Abstract
Purpose:
The purpose of this study was to examine the relationship between the local bone density derived from a cone-beam computed tomography (CBCT) scan from different sites in the maxilla and mandible and the insertion torque values, for the success of oral implants.
Materials and Methods:
A total of 73 patients who reported to our unit, with missing teeth and a desire for replacement with dental implants, were included in this study. A total of 118 implants were placed from 2008 to 2011. The number of male and female patients included in the study was 43 and 30, respectively. The mean age of the patients was 43.2 years. NobelReplace Select Tapered Implant system was used for all patients.
Results:
The mean bone density of all 118 implants was 620 ± 251 Hounsfield units (HU). The mean bone density and insertion torque values of the six failed implants were 459 ± 131 HU and 28 ± 5 Ncm, respectively. The mean bone density and insertion torque values of the 112 successful implants were 678 ± 217 HU and 36 ± 2 Ncm, respectively. A significant strong positive correlation was observed between bone density and torque at all sites.
Conclusion:
CBCT is a useful tool to determine the bone density of the concerned areas before implant placement. The valuable information derived from the CBCT about bone quality may help clinicians to avoid the placement of implants into the very poorest qualities of bone, where failure is more likely.
Keywords: Bone density, CBCT, dental implant, implant stability, insertion torque, primary stability
INTRODUCTION
Restoring single or multiple missing teeth using dental implants is the most ideal and durable option available for the arsenal of a dentist. As their use has become widespread, many advances have been made in designing the implant, improving the surface properties of the implant, and planning the treatment. The success of any implant depends on many parameters, which include but are not limited to the general health of the patient, the biocompatibility of the implant material, available hard tissue, the quality of the bone, and most of all the surgical procedure itself.[1]
Primary implant stability is essential for successful osseointegration. This concept has been described by Branemark, as “consisting of a highly-differentiated tissue making a structural and functional connection between living bone and the surface of an implant.”[2] Osseointegration of dental implants largely depends on bone quality, quantity, and site preparation technique. The implant stability is reduced when either of the above factors is compromised and in turn, jeopardizes osseointegration. The bone density at the implant placement site plays a major role in designing the treatment plan, selecting the implant size, finalizing the surgical approach, and approximating the healing process.[3,4]
Three requirements necessary for the success of an implant, that is, a close approximation of the bone-to-implant material, atraumatic site preparation, and absence of mobility postoperatively during the healing phase are closely dependent on bone density at the site of implant placement.[5] The implant survival rates between the maxilla and mandible are largely dependent on bone quality, where the poor degree of bone mineralization is the major reason for high failure rates.[6]
Cone beam computed tomography (CBCT) could offer the best radiographic method for qualitative analysis of the residual bone. The Hounsfield units (HU) (quantitative measurement of density) determined by the software programs in the CBCT machine range from 1000 (air) to 3000 (enamel). Various tissues in the region can be identified by measuring the density values on the scan. bone: 150–1800 HU, cartilage: 80–130 HU, fibrous tissue: 70–90, and muscle: 35–70 HU.[7]
Using CBCT, bone quality can be characterized as:
D1 bone: >1250 HU
D2 bone: 850–1250 HU
D3 bone: 350–850 HU
D4 bone: 150–350 HU
Primary implant stability is a mechanical property, that is, related to the quality and quantity of the bone at the site, surgical technique, and type of implant used. It is measured at the time of implant placement. Secondary implant stability is the improvement in stability achieved due to new bone deposition, followed by its remodeling at the implant–tissue interface.[8] Primary implant stability can be measured by non-invasive clinical methods, namely, 1) insertion torque, 2) the periotest, and 3) resonance frequency analysis.
The efficacy of CBCT scan to assess bone volume and morphology have been reported earlier.[7,9,10,11] However, there are only a few reports, which try to establish a relationship between bone density from a CBCT scan and the initial implant stability at sites of implant placement.
The purpose of this study was to examine the relationship between the local bone density derived from CBCT scans from different sites in the maxilla and mandible and the insertion torque values, for the success of oral implants.
MATERIALS AND METHODS
The aim of the present study was to examine the correlations between the local bone density from CBCT and the implant stability parameters, including insertion torque and implant survival rates.
