigidity.
The inner cortex can be mobilized to meet metabolic needs without severely compromising bone strength;
this is the reason patients with osteoporosis have bones with a normal diameter but thin cortices. Even under
severe metabolic stress, the body follows a cardinal principle of bone physiology: maximal strength with
minimal mass.
BONE METABOLISM
Restoration of esthetics and function with implant supported prostheses requires substantial bone
manipulation. The biomechanical response to altered function and applied loads depends on the metabolic
status of the patient. Bone metabolism is an important aspect of clinical medicine that is directly applicable to
implant dentistry. This section discusses the fundamentals of bone metabolism with respect to clinical practice.
The skeletal system is composed of highly specialized mineralized tissues that have structural and
metabolic functions. Structurally, lamellar, woven, composite, and bundle bone are unique types of osseous
tissue adapted to specific functions. Bone modeling and remodeling are distinct physiologic responses to
integrated mechanical and metabolic demands.
Biomechanical manipulation of bone is the physiologic basis of stomatognathic reconstruction.

However, before addressing dentofacial considerations, the clinician must assess the patient's overall health
status. Implantology is bone-manipulative therapy, and favorable calcium metabolism is an important
consideration. Because of the interaction of structure and metabolism, a thorough understanding of osseous
structure and function is fundamental to patient selection, risk assessment, treatment planning, and retention
of desired dentofacial relationships. Bone is the primary calcium reservoir in the body. Approximately 99% of
the calcium in the body is stored in the skeleton. The continual flux of bone mineral responds to a complex
interaction of endocrine, biomechanical, and cell-level control factors that maintain the serum calcium level at
about 10 mg/dL (10 mg%)
Calcium homeostasis is the process by which mineral equilibrium is maintained. Maintenance of serum
calcium levels at about 10 mg/dL is an essential life support function. Life is thought to have evolved in the sea;
calcium homeostasis is the mechanism of the body for maintaining the primordial mineral environment in
which cellular processes evolved.
20

Calcium metabolism is one of the fundamental physiologic processes of life support. When substantial
calcium is needed to maintain the critical serum calcium level, bone structure is sacrificed . The alveolar
processes and basilar bone of the jaws also are subject to metabolic bone loss. Even in cases of severe skeletal
atrophy, the outer cortex of the alveolar process and the lamina dura around the teeth are preserved. This
preservation is analogous to the thin cortices characteristic of osteoporosis. Calcium homeostasis is supported
by three temporally related mechanisms:
(1) rapid (instantaneous) flux of calcium from bone fluid (which occurs in seconds);
(2) short-term response by osteoclasts and osteoblasts (which extends from minutes to days); and
(3) longterm control of bone turnover (over weeks to months)
Precise regulation of serum calcium levels at about 10 mg/dL is essential for nerve conductivity and
muscle function. A low serum calcium level can result in tetany and death. A sustained high serum calcium
level often is a manifestation of hyperthyroidism and some malignancies.
Hypercalcemia may lead to kidney stones and dystrophic calcification of soft tissue. Normal physiology
demands precise control of the serum calcium level Instantaneous regulation of calcium homeostasis is
accomplished in seconds by selective transfer of calcium ions into and out of bone fluid . Bone fluid is
separated from extracellular fluid by osteoblasts or relatively thin bone-lining cells (the latter are thought to
be atrophied remnants of osteoblasts).
A decrease in the serum calcium level stimulates secretion of PTH, which enhances transport of
calcium ions from bone fluid into osteocytes and bone-lining cells. The active metabolite of vitamin D (1,25-
dihydroxycholecalciferol [1,25DHCC]) enhances pumping of calcium ions from bone-lining cells into the
extracellular fluid. By means of this sequence of events, calcium is transported across the bone-lining cells,
resulting in a net flux of calcium ions from bone fluid to extracellular fluid.
Within physiologic limits, support of calcium homeostasis is possible without resorption of bone.
Radioisotope studies have confirmed that bone contains a diffuse mineral component that can be mobilized or
redeposited without osteoblastic and osteoclastic activity. However, a sustained negative calcium balance can
be compensated for only by removing calcium from bone surfaces.
Short-term control of serum calcium levels affects rates of bone resorption and formation within
minutes through the action of the three calcific hormones: (1)PTH, (2)1,25-DHCC, and (3)Calcitonin.
Calcitonin, a hormone produced by interstitial cells in the thyroid gland, is believed to help control
hypercalcemia by transiently suppressing bone resorption.
Parathyroid hormone, acting in concert with 1,25-DHCC, accomplishes three important tasks: it
21

(1) enhances osteoclast recruitment from promonocyte precursors;
(2) increases the resorption rate of existing osteoclasts; and
(3) may suppress the rate at which osteoblasts form bone .
Long-term regulation of metabolism has profound effects on the skeleton. Biomechanical factors (eg..
normal function, exercise, posture, habits),
Noncalcific hormones (e.g., sex steroids, growth hormone), and the metabolic mechanisms previously
discussed dictate mass, geometric distribution, and the mean age of bone. Mass and geometric distribution of
bone are influenced strongly by load history (biomechanics) and sex hormone status.
Parathyroid hormone is the primary regulator of the frequency of remodeling . Because the adult
skeleton is composed almost entirely of secondary (remodeled) bone, the
PTH - mediated activation frequency determines mean bone age. Bone age is an important
determinant of fragility because old bone presumably has been weakened by fatigue damage.
METABOLIC BONE DISEASE
Osteoporosis is a generic term for low bone mass (osteopenia). The most important risk factor for the
development of osteoporosis is age: after the third decade, osteopenia is related directly to longevity. Other
high-risk factors are;
(1) a history of long-term glucocorticoid treatment, (6) low-calcium diet
(2) Slight stature , (7) excessive consumption of alcohol,
(3) smoking, (8) vitamin D deficiency,
(4) menopause or dysmenorrhea, (9) kidney failure,
(5) lack of or little physical activity, (10) liver disease (cirrhosis) and
(11) a history of fractures.
These risk factors are effective in identifying 78% of those with the potential for osteopenia. This is a
particularly good screening method for skeletally asymptomatic dental patients. However, one must realize
that more than 20% of individuals who eventually develop osteoporosis have a negative history for known risk
22

factors. Any clinical signs or symptoms of low bone mass (e.g., low radiographic density of the jaws, thin
cortices, excessive bone resorption) are grounds for referral. A thorough medical workup, including bone
mineral density measurement, usually is necessary to establish the diagnosis of osteopenia.
The term osteoporosis usually is reserved for patients with evidence of fracture or other osteoporotic
symptoms. The treatment of metabolic bone diseases such as osteoporosis depends on the causative factors.
Medical management of these often complex disorders is best handled by physicians specifically trained in
bone metabolism, Because the loss of teeth is an important risk factor for osteoporosis, dental patients,
especially adult women, are at high risk for developing osteoporosis. A sampling of all adult female dental
patients at a midwestern dental school showed that about 65% were at high risk for developing osteoporosis
(estrogen deficient or had at least two other risk factors).
BIOMECHANICS
Gravitational loads have a substantial influence on normal skeletal physiology. Osteoblast

differentiation that leads to new bone formation is stimulated by mechanical loading but inhibited by
weightlessness. Space flight studies have established that gravity helps maintain skeletal mass. A substantial
part of the physiologic loading of the mandible is related to antigravity posturing. In erect posture, gravity
tends to open the mouth; muscular force is used to hold the mouth closed. Apparently, growth of the rat
mandibular condyle may be inhibited during space flight because of weightlessness and the decrease in
functional loading. Gravity may prove to be an important factor in the secondary growth mechanism of the
mandible. Mechanical loading is essential to skeletal health. Control of most bone modeling and some
remodeling processes are related to strain history, which usually is defined in microstrain (pe). Repetitive
loading generates a specific response, which is determined by the peak strain.
In an attempt to simplify the often conflicting data, Frost" proposed the mechanostat theory.
Reviewing the theoretical basis of this theory, Martin and Burr proposed that
(1) subthreshold loading of less than 200 ue results in disuse atrophy, manifested as a decrease in
modeling and an increase in remodeling;
(2) physiologic loading of about 200 to 2500 μe is associated with normal, steady state activities;
(3) loads exceeding the minimal effective strain (about 2500 ue) result in a hyper-trophic increase in
modeling and a concomitant decrease in remodeling: and
(4) after peak strains exceed about 4000 μe, the structural integrity of bone is threatened, resulting in
pathologic overload.
23

Many of the concepts and micro strain levels are based on experimental data. The strain range for each
given response probably varies between species and may be site specific in the same individual. However, the
mechanostat provides a useful clinical reference for the hierarchy of biomechanical responses to applied loads.
Normal function helps build and maintain bone mass. Suboptimally loaded bones atrophy as a result of
increased remodeling frequency and inhibition of osteoblast formation. Under these conditions, trabecular
connections are lost and cortices are thinned from the endosteal surface.
Eventually the skeleton is weakened until it cannot sustain normal function. Assuming that the
negative calcium balance is corrected and adequate bone structure remains, patients with a history of
osteoporosis or other metabolic bone disease are viable candidates for reconstructive dental procedures. The
crucial factor is the residual bone mass in the area of interest after the disease process has been arrested .
When flexure (strain) exceeds the normal physiologic range, bones compensate by adding new mineralized
tissue at the periosteal surface. Adding bone is an essential compensating mechanism because of the inverse
relationship between load (strain magnitude) and the fatigue resistance of bone. When loads are 81 Dynamic
loading less than 2000 μe, lamellar bone can withstand millions of loading cycles, more than a lifetime of
normal function.
However, increasing the cyclic load to 5000 με, about 20% of the ultimate strength of cortical bone,
can produce fatigue failure in 1000 cycles, which is achieved easily in only a few weeks of normal activity.
Repetitive overload at less than one fifth of the ultimate strength of lamellar bone (25,000 μe, or 2.5%
deformation) can lead to skeletal failure, stress fractures, and shin splints. From a dental perspective, occlusal
prematurities or para-function may lead to compromise of periodontal bone support. Localized fatigue failure
may be a factor in periodontal clefting, alveolar recession, tooth oblation (cervical ditching), or TMJ arthrosis.
Guarding against occlusal prematurities and excessive tooth mobility, while achieving an optimal distribution
of occlusal loads, are important objectives for orthodontic treatment.
The human masticatory apparatus can achieve a biting strength of more than 2200 N, or more than
500 lb of force. 82,83 Because of the high magnitude and frequency of oral loads, functional prematurities
during reconstructive treatment could contribute to isolated incidences of alveolar clefting and root
resorption. Excessive tooth mobility should be monitored carefully. Prevention of occlusal prematurities is a
particular concern in treating periodontally compromised teeth.
24

