Vaddamanu et al.

International Journal of Implant Dentistry (2024) 10:56 International Journal of

https://doi.org/10.1186/s40729-024-00565-8
Implant Dentistry

RESEARCH Open Access

A comparative study on bone density

before and after implant placement using
osseodensification technique: a clinical
evaluation
Sunil Kumar Vaddamanu1, Ravinder S. Saini1, Rajesh Vyas1, Masroor Ahmed Kanji1, Abdulkhaliq Ali F. Alshadidi1,
Salah Hafedh2*, Marco Cicciù3 and Giuseppe Minervini4,5

Abstract
Background Dental implant success critically depends on the primary stability of the implant, which is significantly
influenced by the bone density at the osteotomy site. Traditional drilling techniques for osteotomy preparation
often compromise bone volume and quality. This study aimed to evaluate the impact of osseodensification, a novel
osteotomy preparation technique, on bone density and implant stability. The technique utilizes specialized drills
that operate in a counter-clockwise direction to compact autografted bone laterally and apically, preserving and
enhancing bone density.
Methods A total of 32 patients undergoing dental implant surgery were included in this study. Pre-operative and
post-operative bone densities at the apical, mesial, and distal regions of the osteotomy sites were measured using
Dentascan (CT) and analyzed with Radiant DICOM software. The study utilized osseodensification drills for osteotomy
preparation, comparing pre-operative and post-operative bone densities to assess the technique’s efficacy.
Results The study found a statistically significant increase in bone density post-operatively (p < 0.001), with the
greatest improvement observed in the distal region, followed by the mesial and apical regions. The findings
underscore osseodensification’s effectiveness in enhancing bone density and primary stability, with the distal region
exhibiting the highest bone density.
Conclusion Osseodensification represents a significant advancement in implant dentistry for osteotomy preparation.
By preserving and increasing bone density through compact autografting, this technique not only improves primary
stability but also offers potential benefits in indirect sinus lifting and alveolar ridge expansion. The study advocates
for the broader adoption of osseodensification drills in clinical practice to achieve better outcomes in dental
implantology.

*Correspondence:
Salah Hafedh
[email protected]
Full list of author information is available at the end of the article

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Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 2 of 9

Trial Registration This study received ethical approval from The Research Ethics Committee at King Khalid
University’s under Approval no. ECM#2024 − 216. Additionally, it was registered with ClinicalTrials.gov, identifier no:
NCT06268639.
Graphical Abstract

Keywords Osseodensification, Dental implants, Bone density, Osteotomy preparation, Primary stability, Autografting

Background techniques, and biomechanical preparation [4]. Central

The increasing adoption of dental implants as a preferred to the placement of dental implants, achieving primary
modality for replacing missing teeth is underscored by stability is governed by bone density, surgical protocol,
the critical role of implant therapy success, which hinges and the macro and micro-design of the implant, among
on the stability of the primary implant to facilitate osseo- others. The conventional approach to creating osteoto-
integration [1, 2]. Osseointegration, as defined by Bråne- mies involves bone-removal drills, with the final drill
mark and colleagues in 1977, is a direct structural and size being slightly smaller than the implant to ensure pri-
functional connection between living bone and the sur- mary stability. This practice aims to preserve bone bulk,
face of the implant [2]. This phenomenon is pivotal for thereby enhancing the primary mechanical stability of
the implant’s loading capacity and its long-term clinical bone-to-implant contact and, subsequently, the implant’s
success. The achievement of primary stability, influenced secondary stability [5–8].
by variables such as surgical techniques, and the quan- Expanding on these findings, previous studies have
tity and quality of bone, is deemed essential for optimal further validated the impact of bone quality on implant
osseointegration [3–5]. stability, highlighting the benefits of adapted surgi-
The literature highlights the multifaceted aspects con- cal techniques in areas of low bone density to improve
tributing to osseointegration, including the material, implant survival rates [9, 10].
surface, and design of the implant, host factors, surgical
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 3 of 9

