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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 65-75

The influence of local and systemic factors upon dental implant osseointegration: A critical review

Head of Periodontology Department, School of Dentistry, Tishik International University, Erbil, Kurdistan Region, Iraq

Date of Submission02-Nov-2019
Date of Decision04-Jan-2020
Date of Acceptance16-Mar-2020
Date of Web Publication12-Jun-2020

Correspondence Address:
Dr. Jafar Naghshbandi
Tishik International University, Erbil, Kurdistan Region
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjos.SJOralSci_79_19

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Successful dental implant therapy largely depends upon the implant osseointegration. Many local and systemic factors interfere with this process. Hence, this study critically reviews the impact that these factors might have on the osseointegration. This review emphasizes the importance of a vigilant preoperative assessment of the local and systemic risk factors as they play a significant role in the long-term success of dental implants.

Keywords: Alveolar bone, diabetes, implant, osseointegration, risk factors, systemic conditions

How to cite this article:
Naghshbandi J. The influence of local and systemic factors upon dental implant osseointegration: A critical review. Saudi J Oral Sci 2020;7:65-75

How to cite this URL:
Naghshbandi J. The influence of local and systemic factors upon dental implant osseointegration: A critical review. Saudi J Oral Sci [serial online] 2020 [cited 2023 Feb 6];7:65-75. Available from: https://www.saudijos.org/text.asp?2020/7/2/65/286565

  Introduction Top

Osseointegration is the anchorage of the implant in the bone.[1],[2],[3] Local [4],[5],[6],[7] and systemic factors may influence osseointegration [8],[9],[10],[11],[12],[13],[14] and contribute to implant failure and often lead to early failure.[15] Late implant failures are influenced mainly by both the microbial environment and the prosthetic factors.[15],[16] The present review aimed to critically assess the influence of local and systemic factors upon implants osseointegration.

  Materials and Methods Top

Focused question

The addressed focused question was “What is the impact of local and systemic factors on osseointegration of dental implants?”

Search strategy

To address the focused question, MEDLINE/PubMed and Cochrane databases were viewed and searched. Databases were searched from 1976 up to 2018 using various combinations of the following keywords: “alveolar bone,” “implant,” “diabetes,” “risk factors,” “osseointegration,” “periodontal,” “radiotherapy,” and “systemic conditions. The inclusion criteria were based on the following: (1) human and experimental studies; (2) articles published only in English; and (3) reference list of potentially related original and review studies. The second step was to hand-search the reference list of original and review studies that were found to be relevant in the first step. After the final selection of the papers, those that fulfilled the selection criteria were processed for data extraction.

  Local Factors Influencing Osseointegration of Dental Implants Top

Implant design

Design parameters include implant diameter, length, thread pitch, shape, and depth.[17] The geometric features of an implant influence initial contact that helps implants primary stability.[18] Microscopic and macroscopic surface topography of implant design maybe helps to stabilize bone–implant interface in a low-density bone and to minimize marginal bone loss.[19],[20] Screw-shaped and full-body cylindrical implants produced less strain compared to small radii of conical shape and hollow cylinder (HC) implants.[21] A higher implant failure rate with parallel-walled/cylindrical nonthreaded implants,[22] where tapered implants shape similar to natural root form, may yield better load distribution to surrounding bone.[23],[24],[25],[26] The majority of the stresses were seen at the tip and along the apical aspect of the thread.[27],[28] Thread shapes may impact the bone–implant contact (BIC) surface area. Currently available thread design shapes are V shape, square shape, buttress shape, and reverse buttress shape. The asymmetric thread was reported to be the best outcome thread design for BIC.[29] Knefel investigated five different thread profiles and found that the most favorable stress distribution was by an asymmetric thread, the profile of which varied along the length of an implant [Table 1].[30]
Table 1: The effect of implant characteristics on osseointegration

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Diameter and length

The risk of failure for short and wide implants is a matter of controversy. Reasons for the higher failure rate in wider and shorter implants might be due to poor bone density and operator skill and minimal BIC.[31] Studies have shown that short implants <10 mm and narrow implant diameter had a higher failure rate.[32],[33] Some reported implant success is significantly impacted by implant diameter.[34] On the contrary, other reported implant length is more important for stability and success than implant diameter and others have confirmed no significant for implant length on its success.[35],[36],[37]