To regard implants as successful, the following objectives had to be met:
No radiolucent zone around the implant,
No pain or ongoing pathological process,
Minimum crevicular bone loss around the implant,
The implant is acting as an anchor for the functional prosthesis.
Confirmed individual implant stability.
This retrospective study was done in Dental Surgery. Ethical Clearance was obtained from the Institutional Ethical Committee with Ref no SSCDS/IRB/2019 dated 02/01/2019. This study included 73 patients who reported to our unit with missing teeth and a desire for replacement with dental implants. A total of 118 implants were placed. The number of male and female patients included in the study was 43 and 30, respectively. The mean age of the patients was 43.2 years. NobelReplace Select Tapered Implant system was used for all patients. Tables 1 and 2 give the details of the implants used and the implant recipient sites. Only implants before the prosthesis delivery were considered in the study to disregard the effect of loading procedures on implant success.
Table 1.
Implant sites and number of implants
| Implant sites | Number of implants | Bone density in HU | Insertion torque values | |||
|---|---|---|---|---|---|---|
| Maxilla | 40 | 452±152 HU | 33±3 Ncm | |||
| Anterior maxilla | 21 | 567±196 HU | 36±4 Ncm | |||
| Posterior maxilla | 19 | 337±109 HU | 30±3 Ncm | |||
| Mandible | 78 | 660±237 HU | 38±2 Ncm | |||
| Anterior mandible | 53 | 816±264 HU | 41±2 Ncm | |||
| Posterior mandible | 25 | 504±211HU | 35±2 Ncm |
Table 2.
Dimensions and number of implants placed
| Dimension of implants (mm) | Number of implants placed | |
|---|---|---|
| 3.5×13 | 12 | |
| 3.5×10 | 21 | |
| 4.3×13 | 09 | |
| 4.3×11.5 | 21 | |
| 4.3×10 | 39 | |
| 5×11.5 | 10 | |
| 5×8 | 06 |
Inclusion criteria
All clinically stable patients with missing teeth and a desire for replacement with oral implants were included in the study. Patients with edentulous or partially dentulous arches with good oral hygiene, sound gingival/periodontal status of adjacent teeth, and availability for follow-up were added to the study. In addition to the above, the presence of adequate bone height and width at the implant placement site was the most crucial criterion.
Exclusion criteria
All clinically unstable patients, patients with pre-existing bone conditions (osteoporosis, pathologies), and patients with a history of radiations to the head and neck were excluded from the study. Implant recipient sites that required bone grafting either preoperatively or intraoperatively were not considered for the study. Patients with pronounced bruxism were also removed from the study.
The pre-surgical evaluation consisted of clinical and radiographic examination including a CBCT scan. All patients were thoroughly informed about the procedure and signed a written consent.
Cone beam computed tomography scan
To assess the bone density of the implant recipient site, a CBCT machine (Carestream CS 9300) was utilized. The same scanning conditions (tube voltage 90 kV, tube current 15 mA, slice thickness 1 mm, and slice interval 1 mm) were provided for each scan. Cross-sectional, coronal, and axial images for each maxilla/mandible were obtained from the CBCT machine. The mean bone density of the implant recipient area was measured using the software (CS 3D imaging software) incorporated in the CBCT machine. The bone density measurements were recorded in HU. CBCT scan was also used to assess the available bone height. Figures 1-3 show imaging software used to measure bone density. Hand-held torque wrench was used to measure the insertion torque values [Figure 4].
Figure 1.
CBCT image 1: Axial view for potential implant site assessment
Table 3.