Earlier in implant dentistry the surgical technique used Objectives

were undersized implant site preparation [10] and osteo-
tome was used to condense the bone [11]. The use of the 1. To evaluate preoperative bone density: This
osteotome in poor density bone allows fracturing and objective involves the comprehensive assessment
condensing of bone trabeculae, but this technique does of the bone density at the intended site of implant
not improve peri-implant bone density and it may also placement prior to the surgical procedure. Such
cause bone fracture [12]. an evaluation is crucial for establishing a baseline
In contrast to traditional drilling techniques, which against which postoperative outcomes can be
remove bone to create osteotomies, the advent of compared, thereby enabling an understanding of the
osseodensification, a technique developed by Huwais in bone’s condition before any intervention.
2013, presents a novel approach. This technique, char- 2. To evaluate postoperative bone density using
acterized by the use of specially designed burs that com- osseodensification technique: Postoperative
pact and autograft bone along the osteotomy, not only assessment of bone density is essential to ascertain
preserves bone bulk but also enhances the bone density the effectiveness of the osseodensification technique.
around dental implants, thereby improving their primary By comparing the bone density after the implant
stability. Unlike conventional drilling, osseodensification placement with the preoperative levels, this objective
does not excavate bone tissue. Rather, it preserves bone seeks to quantify the impact of osseodensification on
bulk, so bone tissue is simultaneously compacted and enhancing bone density around the implant site.
autografted in an outwardly expanding direction to form 3. To inter-compare bone density before and after
the osteotomy. The unexcavated bone mass increases the placement using osseodensification technique:
bone dentistry in both the mesial-distal and apical oste- The core of the study revolves around a comparative
otomy site [1, 13, 14]. That increase in bone density is analysis of bone density measurements taken before
checked by the comparing the patient pre-operative and and after the application of the osseodensification
post-operative dentascan (CT) [15]. technique. This comparative analysis aims to provide
Osseodensification represents a modern biomechani- empirical evidence regarding the technique’s role in
cal bone preparation process that facilitates the place- improving bone density, which is a critical factor in
ment of dental implants by developing a densification achieving primary stability and long-term success of
layer around the osteotomy site [15–19]. This process, dental implants.
which involves compacting and autografting bone across
the entire depth of the osteotomy, has been shown to The realization of these objectives will contribute signifi-
increase bone density and expansion, thereby offering a cantly to the body of knowledge on dental implantology,
promising alternative to traditional drilling techniques. specifically highlighting the benefits and implications
Subsequent research, has continued to explore the of employing osseodensification as a technique for pre-
effects of bone density and surgical techniques on implant paring the implant site. Through this study, dental pro-
stability and success [20–24]. These investigations have fessionals and researchers will gain valuable insights
contributed to a nuanced understanding of how modifi- into advanced surgical techniques that could potentially
cations in surgical approach, such as osseodensification, enhance the success rates of dental implant procedures.
can positively influence implant outcomes, especially in
low-density bone environments. Methods
The cumulative evidence from these studies under- This study received ethical approval from The Research
scores a critical evolution in dental implantology. By Ethics Committee at King Khalid University’s under
focusing on the interplay between bone density, surgi- Approval no. ECM#2024 − 216. Additionally, it was
cal techniques, and implant design, the field has moved registered with ClinicalTrials.gov, identifier no:
towards personalized, evidence-based strategies that NCT06268639.
enhance implant stability and success.
This study aims to elucidate the impact of pre-opera- Inclusion criteria
tive and post-operative increases in bone density around The study focused on individuals exhibiting either partial
implant surfaces facilitated by osseodensification drills. or complete edentulous ridges in the maxilla or mandi-
By employing digital radiographic techniques such as ble. This broad inclusion criterion was chosen to encom-
dentascan (CT), this investigation seeks to delineate the pass a wide range of dental implant candidates, providing
efficacy of osseodensification drills in achieving enhanced a comprehensive understanding of osseodensification’s
primary stability and to document the variation in bone impact across varied clinical scenarios.
density pre and post-operatively.
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 4 of 9

