424 THREE OSTEOTOMY TECHNIQUES SLETE ET AL

Histomorphometric Comparison of 3
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Osteotomy Techniques
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Frederic B. Slete, DDS,* Paul Olin, DDS, MS,† and Hari Prasad, MS‡

he evolution of modern dental Purpose: This pilot study com- samples was performed to compare

T implant treatment can be traced

to at least 2500 BC with the
Egyptian civilization.1 Throughout
pares the histomorphometric structure
of osteotomy preparation through
standard extraction drilling (SD),
immediate bone-to-implant contact
(BIC) and the percentage of bone
volume within a 2-mm zone sur-
this evolution, much time, effort, and Summers osteotomes (SO), and rounding the implant.
research have been directed toward the
a new method of nonextraction dril- Results: OD achieved 60.3%
single root form implant fixture. In the
last few decades, an endless array of ling called osseodensification (OD). BIC, SO 40.7% BIC, and standard
shapes, grooves, threads, tapers, plat- Method and Materials: Fresh extraction drilling (SD) 16.3% BIC.
forms, surface coatings, alloys, ce- porcine tibia plateau was used as The percentage of bone volume in
ramics, etchings, polishes, and designs the surgical specimen. Three prepa- the surrounding 2-mm width from
have been tried, tested, and marketed.2,3 ration methods (N ¼ 6 for each) the implant body using the same
All in an effort to gain or increase were used to prepare 18 osteotomies area units per sample was found to
primary stability and the promise of according to manufacturer proto- be greatest for OD.
subsequent secondary stability or os- cols. Eighteen tapered screw-vent Conclusion: This study demon-
seointegration. (4.7 3 13 mm) implants were strated that osteotomy preparation
As recently as 1995, it was postu- placed. After osteotomy preparation can influence both BIC and per-
lated that in implant dentistry “the sys- and implant placement, all porcine centage of bone volume around
tem has not been fully optimized.”4
tibias were placed in 10% formalin the implant. (Implant Dent
Dentistry is still on a quest to achieve
and enhance primary stability and thus solution in preparation for histolog- 2018;27:424–428)
predictably allow for immediate or ear- ical staining and sectioning. Histo- Key Words: osseodensification,
lier loading of implants. morphometric analysis of all BIC, BV%, primary stability
Primary stability of implants is
defined as dependent upon bone quality
and quantity, implant fixture design, less than 50- to 150-mm thresholds until tissue. Osteotome techniques have been
and surgical technique.5–7 The goal of osseointegration occurs.8–10 shown to create a layer of compacted
primary stability is achieved when The most common osteotomy bone at the implant interface in the can-
implant micromotion can be limited to preparation technique for implant cellous bone.14–16 This can enhance pri-
placement is surgical extraction drilling mary stability of the implant. However,
*Private Practice, Jackson, MI; Graduate, University of
of bone. Commercially available surgi- limitations of this technique include sur-
Minnesota School of Dentistry Certificate Program in
Contemporary, Implant, and Esthetic Dentistry, Minneapolis,
cal burs are modeled after drill bits or gical trauma, unintentional fracture or
MN.
†Associate Professor, Director, Division of Prosthodontics,
burs designed to cut materials other displacement of bone, and even patient
Department of Restorative Services, Dental Implant Program,
University of Minnesota School of Dentistry, Minneapolis, MN.
than bone such as metal or wood.11 vertigo.17
‡Assistant Director, Hard Tissue Research Laboratory, Senior
Research Scientist, University of Minnesota, School of Dentistry,
These burs, adapted for dental use, pro- A new osteotomy technique, as
Minneapolis, MN. duce an osteotomy through removal or described by Huwais and Meyer,18 has
extraction of bone tissue to create recently been introduced. This method
Reprint requests and correspondence to: Frederic
B. Slete, DDS, 306 W, Washington, Suite 205, Jackson, a “hole” to receive the implant fixture.12 of osseous densification and bone com-
MI 49201, Phone: 517-787-5055, Fax: 517-787-9346, Bone preparation without “extrac- paction (osseodensification) occurs
E-mail: [email protected]
tion” drilling can be achieved using os- without the extraction of the bony
ISSN 1056-6163/18/02704-424 teotomes. This technique was introduced matrix, but rather takes advantage of
Implant Dentistry
Volume 27
Number 4 by Summers13 in an attempt to increase the viscoelastic and plastic abilities of
Copyright © 2018 Wolters Kluwer Health, Inc. All rights
reserved. primary stability and expand the edentu- the bone to deform using a time-
DOI: 10.1097/ID.0000000000000767 lous ridge without the extraction of bone dependent stress (force) to create a

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 SLETE ET AL IMPLANT DENTISTRY / VOLUME 27, NUMBER 4 2018 425

immediately surrounding the implant at

the time of placement also known as bone
volume percentage (BV%), and trabecu-
lar integrity after preparation.
MATERIALS AND METHODS
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Experimental Design
Commercially available surgical
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burs were used to prepare the implant

osteotomies in the standard drilling (SD)
group using the manufacturers’ recom-
mendations. This drilling sequence
included a pilot drill (1.7 mm) followed
by the manufacturers’ sequence for the
appropriate implant size (4.7 mm). The
Summers osteotome (SO) group was
prepared with a pilot drill (1.7 mm) fol-
lowed by consecutive Osteotome com-
paction to size the osteotomy through
instrumentation sizes I, II, III of the set.
Osseodensification (OD) was performed
through a pilot drill (1.7 mm) and
consecutive densification burs with max-
imum diameters of 2.5, 3.5, and 4.5 mm.
Water irrigation was used during
preparation.