Stability parameters
| Follow up | Clinical and radiographic changes | Jaw location |
||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Anterior maxilla | Posterior maxilla | Anterior mandible | Posterior mandible | |||||||||||||||
|
|
|
|
|
|||||||||||||||
| n | % | n | % | n | % | n | % | |||||||||||
| RZ 1 week | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| RZ 3 months | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| RZ loading | Absent | 20 | 95.2% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 1 | 4.8% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| OP 1 week | Absent | 20 | 95.2% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 1 | 4.8% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| OP 3 months | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| OP loading | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| CB 1 week | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| CB 3 months | Absent | 20 | 95.2% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| Present | 1 | 4.8% | 0 | 0.0% | 0 | 0.0% | 0 | 0.0% | ||||||||||
| CB loading | Absent | 20 | 95.2% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 1 | 4.8% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| S 1 week | Absent | 21 | 100.0% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 0 | 0.0% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| S 3 months | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| S loading | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| P 1 week | Absent | 21 | 100.0% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 0 | 0.0% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| P loading | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| WD 1 week | Absent | 21 | 100.0% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 0 | 0.0% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| WD loading | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| IM 1 week | Absent | 21 | 100.0% | 19 | 100.0% | 53 | 100.0% | 25 | 100.0% | |||||||||
| IM 3 months | Absent | 20 | 95.2% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 1 | 4.8% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
| IM loading | Absent | 20 | 95.2% | 15 | 78.9% | 53 | 100.0% | 24 | 96.0% | |||||||||
| Present | 1 | 4.8% | 4 | 21.1% | 0 | 0.0% | 1 | 4.0% | ||||||||||
Figure 4.
Hand-held torque wrench to measure the insertion torque values
Figure 2.
CBCT image 2: Panorama view
Figure 3.
CS 3D imaging software used to assess the bone density (coronal section)
Insertion torque measurement
The insertion torque values were measured at the time of the placement of the implant with the torque wrench available in the NobelReplace Select Tapered Implant system kit. The values, when the rotation stopped, were recorded.
Implant success and failure criteria
The following parameters were used to assess implant success at 1 week, 3 months, and at the time of loading.
Radiological parameters
The radiolucent zone around the implant (RZ) Present/absent
Ongoing pathological process (OP) Present/absent
Crevicular bone loss (CB) Present/absent
Clinical parameters
Suppuration (S) Present/absent
Pain (P) Present/absent
Inflamed mucosa (IM) Present/absent
Wound dehiscence (WD) Present/absent
Statistical analysis
A significant strong positive correlation was observed between bone density and torque at all four sites (Pearson’s correlation coefficient).
RESULTS
A total of 73 patients were treated with 118 implants placed in both maxillary and mandibular arches under local anesthesia. The mean age of the patients was 43.2 years (range 18–59 years) comprising 43 males and 30 females. The most common cause for loss of teeth was tooth decay (38 cases), followed by periodontal disease (21 cases), root canal failure (9 cases), and traumatic avulsion of the tooth (5 cases). Six implants were lost, five in male patients and one in female patients, resulting in a failure rate of 5.08%. Out of the six failed implants, four failed in the posterior maxillary region, one failed in the anterior maxilla, and one failed in the posterior mandible. Only the implants that failed before the prosthesis delivery were included in this study.
A total of 118 implant sites consisted of 21 anterior maxillary sites, 19 posterior maxillary sites, 53 anterior mandible sites, and 25 posterior mandible sites. The range of bone densities of these implant sites in HU according to the CBCT scans is given in Table 1. The mean bone density of all 118 implants was 620±251 HU.
The average insertion torque measured after the final placement of the implants at the different implant sites was noted [Table 1]. The mean insertion torque of 118 implants was 38±2 Ncm. The mean bone density and insertion torque of the six failed implants were 359±131 HU and 28 5 Ncm, respectively. The stability parameters were used at a period of 1 week, 3 months, and at the time of placement to assess the success of implants [Table 3].
The mean bone density and insertion torque values of the 112 successful implants were 702±229 HU and 37±2 Ncm, respectively [Table 1], which indicated a significant correlation between bone density determined preoperatively using a CBCT scan and the insertion torque measured clinically after the final placement on the implants [Tables 4 and 5].
Table 4.
Pearson’s correlation between maxilla and mandible
| Jaw location | Insertion torque in Ncm | |||||
|---|---|---|---|---|---|---|
| Anterior maxilla | Bone density in HU | Correlation coefficient | 0.872** | |||
| P | <0.001 | |||||
| n | 21 | |||||
| Posterior maxilla | Bone density in HU | Correlation coefficient | 0.773** | |||
| P | <0.001 | |||||
| n | 19 | |||||
| Anterior mandible | Bone density in HU | Correlation coefficient | 0.748** | |||
| P | <0.001 | |||||
| n | 53 | |||||
| Posterior mandible | Bone density in HU | Correlation coefficient | 0.750** | |||
| P | <0.001 | |||||
| n | 25 | |||||
**Statistically not significant
Table 5.