Exclusion criteria Fabrication of splint with radio-opaque marker

Individuals were excluded from the study under the fol- The initial patient appointment involved taking a diag-
lowing conditions: nostic impression using irreversible hydrocolloid mate-
rial, which was then poured into a dental stone using a
•  Fractured jaw: Patients with a history of jaw vacuum mixing machine. A surgical splint was fabricated
fractures were excluded to prevent confounding from auto-polymerizing acrylic resin on the diagnos-
factors related to bone healing and integrity that tic cast, incorporating Gutta-percha as a radio-opaque
could potentially skew the results of the study marker at the planned implant sites. This splint, finished
regarding the effectiveness of osseodensification. and polished, was used during the Dentascan (CT) to
•  General bone or blood disorders: Those with accurately indicate osteotomy locations.
systemic bone or blood disorders that could impair
osseointegration were also excluded. Conditions Pre-operative bone density analysis
such as osteoporosis, osteopenia, or hematologic The second patient appointment entailed a preopera-
disorders could interfere with the body’s ability to tive Dentascan (CT)( GE Healthcare LightSpeed. Expo-
form a stable integration between the implant and sure 90kv, 2.5 mA,15s and dose – 1179mGy.cm2) at
bone, thus affecting the study’s outcomes. Rohilkhand Medical College and Hospital’s Department
of Radiology. Using Radiant DICOM software, the pre-
These criteria were meticulously set to ensure the study’s operative scans, marked with radio-opaque indicators for
participants were best suited to provide clear insights precise osteotomy positioning, were analyzed. Bone den-
into the effectiveness of osseodensification in enhanc- sity was measured in Hounsfield units at apical, mesial,
ing bone density at the implant site, thereby offering a and distal points relative to each implant site, with the
focused examination of its potential benefits in dental data recorded and categorized as Group I. Figure 1.
implantology.
The methodology of this study encompasses a detailed Osteotomy site preparation
procedural framework, systematically designed to evalu- Under local anesthesia, the surgery proceeded in the
ate the impact of osseodensification on bone density at Department of Prosthodontics. After administering an
dental implant sites. This methodology is structured into incision and raising a flap, a pilot osteotomy was created
several key stages (Table 1). using a pilot drill at speeds between 800 and 1500 RPM.
Subsequent osseodensification drilling expanded the
Selection of the sample size osteotomy sites, followed by implant placement, flap clo-
Utilizing G*Power software, the study defined a sample sure, and suturing [25]. Figure 2 Post-operative care was
size of 32 patients based on specific statistical param- administered, and patients were prepared for subsequent
eters: a significance level (α) of 0.05 and a power of 0.80 Dentascan analysis.
(80%). This population was divided into two groups for
analytical purposes: Post-operative bone density analysis
Post-operative Dentascan evaluations were conducted,
•  Group I: Consisting of the pre-operative bone again using Radiant DICOM software to assess bone
density at 32 osteotomy sites. density at specified positions around the implant sites,
•  Group II: Comprising the post-operative bone with results recorded in Hounsfield units and categorized
density at the same 32 osteotomy sites. as Group II. Figure 3.

Statistical analysis
Data collected were organized using Microsoft Excel and
analyzed with SPSS version 22. The analysis focused on
mean bone density and standard deviation, employing
Table 1 Comparison of preoperative and postoperative bone the student paired t-test to identify significant differences
density in bone density from pre-operative to post-operative
Site Pre-op mean Post-op mean Change p-value stages. A P-value less than 0.05 was deemed indicative of
density (HU) density (HU) in density
(HU)
statistical significance.
Apical 821.3 ± 485.5 1126.7 ± 373.6 305.5 < 0.001*
Mesial 758.3 ± 268.3 1203.7 ± 323.2 445.4 < 0.001* Results
Distal 781.4 ± 283.6 1238.4 ± 332.7 457.1 < 0.001* The study meticulously evaluated the impact of the
*The p-value indicates that the increase in bone density is statistically significant osseodensification technique on bone density at
for each site dental implant sites, comparing pre-operative and
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 5 of 9

