Received: 3 June 2024 Revised: 13 September 2024 Accepted: 24 September 2024

DOI: 10.1002/JPER.24-0343

H UMAN RANDOMIZED CONTROL TRIAL

Ridge dimensional changes and implant stability utilizing

the osseodensification protocol: A randomized clinical trial

Aziz M. Saqr1 Srinivas Ayilavarapu1 Kavan Gandhi2 Chun-Teh Lee1

Popi Stylianou1

1 Department of Periodontics and Dental

Hygiene, University of Texas Health Abstract
Science Center at Houston, School of Background: There is limited evidence on the effect of osseodensification
Dentistry, Houston, Texas, USA
2 Department of Diagnostics and
drilling (OD) on alveolar ridge dimension changes and implant stability com-
Biomedical Sciences, University of Texas pared to standard drilling (SD). The purpose of this study was to compare
Health Science Center at Houston, School the effect of both drilling protocols on ridge dimensional changes and implant
of Dentistry, Houston, Texas, USA
stability.
Correspondence Methods: Fifteen patients were recruited for a total of 20 pairs of implants.
Popi Stylianou, Department of Pre- and postdrilling ridge widths were measured at the crest and 5 and 10 mm
Periodontics, University of Texas School
apical to the crest, using a premarked surgical guide as a reference to stan-
of Dentistry at Houston, 7500 Cambridge
St. SOD6477, Houston, TX 77054, USA. dardize recordings. Following implant placement, insertion torque and implant
Email: [email protected] stability quotients (ISQ) were recorded. ISQ were also recorded at 3, 6, and
Funding information
12 weeks post-op. Six-month post-op changes in buccal bone thickness (BBT)
University of Texas School of Dentistry; were measured via pre-op and post-op cone beam computed tomography (CBCT)
American Academy of Periodontology superimposition analysis.
Foundation
Results: Greater ridge width changes were observed at the crest and 5 mm api-
cal from the crest, favoring OD, with no difference at 10 mm. When comparing
BBT 6 months post-op, OD maintained BBT better than SD. Additionally, greater
insertion torque, ISQ, and high implant stability (HIS) were observed following
OD compared to SD.
Conclusion: OD results in greater ridge dimensional changes compared to SD
following osteotomy preparation, predictably maintains BBT and reduces the
risk of buccal dehiscence and resorption, obtains superior torque at placement,
higher ISQ values, and a greater number of implants achieving HIS, which is
maintained throughout the entire healing period.

KEYWORDS
bone tissue, cone beam computed tomography, dental implants, randomized controlled trial,
wound healing

1 INTRODUCTION ments, there is limited evidence for evaluating different

drilling protocols for implant healing. In 2004, Albrekts-
Implant surface modifications and design have been son et al. suggested enhancing surgical protocols could
shown to improve implant healing and osseointegration improve clinical outcomes.3 Huwais introduced the con-
of the implant in the long term.1,2 Despite these advance- cept of osseodensification, a nonsubtractive bone drilling

J Periodontol. 2025;96:739–747. wileyonlinelibrary.com/journal/jper © 2024 American Academy of Periodontology. 739

 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
740 SAQR et al.

