Huwais2016 JOMIArticle
Huwais2016 JOMIArticle
Huwais2016 JOMIArticle
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Purpose: It is essential to have sufficient bone bulk and density at the implant site in order to achieve good bone-
to-implant contact and primary stability, which are crucial for osseointegration. A new osteotomy preparation
technique was recently introduced that uses a bone preservation method that creates a layer of compacted
bone along the surface of the osteotomy. The hypothesis of this study was that this novel technique would
increase primary implant stability, bone mineral density, and the percentage of bone at the implant surface
compared with drilling technique. Materials and Methods: A total of 72 osteotomies were created in porcine
tibial plateau bone samples using three preparation techniques: standard drilling; osseous extraction drilling with
a new tapered, multi-fluted bur design; and osseous densification with the same multi-fluted bur rotating in a
reversed direction that preserved and created a compacted layer of bone. The surgical process (temperature
increase, drilling force, and torque), mechanical stability during the insertion and removal of 4.1-mm and 6.0-
mm diameter implants (implant torque and stability quotient), and bone imaging (scanning electron microscopy,
microcomputed tomography measurement of bone mineral density, and histomorphology) were compared among
the three preparation techniques. Results: Osseous densification significantly increased insertion and removal
torques compared to standard drilling or extraction drilling. No significant differences in implant stability quotient
readings or temperature increases were demonstrated among the three groups. Although the same bur was
used for extraction drilling and osseous densification techniques, the osseous densification osteotomy diameters
were smaller than both the extraction drilling and standard drilling osteotomies due to the spring-back effect of
bone elastic strain created. Imaging methods documented a layer of increased bone mineral density around the
periphery of osseous densification osteotomies. The percentage of bone at the implant surface was increased
by approximately three times for implants prepared with osseous densification compared with standard drilling.
Conclusion: This study confirmed the hypothesis that the osseous densification technique would increase primary
stability, bone mineral density, and the percentage of bone at the implant surface compared with drilling. By
preserving bulk bone, it is hypothesized that the healing process will be accelerated due to the bone matrix, cells,
and biochemicals that are maintained in situ and autografted along the surface of the osteotomy site. The healing
response requires further study in vivo. Int J Oral Maxillofac Implants 2016; (10 pages). doi: 10.11607/jomi.4817
Keywords: autografting, biomechanics, bone mineral density, compaction, implant fixation, osseodensification,
primary stability
E
1Private Practice, Periodontics and Implantology, Jackson, ndosseous implants have demonstrated success
Michigan, USA; Adjunct Assistant Clinical Professor, University rates of more than 90% over the past 10 years1 and
of Minnesota, Minneapolis, Minnesota, USA.
2 Associate Professor, Experimental Biomechanics Laboratory, implant stability is considered to be one of the most im-
and Assistant Professor, Lawrence Technological University, portant factors in that success.2 There are many factors
Southfield, Michigan, USA. that can affect initial biomechanical primary stability,
such as the drilling or osteotome surgical preparation
T his research has been previously presented at the 2014
technique,3,4 bone type and bone mineral density,5
American Academy of Periodontology Annual Meeting in San
Francisco, California, USA; the 2014 American Academy of and the diameter, length, taper, threading, and surface
Implant Dentistry Annual Meeting in Orlando, Florida, USA; and design parameters of the implant.6,7 Osseointegration
the 2015 Academy of Osseointegration Annual Meeting in San is defined as a direct structural and functional con-
Francisco, California, USA. nection between living bone and an implant surface
Correspondence to: Eric G. Meyer, Associate Professor, and is considered a prerequisite for implant loading
Experimental Biomechanics Laboratories Assistant Professor, and long-term clinical success.8 Two frequently cited
Department of Biomedical Engineering, College of Engineering, factors affecting osseointegration are the direct bone-
Lawrence Technological University 21000 West Ten Mile Road to-implant contact at the microscopic level9 and the
Southfield, MI 48075, USA. Fax: (248) 204-2527. quality and quantity of the histologic structure of
Email: emeyer@ltu.edu
bone at the implant interface, which is strongly corre-
©2016 by Quintessence Publishing Co Inc. lated with bone mineral density.10 Increased primary
© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
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Huwais et al
stability and maintaining the bulk of bone mineral an osteotomy without removing any bone stock but
and collagen material has been shown to accelerate rather displacing it.29 On the other hand, buccal plate
the healing process after surgery.11–13 Therefore, it is fracture during this procedure may affect implant in-
important for endosseous implant success to preserve sertion stability.30
bone bulk and to maintain the bone’s histologic struc- Osteotome techniques and undersized drilling
ture during the preparation of an osteotomy. have been shown to create a layer of compacted bone
Drilling is a widespread osteotomy preparation at the implant interface, which increases primary sta-
technique that involves the cutting and extraction bility of low-density cancellous bone.31,32,33 However,
of bone tissue to create a cylindrical osteotomy that these techniques also present limitations during sur-
will receive an implant fixture.14 The medical profes- gery. The repeated impacting of a mallet is required
sion has generally adapted commercially available to advance the Summers osteotome, which is a trau-
instruments that have been developed for drilling in matic technique that may be difficult for the surgeon
other materials.15 Drills, sometimes called drill bits or to control and in some cases can result in uninten-
burs, consist of a specified length and diameter shank. tional displacement, fracture, or patient side effects
At the end there is a pointed chisel edge and cutting such as vertigo.34 Expander drills offer an atraumatic
lips that extend to the outer diameter of the drill. The technique but may be cumbersome or difficult for the
shank includes spiral guides called lands and channels surgeon to use because the threading pattern creates
called flutes that remove debris from the hole. Along direct coupling between feed rate and expansion rate,
each flute there is a secondary cutting edge that has a which limits the surgeon’s control.
positive angle called the rake to remove a small thick- A new osteotomy preparation technique, osseous
ness of material with the rotational pass of each flute. densification, has recently been introduced. This bone
Twist drills designed for the most efficient cutting of preservation technique is made possible with a spe-
bone usually have two or three flutes with cutting edg- cially designed bur that has many lands with a large
es that have a 25- to 35-degree rake angle. However, negative rake angle, which work as noncutting edges
the removal of bone during drilling can compromise to increase the density of the bone as they expand an
implant fixation stability and pullout strength.16 Bone osteotomy.35 These densifying burs have four or more
drilling may also lead to other clinical complications, lands and flutes that smoothly compact the bone
such as heat generation–induced necrosis if sufficient (Fig 1). Densifying burs are novel surgical devices as
cooling and irrigation is not applied,17 drill-tip skiving they are designed to have a cutting chisel edge and a
along the bone surface,18 or vibration as the cutting tapered shank, so as they enter deeper into the oste-
resistance vector is constantly changing due to unho- otomy they have a progressively increasing diameter
mogenous bone properties, which can compromise that controls the expansion process.36 These burs are
the geometric accuracy of the osteotomy.19 For more used with a standard surgical engine and can densify
than a decade, clinicians have been asking for im- bone by rotating in the noncutting direction (counter-
provement in bone drilling and preparation.20 clockwise at 800–1,200 rotations per minute) or drill
Several techniques have been introduced to pre- bone by rotating in the cutting direction (clockwise at
vent bone tissue from being sacrificed during the 800–1,200 rotations per minute).
osteotomy preparation process. The undersized prepa- This new technique’s proposed method of bone
ration drilling technique has been shown to improve compaction is through the application of controlled
the early fixation of oral implants in both clinical and deformation due to rolling and sliding contact along
histologic studies21,22; however, this improvement did the inner surface of the osteotomy with the rotating
not translate directly to improved peri-implant bone lands of the densifying bur. The bone deformation
volume23 and did not allow an enhanced healing occurs through viscoelastic and plastic mechanisms
process.24 Bone compaction utilizing the osteotome when the load is controlled beneath the ultimate
technique was introduced by Summers to increase the strength of bone. Copious amounts of irrigation fluid
primary stability of dental implants without removing during this procedure provide lubrication between
bone tissue25 and is believed to improve final bone the bur and bone surfaces and eliminate overheating.