Gravity Gravitational loads Osteoporosis

mechanostat theory muscular force Bone age
Frost Parathyroid hormone trabecular bone
Implantology
___________1. Who proposed the mechanostat theory.
___________2. It is the primary regulator of the frequency of remodeling .
___________3. gravity tends to open the mouth; ______ is used to hold the mouth closed.
___________4. It helps maintain skeletal mass.
___________5. Provides a useful clinical reference for the hierarchy of bio-mechanical responses to applied
loads.
___________6. The primary metabolic calcium reserves of the body are found in ______ and the endosteal
half of the cortices.
___________7. Have a substantial influence on normal skeletal physiology.
___________8. It is an important determinant of fragility because old bone presumably has been weakened
by fatigue damage.
___________9. It is bone-manipulative therapy, and favorable calcium metabolism is an important

consideration.
__________10. It is a generic term for low bone mass (osteopenia).
25

1. They are at high risk for developing osteoporosis.
A. Adult men B. Adult women C. Teenagers D. Children
2. The term is usually is reserved for patients with evidence of fracture or other
osteoporotic symptoms.
A. Scoliosis B. Diabetes C. Osteoporosis D. Bone cancer
3. It is mediated activation frequency determines mean bone age.
A. Parathyroid hormone B. Noncalcific hormones C. muscular force D. calcium homeostasis
4. It is composed of highly specialized mineralized tissues that have structural and metabolic functions.
A. The skeletal system B. The muscular system C. Digestive system D. Cardiovascular system
5. The process by which mineral equilibrium is maintained.
A. Calcium metabolism B. Calcium C. Calcitonin D. Calcium homeostasis
6. Kind of bone that varies considerably in structure; it is realtively weak, disorganized, and poorly
mineralized.
A. Lamellar bone B.Woven bone C. Composite bone D. Bundle bone
7. It is a dynamic structure that is adapting to its environment.
A. Bone remodeling B. Bone C. Osteology D. Ischemic agents
8. Define the physiologic basis of orthodontics.
A. Morphology B. Geology C. Osteology D. Biology
26

9. He provided the modern basis of cranio-facial osseous morphology as it relates to the
Biomechanics of stomatognathic function.
A. Robert et.al B. Noorda 37 C. Melsen D.Spencer Atkinson
10. Has relatively thin cortices that are interconnected by a network of trabeculae.
A. Maxilla B. trabeculae C. Mandible D. Cranioficial

1. Who proposed the mechanostat theory ?
2. What is a dynamic structure that is adapting constantly to its

environment.
3. What is the process by which mineral equilibrium is maintained.
4. It is an important determinant of fragility because old bone presumably

has been weakened by fatigue damage.
SCORE:
27

C. LESSON WRAP-UP

A. Work Tracker
completed.
FAQs
-
1. What is Bone age?
Answer: Bone age is the degree of maturation of a child’s bones. As a person grows from fetal life
through childhood, puberty and finishes as a young adult, the bones of the skeleton change in size and shape.
2. How can age affect bone?
Answer: Bones become brittle and may break more easily. Over all height decreases, mainly because the
trunk and spine shorten. Breakdown of the joints may lead to inflammation, pain, stiffness, and deformity. Joint
changes affect almost all older people.
28

KEY TO CORRECTIONS

Answer Key:
1. B 2. C 3. A 4. A 5. D 6. B 7. C 8. C 9. D 10. A
Answer Key:
1. Who proposed the mechanostat theory? FROST

2. What is a dynamic structure that is adapting
constantly to its environment? Bone
3. What is the process by which mineral equilibrium is
maintained. Calcium Homeostasis
4.It is an important determinant of fragility because
old bone presumably has been weakened by fatigue
Bone Age
damage.

Adult Women
SCORE:
29


Prepared by:

30

Lesson title: Prosthetic Options in Implant Dentistry Materials:

Pen, pencil and highlighter
Lesson Objectives: At the end of this module, you should be able to: References:
1. Determine the classification of implant supported fixed dental Contemporary of Implant
prosthetics Dentistry. 3rd Edition.
2. Know the importance and advantages of implant supported Carl E. Misch
dental prosthesis over the conventional crown and bridge
restorations and RPD.
Productivity Tip:”Be an individual, work hard, study, get your mind straight and trust nobody”
Implant dentistry is similar to all aspects of medicine in that treatment begins with a diagnosis of the
patient's condition. Many treatment options stem from the diagnostic information. Traditional dentistry
provides limited treatment options for the edentulous patient. Because the dentist cannot add abutments, the
restoration design is directly related to the existing oral condition. On the other hand, implant dentistry can
provide a range of additional abutment locations.

of this module.

What is the goal of implant
dentistry?
They should be aware of future
compromises in bone loss and its
associated problems with minimal
treatment options.
What replaces the crown and a

portion of the root?
11

B.MAIN LESSON
Historically in implant dentistry, bone available for implant insertion dictated the number and
locations of dental implants. The prosthesis then was often determined after the position and number of
implants were selected. The goals of implant dentistry are to replace a patient's missing teeth to normal
contour, comfort, function, esthetics, speech, and health, regardless of the previous atrophy, disease, or injury
of the stomatognathic system. It is the final restoration, not the implants, that accomplish these goals. In
other words, patients are missing teeth, not implants. To satisfy predictably a patient's needs and desires, the
prosthesis should first be designed. In the stress treatment theorem, the final restoration is first planned,
similar to the architect designing a building before making the foundation. Only after this is accomplished can
the abutments necessary to support the specific predetermined restoration be designed.
Bone augmentation may further modify the existing edentulous condition in both the partial and total
edentulous arch and therefore also affects the final prosthetic design. As a result, a number of treatment
options are available to most partially and completely edentulous patients. Therefore, once the diagnosis is
complete, the implant treatment plan of choice at a particular moment is patient and problem based. Not all
patients should be treated with the same restoration type or design. Almost all man-made creations, whether
art, building, or prostheses, require the end result to be visualized and precisely planned for optimal results.
Blueprints indicate the finest details for buildings. The end result should be clearly identified before the
project begins, yet implant dentists often forget this simple but fundamental axiom.
COMPLETELY EDENTULOUS PROSTHESIS DESIGN
The completely edentulous patient is too often treated as though cost were the primary factor in
establishing a treatment plan. However, the doctor and staff should specifically ask about the patient's desires.
Some patients have a strong psychologic need to have a fixed prosthesis as similar to natural teeth as possible.
On the other hand, some patients do not express serious concerns whether the restoration is fixed or
removable as long as specific problems are addressed. To assess the ideal final prosthetic design, the existing
anatomy is evaluated after it has been determined whether a fixed or removable restoration is desired. An
axiom of implant treatment is to provide the most predictable, most cost-effective treatment that will satisfy
the patient's anatomical needs and personal desires. In the completely edentulous patient, a removable
implant supported prosthesis offers several advantages over a fixed-implant restoration.
Advantages of Removable Implant-Supported Prostheses in the Completely Edentulous Patient Facial

esthetics can be enhanced with labial flanges and denture teeth compared with customized metal or porcelain
teeth. The labial contours of the removable restoration can replace lost bone width and height and support
12

the labial soft tissues without hygienic compromise. The prosthesis can be removed at night to manage
nocturnal parafunction. Fewer implants may be required. Less bone augmentation may be necessary before
implant insertion. Shorter treatment if no bone augmentation is required. The treatment may be less
expensive for the patient. Long-term treatment of complications is facilitated. Daily home care is easier.
However, some completely edentulous patients require a fixed restoration because of desire or
because their oral condition makes the fabrication of teeth difficult if a superstructure and removable
prosthesis are planned. For example, when the patient has abundant bone and implants have already been
placed, the lack of crown height space may not permit a removable prosthesis. Too often, treatment plans for
completely edentulous patients consist of a maxillary denture and a mandibular over denture with two
implants. However, in the long term, this treatment option may prove a disservice to the patient.
The maxillary arch will continue to lose bone, and the bone loss may even be accelerated in the
premaxilla. Once this dimension is lost, the patient will have much more difficulty with retention and stability
of the restoration. In addition, the lack of posterior implant support in the mandible will allow posterior bone
loss to continue. Paresthesia, facial changes, and reduced posterior occlusion on the maxillary prosthesis are
to be expected. The doctor should diagnose the amount of bone loss and its consequences on facial esthetics,
function, and the psychological and overall health.
Patients should be made aware of future compromises in bone loss and its associated problems with
minimal treatment options, which do not address the continued loss of bone in regions where implants are
not inserted. It is even more important to visualize the final restoration at the onset with a fixed-implant
restoration.
After this first important step, the individual areas of ideal or key abutment support are determined to
assess whether it is possible to place the implants to support the intended prosthesis. The patient's force
factors and bone density in the region of implant support are evaluated. The additional implants to support
the expected forces on the prosthesis designed may then be determined with implant size and design selected
to match force and area conditions. Only then is the available bone evaluated to assess whether it is possible
to place the implants to support the intended prosthesis.
In inadequate natural or implant abutment situations, the existing oral conditions or the needs and
desires of the patient must be altered. In other words, either the mouth must be modified by augmentation to
place implants in the correct anatomical positions, or the mind of the patient must be modified to accept a
different prosthesis type and its limitations.
A fixed-implant restoration may be indicated for either the partially or the completely edentulous
patient. The psychological advantage of fixed teeth is a major benefit, and edentulous patients often feel the
implant teeth are better than their own. The improvement over their removable restoration is significant. The
completely implant-supported over denture requires the same number of implants as a fixed implant
13