protocol using fluted burs* that drill in reverse, creat- selected to receive at least two dental implants† in single-
ing a layer of compacted bone along the surface of the unit or larger-span edentulous spaces in the Graduate
osteotomy to expand ridges and increase primary stability, Periodontics Clinic at UTSD, totaling 40 implants (20 in
bone density, and bone-to-implant contact.4 each group). Inclusion criteria included two or more eden-
Currently, evidence on the effect of osseodensification tulous spaces in the same arch, 10 weeks or longer post
on ridge expansion is limited. Frizzerra et al. reported extractions, located in the same or contralateral quad-
0.66 mm of crestal ridge expansion and a lower incidence rants. Bone type was D3 or D4 with at least 1.5 mm of
of buccal bone defects at implant placement following buccal bone present at the anticipated implant position.15
osseodensification.5 Koutouzis et al. evaluated alveolar Exclusion criteria included restoratively driven implant
ridge expansion in varying ridge widths in humans, positions requiring bone grafting, history of xenogenic
showing significant increases in ridge width when using bone graft material, smoking more than five cigarettes
osseodensification drilling (OD) protocols.6 However, no per day, alcoholism or drug abuse in the last 5 years, or
study has compared ridge expansion and 6-month post- any systemic disease or medication affecting healing, such
op cone beam computed tomography (CBCT) buccal bone as uncontrolled Type II diabetes or bisphosphonate use.
thickness (BBT) changes following osseodensification and Written informed consent was obtained from all patients,
standard drilling (SD). and implant site allocation was determined by randomized
Recent studies show that osseodensification results in coin toss.
narrower osteotomies, greater implant insertion torque,
implant stability, and bone-to-implant contact compared
to SD.4,7–14 These improvements are attributed to the vis- 2.2 Surgical protocol
coelastic nature of bone, increased autologous bone chips
along osteotomy walls, and increased bone density after Implant planning software‡ was used to ensure restora-
implant placement.4,7–11 Studies by Arafat et al. and Berg- tively driven positions and to fabricate surgical guides.
amo et al. found greater primary and secondary implant After obtaining local anesthesia, a full-thickness flap was
stability following OD compared to SD.12,13 Althobaiti elevated to measure the alveolar ridge 10 mm apical to
et al. confirmed these findings, showing greater implant the crest (Figure 1A). The surgical guide was seated and
stability quotient (ISQ) values and bone density at the used as a reference to standardize recordings. Using a sur-
bone-to-implant interface following osseodensification.14 gical pen§ , dots were placed at the crest and 5 mm and
The primary objective of this study was to compare ridge 10 mm apical from the crest, in line with the middle of
dimensional changes at the crest and 5 mm and 10 mm api- the osteotomy (Figure 1B). Initial ridge dimensions were
cal from the crest immediately following SD (control) and recorded using a caliper‖ (Figure 1C). Standard or OD was
OD (test) protocols in addition to BBT changes 6 months performed, followed by postdrilling measurements at the
following implant placement via CBCT analysis. The sec- same points (Figure 1D). Implants were placed, insertion
ondary objective was to evaluate the effect of SD and OD torques recorded, and ISQ were measured using an ISQ
on implant stability at the time of implant placement and recording device¶ (Figure 1E). ISQ of 70 or higher indi-
at 3, 6, and 12 weeks following treatment. cate high implant stability (HIS) and allow for immediate
loading. ISQ readings were taken at 3, 6, and 12 weeks
(Figure 1F). Implants with insertion torques of less than
2 MATERIALS AND METHODS 35 Ncm were excluded from 3- and 6-week readings; 12-
week ISQ were obtained at second-stage implant surgery.
2.1 Patient enrollment Six periodontics residents performed the surgeries under
the guidance of board-certified periodontists (P.S. and
This randomized controlled trial (protocol number HSC- S.A.). All data recordings were made by A.S. under the
DB-21-0597) was reviewed and approved by the institu- supervision of either S.A. or P.S.
tional review board of the UT Health Science Center at
Houston (UTSD, University of Texas School of Dentistry),
conducted in accordance with the Helsinki Declaration † NobelReplace Conical Connection Implants; Nobel Biocare, Zurich,

of 1975 as revised in 2013, and registered at ClinicalTri- Switzerland.

‡ 3Shape Trios; 3Shape, Copenhagen, Denmark.
als.gov (ID number NCT05283928). Fifteen patients were
§ Mini McKesson Surgical Skin Marker; McKesson Medical-Surgical Inc.,

Richmond, Virginia, USA.

‖ Krekeler Implant Caliper; ProDent USA, East Brunswick, New Jersey,

USA.
* Densah drills; Versah, Troy, Michigan, USA. ¶ Osstell Beacon; Integration Diagnostics AB, Göteborg, Sweden.
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SAQR et al. 741

F I G U R E 1 Surgical and radiographic analysis protocol. (A) Full-thickness flap elevation. (B) Surgical guide was seated with
measurement markings. (C) Measurements obtained using Krekeler caliper. (D) Postdrilling measurements were obtained, and implants were
placed. Insertion torque and implant stability quotient (ISQ) obtained. (E) Healing abutments seated and flap closure obtained. (F) ISQ
obtained at 3, 4, and 12 weeks post-op. (G) Pre-op and 6-month post-op cone beam computed tomography (CBCT) are superimposed using
Invivo Anatomage. Once superimposed, pre-op CBCT is hidden, and 1.5- and 5-mm measurements are taken from implant platform. Buccal
bone thickness (BBT) is measured and recorded 1.5 and 5 mm apical to implant platform. (H) Once all post-op measurements were made,
post-op CBCT was removed, maintaining position of BBT measurement. (I) Exact measurements were obtained on pre-op CBCT alone
according to position of buccal bone. Changes in alveolar ridge dimensions were determined. Same method was used to measure alveolar
ridge width changes at crest and 5 mm from crest.