Surface topography

Many studies have reported that BIC can influence peri-implant bone healing and the osseointegration process.[38],[39],[40] Different surface treatments have been developed; chemical via acid-etching and mechanical via grit-blasting or a combination of the two. The chemically etched implants produce a large fractal dimension and punching surfaces that help cell proliferation and increase in BIC and initial osteoblast anchorage.[41],[42] Sandblasting increases commercially pure titanium roughness, a biomechanical feature of a dental implant that influences the primary stability and macrophagic, epithelial, and osteoblast cell surface adhesion.[43] The titanium plasma spray improves surface roughness and wettability; its porous-like topography allows bone ingrowth into the implant surface and direct connection between bone and the implant (osseointegration).[44],[45] Conserva et al. found that rough implant surface improved bone anchorage compared to a smooth implant surface, and it also promotes mesenchymal cell differentiation toward an osteoblastic phenotype.[46] Ideal superficial microtopography can be achieved to stimulate macrophages as well as the proliferation and a pro-angiogenic activity of the endothelial cells immediately after implant placement.[41],[43] However, other investigators have reported increased titanium wear with surface-treated implants compared to smooth surfaces during the insertion, especially during the screwing process [Table 1].[47],[48]

Bone quality and quantity

Bone quality and quantity of available bone at the implant site are among the most vital local factors in the dental implant success.[49],[50] Bone density classification categorizes the bone density to four types of bone according to the ratio of cortical bone to spongy bone.[51] Sakka and Coulthard reported that the dental implant placed into bone Types 1, 2, and 3 has good clinical outcomes compared to Type 4 with a lower success rate.[52] A clinical study with 158 implant sites from 85 patients indicated strong correlations between bone density values from computed tomography and stability parameters.[53] Primary implant stability has been proposed as a key factor influencing the survival rate of implants.[54] Bass and Triplett [55] reported that the success rate of implants was 93.4% in the maxilla and 97.2% in the mandible. They concluded that poor bone quality factor plays a major role in implant failure rate.

Better bone quality of the mandible compared to the maxilla, particularly in the interforaminal region, is probably the reason for implant loading high survival rates in the anterior part of the mandible.[6],[56] In this context, the clinicians should confirm their assumptions regarding bone density at the time of osteotomy development, since bone density at an implant site is a significant feature with respect to surgical protocol and osseointegration. It has been reported that implant stability in the long term after loading seems to be increased due to the significant increase of the peri-implant bone density at the implant–bone interface.[4],[57]

History of periodontitis

Patients with a history of periodontitis are at increased risk of developing peri-implant diseased around dental implants.[58] Meta-analyses showed a significantly higher risk of developing peri-implantitis in patients with a history of periodontitis compared to healthy periodontal subjects.[59] Other studies reported that the microbiota associated with peri-implantitis are similar to periodontitis microbiota and that the deep periodontal pockets could act as a reservoir for microorganisms.[60],[61] Possible risk of bacteria contamination from periodontally diseased sites to peri-implant sulcus.[62],[63],[64]

Peri-implant mucositis is a term used to describe a reversible inflammatory reaction in the mucosa adjacent to an implant,[65] whereas peri-implantitis is defined as an inflammatory process that (a) affects the tissues around an osseointegrated implant in function and (b) may result in loss of supporting bone, if left untreated.[66] According to Sanz et al., the presence of clinical inflammation together with a peri-implant bone level of 2 mm from the expected level after bone remodeling should be considered as a criterion for defining peri-implantitis in clinical studies.[67] The response of the gingiva and the peri-implant mucosa to early and long-standing periods of plaque formation has been investigated. Histological results from the studies on animal models have reported severe inflammatory conditions in sites affected by peri-implantitis and periodontitis.[68],[69] Lang et al. reported that the peri-implantitis lesion is poorly encapsulated, extends into marginal bone tissue, and may continue to progress, resulting in implant loss. It may, therefore, be postulated that individuals having a previous history of periodontitis may be more susceptible to implant failure compared to their respective controls (individuals without a history of periodontitis).[69] Several studies reported high survival rates of implants in individuals with a history of periodontitis-associated tooth loss and patients who received periodontal treatment with supportive maintenance therapy.[59],[70],[71],[72],[73]