Fig. 1 Showing pre-operative bone density analysis

Fig. 2 a) graphical representation of osseodenstification technique b) graphical representation of implant site preparation Courtesy by – Osseodensifica-
tion Paraigm Shift [25]
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 6 of 9

Fig. 3 Showing post-operative bone density analysis

post-operative values across apical, mesial, and distal Distal region

regions. The findings reveal a notable increase in bone
density following the application of osseodensification, •  Pre-operative mean bone density: 781.4 ± 283.6
indicating its effectiveness in enhancing the bone envi- HU.
ronment for dental implants. Below is a consolidated pre- •  Post-operative mean bone density: 1238.4 ± 332.7
sentation of the results: HU.
•  Increase in mean bone density: 457.1 HU.
Overview of bone density changes •  Significant gains in bone density were noted, with
Apical region pre-operative values from 204 HU to 1509 HU and
post-operative values from 552 HU to 1879 HU.
•  Pre-operative mean bone density: 821.3 ± 485.5
Hounsfield Units (HU).
•  Post-operative mean bone density: 1126.7 ± 373.6 Significance of findings
HU. The study’s findings demonstrate a significant enhance-
•  Increase in mean bone density: 305.4 HU. ment in bone density across all regions analyzed (apical,
•  The analysis showed a significant increase in bone mesial, and distal) following the use of osseodensification.
density, with values ranging from 247 HU to 2860 This technique not only preserves but also significantly
HU pre-operatively and from 420 HU to 2143 HU improves the density of bone around dental implants.
post-operatively. Such an increase in bone quality is critical for achieving
primary stability, which is essential for the long-term suc-
cess of dental implants.
Mesial region The observed increases in bone density, evidenced by
the substantial changes in Hounsfield Units, underscore
•  Pre-operative mean bone density: 758.3 ± 268.3 the effectiveness of osseodensification as a valuable
HU. technique in dental implantology. By promoting a more
•  Post-operative mean bone density: 1203.7 ± 323.2 favorable bone environment for implant integration,
HU. osseodensification could lead to improved outcomes for
•  Increase in mean bone density: 445.4 HU. dental implants, particularly in cases where bone quality
•  Bone density improvements were observed, with is a concern (Table 2).
pre-operative values from 225 HU to 1497 HU and Overall, the results affirm the hypothesis that
post-operative values from 679 HU to 1908 HU. osseodensification is a beneficial adjunct to traditional
dental implant preparation techniques, offering a prom-
ising avenue for enhancing osseointegration and poten-
tially increasing the success rates of dental implants.
The increase in bone density from pre-operative to
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 7 of 9