2.3 Six-month CBCT analysis ment (Figure 1H). The same measurements were then
obtained on the pre-op CBCT alone, according to the
CBCT was obtained 6 months post-placement for radio- position of the buccal bone (Figure 1I). Changes in BBT
graphic analysis, performed by a blinded dental radiologist were then determined. Implants grafted at placement were
(K.G.) using 3D imaging software.# Pre- and post-op excluded from the 6-month CBCT analysis.
CBCTs were superimposed, and once accurately super-
imposed and the center of the implant was identified,
the pre-op CBCT was hidden, leaving the post-op CBCT 2.4 Statistical analysis
visible (Figure 1G). BBT was recorded at 1.5 mm and 5
mm from the implant platform. The BBT was recorded Sample size calculations assuming 90% power for testing,
as the distance from the implant surface to the most effect size = 1.0, and α = 0.05 resulted in 13 implants
buccal aspect of the alveolar bone (Figure 1G). Once all required per group. Assuming a 35% loss to follow-up or
post-op measurements were made, the post-op CBCT was treatment failure, the desired implant recruitment was 20
removed, maintaining the position of the BBT measure- per group. Considering a single patient may contribute
more than one implant per group, the Type II Wald
chi-square test was used to compare baseline character-
# Invivo 6 Anatomage Inc., Santa Clara, California, USA. istics, intragroup changes, and intergroup changes over
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
742 SAQR et al.

time using linear mixed-effects models. All analyses were T A B L E 1 Baseline clinical ridge width and cone beam
performed using statistical software.16 computed tomography (CBCT) buccal bone thickness (BBT).
10 mm
5 mm apical apical to
3 RESULTS Clinical At crest to crest crest
SD group 5.40 ± 2.02 7.42 ± 2.37 9.41 ± 2.59
In total, 15 patients were recruited for 20 pairs of implants OD group 5.46 ± 1.66 7.58 ± 1.91 9.35 ± 2.33
between January 2022 and December 2023. One patient p value 0.817 0.688 0.907
was discontinued from the study due to implant failure 1.5 mm
of the control at 3 weeks. Six pairs were excluded from 3- from 5 mm from
and 6-week ISQ recordings due to torque values <35 Ncm, implant implant
BBT platform platform
requiring two-stage implant therapy. Two pairs of implants
were excluded from the 6-month CBCT analysis because SD group 2.06 ± 0.66 2.65 ± 1.34

implants adjacent to the study implants required grafting OD group 2.16 ± 0.99 2.58 ± 1.73
at the time of implant placement. p value 0.650 0.787
There was no difference in subject characteristics Note: p values were obtained using linear mixed-effects model.
between the two groups, as the pair of implants were Abbreviations: OD, osseodensification drilling; SD, standard drilling.

placed in the same jaw of the same patient. All subjects

were either American Society of Anesthesiologists (ASA)
Class I or II, and only one subject had a history of smoking. sured in millimeters (p = 0.579) and percentage of ridge
No subjects were current smokers. expansion (p = 0.269). We also found no effect of distance
To standardize implant sites, most subjects had both sur- from the crest on the extent of expansion in millimeters
gical sites either grafted with freeze-dried bone allograft (p = 0.055); however, we observed an effect on the percent-
(FDBA) or underwent extraction with no history of ridge age of ridge expansion (p = 0.012), indicating the greater
preservation or guided bone regeneration. However, three the distance from the crest, the less percentage of ridge
pairs had different surgical sites consisting of either grafted expansion.
or native bone, which was addressed in our analysis.
No significant difference was found in implant diameter
(p = 0.178), implant length (p = 0.129), and bone density of 3.1.2 Radiographic results
surgical sites in Hounsfield units (HU) (p = 0.427) between
the two groups (see Table S1 in online Journal of Periodon- In the 6-month CBCT analysis, buccal bone resorption
tology). Regarding initial ridge width at the crest (p = 0.817) was noted 1.5 mm from the implant platform follow-
and 5 mm (p = 0.688) and 10 mm apical from the crest ing SD (−0.47 mm ± 0.54), while OD maintained BBT
(p = 0.907) and pre-op BBT 1.5 mm (p = 0.650) and 5 mm (0.02 mm ± 0.67) (p < 0.001). Similar findings were
from the implant platform position measured on CBCT found 5 mm from the implant platform following SD
(p = 0.787), no significant difference was found between (−0.52 mm ± 0.59) compared to OD (0.12 mm ± 0.47)
the two groups (Table 1). (p < 0.001) (Table 2). OD minimally increased the percent-
age BBT 1.5 mm (6.24% ± 31.8) and 5 mm from the implant
platform (8.61% ± 25.3) compared to BBT resorption follow-
3.1 Primary outcomes: Ridge ing SD 1.5 mm (−21.3% ± 20.3) (p < 0.001) and 5 mm from
dimensional changes comparing SD and the implant platform (−15.1% ± 21.6) (p < 0.001) (Table 2).
OD protocols