For overall implant sites
| Insertion torque in Ncm | ||
|---|---|---|
| Bone density in HU | ||
| Correlation coefficient | 0.927 | |
| P | 0.001* | |
| n | 118 |
*Statistical significance set at ≤ 0.05
There were no signs of radiolucency around the implants at any of the four sites of implant placement at 1 week and 3 months. During loading, radiolucency around implants was seen in 4.8% of the anterior maxilla, 21.1% of the posterior maxilla, none in the anterior mandible, and 4% in posterior mandibular sites.
In the 1st week, ongoing pathological processes around implants were seen in 4.8% of the anterior maxilla, 21.1% of the posterior maxilla, none in the anterior mandible, and 4% in posterior mandibular sites. No such signs were seen at 3 months and during loading.
DISCUSSION
Lekholm and Zarb[12] developed the most popular method of assessing bone quality, which is being used widely. They introduced a scale of 1 to 4 based on the preoperative radiographic assessment and the resistance experienced by the operator during the implant site preparation. This method was, however, less desirable when it comes to reproducing the values.[13]
It is well established that the external structure or quantity or volume of the edentulous sites that are being prepared is described by the height and width available. In addition to the external structure, the internal structure of bone, which reflects its strength, is defined by its quality or density. The success of the implant heavily depends on both these structures.[14] Bone density alone plays a significant role in the selection of implants, surgical approach, postoperative healing, and achieving primary implant stability.[15]
Hormones, vitamins, and other mechanical factors play a significant role in changes in the bone.[16] The relation of bone density to dental implants was first given in 1970 by Linkow.[12]
Linkow, Lekholm, and Zarb[12] described a method to assess bone quality for implant placements, which referred to individual experience and provided only a rough mean value of the edentulous area, hence these methods were later on questioned. Johansson and Strid described a technique in which bone density can be measured during implant osteotomy.[17] Through their technique, they were able to provide useful facts about bone density.
Orthopantomogram is a useful diagnostic aid in dentistry, which provides anatomic details of the lower and the middle third regions of the face, but it is inefficient to evaluate bone density. Techniques such as densitometry, bone biopsies, ultrasound, and dual photon absorptiometry, although efficient and easily available, are not practical for implant dentistry.[18]
The ability to visualize bone three-dimensionally changed the dynamics of implant dentistry. CBCT, being more objective and trustworthy, proved to be the best imaging method for the quantitative and qualitative analysis of the residual bone.[10,11,14] The use of the HU value obtained from a computed tomography (CT) scan for the proposed implant site could help the dentist to tailor the primary stability, especially in areas with low bone density.[19] CBCT scan is a digital and mathematical imaging technique that creates tomographic sections where the tomographic layer is not contaminated by blurred structures from the adjacent anatomy. Additionally, and most importantly, CT helps to differentiate and quantify both hard and soft tissues.
The CS 3D imaging software provides a precise measurement of bone quantity. It also gives information about the nerves and other important anatomic structures approximating the tooth root. The radiologist indicates the curvature of the mandibular or maxillary arch and the computer is programmed to generate referenced cross-sectional and panoramic images of the alveolus along with 3D images of the arch. The images are spaced 1 mm apart. CBCT enables the identification of disease, determination of bone quality and quantity, identification of critical structures at the proposed region, and determination of the position and orientation of the dental implants.