Table 2 Preoperative and postoperative density ranges three dimensions, a significant advancement over tradi-
Site Pre-op min Pre-op max Post-op min Post- tional two-dimensional radiographic techniques [17].
(HU) (HU) (HU) op
The study utilized the Radiant DICOM software for
max
(HU) pre-operative and post-operative bone density analy-
Apical 247 2860 420 2143 sis, highlighting the software’s capabilities in image
Mesial 225 1497 679 1908 manipulation and measurement [31–33]. Following the
Distal 204 1509 552 1879 osseodensification technique, a significant increase in
bone density was observed, particularly in the mesial and
distal positions relative to the apical position. This find-
post-operative measurements was statistically significant ing is consistent with previous research indicating that
(p < 0.001). The significant differences in bone density osseodensification not only enhances primary stability
from pre-operative to post-operative phases validate the but also promotes bone healing and improves the prog-
technique’s role in improving the structural and func- nosis of the implant.
tional integration of dental implants with the surround- Osseodensification, by preventing bone excavation and
ing bone. facilitating lateral and apical bone compaction, represents
a significant advancement in implant bed preparation.
Discussion This technique offers numerous advantages, including
The field of implant dentistry has experienced significant enhanced bone density, residual ridge expansion, and
advancements in recent decades, with increasing patient increased implant stability, thereby contributing to the
awareness about the latest technological and surgical long-term success of dental implants. This study under-
improvements. This evolution has positioned implant scores the importance of osseodensification in improving
dentistry as the preferred treatment option for both peri-implant bone density and primary stability, marking
completely and partially edentulous patients, utilizing a a pivotal development in implant dentistry.
variety of implant modules that leverage both conven-
tional and computerized imaging technologies for opti- Conclusion
mal implant placement. A critical factor in the success of The findings from this study demonstrate that osseoden-
implant therapy is the achievement of primary stability, sification, through the use of specialized drills in a coun-
which is closely linked to the bone density of the patient ter-clockwise direction, significantly enhances bone
[26]. Consequently, primary stability tends to be higher density at the osteotomy site, particularly in the distal
in the mandibular arch than in the maxillary arch, with direction where the greatest bone density is observed,
bone density, surgical protocol, implant thread type, and followed by the mesial and then the apical areas. This
geometry being key factors in enhancing implant pri- densification process not only preserves but also aug-
mary stability [8, 9, 27]. ments bone volume and quality by compacting auto-
Historically, surgical techniques in implant dentistry grafted bone laterally and apically, thereby improving
have included undersized implant site preparation and primary stability and facilitating bone healing around
the use of osteotomes for bone condensation [10, 11]. the implant. The osseodensification technique emerges
However, these methods, particularly in low-density as a groundbreaking, bone-preserving method for oste-
bone, may not improve peri-implant bone density and otomy preparation, offering additional benefits such as
risk bone fracture [12]. potential indirect sinus lifting and alveolar ridge expan-
This study explores the enhancement of bone density sion. This technique represents a significant advance-
at various osteotomy sites using the osseodensification ment in implant dentistry, promoting better outcomes
drill, introduced by Dr. Salah Huwais in 2014. Unlike tra- for implant stability and longevity.
ditional drilling, osseodensification preserves bone bulk
Acknowledgements
by compacting and autografting bone in an outwardly The authors extend their appreciation to the Deanship of Research and
expanding direction, thus increasing bone density around Graduate Studies at King Khalid University for funding this work through
the implant. This increase in bone density is quantita- Review Article Project unde grant number RA.KKU/19/45.

tively assessed through pre-operative and post-operative Author contributions

Dentascan (CT) comparisons [1, 2, 15, 28–30]. Conceptualization, SKV, and RSS; methodology, SKV; software, RSS; validation,
Radiographic guides, essential for accurate treatment SKV,RV; formal analysis, MAK; investigation, AAFA; resources, SKV,AAFA; data
curation, SKV; writing-original draft preparation, SKV,RSS and GM; writing—
planning in implant dentistry, were fabricated using review and editing, GM, SKV, RV; visualization, SH, MC; supervision, GM project
various radiopaque markers, including gutta-percha, to administration, SKV. All authors have read and agreed to the published version
pinpoint the osteotomy sites on Dentascan (CT). These of the manuscript.

guides not only facilitate precise implant placement but

also allow for the assessment of surgical implant sites in
Vaddamanu et al. International Journal of Implant Dentistry (2024) 10:56 Page 8 of 9