3.1.1 Clinical results 3.2 Secondary outcome: Torque at

placement and ISQ at placement, 3, 6, and
Greater ridge expansion was observed following OD at 12 weeks
the crest (0.84 mm ± 0.59) and 5 mm apical from the
crest (0.62 mm ± 0.65) compared to SD at the crest Greater insertion torque was noted at the time of implant
(0.01 mm ± 0.45) (p < 0.001) and 5 mm apical from the placement following OD (57.7 ± 23.4 Ncm) compared to
crest (0.11 mm ± 0.64) (p = 0.008) (Table 2). No differ- SD (45.0 ± 25.5 Ncm) (p = 0.029). The average ISQ val-
ence was observed 10 mm from the crest following SD ues observed at 0, 3, 6, and 12 weeks were 67.0 ± 8.26,
(0.01 mm ± 0.46) and OD (0.29 mm ± 0.76) (p = 0.159) 69.8 ± 7.99, 70.8 ± 9.25, and 73.3 ± 7.31 for SD, respectively,
(Table 2). We found no effect of initial ridge width as mea- and 73.7 ± 7.23, 75.0 ± 6.87, 75.3 ± 6.16, and 76.8 ± 5.18
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SAQR et al. 743

T A B L E 2 Clinical ridge width changes at placement and buccal bone thickness (BBT) changes at 6-month cone beam computed
tomography (CBCT).
Clinical At crest 5 mm apical to crest 10 mm apical to crest
SD group 0.01 mm ± 0.45 0.11 mm ± 0.64 0.01 mm ± 0.46
OD group 0.84 mm ± 0.59 0.62 mm ± 0.65 0.29 mm ± 0.76
p value <0.001* 0.008** 0.159
BBT (mm) 1.5 mm from implant platform 5 mm from implant platform
SD group −0.47 mm ± 0.54 −0.52 mm ± 0.59
OD group 0.02 mm ± 0.67 0.12 mm ± 0.47
p value <0.001* <0.001*
BBT (percentage) 1.5 mm from implant platform 5 mm from implant platform
SD group −21.3% ± 20.3 −15.1% ± 21.6
OD group 6.24 % ± 31.8 8.61% ± 25.3
p value <0.001* <0.001*
Note: p values were obtained using linear mixed-effects model.
Abbreviations: OD, osseodensification drilling; SD, standard drilling.
*Statistically significant at p < 0.001; **statistically significant at p < 0.05.

TA B L E 3 Implant insertion torque and implant stability quotient (ISQ) following drilling protocols.
ISQ
Insertion torque Placement (t = 0) 3 weeks (t = 3) 6 weeks (t = 6) 12 weeks (t = 12)
SD group 45.0 ± 25.5 Ncm 67.0 ± 8.26 69.8 ± 7.99 70.8 ± 9.25 73.3 ± 7.31
OD group 57.7 ± 23.4 Ncm 73.7 ± 7.23 75.0 ± 6.87 75.3 ± 6.16 76.8 ± 5.18
p value 0.029*
Note: p values were obtained using a linear mixed-effects model with a chi-square test.
Abbreviations: OD, osseodensification drilling; SD, standard drilling.
*Statistically significant at p < 0.05.

for OD, respectively (Table 3). In this study, ISQ values T A B L E 4 Linear mixed-effects modeling evaluating effect of
of above 70 at the time of placement following OD were treatment (SD and OD), time (0, 3, 6, and 12 weeks), and bone
reported and remained above 70 throughout the healing (grafted and native) on implant stability quotient (ISQ) and effect of
process. In contrast, ISQ values following SD begin below treatment on ISQ70.