In the present study, out of 118 implant sites used for the placement of implants, none of the implant sites were categorized as D1 bone. The average bone density in 53 implant sites of the anterior mandible and 14 implant sites of the posterior mandible fell in the category of D2 bone. The mean bone density of the 53 implant sites of the anterior mandible was 816±264 HU and the insertion torque value was 41±2 Ncm, the mean bone density of the 8 implant sites of the posterior mandible was 692HU and the insertion torque was 33±2 Ncm. The mean bone density values for D2 implant sites as per Srerama[17] and Almasoud et al.[20] were 862.8±203.4 and 776±165 HU, respectively. The insertion torque values for the implants placed in D2 bone according to Habib[21] and Lekholm et al.[12] were 65.5±15.6 and 38±3 Ncm, respectively. The mean bone density value for the posterior mandible according to Dahiya et al.[1] was 628±20.19. In a study conducted by Turkyilmaz et al.,[22] the bone density and insertion torque values for 62 anterior mandible sites were 912±228 HU and 42.2±5 Ncm, respectively, and for 37 posterior mandible sites were 698±205 HU and 38.3±5 Ncm, respectively. In another study conducted by Turkyilmaz et al.,[23] the mean bone density values of 58 anterior mandible sites and 28 posterior mandible sites were 911±231HU and 604±226 HU, respectively.
The average bone density in 21 implant sites of the anterior maxilla and 11 implant sites of the posterior mandible fell in the category of D3 bone. The mean bone density of the 21 implant sites of the anterior maxilla was 567±196 HU and the insertion torque value was 36±4 Ncm, the mean bone density of the 11 implant sites of the posterior mandible was 551±169 HU and the insertion torque value was 31±2 Ncm. The mean bone density values for anterior maxillary implant sites as per Srerama[17] and Almasoud et al.[20] were 594.2±59.2 HU and 313.84±190.7 HU, respectively. The insertion torque values for the implants placed in the D3 bone according to Habib[21] and Lekholm et al.[12] were 55.5±19.6 and 34±3 Ncm, respectively. In a study conducted by Turkyilma et al.,[22] the bone density and insertion torque values for 31 anterior maxillary sites were 651±154 HU and 40.4±6 Ncm, respectively. In another study conducted by Turkyilmaz et al.,[23] the mean bone density of the 24 anterior maxilla sites was 723±207 HU.
Out of the 118 implant sites, 19 implant sites of the posterior maxilla fell in the category of D4 bone. The mean bone density of the 19 implant sites of the posterior maxilla was 337±109 HU and the insertion torque value was 33±3 Ncm. The mean bone density values for D4 implant sites as per Srerama[17] and Almasoud et al.[20] were 438.1±110.2 HU and 320.05 HU, respectively. The insertion torque values for the implants placed in the D4 bone according to Habib[21] and Lekholm et al.[12] were 36.6±21.7 and 29±3 Ncm, respectively. Ji Hyun Kim et al.[19] observed a mean bone density value of 404±165 HU and a maximum implant insertion torque value of 36.1±4.9 Ncm for 60 implants placed in the posterior maxilla. In a study conducted by Turkyilma et al.,[22] the bone density and insertion torque values for 28 posterior maxillary sited were 467±124 HU and 34.9±9, Ncm respectively. In another study conducted by Turkyilmaz et al.,[23] the mean bone density of the 21 posterior maxillary sites was 433±177 HU.
The bone density recorded in the present study was 567±196 HU for the anterior maxilla, 337±109 HU for the posterior maxilla, 816±264 HU for the anterior mandible, and 504±211 HU for the posterior mandible, which are comparable with the reports from around the world.[17,19,20,22,23] The difference in bone density values was noted mainly due to the differences in age and gender of patients. In the present study, higher mean bone density values were found in males than in females, which may be due to a greater bone mass in males and hormonal changes in females. An earlier study measured the bone mineral contents in the hip and lumbar spine and disclosed lower bone mineral densities in females when compared with males.[24] A review conducted by Pisulkar SG et al.[25] showed a significant relationship in bone mineral density between the jaws and other skeletal bones.
The mean insertion torque values in the present study for anterior maxilla, posterior maxilla, anterior mandible, and posterior mandible were 36±4 Ncm, 30±3 Ncm, 41±2 Ncm, and 35±2 Ncm, respectively, which are comparable with those reported in previous studies.[17,19,21,26] The mean insertion torque values for 158 implants placed by Turkyilmaz for the anterior maxilla, posterior maxilla, anterior mandible, and posterior mandible were 37 Ncm, 34 Ncm, 38 Ncm, and 33 Ncm, respectively.[22] A strong correlation between bone density values from CT scans and insertion torque values in the present study was consistent with that reported in previous studies.