Surgical techniques

A variety of surgical techniques for implant site preparation and technique to preserve osseous structures have been introduced such as Piezoelectric bone surgery, flapless implant placement, and osseodensification using Densah burs.[74] Studies have shown that undersized drilling technique increased lateral compression during the implant placement and the use of osteotomes for bone condensations increased primary stability in implants and BIC in poor density bone.[75],[76],[77] The osteotome technique was proposed to compact the bone with the mechanical action of cylindrical instruments along the osteotomy walls.[76] However, another report concluded that such technique has caused trabecular fractures with debris, which caused an obstruction to the process of osseointegration.[78] Implant site preparation with piezoelectric devices has been reported to have minimal trauma on hard and soft tissues and has been recommended for areas with thin bone and during the maxillary sinus augmentation.[79],[80],[81] Stacchi et al. stated that piezoelectric preparation has a positive effect on osseointegration, which results in earlier transition from primary to secondary implant stability.[82]

Flapless implant placement

The flapless technique reported having significantly less bone loss.[83],[84] Denudation of interdental bone in the proximity of the implant from the periosteum can affect the nutrition of the bone and papillae, resulting in an unpredictable degree of resorption of the interproximal marginal bone. In contrast, Pisoni et al.[85] found no statistical differences in the peri-implant bone resorption between the flap and flapless groups, both at the basal record, implant loading, and 3-year control. Other studies reported statistically significant less mean pain severity and duration in the flapless technique compared to the conventional flap procedure for implant placement.[86],[87] The reasons for different outcomes' report are due to the fact of using standardized testing tools to measure the bone loos between different techniques. Osseodensification is a surgical technique that creates an autograft layer of condensed bone at the periphery of the implant bed by the aid of specially designed burs.[88] Studies have found that osseodensification technique enhances bone density, ridge width, and implant primary and secondary stability, comparing to regular drilling.[89],[90]

  Systemic Factors Influencing Osseointegration of Dental Implants Top

Diabetes mellitus

Patients with diabetes mellitus (DM) may show delayed wound healing, increased alveolar bone loss, increased periodontal disease, and increased inflammatory tissue destruction compared to nondiabetic individuals.[91]

Advanced glycation end-products (AGEs), in the periodontal tissues, contribute to the pathogenesis and altered periodontal wound healing observed in patients with diabetes by activating receptors called “receptors for AGEs” located on the periodontium.[92],[93] Oates et al. reported delayed healing and osseointegration in patients with poor glycemic control, while similar success rates were observed 1 year after implant loading for patients with and without DM, including those with poorly-controlled diabetes.[94]

Fiorellini et al., in a study of 40 patients, found a lower success rate of implants in the diabetic compared to nondiabetic patients. The authors reported that the duration of diabetes had an effect on implant success and that greater failure rates were found in patients who had diabetes for longer periods compared to individuals with a shorter history of the metabolic disorder.[95] To evaluate the influence of the duration of diabetes on the implant survival rate, Tawil et al. divided the diabetic patients into four groups (regarding the duration of diabetes) and the results showed no significant differences in implant survival rates between the groups.[96] Furthermore, Javed and Romanos, in their systematic review, reported that dental implants can osseointegrate and remain functionally stable in patients with well-controlled DM compared to patients with poor metabolic control of DM.[4]

A follow-up study between 20 and 36 years found that no differences in survival rates were observed for patients with and without Type 2 diabetes.[97] A meta-analysis report found no direct association between implant failure and glycemic level [Table 3].[98]
Table 2: The effect of implant timing and loading on osseointegration

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Table 3: The effect of diabetes mellitus on osseointegration

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The irradiated hypocellular, hypovascular, and hypoxic tissues are the main cause of dental implants osseointegration failure.[99] Meta-analysis study found almost three-fold increased failure risk for implants placed in the irradiated bone and an almost six-fold risk for implants placed in irradiated bone in the maxilla compared to irradiated bone in the mandible.[100] Another meta-analysis showed a significantly higher implant survival in the nonirradiated bone.[101]

The role of radiation dose

Studies have suggested that osteoradionecrosis (ORN) and implant survival may depend on the dose of radiation.[99],[102] Different investigators submitted a diverse radiation dose range for the risk of ORN. Doses that exceed 50,[103] 60,[104] 65,[102] and 70 Gy [99] have been reported to increase the risk of ORN. Jones et al. reported that soft tissue necrosis can happen with doses <50 Gy, and injury to the salivary glands can occur with doses of even lesser than 20 Gy.[105] The risk and severity of ORN are related to radiation dose, the volume of irradiated tissue, and the dental health of the patients.[106] Tanaka et al. stated the importance of consultation with a radiation oncologist to assist in planning the best locations for implants' placement.[107]