restoration. Thus the cost of implant surgery may be similar for fixed or removable restorations. Fixed
prostheses often last longer than over dentures, Because Advantages of Fixed Restorations in the Partially
Edentulous Patient
1. Psychological (feels more like natural teeth
2. Less food entrapment
3. Less maintenance (no attachments to change or adjust)
4. Longevity (lasts the life of the implants)
5. Similar overhead cost as completely implant-supported overdentures
Prosthodontic Classification
1. TYPE FP-1 Fixed prosthesis; replaces the crown and a portion of the root; Crown contour appears
normal in the occlusal half but is elongated or hypercontoured in the gingival half Fixed prosthesis;
Replaces missing crowns and gingival color and portion of the edentulous site; prosthesis most often uses
denture teeth and acrylic gingiva, but may be porcelain to metal Removable prosthesis; Over denture
supported completely by implant Removable prosthesis; Over denture supported by both soft tissue and
implant From Misch CE: Bone classification training keys, Dent Today 8:39-44, 1989.
FP-2 FP-3 RP-4 RP-5 DEFINITION
Fixed prosthesis; replaces only the crown; looks like a natural tooth attachments do not require
replacement and acrylic denture teeth wear faster than porcelain to metal. The chance of food entrapment
under a removable over denture is often greater than for a fixed restoration, as soft tissue extensions and
support are often required in the latter. The laboratory fees for a fixed prosthesis may be similar to a bar,
coping attachments, and over denture. Because the denture or partial denture fees are much less than fixed
prostheses, many clinicians charge the patient a much lower fee for removable over dentures on implants. Yet
chair time and laboratory fees are often similar for fixed or removable restorations that are completely
implant supported. One should consider increasing the patient fees for over dentures to a level more in line
with fixed restorations.
PARTIALLY EDENTULOUS PROSTHESIS DESIGN
A common axiom in traditional prosthodontics for partial edentulism is to provide a fixed partial
denture whenever applicable . The fewer natural teeth missing, the better the indication for a fixed partial
denture. This axiom also applies to implant prostheses in the partially edentulous patient. Ideally, the fixed
partial denture is completely implant supported rather than joining implants to teeth. This concept leads to
14

the use of more implants in the treatment plan. Although this may be a cost disadvantage, it is outweighed by
significant intra oral health benefits.
The added implants in the edentulous site result in fewer pontics, more retentive units in the
restoration, and less stress to the supporting bone. As a result, complications are minimized and implant and
prosthesis longevity are increased.
PROSTHETIC OPTIONS
In 1989, Misch proposed five prosthetic options for implant dentistry. The first three options are fixed
prostheses (FPS). These three options may replace partial (one tooth or several) or total dentitions and may be
cemented or screw retained. They are used to communicate the appearance of the final prosthesis to all the
implant team members. These options depend on the amount of hard and soft tissue structures replaced and
the aspects of the prosthesis in the esthetic zone. Common to all fixed options is the inability of the patient to
remove the prosthesis. Two types of final implant restorations are removable prostheses (RPs); they depend
on the amount of implant support, not the appearance of the prosthesis.
Fixed Prostheses FP-1 An FP-1 is a fixed restoration and appears to the patient to replace only the
anatomical crowns of the missing natural teeth. To fabricate this restoration type, there must be minimal loss
of hard and soft tissues. The volume and position of the residual bone must permit ideal placement of the
implant in a location similar to the root of a natural tooth. The final restoration appears very similar in size and
contour to most traditional fixed prostheses used to restore or replace natural crowns of teeth . The FP-1
prosthesis is most often desired in the maxillary anterior region, especially in the esthetic zone during smiling
or speaking.
The final FP-1 restoration appears to the patient to be similar to a crown on a natural tooth. However,
the implant abutment can rarely be treated exactly as a natural tooth prepared for a full crown. The cervical
diameter of a maxillary central incisor is approximately 6.5 mm with an oval to triangular cross section.
However, the implant abutment is usually 4 mm in diameter and round in cross section. In addition, the
placement of the implant rarely corresponds exactly to the crown-root position of the original tooth.
The thin labial bone lying over the facial aspect of a maxillary anterior root remodels after tooth loss
and the crest width shifts to the palate, decreasing 40% within the first 2 years." The occlusal table is also
usually modified in unesthetic regions to conform to the implant size and position and to direct vertical forces
to the implant body. For example, posterior mandibular implant-supported prostheses have narrower occlusal
tables at the expense of the buccal contour, because the implant is smaller in diameter and placed in the
central fossa region of the tooth. Because the width or height of the crestal bone is frequently lacking after the
loss of multiple adjacent natural teeth, bone augmentation is often required before implant placement to
achieve natural-looking crowns in the cervical region .
15

There are no inter dental papillae in edentulous ridges; therefore soft tissue augmentation also is often
required to improve the inter-proximal gingival contour. Ignoring this step causes open "black" triangular
spaces (where papillae should usually be present) when the patient smiles. FP-1 prostheses are especially
difficult to achieve when more than two adjacent teeth are missing. The bone loss and lack of interdental soft
tissue complicate the final esthetic result, especially in the cervical region of the crowns. The restorative
material of choice for an FP-1 prosthesis is porcelain to noble-metal alloy. A noble-metal substructure can
easily be separated and soldered in case of a non-passive fit at the metal try-in, and noble metals in contact
with implants corrode less than non-precious alloys. Any history of exudate around a subgingival basemetal
margin will dramatically increase the corrosion effect between the implant and the base metal.
A single tooth FP-1 crown may use aluminum oxide cores and porcelain crowns, or ceramic abutments
and porcelain crowns. However, the risk of fracture may increase with the latter scenario, as impact forces are
greater on implants than natural teeth.
Fixed Prostheses 2
The FP-2 fixed prosthesis appears to restore the anatomical crown and a portion of the root of the
natural tooth. The volume and topography of the available bone is more apical compared with the ideal bone
position of a natural root (1 to 2 mm below the cement-enamel junction) and dictate a more apical implant
placement compared with the FP-1 prosthesis. As a result, the incisal edge is in the correct position, but the
gingival third of the crown is over extended, usually apical and lingual to the position of the original tooth.
These restorations are similar to teeth exhibiting periodontal bone loss and gingival recession.
The patient and the clinician should be aware from the onset of treatment that the final prosthetic
teeth will appear longer than healthy natural teeth (without bone loss). The esthetic zone of a patient is
established during smiling in the maxillary arch and during speech of sibilant sounds for the mandibular arch.
If the high lip line during smiling or the low lip line during speech do not display the cervical regions, the longer
teeth are usually of no esthetic consequence, provided that the patient has been informed before treatment.
As the patient becomes older, the maxillary esthetic zone is altered. Only 10% of younger patients do
not show any soft tissue during smiling, whereas 30% of 60 year olds and 50% of 80 year olds do not display
gingival regions during smiling. The low lip position during speech is not affected as much as the high smile line.
Only 10% of older patients show the mandibular soft tissue during speech. A multiple-unit FP-2 restoration
does not require as specific an implant position in the mesial or distal position because the cervical contour is
not displayed during function.
The implant position may be chosen in relation to bone width, angulation, or hygienic considerations
rather than purely esthetic demands (as compared with the FP-1 prosthesis). On occasion, the implant may
even be placed in an embrasure between two teeth. This often occurs for mandibular anterior teeth for full-
arch fixed restorations. If this occurs, the most esthetic area usually requires the incisal two thirds of the two
16

crowns to be ideal in width, as though the implant were not present . Only the cervical region is compromised.
Although the implant is not positioned in an ideal mesiodistal position, it should be placed in the correct facial-
lingual position to ensure that contour, hygiene, and direction of forces are not compromised. The material of
choice for an FP-2 prosthesis is precious metal to porcelain. The amount and contour of the metal work is
different than for a FP-1 restoration and is more relevant in an FP-2 prosthesis, because the amount of
additional volume of tooth replacement increases the risk of unsupported porcelain in the final prosthesis,
when the metal work is under contoured.
Fixed Prostheses-3
The FP-3 fixed restoration appears to replace the natural teeth crowns and has pink-colored
restorative materials to replace a portion of the soft tissue. As with the FP 2 prosthesis, the original available
bone height has decreased by natural resorption or osteoplasty at the time of implant placement. To place the
incisal edge of the teeth in proper position for esthetics, function, lip support, and speech, the excessive
vertical dimension to be restored requires teeth that are unnatural in length. However, unlike the FP-2
prosthesis, the patient may have a normal to high maxillary lip line during smiling or a low mandibular lip line
during speech.
The ideal high smile line displays the interdental papilla of the maxillary anterior teeth but not the soft
tissue above the midcervical regions. Approximately 7% of males and 14% of females have a high smile or
"gummy" smile and display more than 2 mm of gingival above the free gingival margin of the teeth. The
patient may also have greater esthetic demands even when the teeth are out of the esthetic smile and speech
zones. Patients complain that the display of longer teeth appears unnatural even though they must lift or
move their lips in unnatural positions to see the covered regions of the teeth.
As a result of the restored gingival color of the FP-3, the teeth have a more natural appearance in size
and shape and the pink restorative material mimics the interdental papillae and cervical emergence region.
The addition of gingival-tone acrylic or porcelain for a more natural fixed prosthesis appearance is often
indicated with multiple implant abutments because bone loss is common with these conditions.
There are basically two approaches for an FP-3 prosthesis:
(1) a hybrid restoration of denture teeth and acrylic and metal substructure's or
(2) A porcelain metal restoration
The primary factor that determines the restoration material is the amount of crown height space. An
excessive crown height space means a traditional porcelain-metal restoration will have a large amount of
metal in the substructure, so the porcelain thickness will not be greater than 2-mm thick. Otherwise there is
an increase in porcelain fracture. Precious metals are indicated for implant restorations to decrease the risk of
17

corrosion and improve the accuracy of the casting, as non precious metals shrink more during the casing
process. However, the large amount of metal in the substructure acts as a heat sink and complicates the
application of porcelain during the fabrication of the prosthesis.
In addition, as the metal cools after casting, the thinner regions of metal cool first and create porosities
in the structure. This may lead to fracture of the framework after loading. Furthermore when the casting is
reinserted into the oven to bake the porcelain, the heat is maintained within the casting at different rates,
thus the porcelain cool-down rate is variable, which increases the risk of porcelain fracture. In addition, the
amount of precious metal in the casting adds to the weight and cost of the restoration. An FP-3 porcelain-to-
metal restoration is more difficult to fabricate for the laboratory technician than an FP-2 prosthesis. The pink
porcelain is harder to make appear as soft tissue and usually requires more baking cycles. This increases the
risk of porosity or porcelain fracture.
An alternative to the traditional porcelain-metal fixed prosthesis is a hybrid restoration . This