Specimens
A total of 18 implant sites were
prepared in 6 porcine tibia plateau bone
samples. The bone samples were pre-
pared by removing the articular surface
and subchondral layers to expose the
cancellous bone. Groups of 3 osteoto-
mies were randomly prepared in each
tibia, using the 3 preparation techni-
ques. Care was taken to place each
osteotomy outside the central softer
medullary area of the tibia bone. A
Fig. 1. A, Three preparation methods with longitudinal section of the implant/bone relation- total of N ¼ 6 for each technique was
ship at day zero, 320, 350, and 3100 magnification. The longitudinal section demonstrates completed. A standardized 4.7mm 3
that standard drilling produced minimal bone occupancy within the threads. The OD method 13mm tapered screw-vent implant
demonstrates increased unfractured and compacted bone within the threads compared with was fully seated in each osteotomy
the osteotome method, which reveals fractured and less dense bone segments. B, Three immediately upon completion of os-
preparation methods’ cross-sectional view of implant/bone at day zero, 350 and 3100 teotomy preparation.
magnification. The center horizontal row is stained with Stevenel’s blue and van Gieson’s
picrofuchsin and analyzed with polarized light. Vital bone (red), nonvital bone (green), and
Histologic Preparation and
nuclei and cells (blue). Standard drilling produced minimal bone contact with the implant body.
Quantitative Analysis
The OD method demonstrates intimate contact of compacted bone particles with the implant.
The osteotome method produced an irregular contact with the implant and a scattered pattern The specimens were harvested and
of compacted fractured trabecular bone segments. placed in 10% neutral buffered formalin
immediately upon implant placement.
Upon receipt in the Hard Tissue Research
time-dependent strain (deformation).18–20 The purpose of this investigation was Laboratory at the University of Minne-
This technique produces a “burnished” to compare 3 techniques of osteotomy sota, the implant and bone specimen
crust of increased bone mineral density preparation through analysis of a histolog- were sectioned vertically in an anterior/
around the osteotomy site circumferen- ical survey for bone-to-implant contact posterior (mesial/distal) orientation ac-
tially and apically.18 (BIC), bone density, and distribution cording to protocol specifications.

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 426 THREE OSTEOTOMY TECHNIQUES SLETE ET AL

40.7%, and SD 16.3% of implant

perimeter in contact with bone. BV%
within 2 mm of the implant (Fig. 2) pro-
duced was 62% for OD, 49% for SO,
and 54% for standard drilling (SD).
It was also noted that the osseodensifi-
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cation (OD) method consistently pro-

duced an increase in fine bone
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particles dispersed within the surround-