70 and gradually increase during healing. Analysis of deviance table (Type II Wald chi-square test)
Considering these data, we created a linear mixed- Response: ISQ Chisq Df Pr(<Chisq)
effects model and used a Type II Wald chi-square test trt 93.7631 1 <0.001 *
to evaluate the effects of drilling type, time (0, 3, 6, bone 1.3724 1 0.190
and 12 weeks), and history of native or grafted bone on time 50.7124 1 <0.001 *
ISQ and showed significant statistical interaction between trt:bone 0.0001 1 0.718
treatment (trt) and time (trt:time p = 0.009) with no signif- trt:time 5.5334 1 0.009 **
icant effect of native or grafted bone on implant stability bone:time 0.2043 1 0.618
(Table 4). Therefore, the effect of the drilling technique trt:bone:time 0.1715 1 0.594
on ISQ changes over time. When evaluating the effect of Response: ISQ70 Chisq Df Pr(<Chisq)
time on ISQ in the SD group, there is a significant differ- trt 5.008 1 0.025 **
ence in ISQ between placement and 6 weeks (p = 0.022),
time 5.686 3 0.128
placement and 12 weeks (p < 0.001), 3 and 12 weeks
trt:time 2.158 3 0.540
(p = 0.003), and 6 and 12 weeks (p = 0.039) (see Table
Note: p values were obtained using a linear mixed-effects model with a chi-
S2 in online Journal of Periodontology). For the OD group,
square test.
we observed a significant difference between 12 weeks and Abbreviations: Chisq, chi-square; ISQ70, high implant stability; OD, osseoden-
placement (p < 0.001), 3 weeks (p = 0.010), and 6 weeks sification drilling; SD, standard drilling; Trt, treatment; Pr, probability.
(p = 0.034) (see Table S3 in online Journal of Periodontol- *Statistically significant at p < 0.001; **statistically significant at p < 0.05.
ogy). Figure 2 represents ISQ values following SD and OD
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
744 SAQR et al.

FIGURE 2 Effect of standard drilling (SD) and osseodensification drilling (OD) on implant stability quotient (ISQ) during healing.

from placement to 12 weeks post-op. When evaluating HIS observed in the SD group, the mean ridge width changes
for immediate loading (ISQ ≥ 70), we identified implants in the OD group at the crest and 5 mm from the crest were
achieving HIS at all timepoints (see Table S4 in online 0.84 mm ± 0.59 (p < 0.001) and 0.62 mm ± 0.65 (p = 0.008),
Journal of Periodontology) and used the same mixed-effects respectively. These findings are consistent with a study by
model with a binomial distribution (ISQ of ≥70 = 1; ISQ Frizzerra et al., who showed 0.66 mm of ridge expansion at
of <70 = 0). Implants placed using OD achieved and sus- the crest in porcine mandibles after OD.5 Koutouzis et al.
tained HIS compared to SD (p = 0.025) with no effect of showed a decline in ridge expansion further away from
time (p = 0.128) (Table 4) (see Figure S1 in online Journal the crest and 2.83 ± 0.66 , 1.5 ± 0.97 mm, and 1.14 ± 0.89
of Periodontology). increase in ridge width when using OD in ridges with
1–3, 5–6, and 7–8 mm at the crest.6 While they reported
greater values of ridge expansion than in the present study,
4 DISCUSSION Koutouzis et al. also included narrower ridges for evalua-
tion of ridge expansion and did not present a control group.
During treatment planning for implant placement, we In the present study, no difference in ridge expansion was
often find insufficient ridge width, BBT, and bone den- noted in ridges with different widths. This may be due to
sity, which can affect implant stability and long-term our study’s limited number of narrow ridges. Regarding the
outcomes. Various surgical techniques have been devel- progressive decline in ridge expansion further away from
oped to augment ridge width and improve implant stability the crest, we found similar results attributed to the apical
throughout healing. Despite advancements in implant tapering of the drills and an increase in horizontal ridge
design and surface characteristics, improvements in the dimensions, resembling an inverted triangular shape.17
implant drilling protocol have been lacking. To the best Additionally, we evaluated BBT changes following
of our knowledge, no study has been published evaluat- implant placement via 6-month CBCT analysis. We noted
ing ridge dimensional changes at implant placement and average BBT changes of 0.02 mm (6.24%) 1.5 mm from
6 months post-op, in addition to implant stability through- the implant platform and 0.12 mm (8.61%) 5 mm from
out the healing period. The primary objective of this study the implant platform in the OD group and −0.47 mm
was to evaluate if OD increases ridge dimensions at the (−21.3%) and −0.52 (−15.1%) in the SD group, respectively.
crest and 5 and 10 mm apical to the crest at the time Less buccal bone resorption was found in millimeters and
of implant placement and to evaluate changes in BBT percentage following OD compared to the SD 1.5 mm
6 months post-op compared to SD. The secondary objec- (p < 0.001 and p < 0.001, respectively) and 5 mm from
tive of this study was to assess the effect of OD on implant the implant platform (p < 0.001 and p < 0.001, respec-
insertion torque and stability over time compared to SD. tively). BBT was measured 1.5 and 5 mm from the implant
In this study, a significant difference in ridge width platform instead of the crest due to varying subcrestal and
changes between OD and SD at the crest and 5 mm from equicrestal implant positions and crestal remodeling fol-
the crest was noted, with no difference between the two lowing implant placement. Hartman and Cochran showed
groups 10 mm from the crest. While no changes were 1.10 mm of crestal bone remodeling following SD with
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SAQR et al. 745