restoration design uses a smaller metal framework, with denture teeth and acrylic to join these elements
together. This restoration is less expensive to fabricate and is highly esthetic because of the premade denture
teeth and acrylic pink soft tissue replacements. In addition, the intermediary acrylic between the denture
teeth and framework may reduce the impact force of dynamic occlusal loads. The hybrid prosthesis is easier to
repair in porcelain fracture, as the denture tooth may be replaced with less risk than adding porcelain to a
traditional porcelain-metal restoration. However, the fatigue of acrylic is greater than the traditional
prosthesis; therefore repair of the restoration is more commonly needed.
The crown height space determination for a hybrid versus the traditional porcelain-metal restoration is
15 mm from the bone to the occlusal plane. When less than this dimension is available, a porcelain-tometal
restoration is suggested. When a greater crown height space is present, a hybrid restoration is often
fabricated. Implants placed too facial, lingual, or in embrasures are easier to restore when vertical bone has
been lost and an FP-2 or FP-3 prosthesis is fabricated, because even extremely high smile lip lines do not
expose the implant abutments.
The greater crown heights allow the correction of incisal edge positions. However, the FP-2 or FP-3
restoration has greater crown height compared with the FP-1 fixed types of prostheses; therefore a greater
moment of force is placed on the implant cervical regions, especially during lateral forces (e.g., mandibular
excursions or with cantilevered restorations). As a result, additional implant abutments or shorter cantilever
lengths should be considered with these restorations. An FP-2 or FP-3 prosthesis rarely has the patient's
interdental papillae or ideal soft tissue contours around the emergence of the crowns, because these
restorations are used when there is more crown height space and the lip does not expose the soft tissue
regions of the patient. In the maxillary arch, wide open embrasures between the implants may cause food
impaction or speech problems.
18

These complications may be solved by using a removable soft tissue replacement device or making
over contoured cervical restorations. The maxillary FP-2 or the FP-3 prosthesis is often extended or juxtaposed
to the maxillary soft tissue so that speech is not impaired. Hygiene is more difficult to control, although access
next to each implant abutment is provided. The mandibular restoration may be left above the tissue, similar to
a sanitary pontic. This facilitates oral hygiene in the mandible, especially when the implant permucosal site is
level with the floor of the mouth and the depth of the vestibule. However, if the space below the restoration is
too great, the lower lip may lack support in the labiomental region.
Removable Prosthesis
There are two kinds of removable prostheses, based upon support of the restoration . Patients are able
to remove the restoration, but not the implant supported superstructure attached to the abutments. The
difference in the two categories of removable restorations is not in appearance (as it is in the fixed categories).
Instead, the two removable categories are determined by the amount of implant support. The most common
removable implant prostheses are over dentures for completely edentulous patients. Traditional removable
partial dentures with clasps on implant abutment crowns have not been reported in the literature with any
frequency. No long-term or short-term studies are currently available.
On the other hand, complete removable over dentures have often been reported with predictability.
As a result, the removable prosthetic options are primarily over dentures for the completely edentulous
patient. RP-4 is a removable prosthesis completely supported by the implants, teeth, or both. The restoration
is rigid when inserted: over denture attachments usually connect the removable prosthesis to a low-profile
tissue bar or superstructure that splints the implant abutments.
Usually five or six implants in the mandible and six to eight implants in the maxilla are required to
fabricate completely implant-supported RP-4 prostheses in patients with favorable dental criteria . The
implant placement criteria for an RP-4 prosthesis is different than that for a fixed prosthesis. Denture teeth
more acrylic are required for the removable restoration. In addition, a superstructure and over denture
attachments must be added to the implant abutments. This requires a more lingual and apical implant
placement in comparison with the implant position for a fixed prosthesis. The implants in an RP-4 prosthesis
(and an FP-2 or FP-3 restoration) should be placed in the mesiodistal position for the best biomechanical and
hygienic situation.
On occasion, the position of an attachment on the superstructure or prosthesis may also affect the
amount of spacing between the implants. For example, a Hader clip requires the implant spacing to be greater
than 6 mm from edge to edge, and as a consequence reduces the number of implants that may be placed
between the mental for-amen. The RP-4 prosthesis may have the same appearance as an FP-1, FP2, or FP-3
restoration. A porcelain-to-metal prosthesis with attachments in selected abutment crowns can be fabricated
for patients with the cosmetic desire of a fixed prosthesis.
19

The over denture attachments permit improved oral hygiene or allow the patient to sleep without the
excess forces of nocturnal bruxism on the prosthesis.
RP-5
RP-5 is a removable prosthesis combining implant and soft tissue support. The amount of implant
support is variable. The completely edentulous mandibular over denture may have:
(1) two anterior implants independent of each other;
(2) splinted implants in the canine region to enhance retention;
(3) three splinted implants in the premolar and central incisor areas to provide lateral stability; or
(4) implants splinted with a cantilevered bar to reduce soft tissue abrasions and to limit the amount of
soft tissue coverage needed for prosthesis support.
The primary advantage of an RP-5 restoration is the reduced cost. The prosthesis is very similar to
traditional over dentures supported by natural teeth. A preimplant treatment denture may be fabricated to
ensure the patient's satisfaction. This technique is especially indicated for patients with demanding needs and
desires regarding the final esthetic result. The implant dentist can also use the treatment denture as a guide
for implant placement. The patient can wear the prosthesis during the healing stage. After the implants are
uncovered, the superstructure is fabricated within the guidelines of the existing treatment restoration.
Once this is achieved, the pre-implant treatment prosthesis may be converted to the RP-4 or RP-5
restoration. The clinician and the patient should realize that the bone will continue to resorb in the soft tissue-
borne regions of the prosthesis. Relines and occlusal adjustments every few years are common maintenance
requirements of an RP-5 restoration. Bone resorption with RP-5 restorations may occur two to three times
faster than the resorption found with full dentures. This can be a factor when considering this type of
treatment in young patients, despite the lesser cost and low failure rate.
20

Implant dentistry Traditional dentistry fixed-implant restoration
The amount of crown height space Prosthesis RP5-Removable prosthesis
Bone Augmentation hybrid restoration Healing stage
FP-1 Fixed prosthesis
___________1. What is a similar to all aspects of medicine in that treatment begins with a diagnosis of the
patient's condition?
___________2. It may be indicated for either the partially or the completely edentulous patient.
___________3. When ca a patient wear the prosthesis?
___________4. It is a type of fixed restoration and appears to the patient to replace only the anatomical
crowns of the missing natural teeth.
___________5. It provides limited treatment options for the edentulous patient.
___________6. What primary factor that determines the restoration material?
___________7. It affects the final prosthetic design.
___________8. What is an alternative to the traditional porcelain-metal fixed prosthesis?
___________9. What is a removable prosthesis combining implant and soft tissue support. The amount of
implant support is variable?
__________10. It can be removed at night to manage nocturnal para-function.
21

1. What design is directly related to the existing oral condition?
A. Prosthetic design B. Removable restoration C. Restoration design
D. Fixed-implant Restoration
2. What is often determined after the position and number of implants were selected?
A. Implant B. Prosthesis C. Final Restoration
D. Bone Augmentation
3. What dimension is lost, when the patient will have much more difficulty with retention and stability of
the restoration?
A. maxilla B. mandibullar arch C. mandible D. maxillary arch
4. What is the advantage of fixed-implant restoration?
A. Psychological (feels more like natural teeth)

B. Less food entrapment, less maintence (no attachments to change of adjust)
C. Longevity
D. All of the above
5. What type of prosthesis replaces the crown and a portion of the root?
A.Type FP-1 B. Type FP-2 C. Type FP-3 D. Type FP-4
6. The denture or partial denture fees are much less than;
A. Restoration B. Prosthesis C. Fixed prosthesis D. Fixed implant
7. What is an alternative to the traditional porcelain-metal fixed prosthesis?
A. Hybrid restoration B. fixed restoration C. Final restoration D. Restoration
8. The completely edentulous mandibular over denture may have, EXCEPT one;
A. Two anterior implants dependent of each other

B. Three splinted implants in the molars
22

C. Splinted implants in the canine region to enhance retention

D. Three splinted implants in the premolar and central incisor areas to provide lateral stability
9. It appears to replace the natural teeth crowns and has pink-colored restorative materials to replace a
portion of the soft tissue.
A. FP 1 B. FP 2 C. FP 3 D. FP 5
10. What are the two approaches for an FP-3 prosthesis?
A. a hybrid restoration of denture teeth and acrylic and metal substructure's
B. A porcelain metal restoration
C. Full-arch fixed restorations
D. Apical and lingual to the position of the teeth.
23


1. What is very similar to traditional over dentures

supported by natural teeth?
2. It has greater crown height compared with the FP-1
fixed types of prostheses
3. What primary factor that determines the restoration
material?
4. Who proposed five prosthetic options for implant
dentistry?
5. What is similar to all aspects of medicine in that treatm
ent begins with a diagnosis of the patient's condition
SCORE:
24

C. LESSON WRAP-UP

A. Work Tracker
completed.
FAQs
-
1. What is Dental Implant restoration?
Answer: Dental implant restoration is a procedure that creates an artificial tooth to replace a missing
one. The process involves attaching this tooth to an implanted root that fuses with bone over a period.
2. Can implants be done in one day?
Answers: During the all on 4 procedure, a dentist can place implants and attach a temporary denture to
them in a single day. A permanent denture is attached a few months later. For other implant procedures, there
is usually a healing period of a few months after the placement surgery before any restorations are attached.
25

KEY TO CORRECTIONS

Answer Key:
1. C 2. B 3. D 4. D 5. A 6. C 7. A 8. B 9. C 10. B
Answer Key:
1. What is similar to traditional over dentures supported Prosthesis

by natural teeth?
2. It has greater crown height compared with the FP-1
fixed types of prostheses. FP-2 or FP-3 Restoration
3. What primary factor that determines the restoration
material? The amount of crown height space
4. Who proposed five prosthetic options for implant
dentistry? Misch
5. What is similar to all aspects of medicine in that
treatment begins with a diagnosis of the patient's Implant Dentistry
condition
SCORE:
26


Prepared by:

27

Lesson title: Bone Density Materials:

Pen, pencil and highlighter
Lesson Objectives: At the end of this module, you should be able to: References:
1. Classify the different bone density and appreciate its importance Contemporary of Implant
and how it contributes to the success of dental implant treatment. Dentistry. 3rd Edition.
2. Know the different treatment management approach based and Carl E. Misch
related to the density of the bone available.
Productivity Tip:”Be an individual, work hard, study, get your mind straight and trust nobody”
A bone density test determines if you have osteoporosis — a disorder characterized by bones that
are more fragile and more likely to break.
The test uses X-rays to measure how many grams of calcium and other bone minerals are packed
into a segment of bone. The bones that are most commonly tested are in the spine, hip and
sometimes the forearm.

of this module.