In the present study, out of 118 implants, 36 implants were placed in smokers and 4 implants were lost (11.1%), whereas 82 implants were placed in non-smokers and 2 implants were lost (2.4%). The percentage of implant failures in the smokers seen in the present study is in agreement with the studies conducted by Thiebot N et al.[27] with an 8.3% failure rate and Compton et al.[28] with a 9.4% failure rate. However, Gupta et al.[29] and Aparna et al.[30] reported failure rates of 5.56% and 6.9%, respectively. Strietzel et al.[31] placed 71 implants in smokers and 13 implants were lost (16.6%). Strietzel et al.[31] concluded an increased risk of post-insertion complications within the smoking population and correlated smoking as a risk factor for dental implant therapy. Furthermore, smoking aids peri-implantitis, affecting the overall success of bone grafts when used.[31,32] The mean bone density and insertion torque of the six failed implants were 359±131 HU and 28±5 Ncm, respectively, which are comparable to the study by Turkyilmaz et al.[6] who reported corresponding values of 267±47 HU and 21.8±4 Ncm for 20 failed implants.
Simão et al.[33] concluded that the quality of bone is directly proportional to the success rate of dental implants. In a monocentric retrospective observational investigation conducted by Nicolas et al.,[27] a failure rate of 70% was reported in D3-D4 bone, out of which 83% of failures occurred in the maxilla. Also, 91.6% of these implants failed in the posterior region. No difference in the failure rates was seen due to the difference in the insertion torque values. However, Lin et al.[34] suggested that the implant failure risk is more in the anterior mandibular region. The anterior mandible has a greater bone density than the anterior maxilla, which in turn has better bone density than the posterior mandible. The poorest bone quality in the oral environment is observed in the posterior maxilla.
Strong correlations were observed between the bone density obtained from CBCT scans and insertion torque values at implant placement. From the results obtained above, it can be stated that D2 and D3 bones are the most ideal for placement of NobelReplace Select Tapered Implants. The study also strengthens the hypothesis that it is possible to predict and quantify initial implant stability and bone quality from pre-surgical CBCT diagnosis. It remains pertinent to be aware of the attendant risk of CBCT, which continues to impart a higher radiation dosage compared to conventional radiographs and weigh this against the power of the diagnostic information that it can provide.
CONCLUSION
CBCT is a useful tool to determine the bone density of the concerned areas before implant placement. The valuable information derived from the scan about the bone quality may help clinicians to avoid placement of implants into the very poorest qualities of bone, where failure is more likely. Bone density of interest areas obtained from CBCT scan can be used to make better treatment planning.
Our in vivo data, supported by the results of other studies, conclude that the preoperative CBCT assessment is a useful asset for predicting primary implant stability, which defines the success of dental implants.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors extend their appreciation to the Deanship of Postgraduate and Scientific Research at Dar Al Uloom University, Riyadh, KSA, for supporting this work.
Funding Statement
Nil.