ing marrow spaces and between the
implant threads.
Fig. 2. Graphic representation of computerized image analysis of vital bone, nonvital bone,
and nonbone elements within 2 mm of the implant after preparation through each of the 3 DISCUSSION
tested methods. BIC and BV% were analyzed and calculated for each method. The OD
method improved both the BIC and BV% within 2 mm of the implant versus the other methods Comparing the histologic slides in
tested. Figure 1, A and B at 3100 magnifica-
tion, some obvious and significant dif-
ferences can be observed. The SD
Immediately after sectioning specimens • Nonvital bone and osteoid stain (standard drilling) method of prepara-
were dehydrated with a graded series of bright green tion produced an implant fixture sur-
alcohols for 9 days. After dehydration, • Nuclei of cells, including osteo- rounded by native bone with some
the specimens were infiltrated with blasts, osteoclasts, and osteocytes, trabecular bone contact consistent upon
a light-curing embedding resin (Techno- stain blue the outer edge or perimeter of the
vit 7200 VLC; Kulzer, Wehrheim, Ger- • Connective tissue stains various implant threads, with even and undis-
many). After 20 days of infiltration with shades of green. rupted marrow spaces. There was very
constant shaking at normal atmospheric little, if any, trabecular bony structure
pressure, the specimens were embedded between or in contact with the inner
Histomorphometric Analysis portion of the thread design or implant
and polymerized by 450-nm light with
After histological preparation, the body core. This was consistent in both
the temperature of the specimens never
specimens were evaluated histomor- the longitudinal and cross-cut implant
exceeding 40°C. The specimens were
phometrically. All the specimens were sections produced (Fig. 1, A and B).
then prepared by the cutting/grinding
digitized at the same magnification The distribution and pattern of the tra-
method of Donath and Rohrer.21,22 becular and marrow space architecture
using a Nikon Eclipse 50i microscope
The specimens were cut to a thick- immediately surrounding the implant
(Nikon Corporation, Tokyo, Japan) and
ness of 150 mm on an EXAKT cutting/ were unaltered by preparation and
a SPOT Insight 2 mega sample digital
grinding system (EXAKT Technolo- implant placement.
camera (Diagnostic Instruments Inc.,
gies, Oklahoma City, OK). Then, speci- In the samples produced through
Sterling Heights, MI). Histomorpho-
mens were then polished to a thickness metric measurements were completed SO, there was visible compression and
of 45 to 65 mm using a series of polish- using a combination of programs of the condensation of the trabecular pattern
ing sandpaper discs from 800 to 2400 SPOT Insight 2 mega sample digital in the area immediately adjacent and in
grit using an EXAKT microgrinding camera (Adobe Photoshop, Adobe Sys- contact with the implant. Bony contact
system followed by a final polish with tems, and National Institutes of Health with the perimeter and intrathread di-
0.3-mm alumina polishing paste. The [NIH] Image). mensions was enhanced compared with
slides were stained with Stevenel’s blue At least 2 slides of each specimen standard drilling (SD). The pattern of
and van Gieson’s picrofuchsin and were evaluated. Histomorphometric compression and condensation was non-
cover-slipped for histologic analysis analysis was performed, and the param- uniform longitudinally and in cross-
by means of bright field and polarized eters measured were the percentage of section. Some areas of the implant had
microscopic evaluation. total bone area, connective tissue, and a compressed trabecular pattern, and
This method differentially stains marrow space. BIC was also calculated some areas did not, displaying irregular
material within the specimens. Very for each specimen evaluated (Fig. 2). compression patterns. Furthermore, tra-
precise determinations of the percent- Slide magnification views of 320, becular integrity was compromised con-
age of vital, nonvital bone, and nonbone 350, and 3100 were prepared for anal- sistently in the SO method, evident by
components are possible using comput- ysis, observation, and comparison. the appearance of broken, fractured, and
erized image analysis. partial piece trabeculae throughout the
compressed bony matrix in contact with
• Vital bone stains bright red with RESULTS or near the implant (Fig. 1, A and B).
variations in intensity depending In quantifying BIC (Fig. 2), OD Although the data in this study resulted
on the maturity of the bone preparation produced 60.3%, SO in a higher bone volume calculated in

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 SLETE ET AL IMPLANT DENTISTRY / VOLUME 27, NUMBER 4 2018 427

the 2-mm zone around the implant evident by the resulting fractured and Clinical Application
through standard drilling (SD) 54% ver- broken trabeculae, may promote a pro- Clinically, the preparation tech-
sus SO 49% method (Fig. 2), the histol- longed inflammatory and “clean-up” nique could have a significant influence
ogy immediately adjacent and in BIC stage of healing before new bone growth on our ability to more consistently
calculated demonstrates enhanced bony and remodeling can ensue. achieve an increase in primary stability
geometry resulting through SO. In vivo studies on sheep have on the day of surgery. Bone preparation
shown that fine bony particles in the
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In the osseodensification (OD) techniques that promote BIC, BV%,

method, compression and condensation walls of the osteotomy and in between bone quality around the newly placed
implant enhance primary stability by
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of whole, intact trabeculae was observed the threads of the implant body act
surrounding the implant fixture in lon- as new bone growth initiators to definition.
gitudinal and cross-section specimens enhance progression to secondary sta- The presence of autogenous bone
(Fig. 1, A and B). Furthermore, bony bility.29–31 Furthermore, osteotomy graft particles could act as early new bone
condensation was also observed at the production without extraction of exist- growth mediators and promote earlier
apical tip of the implant that was not ing bone preserves existing collagen healing. This could result in increased
consistently produced through the other and bone bulk. The presence of colla- initial torque values, higher implant sta-
2 methods (Fig. 1A). The resulting com- gen and bone bulk enhances revascu- bility quotient values, decreased micro-
pression and condensation of bone was larization, a critical element in new motion, and more predictable progression
much more consistent and uniform bone growth and remodeling.9 to secondary stability. The possibility of
throughout, and the zone of visible com- Further investigation into the result- achieving immediate or early loading
pression was consistent at roughly ing new bone growth and revasculariza- parameters is enhanced.
0.7 mm laterally and apically. The inti- tion after OD is warranted. Investigation
macy of BIC is visible at 320, 350, and into cellular repair mechanisms and DISCLOSURE
3100 magnification (Fig. 1, A and B). bone morphogenic protein timing and
The completeness of intrathread spaces response comparing osseodensifica- No funding was received for this
completely filled by whole, intact trabec- tion versus standard drilling and os- work. Drs. F. B. Slete and P. Olin both
ular structures should be noted. This is teotome preparation would also be have a minority financial interest in
significant clinically in that trabecular beneficial in understanding this new Versah, LLC.
bone condensation has been shown to technique.
increase primary stability, increase APPROVAL
BIC, and accelerate bone healing.15,16,23
Bone mineralization and organic This study did not involve live or
tissue properties along with its architec- CONCLUSION in vivo use of human or animals and did
tural distribution determine the mechan- In this study: not require IRB or ERB approval.
ical competence properties of bone.24
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