1. Who observed that 78% of all
reported implant failures were in
soft bone types.
2.What is an organ that is able to
change in relation to a number of
factors, including hormones, vitamins,
and mechanical influences.
3.What condition is more common

in older women ?
11

B.MAIN LESSON
Available bone is particularly important in implant dentistry and describes the external
architecture or volume of the edentulous area considered for implants. Historically, the available bone
was not modified in the implant candidate. Instead, the existing bone volume was the primary factor
used to develop a treatment plan. Short implants and fewer implants were used in less available bone
and long implants in greater numbers were inserted in larger bone volumes.
Today, the treatment plan first considers the final prosthesis options. The patient force factors are
then noted. The next consideration is the bone density in the sites of the implant abutments. The
internal structure of bone is described in terms of quality or density, which reflects a number of
biomechanical properties, such as strength and modulus of elasticity. The external and internal
architecture of bone controls virtually every facet of the practice of implant dentistry. The density of
available bone in an edentulous site is a determining factor in treatment planning, implant design,
surgical approach, healing time, and initial progressive bone loading during prosthetic reconstruction.
This chapter presents the aspects of bone density related to overall planning of an implant prosthesis.
INFLUENCE OF BONE DENSITY ON IMPLANT SUCCESS RATES
The quality of bone is often dependent upon the arch position. The most dense bone is usually
observed in the anterior mandible, followed by the anterior maxilla and posterior mandible, and the
least dense bone is typically found in the posterior maxilla. Following a standard surgical and
prosthetic protocol,
Adell et al reported an approximately 10% greater success rate in the anterior mandible as
compared with the anterior maxilla. Schnitman et al also noted lower success rates in the posterior
mandible as compared with the anterior mandible when the same protocol was followed. The highest
clinical failure rates have been reported in the, posterior maxilla, where the force magnitude is greater.
A range of implant and the bone density is poorer." survival has been found relative to arch location.
In addition to arch location, several independent groups have reported different failure rates related to
the quality of the bone.Engquist et al observed that 78% of all reported implant failures were in soft
bone types. Friberg et al observed that 66% of their group's implant failures occurred in the resorbed
maxilla with soft bone. Jaffin and Berman, in a 5-year study, reported a 44% implant failure when
poor-density bone was observed in the maxilla. The article documented a 35% implant loss in any
region of the mouth when bone density was poor. Fifty-five percent of all implant failures within their
study sample occurred in the soft bone type. Johns et al. reported 3% failure of implants in
moderate bone densities, but a 28% implant failure in the poorest bone type. Smedberg et al
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reported a 36% failure rate in the poorest bone density. The reduced implant survival most often is
more related to bone density than arch location. In a 15-year follow-up study. Snauwaert et al
reported early annual and late failures were more frequently found in the maxilla. Hermann et al 13
found implant failures were strongly correlated to patient factors, including bone quality, especially
when coupled with poor bone volume (65% of these patients experienced failure).
These reported failures are not primarily related to surgery healing, but instead occur after
prosthetic loading. Therefore, over the years, many independent clinical groups, following a
standardized surgical protocol, documented the indisputable influence of bone density on clinical
success . However, a protocol established by the author, which adapts the treatment plan, implant
selection, surgical approach, healing regimen, and initial prosthetic loading has resulted in similar
implant success rates in all bone densities and all arch positions. This chapter proposes a scientific
rationale for the modification of a treatment plan in function of implant density to achieve comparable
success rates in all bone types.
ETIOLOGY OF VARIABLE BONE DENSITY
Bone is an organ that is able to change in relation to a number of factors, including hormones,
vitamins, and mechanical influences. However, biomechanical parameters, such as duration of
edentulous state, are predominant. Awareness of this adaptability has been reported for more than a
century.
In 1887, Meier qualitatively described the architecture of trabecular bone in the femur. In 1888,
Kulmann noticed the similarity between the pattern of trabecular bone in the femur and tension
trajectories in construction beams. Wolff, in 1892, further elaborated on these concepts and
published, "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. "
The modified function of bone and the definite changes in the internal and external formation of
the vertebral skeleton as influenced by mechanical load were reported by Murry. Therefore the
external architecture of bone changes in relation to function, and the internal bony structure is also
modified. Mac Millan and Parfitt have reported on the structural characteristics and variation of
trabeculae in the alveolar regions of the jaws. For example, the maxilla and mandible have different
biomechanical functions. The mandible, as an independent structure, is designed as a force-
absorption unit. Therefore, when teeth are present, the outer cortical bone is denser and thicker and
the trabecular bone is more coarse and dense. On the other hand, the maxilla is a force unit. Any
strain to the maxilla is transferred by the zygomatic arch and palate away from the brain and orbit. As
a consequence, the maxilla has a thin cortical plate and fine trabecular bone supporting the teeth.
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They also noted that the bone is most dense around the teeth (cribriform plate) and more dense
around the teeth at the crest, compared with the regions around the apices .
Alveolar bone resorption associated with orthodontic therapy also illustrates the
biomechanical sensitivity of the alveolar processes. 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.
Bone density in the jaws also decreases after tooth loss. This loss is primarily related to the
length of time the region has been edentulous and not loaded appropriately, the initial density of the
bone, flexure and torsion in the mandible, and parafunction before and after tooth loss. In general, the
density change after tooth loss is greatest in the posterior maxilla and least in the anterior mandible.
Cortical and trabecular bone throughout the body are remodeling constantly modified by either
modeling or Modeling has independent sites of formation and resorption and results in the change of
the shape of 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, including that region where teeth are
lost or the bone next to an endosteal implant. These adaptive phenomena have been associated with
the alteration the mechanical stress and strain environment within the host bone. Stress is
determined by the magnitude of force divided by the functional area over which it is applied. Strain is
defined as the change in length of a material divided by the original length. The greater the magnitude
of stress applied to the bone, the greater the strain observed in the bone. Bone modeling and
remodeling are primarily controlled, in part or whole by the mechanical environment of strain. Overall,
the density of alveolar bone evolves as a result of mechanical deformation from micro strain.
Frost proposed a model of four histologic patterns for compact bone as it relates to
mechanical adaptation to strain. The pathologic overload zone, mild overload zone, adapted window,
and acute disuse window were described for bone in relation to the amount of the microstrain
experienced. These four categories also may be used to describe the trabecular bone response in the
jaws. The bone in the acute disuse window loses mineral density, and disuse atrophy occurs because
modeling for new bone is inhibited and remodeling is stimulated, with a gradual net loss of bone.
The micro strain of bone for trivial loading is reported to be 0 to 50 micro strain. This
phenomenon may occur throughout the skeletal system, as evidenced by a 15% decrease in the
cortical plate and extensive trabecular bone loss consequent to immobilized limbs for 3 months.
A cortical bone density decrease of 40% and a trabecular bone density decrease of 12%
also have been reported with disuse of bone . Interestingly, bone loss similar to disuse atrophy has
14