healing.26,27 On the other hand, Buchter et al reported A recommended technique is for the surgeon to utilize
the osteotome technique led to decreased implant a bouncing motion of the bur in and out of the oste-
stability and related this effect to microfractures that otomy, which will induce a pressure wave ahead of the
were created in the peri-implant bone.28 Stavropoulos point of contact. The irrigation fluid that is then forced
et al also reported that the osteotome method had a into the osteotomy may also facilitate autografting of
deleterious effect on osseointegration.3 Ridge expan- bone particles along the inner surface of the osteot-
sion and spreading utilizing screw-type expanders are omy. The autografting supplements the plastic bone
other reported techniques to expand bone and create compaction to further densify the inner walls of the
2 doi: 10.11607/jomi.4817
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NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Huwais et al
© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Huwais et al
a b c
Time (s)
0
0 10 20 30 40 50 60
Depth (mm) Cycle –2
Depth from surface (mm)
4 –4 1
–6 2
6 Fig 3 Materials test-
ing machine program for
–8 3
8 creating a 14-mm oste-
otomy using the clinical
–10 4
10 bouncing technique with
six cycles completed at
–12 5
12 progressive depths with
a 1-mm/sec linear rate
–14 6
14 and 1-second pause at
Cycle each minimum and max-
a b imum depth.
followed by the insertion of the 6.0-mm implant and were measured with or without spacers inserted im-
biomechanical stability measurement. mediately after the osteotomy preparation.
4 doi: 10.11607/jomi.4817
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Huwais et al
120 18
SD ED OD SD ED OD
16
4 * **
20
*
2
0 0
Step 2 Step 3 Step 4 Step 5 Step 2 Step 3 Step 4 Step 5
Fig 4 Measured maximum penetration force during each drill- Fig 5 Measured maximum torque during each drilling step.
ing step. *Significantly different than osseous densification (OD) *Significantly different than osseous densification (OD) and dif-
and different than extraction drilling (ED) based on a one-way ferent than extraction drilling (ED) based on a one-way ANOVA.
ANOVA. SD = standard drilling. SD = standard drilling.
Statistical Comparisons 28
Quantitative biomechanical and temperature data are ex- Drilling
27
pressed as mean ± standard deviation and are based on Osseous densification
groups with three samples each. Differences in tempera- Temperature (°C) 26
ture, drilling force, or drilling torque at each diameter step 25
and differences in the insertion or removal torque of each 24
diameter implant were compared among groups with 23
one-way analysis of variance (ANOVA) statistical compari-
22
sons with Bonferroni post hoc tests. A level of P > .05 was
21
considered significant.
20
Initial temp Step 2 Step 3 Step 4 Step 5
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Huwais et al
180 bur was used for both procedures. The smaller osteot-
SD ED OD omy diameters of the osseous densification technique
Maximum drilling torque (Ncm)
160
demonstrates that elastic strain recovery occurs after
140
this osteotomy preparation technique when the bur is
120
removed from the osteotomy.
10 0 There was a crust of compacted bone with in-
8 0 * creased bone mineral density around the periphery
60 * * of osseous densification osteotomies, but relatively
*
* constant bone mineral density around osteotomies
40 *
*
20
* * created through drilling (Fig 8). Prior to insertion of the
0
implant the crust of increased bone mineral density
4.1-mm 4.1-mm 6.0-mm 6.0-mm around the periphery of osseous densification oste-
insertion removal insertion removal otomies was 0.1 to 0.3 mm along the edges and 0.5 to
Fig 7 Measured maximum 4.0-mm and 6.1-mm implant inser- 1.0 mm at the bottom. After insertion of the implant
tion and removal torques. *Significantly different than osseous or a spacer, the bone mineral density was increased
densification (OD) based on a one-way ANOVA. SD = standard around the periphery of osteotomies created by all
drilling; ED = extraction drilling.
the osteotomy preparation techniques. After implant
insertion the crust thickness of the osseous densifica-
SD ED OD
tion osteotomies was increased to 0.4 to 0.9 mm along
the edges of the implant, while the standard drilling
osteotomies had a crust of 0.2 to 0.6 mm.
HISTOLOGY
DISCUSSION
6 doi: 10.11607/jomi.4817
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Huwais et al
SD ED OD
a b
Fig 9 (a) Histology sections of standard drilling (SD), excavation drilling (ED), and osseous densification (OD) osteotomies stained
with toluidine blue (×10). (b) Microradiograph sections of the same implants. Higher magnification (×50 and ×100) histology at the
bone surface and apical crust regions near the osseous densification implant.