Timing of implant placement

Studies have supported primary implant placement (before radiation therapy) than secondary placement (following radiation therapy) because of damaging effects of radiotherapy.[108],[109] Nooh, in a systematic review of the literature, reported a 92.2% survival rate of dental implants before radiotherapy and 88.9% after radiotherapy.[110] Other studies also reported more predictable osseointegration with primary placement.[108],[111] Some studies recommended a 6–12-month delay after radiotherapy for implant placement.[112],[113],[114],[115] Meta-analysis study concluded that a delay of >12 months would improve the implant success rate.[116] Implant placement decades after radiation therapy has a high failure chance than early placement due to reduction in healing potential because of progressive endarteritis.[117] The use of hyperbaric oxygen therapy before and after implantation may help to stimulate or optimize healing and to decrease ORN risk [Table 2].[118],[119]


Osteoporosis is considered a risk factor for long-term implant survival.[120] Animal studies, using an ovariectomy model of osteoporosis induction with implants inserted in rats, showed that estrogen deficiency results in lower bone turnover rate, lower bone-to-implant contact, lower bone/implant interface biomechanical competence, and lower bone density on cancellous bone. They concluded that systemic change related to osteoporosis can be a risk factor to osseointegration.[121],[122] Dao et al. reported that in patients with osteoporosis, the success rate of dental implant treatment primarily involves two factors: (i) the bone density of the mandible and/or maxilla is reduced along with other parts of the skeleton and (ii) impaired bone metabolism in osteoporosis may reduce the healing capacity of bone around the dental implants and prolong the healing process.[123] Several other studies also reported that a significant decrease in bone healing and regeneration around dental implants in patients with osteoporosis results in higher implant rate failure.[9],[124],[125] Various studies have indicated that dental implant success may be significantly decreased, and complications may arise in relation to dental implants in patients with osteoporosis.[126],[127],[128]

Moy et al.[129] reported the relative risk for implant failure to be significantly higher in females receiving postmenopausal hormone replacement therapy (HRT) compared to their respective controls (patients not receiving HRT). However, August et al. found no significant influence of HRT on implant failure rates among the study participants.[130]

Bisphosphonates (BPs, including alendronate, risedronate, ibandronate, and clodronate) are a group of drugs used for the treatment of oncologic anomalies of the skeletal system. BPs may be administered by either oral or intravenous routes.[131] The chief complication observed in patients under either oral or intravenous BP therapy is osteonecrosis of the jaw (ONJ).[132],[133],[134] It has been recommended that all patients undergoing BP therapy who are expected to receive dental implants should be informed beforehand of the possible risks of development of ONJ and consequent implant loss.[13],[135],[136] Although the risk of developing ONJ in patients undergoing BP therapy is estimated to be low (approximately 0.09%), there is still a controversy over the placement of dental implants in these individuals.[137],[138] In their experimental study on rabbits, Chacon et al. assessed the effect of systemic alendronate therapy on osseointegration of dental implants based on torque-removal values. Seventy-nine identical titanium dental implants were placed in the bilateral distal femur and proximal tibia of 20 New Zealand white rabbits using a standardized surgical protocol. Ten rabbits were given doses of alendronate 1 week before implant placement and continued on weekly dosing for 5 weeks until euthanized. The other ten rabbits were untreated and served as controls. The results showed no significant differences between the alendronate and control groups in both femur and tibia sites. This 6-week follow-up results concluded that orally administered alendronate did not significantly influence the dental implant torque removal after endosseous placement in the femur and tibia.[139] On the contrary, the results of the study by Giro et al.,[140] reported that alendronate usage increases the torque needed to remove the implants. Although further prospective studies are warranted to comprehend the osseointegration of dental implants in patients undergoing BP therapy, a recent literature review concluded that the placement of dental implants in patients taking BPs can have a positive outcome [Table 4].[13]
Table 4: The effect of osteoporosis on osseointegration

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  Conclusion Top

Osseointegration and the overall success of dental implant therapy are dependent on various local and systemic variables as highlighted in the present review. A critical evaluation of such local and systemic risk factors may play an essential role in patient selection, treatment planning, and long-term success of dental implant therapy [Table 5]. In the presence of possible high-risk systemic or local factors, alternative prosthetic treatments should be considered.
Table 5: Local and systemic factors influence on osseointegration

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Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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