been associated with micro gravity environments in outer space, because the micro strain in bone
resulting from the earth's gravity is not present in the "weightless" environment of space." In fact, an
astronaut aboard the Russian Mir space station for 111 days lost nearly 12% of his bone minerals.
The adapted window (50 to 1500 micro strain) represents an equilibrium of modeling and remodeling,
and bone conditions are maintained at this level. Bone in this strain environment remains in a steady
state, and this may be considered the homeostatic window of health.
The histologic description of this bone is primarily lamellar or load-bearing bone. Approximately
18% of trabecular bone and 2% to 5% of cortical bone is remodeled each year in the physiologic
loading zone, which corresponds to the adapted window. This is the range of strain ideally desired
around an endosteal implant, once a stress equilibrium has been established . Bone turn over is
required in the adapted window, as Mori and Burr provide evidence of remodeling in regions of bone
micro fracture from fatigue damage within the physiologic range. The mild overload zone (1500 to
3000 micro strain) causes a greater rate of fatigue micro fracture and increase in the cellular turnover
rate of bone. As a result, the bone strength and density may eventually decrease.
The histologic description of bone in this range is usually woven or repair bone. This may be
the state for bone when an endosteal implant is overloaded and the bone interface attempts to
change the strain environment. During the repair process, the woven bone is weaker 40 than the
more mature, mineralized lamellar bone. Therefore, while bone is loaded in the mild overload zone,
care must be taken because the "safety range" for bone strength is reduced during the repair.
Pathologic overload zones are reached when microstrains are greater than 3000 units.
Cortical bone fractures occur at 10,000 to 20,000 micro strain (1% to 2% deformation).
Therefore pathologic overload may begin at micro strain levels of only 20% to 40% of the ultimate
strength or physical fracture of cortical bone. The bone may resorb and form fibrous tissue, or when
present, repair woven bone in this zone, as a sustained turnover rate is necessary. The marginal
bone loss evidenced during implant overloading maybe a result of the bone in the pathologic overload
zone. Implant failure from overload may also be a result of bone in the pathologic overload zone.
BONE CLASSIFICATION SCHEMES RELATED TO IMPLANT DENTISTRY
An appreciation of bone density and its relation to oral implantology has existed for more than
25 years. Linkow, in 1970, classified bone density into three categories :
Class I bone structure: This ideal bone type consists of evenly spaced trabeculae with small
cancellated spaces.
Class II bone structure: The bone has slightly larger cancellated spaces with less uniformity
of the osseous pattern.
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Class III bone structure: Large marrow-filled spaces exist between bone trabeculae. Linkow
stated that Class III bone results in a loose-fitting implant; Class II bone was satisfactory for implants;
and Class I bone was the most ideal foundation for implant prostheses.
In 1985, Lekholm and Zarb listed four bone qualities found in the anterior regions of the
jawbone.
Quality 1 was composed of homogeneous compact bone.
Quality 2 had a thick layer of compact bone surrounding a core of dense trabecular bone.
Quality 3 had a thin layer of cortical bone surrounding dense trabecular bone of favorable
strength.
Quality 4 had a thin layer of cortical bone surrounding a core of low density trabecular bone.
Irrespective of the different bone qualities, all bone was treated with the same implant design and
standard surgical and prosthetic protocol. Following this protocol. Schnitman and others observed a
10% difference in implant survival between Quality 2 and Quality 3 bone, and 22% lower survival in
the poorest bone density. Johns et al. reported 3% failure in Type III bone, but 28% in Type IV
bone.Smedberg et al. reported a 36% failure rate in Type IV bone. Higuchi and others also
experienced a greater failure in the soft bone of the maxilla.
It is obvious that a standardized surgical, prosthetic, and implant design protocol does not yield
similar results in all bone densities. In addition, these reports are for implant survival, not the quality of
health of surviving implants. The amount of crestal bone loss also has been related to bone
density,and further supports a different protocol for soft bone. In 1988, Misch proposed four bone
density groups independent of the regions of the jaws, based on macroscopic cortical and trabecular
bone characteristics.
The regions of the jaws with similar densities were often consistent. Suggested treatment
plans, implant design, surgical protocol, healing, and progressive loading time spans have been
described for each bone density type. Following this regimen, similar implant survival rates have been
observed for all bone densities,
MISCH BONE DENSITY CLASSIFICATION
Dense or porous cortical bone is found on the outer surfaces of bone and includes the crest
of an edentulous ridge. Coarse and fine trabecular bone types are found within the outer shell of
cortical bone and occasionally on the crestal surface of an edentulous residual ridge. These four
macroscopic structures of bone may be arranged from the least dense to the most dense, as first
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described by Roberts and Frost . In combination, these four increasing macroscopic densities
constitute four bone categories described by Misch (D1, D2, D3, and D4) located in the
edentulous areas of the maxilla and mandible . The regional locations of the different densities of
cortical bone are more consistent than the highly variable trabecular bone.
D1 bone is primarily dense cortical bone.
D2 bone has dense-to-porous cortical bone on the crest and, within the bone, has coarse
trabecular bone.
D3 bone types have a thinner porous cortical crest and fine trabecular bone in the region next
to the implant.
D4 bone has almost no crestal cortical bone.
The fine trabecular bone composes almost all of the total volume of bone next to the implant .
A very soft bone, with incomplete mineralization and large intertrabecular spaces, may be addressed
as D5 bone. This bone type is most often immature bone in a developing sinus graft. The bone
density may be determined by tactile sense during surgery, the general location, or radiographic
evaluation.
BONE DENSITY LOCATION
A review of the literature and a survey of completely and partially edentulous patients post
surgery indicated that the location of different bone densities often may be superimposed on the
different regions of the mouth. D1 bone is almost never observed in the maxilla and is rarely observed
in most mandibles. In the mandible, D1 bone is observed approximately 6% of the time in the Division
A anterior mandible and 3% of the time in the posterior mandible, primarily when the implant is
engaging the lingual cortical plate of bone. In a C-h bone volume (moderate atrophy) in the anterior
mandible, the prevalence of D1 bone approaches 25% in males. The C-h mandible often exhibits an
increase in torsion, flexure, or both in the anterior segment between the foramina during function.
This increased strain may cause the bone to increase in density. D1 bone also may be
encountered in the anterior Division A mandible of a Kennedy Class IV partially edentulous patient
with a history of parafunction and recent extractions. It may also be observed in the anterior or
posterior mandible when the angulation of the implant may require the engagement of the lingual
cortical plate. The bone density D2 is the most common bone density observed in the mandible . The
anterior mandible consists of D2 bone approximately two thirds of the time. Almost half of patients
have D2 bone in the posterior mandible.
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The maxilla presents D2 bone less often than the mandible. Approximately one fourth of
patients have D2 bone, and this is more likely in the partially edentulous patient's anterior and
premolar region, rather than the completely edentulous posterior molar areas. Single-tooth or two-
tooth, partially edentulous spans in either arch almost always have D2 bone. Bone density D3 is very
common in the maxilla . More than half the patients have D3 bone in the upper arch. The anterior
edentulous maxilla has D3 bone about 75% of the time, whereas almost half the patients have
posterior maxillae with D3 bone (more often in the premolar region). Almost half of the posterior
mandibles also present with D3 bone, whereas approximately 25% of the anterior edentulous
mandibles have D3 bone. The softest bone, D4, is most often found in the posterior maxilla
(approximately 40%), especially in the molar regions or after a sinus graft augmentation (where
almost two thirds of the patients have D4 bone). The anterior maxilla has D4 bone less than 10% of
the time-more often after an onlay iliac crest bone graft.
The mandible presents with D4 bone in less than 3% of the patients. When observed, it is
usually Division A bone in a long-term, completely edentulous patient after an osteoplasty to remove
the crestal bone. Generalizations for treatment planning can be made prudently, based on location.
The bone density by location method is the first way the dentist can estimate the bone density in the
implant sites to develop an initial treatment plan. 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, the posterior maxilla as D4 bone, the
anterior mandible as D2 bone, and the posterior mandible as D3 bone. A more accurate
determination of bone density is made with computerized tomograms before surgery or tactilely
during implant surgery.
RADIOGRAPHIC BONE DENSITY
Periapical or panoramic radiographs are not very beneficial to determine bone density,
because the lateral cortical plates often obscure the trabecular bone density. In addition, the more
subtle changes of D2 to D3 cannot be quantified by these radiographs. Therefore the initial treatment
plan, which often begins with these radiographs, follows the bone density by location method. Bone
density may be more precisely determined by tomographic radiographs, especially computerized
tomograms. Computed tomography produces axial images of the patient's anatomy, perpendicular to
the long axis of the body.
Each CT axial image has 260,000 pixels, and each pixel has a CT number (Hounsfield unit)
related to the density of the tissues within the CT Determination of Bone Density D1: D2: D3: 850 to
1250 Hounsfield units 350 to 850 Hounsfield units 150 to 350 Hounsfield units D5: <150 Hounsfield
units D4: CT, Computed tomography. CT Determination of Bone Density D1: D2: D3: 850 to 1250
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Hounsfield units 350 to 850 Hounsfield units 150 to 350 Hounsfield units D5: <150 Hounsfield units
D4: CT, Computed tomography in pixel. In general, the higher the CT number, the denser the tissue.
Modern CT scanners can resolve objects less than 0.5 mm apart. In addition, software is available to
electronically position the implant on the CT scan and evaluate to Hounsfield numbers in contact with
the implant. In a retrospective study of CT scan images from implant patients,
Kirkos and Misch established a correlation between CT Hounsfield units and density at the
time of surgery. The Misch bone density classification may be evaluated on the CT images by
correlation to a range of Hounsfield units . The very soft bone observed after some immaterialized
bone grafts may be 50 to 200 units. Even negative numbers, suggestive of fat tissue, have been
observed with the cortical plates of some jaws, including the anterior mandible.
Norton and Gamble also found an overall correlation between subjective bone density scores
of Lekholm and Zarb and the CT values. Several studies correlating torque forces at implant insertion
with preoperative bone density values from CTs have reported similar conclusions. Preoperative CT
scan data of areas that lead to successful and unsuccessful implant placement have been reported.
In the mandible, failed sites exhibited higher Hounsfield numbers than usual. This was correlated with
failure in dense bone, possibly due to the lack of vascularization or overheating during surgery. By
contrast, in the maxilla, the bone density was low for the failed sites, 8 The bone density may be
different near the crest, compared with the apical region where the implant placement is planned.The
most critical region of bone density is the crestal 7 to 10 mm of bone, as this is where most stresses
are applied to an osteointegrated bone-implant interface. Therefore when the bone density varies
from the most crestal to apical region around the implant, the crestal 7 to 10 mm determines the
treatment plan protocol.
BONE DENSITY-TACTILE SENSE
There is a great difference in the tactile sensation during osteotomy preparation in different
bone densities, as the density is directly related to its strength. To communicate more broadly to the
profession relative to the tactile sense of different bone densities, Misch proposed the different
densities of his classification be compared with materials of varying densities. Site preparation and
implant placement in D1 bone is similar to the resistance on a drill preparing an osteotomy in oak or
maple wood. D2 bone is similar to the tactile sensation of drilling into white pine or spruce. D3 bone is
similar to drilling into a compressed balsa wood. D4 bone is similar to drilling into a compressed
Styrofoam or a light balsa wood.
This clinical observation may be correlated to different histomorphometric bone density

determinations. When an implant drill can operate at 2000 to 2500 rpm, it may be difficult to feel the
19