The osseous densification preparation technique Since fresh, hydrated trabecular bone is a ductile mate-
preserves bone bulk in two ways: compaction of can- rial, it has a good capacity for plastic deformation. The
cellous bone due to viscoelastic and plastic deforma- irrigation fluid and fluid content of the bone help this
tion, and compaction autografting of bone particles process by creating a lubrication film between the two
along the length and at the apex of the osteotomy. surfaces to reduce friction and more evenly distribute
There are other, previously discussed osteotomy tech- the compressive forces.
niques that compact bone through deformation, and Osseous densification was shown to increase the
impaction autografting has been used to improve percentage of bone at the implant surface by increas-
stability of total hip replacements.37 The philosophy ing the bone mineral density in the peri-implant re-
of these techniques runs counter to the outcome of gion. Bone compaction has been shown by many
bone drilling, that healthy bone should be maintained, studies to improve early fixation stiffness and strength
especially in regions where the density is already of dental implants25,31,32 and in other orthopedic appli-
compromised. cations.37,45–47 The osteotome and other compaction
The quality and quantity of bone at the implant techniques have been shown to increase the density
interface is linked to the success rate of osseointegra- of cancellous bone,26,47 allowing for a larger surface
tion.10 The mechanical properties of bone are related area of interdigitation with the implant31,33 and there-
not only to mineral density but also to the architec- fore higher frictional resistance as measured by the
tural distribution and collagen integrity.38 Collagen insertion torque.48 Compacted bone has been shown
gives bone its toughness and its ability to dissipate to maintain its histologic structure, which is directly
energy39; therefore, collagen integrity has been found linked to increased bone-to-implant contact10 and in-
to be directly linked to bone plasticity.40 The plastic creased primary stability.49
deformation of bone occurs as a gradual change that Implant stability depends on direct contact be-
is dependent on time and strain rate.41,42 The fluid tween the implant surface and the surrounding bone
content of bone also plays an important role in deter- so that micromotions at this interface are reduced. The
mining bone viscoelasticity.43 Osseous densification amount of micromotion is determined by the bone
is essentially a burnishing process that redistributes density around the implant.50 In low-density bone, as
material on a surface through plastic deformation.44 was investigated in the current study, drilling proce-
The bur’s counterclockwise rotation causes the lands dures that remove bone inevitably lead to low inser-
to slide across the surface of the bone with a compres- tion torques and further reductions in bone mineral
sive force less than the ultimate strength of the bone. density. In these cases, early loading of the implant will
© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Huwais et al
cause micromotion and may lead to a failed bone heal- stability and bone-to-implant contact leads to im-
ing response.51 Cancellous bone stiffness and strength proved bone healing.12,26
are proportional to bone mineral density.52 With re- This study was designed to validate the osseous
duced bone mineral density there is a higher risk that densification technique’s improvements in bone bio-
the remaining bone will reach or exceed the bone’s mi- mechanics in vitro. The porcine tibia cancellous bone
crodamage threshold. If microdamage does occur, the that was used in this study represents a tissue model
bone remodeling unit may require 3 or more months that was somewhat homogenous with a simple ge-
to repair the damaged bone area.53 On the other hand, ometry. However, it does not represent the anatomical
bone compaction techniques have been shown to in- shape of the mandible or maxilla and had no corti-
crease insertion torque and bone density and therefore cal bone layer. Only one implant design, the straight
reduce micromotion.54 While there is an inverse corre- Brånemark implant, was investigated. This implant
lation between insertion torque and micromotion,55 in design was chosen for this study because its gross ge-
soft bone Trisi et al were not able to achieve more than ometry did not contribute to increased primary stabil-
35 Ncm of peak insertion torque.54 In the current study, ity, as might be the case with more advanced tapered
osseous densification increased the insertion torque implants. The drilling depth of 14 mm was set to elimi-
with a 4.1-mm implant to approximately 49 Ncm, up nate the possibility that the implant would bottom out,
from approximately 25 Ncm with the standard drilling which might have influenced the insertion torque and
technique. The percentage increase in insertion torque implant stability quotient measurements. The pump-
of the 6.0-mm implant was even greater with osseous ing method in this study was precisely controlled by
densification versus drilling. High insertion torque is a materials testing machine, as opposed to the clini-
particularly important in achieving a good clinical out- cal scenario when a surgeon will have the flexibility to
come with early or immediate loading.56 control the applied pressure and therefore the rate at
The spring-back effect has been documented as which the osseous densification process occurs. The
a response of compacted bone that reduces the os- surgical process’ parameters, such as drilling speed,
teotomy to a smaller diameter when the osteotome torque, force, feed rate, and heat generation, as well as
is removed.57 In the current study, when the osseous bleeding and other factors, may also affect the healing
densification osteotomy was left empty during mi- process in vivo. Further in vivo investigations are re-
crocomputed tomography imaging, the diameter was quired to address how the increased primary stability,
reduced to approximately 91% of the bur diameter. autografted bone particles, and compacted bone will
While much of the compaction of cancellous bone is affect healing response during the implant’s transition
permanent deformation that occurs due to its plastic from primary to secondary stability.