Funding 10. Alghamdi H, Anand PS, Anil S. Undersized Implant Site Preparation to
The authors extend their appreciation to the Deanship of Research and Enhance Primary Implant Stability in poor bone density: a prospective clinical
Graduate Studies at King Khalid University for funding this work through study. J Oral Maxillofac Surg. 2011;69(12):e506–12.
Review Article Project under grant number RA.KKU/19/45. 11. Summers RB. A new concept in maxillary implant surgery: the osteotome
technique. Compendium. 1994;15(2):152. 154–6, 158 passim; quiz 162.
Data availability 12. Shalabi MM, Wolke JGC, De Ruijter AJE, Jansen JA. Histological evaluation of
Dr. Sunil Kumar Vaddamanu will have access to the data that were the basis for oral implants inserted with different surgical techniques into the trabecular
this article, and can be reached out for data in case is needed for review. bone of goats. Clin Oral Implants Res. 2007;18(4):489–95.
13. Huwais S, Meyer E. A Novel Osseous Densification Approach in Implant
Osteotomy Preparation to increase Biomechanical Primary Stability, Bone
Declarations Mineral density, and bone-to-Implant contact. Int J Oral Maxillofac Implants.
2017;32(1):27–36.
Ethics approval and consent to participate 14. Apparaju V, Velamati SC, Karnati L, Salahshoor A, Nateghi F, Vaddamanu SK.
The study was conducted in accordance with the Declaration of Helsinki, and Does residual bone thickness apical to periodontal defect play a major role
the protocol was approved by the Research Ethics Committee at King Khalid in maxillary sinus mucous membrane thickness? A cone-beam computed
University, Saudi Arabia [ECM#2024 − 216, following the protocol HAPO- tomography-assisted retrospective study. Dent Res J (Isfahan). 2019;16(4):251.
06-B-001]. The study protocol was developed, and all subjects gave their 15. Balasaheb S, Vidyapeeth MB, Lulla S, Dodwad V, Patil S, Vhanmane P, INTERNA-
written informed consent for inclusion before they participated in the study. TIONAL JOURNAL OF CURRENT MEDICAL AND PHARMACEUTICAL RESEARCH
ENHANCING IMPLANT STABILITY WITH OSSEODENSIFICATION-A REVIEW.
Consent for publication Enhancing Implant Stability With Osseodensification-A Review. 2019; ​h​t​t​​p​s​:​/​​/​
Not applicable. d​o​​i​.​​o​r​g​/​1​0​.​2​4​3​2​7​/​2​3​9​5​6​4​2​9​.​i​j​c​m​p​r​2​0​1​9​0​6​6​7​5​​​​​​​
16. Lulla SJ, Lulla S, Dodwad V, Patil S, Vhanmane P, INTERNATIONAL JOURNAL
Competing interests OF, CURRENT MEDICAL AND PHARMACEUTICAL RESEARCH ENHANCING
The authors declare no competing interests. IMPLANT STABILITY WITH OSSEODENSIFICATION-A REVIEW. 2022; ​h​t​t​​p​s​:​/​​/​d​o​​i​.​​
o​r​g​/​1​0​.​2​4​3​2​7​/​2​3​9​5​6​4​2​9​.​i​j​c​m​p​r​2​0​1​9​0​6​6​7​5​​​​​​​
Author details 17. Alshadidi AAF, Alshahrani AA, Aldosari LIN, Chaturvedi S, Saini RS, Hassan SAB,
1
Department of Allied Dental Health Sciences, College of Applied Medical Cicciù M, Minervini G. Investigation on the application of artificial intelligence
Sciences, King Khalid University, Abha, Saudi Arabia in prosthodontics. Appl Sci. 2023;13(8):5004.
2
Orthodontics Department, Faculty of Dentistry, Sana’a University, Sana’a, 18. Talluri S, Vaddamanu S, Apparaju V, Vyas R, Ahuja S, Kanji M. Evaluating
Yemen cortico-cancellous ratio using virtual implant planning and its relation with
3
Department of Biomedical and Surgical and Biomedical Sciences, immediate and long-term stability of a dental implant- A CBCT-assisted
Catania University, Catania, Italy prospective observational clinical study. Niger J Clin Pract. 2019;22(7):982.
4
Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha 19. Apparaju V, Vaddamanu SK, Mandali BK, Vyas R, Gurumurthy V, Vishwanath
Dental College and Hospitals, Saveetha University, Chennai, India S. Does the quality of residual alveolar bone apical to a periodontal lesion
5
Multidisciplinary Department of Medical-Surgical and beneath the maxillary sinus play a vital role in preventing the extension of
Odontostomatological Specialties, University of Campania “Luigi periodontal disease to maxillary sinus? A CBCT-assisted retrospective study.
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20. Reddy GVKM, Vamsi Krishna CH, Lakshmi S, Aditya V, Sekhar NC, Shastry YM.
Received: 17 May 2024 / Accepted: 14 October 2024 Evaluation of bone density around the implants placed using drilling tech-
nique and bone expansion technique: an in vivo study. J Indian Prosthodon-
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