difference between D3 and D4 bone. In D4 bone, the drill may be inserted to the full desired depth
without the drill rotating. In other words, a bone compression rather than extraction process may be
used with the drill. D3 bone is very easy to prepare, but requires the drill to rotate while it is pressed
into position. When this tactile method is the primary site, the surgeon should know how to modify the
treatment plan if this bone density is different than first estimated when developing the treatment plan.
SCIENTIFIC RATIONALE OF A BONE DENSITY-BASED TREATMENT PLAN
Bone Strength and Density Bone is directly related to the strength of bone before micro
fracture.Misch et al. reported on the mechanical properties of trabecular bone in the mandible, using
the Misch density classification. A tenfold difference in bone strength may be observed from D1 to D4
bone. D2 bone exhibited a 47% to 68% greater ultimate compressive strength, compared with D3
bone. In other words, on a scale of 1 to 10, D1 bone is a 9 to 10 relative to strength. D2 bone is a 7 to
8 on this scale. D3 bone is 50% weaker than D2 bone and is a 3 or 4 on the strength scale. D4 bone
is a 1 to 2 and up to 10 times weaker than D1 bone.
Bidez and Misch performed three-dimensional, finite stress analyses on bone volumes of
Division A, B, and C-w patients. Each model reproduced the cortical and trabecular bone material
properties of the four densities described. Clinical failure was mathematically predicted in D4 bone
and some D3 densities under occlusal loads . The bone densities that originally relied on clinical
impression are now fully correlated to quantitative objective values obtained from CT scans and bone
strength measurements. These values can help prevent failure in specific situations of weak densities.
Elastic Modulus and Density The elastic modulus describes the amount of strain (changes in length
divided by the original length) as a result of a particular amount of stress. It is directly related to the
apparent density of bone, The elastic modulus of a material is a value that relates to the stiffness of
the material.
The elastic modulus of bone is more flexible than titanium. When higher stresses are applied
to an implant prosthesis, the titanium has lower strain (change in shape) compared with the bone.
The difference between the two materials may create micro strain conditions of pathologic overload
and cause implant failure. When the stresses applied to the implant are low, the micro strain
difference between titanium and bone is minimized and remains in the adapted window zone,
maintaining load bearing lamellar bone at the interface. Misch et al. found the elastic modulus in the
human jaw to be different for each bone density
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As a result, when a stress is applied to an implant prosthesis in D1 bone, the titanium-D1 bone
interface exhibits very small micro strain difference. In comparison, when the same amount of stress
is applied to an implant in D4 bone, the micro strain difference between titanium and D4 bone is
greater and may be in the pathologic overload zone. As a result, D4 bone is more likely to cause
implant mobility and failure. Several studies using finite element analysis (FEA) models with various
implant designs and bone quality have evaluated the stress/strain distribution in the bone around the
implants. Conclusions agree with the prior study to show the importance of bone.
Bone Density and Bone-Implant Contact Percentage
The initial bone density not only provides mechanical immobilization of the implant during
healing, but after healing also permits distribution and transmission of stresses from the prosthesis to
the implant-bone interface. The mechanical distribution of stress occurs primarily where bone is in
contact with the implant. Open marrow spaces or zones of unorganized fibrous tissue do not permit
controlled force dissipation or micro strain conditions to the local bone cells. Because stress equals
force divided by the area over which the force is applied, the less the area of bone contacting the
implant body, the greater the overall stress, other factors being equal. Therefore the bone-implant
contact percent may influence the amount of stress/strain at the interface. Misch noted in 1990 that
the bone density influences the amount of bone in contact with the implant surface, not only at first
stage surgery, but also at the second stage uncovery and early prosthetic loading.
The bone implant contact (BIC) percentage is significantly greater in cortical bone than in
trabecular bone. The very dense D1 bone of a C-h resorbed anterior mandible or of the lingual
cortical plate of a Division A anterior or posterior mandible provides the highest percentage of bone in
contact with an endosteal implant and may approximate more than 85% BIC , D2 bone, after initial
healing, usually has 65% to 75% BIC , D3 bone typically has 40% to 50% BIC after initial healing .The
sparse trabeculae of the bone often found in the posterior maxilla (D4) offer fewer areas of contact
with the body of the implant. With a machined-surface implant this main approximate less than 30%
BIC and is most related to the implant design and surface condition. Consequently, greater implant
surface area is required to obtain a similar amount of bone-implant contact in soft bone, compared
with a denser bone quality found around an anterior mandibular implant.
Bone Density and Stress Transfer Crestal bone loss and early implant failure after loading
results may occur from excess stress at the implant-bone interface. A range of bone loss has been
observed in implants with similar load conditions. Misch noted in 1990 that part of this phenomenon
may be explained by the evaluation of finite element analysis stress contours in the bone for each
bone density. As a result of the correlation of bone density, elastic modulus bone strength, and bone-
21

implant contact percent, when a load is placed on an implant, the stress contours in the bone are
different for each bone density.
In D1 bone, highest strains are concentrated around the implant near the crest, and the stress
in the region is of lesser magnitude. D2 bone, with the same load, sustains a slightly greater crestal
strain, and the intensity of the stress extends farther apically along the implant body. D4 bone exhibits
the greatest crestal strains, and the magnitude of the stress on the implant proceeds farthest apically
along the implant body . As a result, the magnitude of a prosthetic load may remain similar and yet
give one of the following three different clinical situations at the bone-implant interface, based on
bone density:
(1) physiologic bone loads in the adapted window zone and no marginal bone loss,
(2) mild overload to pathologic overload bone loads and crestal bone loss, or
(3) generalized pathologic overload and implant failure. Therefore, to obtain a similar clinical
result in each implant prosthesis, the variables in each patient must be either eliminated or
accounted for in the treatment plan. As the myriad of variables cannot be eliminated relative to
bone density, the treatment plans (including implant number, size, and design) should be
modified.
TREATMENT PLANNING
When a patient is first examined, the most common radio graphic evaluation is with a
panoramic radio graph, The initial treatment plan is presented to the patient using the anatomical
location as an index of the bone density: anterior mandible and single tooth replacement is D2,
anterior maxilla and posterior mandible is D3, and posterior maxilla is D4. After the following
treatment steps are taken into consideration (e.g., implant key position and number, implant size and
design, and available bone), a more complete treatment plan relative to bone density is obtained by a
CT scan or modified during the surgical procedure using the tactile method to determine bone density,
Four facts form the basis for treatment plan modification in function of the bone quality:
(1) each bone density has a different strength;
(2) bone density affects the elastic modulus;
(3) bone density differences result in different amounts of bone-implant contact percent; and
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(4) bone density differences result with a different stress-strain distribution at the implant-bone
interface.
Bone density is an implant treatment plan modifier in several ways-prosthetic factors, implant
size, implant design, implant surface condition, implant number, and the need or method of
progressive loading. As the bone density decreases, the strength of the bone also decreases. To
decrease the incidence of micro fracture of bone, the strain to the bone should be reduced.
Treatment Plans Bone density/Treatment plan Stress Force/Area = Bone density = ↑ Implant
area Implant number Implant width Implant length Implant design Implant surface condition Strain is
directly related to stress. Consequently, the stress to the implant system should also be reduced as
the bone density decreases .
One way to reduce the biomechanical loads on implants is by prosthesis design to decrease
force. For example, cantilever length may be shortened or eliminated, narrower occlusal tables
designed and offset loads minimized, all of which reduce the amount of load. RP-4 restorations,
rather than fixed prostheses, permit the patient to remove the restorations at night and reduce
nocturnal parafunctional forces. RP-5 prostheses permit the soft tissue to share the occlusal force
and reduce the stress on the implants. Night guards and acrylic occlusal surfaces distribute and
dissipate parafunctional forces on an implant system. As the bone density decreases, these
prosthetic factors become more important. The load on the implant may also be influenced by the
direction of force to the implant body. A load directed along the long axis of the implant body
decreases the amount of stress in the crestal bone region compared with an angled load.
Therefore as the bone density decreases, axial loads on the implant body become more
critical. Bone grafting or bone spreading to increase the width of bone and to better position the
implant relative to the intended load is considered for soft bone types. Stress may also be reduced by
increasing the functional area over which the force is applied. Increasing implant number is an
excellent way to reduce stress by increasing functional loading area. Three implants rather than two
may decrease applied implant moments in half and bone reaction forces by two thirds, depending on
implant position and size." An implant prosthesis with normal patient forces in the bone should have
at least one implant per tooth. In the molar region, two implants for each missing molar may be
appropriate. In D2 bone with normal patient forces, a pontic may replace a tooth between two
implants. In D3 bone, one implant per tooth is often appropriate.
The surface area of the implant macro geometry may be increased to decrease stress to the
implant-bone interface. The width of the implant may decrease stress by increasing the surface area.
23

This may also reduce the length requirement. For every 0.5 mm increase in width, there is an
increased surface area between 10% and 15% for a cylinder implant, and even more difference is
found with threaded-implant body designs.
Because the greatest stresses are concentrated at the crestal region of the implant, width is
more significant than length for an implant design, once adequate length has been established. D4
bone should often require wider implants compared with D1 or D2 bone. This may require on lay
grafts or bone spreading to increase the width of bone, when other stress factors are high. Based on
long-term clinical experience of V shaped threaded implant bodies, the minimum bone height for
initial fixation and early loading for D1 bone is 7 mm; for D2 bone, 9 mm; and for D3 bone, 12 mm.
using the classic V-thread screw implant design and titanium surface condition. D4 bone benefits
from relatively longer implants for initial fixation and early loading compared with other bone densities,
not only for initial fixation, but also because the stress/strain transfer of occlusal forces extends
farther down the implant body.
This implant length requirement may require sinus grafts in the posterior maxilla. However,
because the crestal region is where pathologic overload of bone most often occurs after prosthetic
loading, once initial healing is complete the length of the implant is not as effective to solve crestal
bone loss (and the quality of implant health) as other factors (e.g., implant design, implant width).
The macro design affects the magnitude of stresses and their impact on the bone-implant interface
and can dramatically change the amount and contour of the bone strains concentrated at the
interface. Different implant design criteria respond to different bone densities.
Bone densities exhibit a tenfold difference in strength, and the elastic modulus is significantly
different between D1 and D4. Implants designed for D4 bone should have the greatest surface area.
For example, a classic V-thread screw design has 30% more surface area than a cylinder implant. A
thread design with more threads has more surface area than one with fewer threads. The depth of
the thread is also a variable that may be controlled, based on the surface area desired. The deeper
the thread depth in the implant body, the more functional surface area for the bone implant contact.
An implant body designed for the soft bone should have more and deeper threads than an implant
body designed for hard bone . A D1 implant, on the other hand, may be designed for easy surgical
placement, as the strains under load are minimized, but the surgical failure rates are greater.
Coatings or the surface condition on an implant body can increase the bone-implant contact
percentage and therefore the functional surface area. A rougher surface is strongly suggested in soft
bone and has resulted in improved short-term survival rates when compared with machined
24

titanium." After 1 to 2 years, the mechanical load on the overall implant design is more critical to the
amount and type of bone contact compared with the surface condition on the implant body.
Rough surface conditions also may have some disadvantages. Plaque retention when
exposed above the bone, contamination, and increased cost are a few of the concerns with
roughened surfaces.
The benefit and risk of surface conditions suggests the roughest surfaces are most often used
in only softer bone types. Progressive bone loading provides for a gradual increase in occlusal loads,
separated by a time interval to allow the bone to mature and accommodate to the local strain
environment. Over time, progressive loading changes the amount and density of the implant bone
contact. The increased density of bone at the implant interface improves the overall support system
mechanism.
The softer the bone, the more important the need for progressive loading. A key determinant
for clinical success is the diagnosis of the bone density in a potential implant site. The strength of
bone is directly related to bone density. The modulus of elasticity is related to bone density. The
percentage of bone-implant contact is related to bone density, and the axial stress contours around
an implant are affected by the density of bone. As a consequence, past clinical reports that did not
alter the protocol of treatment related to bone density had variable survival rates.
To the contrary, altering the treatment plan to compensate for soft bone types has provided
similar survival rates in all bone densities. Once the prosthetic option, key implant position, and
patient force factors have been determined, the bone density in the implant sites should be evaluated
to modify the treatment plan. The treatment plan may be modified by reducing the force on the
prosthesis or increasing the area of load by increasing implant number, implant position, implant size,
implant design, or implant body surface condition.
25