REFERENCES
- 1.Dahiya K, Kumar N, Bajaj P, Sharma A, Sikka R, Dahiya S. Qualitative assessment of reliability of cone-beam computed tomography in evaluating bone density at posterior mandibular implant site. J Contemp Dent Pract. 2018;19:426–30. [PubMed] [Google Scholar]
- 2.Kligman S, Ren Z, Chung C-H, Perillo MA, Chang Y-C, Koo H, et al. The impact of dental implant surface modifications on osseointegration and biofilm formation. J Clin Med. 2021;10:1641. doi: 10.3390/jcm10081641. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kivovics M, Pénzes D, Németh O, Mijiritsky E. The Influence of surgical experience and bone density on the accuracy of static computer-assisted implant surgery in edentulous jaws using a mucosa-supported surgical template with a half-guided implant placement protocol-a randomized clinical study. Materials (Basel) 2020;13:5759. doi: 10.3390/ma13245759. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Elsayed MD. Biomechanical factors that influence the bone- implant-interface. Res Rep Oral Maxillofac Surg. 2019;3:023. [Google Scholar]
- 5.Manju V, Iyer S, Menon D, Nair SV, Nair MB. Evaluation of osseointegration of staged or simultaneously placed dental implants with nanocomposite fibrous scaffolds in rabbit mandibular defect. Mater Sci Eng C Mater Biol Appl. 2019;104:109864. doi: 10.1016/j.msec.2019.109864. [DOI] [PubMed] [Google Scholar]
- 6.Turkyilmaz I, McGlumphy EA. Influence of bone density on implant stability parameters and implant success: A retrospective clinical study. BMC Oral Health. 2008;8:32. doi: 10.1186/1472-6831-8-32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Morar L, Băciuț G, Băciuț M, Bran S, Colosi H, Manea A, et al. Analysis of CBCT bone density using the hounsfield scale. Prosthesis. 2022;4:414–23. [Google Scholar]
- 8.Monje A, Ravidà A, Wang HL, Helms JA, Brunski JB. Relationship Between Primary/Mechanical and Secondary/Biological Implant Stability. Int J Oral Maxillofac Implants. 2019;34:s7–23. doi: 10.11607/jomi.19suppl.g1. [DOI] [PubMed] [Google Scholar]
- 9.Liu J, Chen HY, DoDo H, Yousef H, Firestone AR, Chaudhry J, et al. Efficacy of cone-beam computed tomography in evaluating bone quality for optimum implant treatment planning. Implant Dent. 2017;26:405–11. doi: 10.1097/ID.0000000000000542. [DOI] [PubMed] [Google Scholar]
- 10.Jain S, Choudhary K, Nagi R, Shukla S, Kaur N, Grover D. New evolution of cone-beam computed tomography in dentistry: Combining digital technologies. Imaging Sci Dent. 2019;49:179–90. doi: 10.5624/isd.2019.49.3.179. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Cristache CM. Presurgical cone bean computed tomography bone quality evaluation for predictable immediate implant placement and restoration in esthetic zone. Case Rep Dent. 2017;2017:1096365. doi: 10.1155/2017/1096365. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Lekholm U, Zarb GA. Patient selection and preparation. In: Brånemark P-I, Zarb GA, Albrektsson T, editors. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence; 1985. pp. 199–209. [Google Scholar]
- 13.Al-Ekrish AA, Widmann G, Alfadda SA. Revised, computed tomography-based lekholm and zarb jawbone quality classification. Int J Prosthodont. 2018;31:342–5. doi: 10.11607/ijp.5714. [DOI] [PubMed] [Google Scholar]
- 14.Shemtov-Yona K. Quantitative assessment of the jawbone quality classification: A meta-analysis study. PLoS One. 2021;16:e0253283. doi: 10.1371/journal.pone.0253283. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Ivanova V, Chenchev I, Zlatev S, Mijiritsky E. Correlation between primary, secondary stability, bone density, percentage of vital bone formation and implant size. Int J Environ Res Public Health. 2021;18:6994. doi: 10.3390/ijerph18136994. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Bhattarai HK, Shrestha S, Rokka K, Shakya R. Vitamin D, calcium, parathyroid harmone, and sex steroids in bone health and effects of aging. J Osteoporos. 2020;2020:9324505. doi: 10.1155/2020/9324505. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Sreerama R, Kolluru KC, Gottumukkala V, Innampudi CK, Konathala JR, Krishnaveni G. Assessment of the effect of bone density on implant stability: A clinical study. J Pharm Bioallied Sci. 2021;13(Suppl 1):S297–300. doi: 10.4103/jpbs.JPBS_794_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Chakraborty D, Datta P, Dutta K. Radiological assessment of bone morphology for implant treatment planning: A multi detector computed tomography approach. IOSR J Dent Med Sci. 2021;16:30–37. [Google Scholar]