behavior when loaded beyond the yield point,58 the
spring-back is due to the viscoelastic portion of the
deformation.57 Viscoelasticity is a time-dependent CONCLUSIONS
process, so in order to achieve bone compaction of
this nature, it is necessary to apply stress in a time- This study confirmed the hypothesis that the osse-
controlled manner.43,59 Osseous densification occurs ous densification technique would increase primary
in a slow, incremental process that is carefully con- stability, bone mineral density, and the percentage
trolled by the surgeon, in contrast to the impaction of bone at the implant surface compared with drill-
process of Summer’s osteotome. The viscoelastic re- ing technique. Osseous densification was shown to
covery of the osteotomy demonstrates that there are increase the insertion and removal torques of the im-
residual strains created in the bone’s surface during plants compared to standard drilling and extraction
this preparation technique. The residual strain in the drilling. This demonstrates increased implant primary
bone creates compressive forces against the implant, biomechanical stability.54 The new technique was also
therefore increasing the bone-to-implant contact and shown to have similar clinical safety to drilling when
primary stability,31,57 which have been shown to pro- proper rotary speed, penetration speed, and irriga-
mote osteogenic activity through a mechanobiologic tion are used. Trabecular bone compaction produced
healing process.60 This reverse compression applied to during the osseous densification technique created a
the implant by the bone is also likely responsible for smaller osteotomy than drilling due to spring-back re-
the much higher removal torques that were gener- covery of viscoelastic deformation when the bur was
ated with osseous densification compared to drilling. removed from the osteotomy. The bone mineral den-
High insertion torque is an indication of good primary sity of the osseous densification sites were increased
stability and is necessary to achieve early or immedi- by both compaction and autografting bone along the
ate loading.61 Other studies that placed implants into periphery and at the apex of the osteotomies. The per-
compacted bone have shown that increased primary centage of bone at the implant surface was similarly
8 doi: 10.11607/jomi.4817
© 2016 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Huwais et al
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Akram Alsamarae, and John Schoenbeck, who were Biomedical 17. Augustin G, Davila S, Mihoci K, Udiljak T, Vedrina DS, Antabak A.
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18. Jacobs CH, Pope MH, Berry JT, Hoaglund F. A study of the bone
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Director of Center for Innovative Materials Research at LTU, for 19. Wiggins KL, Malkin S. Drilling of bone. J Biomech 1976;9:553–559.
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Dr Susan M. Stover and Tanya Garcia-Nolen of the UC Davis 21. Shalabi MM, Wolke JG, de Ruijter AJ, Jansen JA. A mechanical evalu-
School of Veterinary Medicine for preparation of the histologic ation of implants placed with different surgical techniques into the
slides. We also thank Bob Evans Farms, Hillsdale, Michigan, for trabecular bone of goats. J Oral Implantol 2007;33:51–58.
help procuring the test specimens. Funding was provided by this 22. Shalabi MM, Wolke JG, de Ruijter AJ, Jansen JA. Histological evalua-
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technique and inventor of the patented multi-fluted osteotome 23. Tabassum A, Meijer GJ, Walboomers XF, Jansen JA. Evaluation of
that was investigated. primary and secondary stability of titanium implants using differ-
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