1. What is an implant treatment plan modifier in several ways-prosthetic factors, implant size, implant design,
implant surface condition, implant number, and the need or method of progressive loading.
A. Bone Mass C. Bone Density
B. Bone Mineral Density D. Bone Density Test
2. When a patient is first examined, the most common radio graphic evaluation is
A. With a Cephalometric radio graph C. With a Cephalometric tracing
B. With a Panoramic radio graph D. With a 3D Resin cast
3. The most dense bone is usually observed in ;

A. the anterior mandible C. posterior mandible
B. by the anterior maxilla D. in the posterior maxilla.
4. What organ that is able to change in relation to a number of factors, including hormones, vitamins, and
mechanical influences.
A. Heart C. Lungs
B. Kidney D. Bone
5. This phenomenon may occur throughout the skeletal system, as evidenced by a 15% decrease in the cortical
plate and extensive trabecular bone loss consequent to immobilized limbs for 3 months.
A. Micro strain of Bone C. Trabecular Bone Density
B. Cortical Bone Density D. Bone Density
6. Who proposed a model of four histologic patterns for compact bone as it relates to mechanical adaptation
to strain.
A. Misch C. Norton and Gamble
B. Frost D. Bidez and Misch
7. These are the facts form the basis for treatment plan modification in function of the bone quality EXCEPT
one;
A. each bone density has a different strength C. bone density affects the elastic modulus
26

B. bone density differences result in different D. bone density has a different mass at the implant-
amounts of bone-implant contact percent bone interface.
8. Who nestablished a correlation between CT Hounsfield units and density at the time of surgery.
A. Kirkos and Misch C. Smedberg
B. Bidez and Misch D. Higuchi
9. What is determined by the magnitude of force divided by the functional area over which it is applied ?
A. Strain C. Remodeling
B. Stress D. Micro strain
10. What is defined as the change in length of a material divided by the original length ?
A. Remodeling C. Strain
B.Stress D. Micro strain
11. What is a determining factor in treatment planning, implant design, surgical approach, healing time, and
initial progressive bone loading during prosthetic reconstruction.
A. Bio-mechanical C. Prosthetic
B. Edentulous D. Prosthesis
12. What is found on the outer surfaces of bone and includes the crest of an edentulous ridge.
A. Dense or porous cortical bone C. Cortical bone
B. fine trabecular bone D. Trabecular bone
13. The following are the different clinical situations at the bone-implant interface, based on bone density
EXCEPT one;
A. physiologic bone loads in the adapted window zone and no marginal bone loss.
B. mild overload to pathologic overload bone loads and crestal bone loss.
C. generalized pathologic overload and implant failure.
D. the magnitude of the stress on the implant proceeds farthest apically along the implant body.
27

14. Who classified bone density into three categories ?
A. Linkow C. Smedberg
B. Johns D. Frost
15. Linkow stated that this type of bone structure, results in a loose-fitting implant.
A. Class I Bone structure C. Class III Bone structure
B. Class II Bone structure D. Class IV Bone structure
16. A disorder characterized by bones that are more likely to break.
A. Mononucleosis C. Gum Disease
B. Osteoporosis D. Scoliosis
17. Progressive bone provides a gradual increase in ?
A. Occlusal load C. Stress
B. Edentulous D. Strain
18. The initial treatment plan is presented to the patient using the anatomical location as an index of the bone
density.
A. Anterior mandible and single tooth replacement is D2, anterior maxilla and posterior mandible is D3, and
posterior maxilla is D4.
B. Anterior mandible and single tooth replacement is D3, anterior maxilla and posterior mandible is D4, and
C. Posterior mandible and single tooth replacement is D2, anterior maxilla and posterior mandible is D3, and
D. Posterior mandible and single tooth replacement is D3, anterior maxilla and posterior mandible is D4, and
19. The minimum bone height for initial fixation and early loading for D1 bone is ;
A.12 mm C. 3 mm
B.9 mm D. 7 mm
28

20. When higher stresses are applied to an implant prosthesis,
A. the titanium has higher strain (change in shape) compared with the bone.
B. the titanium will decrease strain (change in shape) compared with the bone.
C. the titanium has lower strain (change in shape) compared with the bone.
D. the titanium will increase strain (change in shape) compared with the bone

1. It was the most dense bone and is usually observed in

the ?
2. What is more significant than length for an implant
design, once adequate length has been established ?
3. What is more precisely determined by tomographic
radio graphs, especially computerized tomograms ?
4. Who proposed a model of four histologic patterns for
compact bone as it relates to mechanical adaptation to
strain.
5. What type of Misch bone density that composes almost
all of the total volume of bone next to the implant.
SCORE:
29

C. LESSON WRAP-UP

A. Work Tracker
completed.
FAQs
-
1. What is the best bone type for implant?
Answer: Type 2 bone is the best bone for osseointegration of dental implants. It provides good cortical
anchorage for primary stability, yet has better vascularity than type 1 bone. Type 3 and 4 are soft bone textures
with the least success in type 4 bone.
2. What is D3 AND D4 bone?
Answer: Misch has classified bone density into four types: D1 is dense cortical bone, D2 is porous cortical
and coarse trabecular bone, D3 is porous cortical bone(thin) and fine trabecular bone, and D4 is fine trabecular
bone.
30

KEY TO CORRECTIONS

Answer Key:
1. C 2. B 3. A 4. D 5. A 6. 7. B 8. D 9. A 10. B 11. B 12. A 13. D 14. A 15. C 16. B
17. A 18. A. 19. D 20. C
Answer Key:
1. It was the most dense bone and is usually observed

in the ? Anterior Mandible
2. What is more significant than length for an implant

design, once adequate length has been established? Width
3. What is more precisely determined by tomographic
radio graphs, especially computerized tomograms ? Bone Density
4. Who proposed a model of four histologic patterns for
compact bone as it relates to mechanical adaptation to Frost
strain.
5. What type of Misch bone density that composes
almost all of the total volume of bone next to the Fine Trabecular Bone
implant
SCORE:
31


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DEN 003 Basic Dental Implantology

Teachers’ Guide Module #1

Name:_______________________________________________________ Class number: ______

Lesson Title: Rationale for Dental Implants Materials:

2) Activity 1: What I Know Chart, part 1 (3mins)

What I Know Questions: What I Learned (Activity 4)

3. What makes implant dentistry

Name:_______________________________________________________ Class number: ______

1) Activity 2: Content Notes (13 mins)

(1) aging population living longer,

(2) tooth loss related to age,

(3) consequences of fixed prosthesis failure,

(4) anatomical consequences of edentulism,

(5) poor performance of removable prostheses,

(6) consequences of removable partial dentures,

(8) predictable long-term results of implant-supported prostheses,

(9) advantages of implant-supported restorations, and

(10) increased public awareness.

Name:_______________________________________________________ Class number: ______

EFFECTS OF AN AGING POPULATION

AGE-RELATED TOOTH LOSS

Fixed Partial Dentures

Name:_______________________________________________________ Class number: ______

Single-Tooth Implants Advantages

Name:_______________________________________________________ Class number: ______

ANATOMICAL CONSEQUENCES OF EDENTULISM

In a longitudinal 25-year study of edentulous patients, lateral cephalograms demonstrated continued

Name:_______________________________________________________ Class number: ______

Consequences of Bone Loss in Fully Edentulous Patients

Name:_______________________________________________________ Class number: ______

ADVANTAGES OF IMPLANT-SUPPORTED PROSTHESES

Advantages of Implant-Supported Prostheses

Name:_______________________________________________________ Class number: ______

2.Activity 3: Skill-building Activities (18 mins + 2 mins checking) :

Identification Test: Identify what is being asked on the following question.

Single Tooth Implant Molars Dental Implants

Three -unit fixed partial denture (FPD) Age Modern Dentistry

Trabeculae and Density Strain and Stress Misch

___________1. It is directly related to every indicator of tooth loss.

___________2. The most common missing teeth.

___________7. It may be applied to the bone surrounding the implant.

___________9. A treatment option to replace a posterior single missing tooth.

Name:_______________________________________________________ Class number: ______

A. Dental implants B. Endosteal Implant C. Single tooth D. Edentulism

2. Is the state of being Edentulous, or without natural teeth.

A. Endosteal B. Peri-implant bone loss C. Edentulism D. Trabeculation

A. Tooth B. Keratinized Gingiva C. Muscle D. Facial esthetics

4. What is the important factor to consider in implant dentistry?

A. Age B. Age population C. Tooth D. Dental Implants

A. Dental Implant B. Implant Dentistry C. Prosthesis D. Prosthetic

A. Three-unit fixed partial denture C. Acrylic denture

Name:_______________________________________________________ Class number: ______

8.It is greater than its maxillary counterpart in all age group.

A. Partial free-end edentulism

B. consequences of fixed prosthesis failure,

C. anatomical consequences of edentulism,

D. poor performance of removable prostheses

A. Partial free-end edentulism

B. Mandibular free-end edentulism

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