- 19.Kim J-H, Lim Y-J, Kim B, Lee J. How do parameters of implant primary stability correspond with ct-evaluated bone quality in the posterior maxilla? A correlation analysis. Materials. 2021;14:270. doi: 10.3390/ma14020270. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Almasoud NN, Tanneru N, Marei HF. Alveolar bone density and its clinical implication in the placement of dental implants and orthodontic mini-implants. Saudi Med J. 2016;37:684–9. doi: 10.15537/smj.2016.6.14274. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Abi-Aad HL, Daher FI, Baba NZ, Cordioli G, Majzoub ZAK. Insertion torque of variable-thread tapered implants in the posterior maxilla: A clinical study. J Prosthodont. 2019;28:e788–94. doi: 10.1111/jopr.12965. [DOI] [PubMed] [Google Scholar]
- 22.Turkyilmaz I, Tözüm TF, Tumer C, Ozbek EN. Assessment of correlation between computerized tomography values of the bone and maximum torque and resonance frequency values at dental implant placement. J Oral Rehabil. 2006;33:881–8. doi: 10.1111/j.1365-2842.2006.01692.x. [DOI] [PubMed] [Google Scholar]
- 23.Turkyilmaz I, Tözüm TF, Tumer C. Bone density assessment of oral implant sites using computerized tomography. J Oral Rehabil. 2007;34:267–72. doi: 10.1111/j.1365-2842.2006.01689.x. [DOI] [PubMed] [Google Scholar]
- 24.Alswat KA. Gender disparities in osteoporosis. J Clin Med Res. 2017;9:382–7. doi: 10.14740/jocmr2970w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Pisulkar SG, Mistry RA, Nimonkar S, Dahihandekar C, Pisulkar G, Belkhode V. The correlation of mineral density of jaws with skeletal bone and its effect on implant stability in osteoporotic patients: A review of patient-based studies. Cureus. 2022;14:e27481. doi: 10.7759/cureus.27481. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.do Vale Souza JP, de Moraes Melo Neto CL, Piacenza LT, Freitas da Silva EV, de Melo Moreno AL, Penitente PA, et al. Relation between insertion torque and implant stability quotient: A clinical study. Eur J Dent. 2021;15:618–23. doi: 10.1055/s-0041-1725575. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Thiebot N, Hamdani A, Blanchet F, Dame M, Tawfik S, Mbapou E, et al. Implant failure rate and the prevalence of associated risk factors: A 6-year retrospective observational survey. J Oral Med Oral Surg. 2022;28:8. [Google Scholar]
- 28.Compton SM, Clark D, Chan S, Kuc I, Wubie BA, Levin L. Dental implants in the elderly population: A long-term follow-up. Int J Oral Maxillofac Implants. 2017;32:164–70. doi: 10.11607/jomi.5305. [DOI] [PubMed] [Google Scholar]
- 29.Gupta A, Rathee S, Suman T, Ahire M, Madhav S, Chauhan MS. Nicotine, the predictor of success or failure of dental implants: A retrospective study. Contemp Clin Dent. 2018;9:597–600. doi: 10.4103/ccd.ccd_597_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Arora A, Reddy MM, Mhatre S, Bajaj A, Gopinath PV, Prasad A. Comparative evaluation of effect of smoking on survival of dental implant. J Int Oral Health. 2017;9:24–7. [Google Scholar]
- 31.Strietzel FP, Reichart PA, Kale A, Kulkarni M, Wegner B, Küchler I. Smoking interferes with the prognosis of dental implant treatment: A systematic review and meta-analysis. J Clin Periodontol. 2007;34:523–44. doi: 10.1111/j.1600-051X.2007.01083.x. [DOI] [PubMed] [Google Scholar]
- 32.Nazeer J, Singh R, Suri P, Mouneshkumar CD, Bhardwaj S, Iqubal MA, et al. Evaluation of marginal bone loss around dental implants in cigarette smokers and nonsmokers. A comparative study. J Family Med Prim Care. 2020;9:729–34. doi: 10.4103/jfmpc.jfmpc_1023_19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Simão BS, Jr, Costa DD, Cangussu MCT, Sotto-Maior BS, Devita RL, de Carvalho JJ, et al. Observational study on the success rate of osseointegration: A prospective analysis of 15,483 implants in a public health setting. BioMed. 2022;2:422–30. [Google Scholar]
- 34.Lin G, Ye S, Liu F, He F. A retrospective study of 30,959 implants: Risk factors associated with early and late implant loss. J Clin Periodontol. 2018;45:733–43. doi: 10.1111/jcpe.12898. [DOI] [PubMed] [Google Scholar]