minimal changes after 6 months.18 Therefore, we mea- loaded and early-loaded implants after 5 years with a mean
sured 1.5 mm from the implant platform to ensure accurate ISQ of 76.92 at placement.24 Trisi et al. correlated the
and consistent measurements. immediate loading of implants to the micromotion implant
Our findings for SD are similar to those of the existing threshold and reported an insertion torque of greater than
literature on BBT following implant placement. Vera et al. 45 Ncm, and an ISQ of 68 or greater is indicated for imme-
found −0.62 mm in horizontal BBT changes 1 mm from diate loading. 25,26 These values were consistently obtained
the implant/abutment connection and −0.57 mm in hori- following OD in the present study. Considering this, we
zontal BBT changes in the mid-implant region.19 Similarly, created another linear mixed-effects model with an ISQ
Spray et al. noted 0.7 mm of buccal bone resorption 0.5 mm of 70 as a cutoff for HIS utilizing a binomial distribu-
apical from the crest 6 months following implant place- tion. Using a Type II Wald chi-square test, we found a
ment when the buccal bone was initially 1.7 mm thick.20 greater number of implants achieving HIS in OD versus
Cardaropoli et al. found 0.4 mm of buccal bone resorp- SD (p = 0.025), with no significant changes over time
tion 1 year following implant placement when the initial (p = 0.128) (see Figure S1 in online Journal of Periodon-
BBT was 1.2 mm.21 Merheb et al. found 0.85 mm of buc- tology). Therefore, OD increased ISQ values, allowed for
cal bone resorption when the initial BBT was 1.1 mm.22 All HIS at placement, and maintained it throughout the entire
of the aforementioned studies showed buccal bone resorp- healing period compared to SD.
tion near the implant platform at least 6 months following Our findings of greater insertion torque and ISQ fol-
implant placement, consistent with our results. To our lowing OD compared to SD are similar to those of the
knowledge, no other studies compared bone changes with existing literature.4,7,10,11 Bergamo et al. showed similar
OD using CBCT. The OD group showed initial ridge expan- findings, namely that OD resulted in greater implant
sion, which may offset the buccal bone resorption shown in torque (60 Ncm) compared to SD (35 Ncm) and greater
the SD group. Therefore, OD can predictably maintain BBT average ISQ (placement: 73; 3 weeks: 70; 6 weeks: 74)
and reduce the risk of buccal bone dehiscence compared to compared to SD (placement: 62; 3 weeks: 59; 6 weeks:
SD 6 months following implant placement. 66).13 While the ISQ values we observed were very sim-
Our secondary objective was to evaluate the effect of ilar to those of Bergamo et al., they noted a drop in ISQ
SD and OD on implant stability at the time of implant at 3 weeks, while we showed a steady increase over time,
placement and 3, 6, and 12 weeks following placement. In which could result from different study protocols. It is cru-
this study, we found a greater insertion torque following cial to recall that insertion torque is an indicator of primary
OD (57.7 ± 23.4 Ncm) compared to SD (45.0 ± 25.5 Ncm) stability, while ISQ is an implant stability parameter that
(p = 0.029). To assess implant healing over time, we ran a is directly related to time and may be used to measure
linear mixed-effects model evaluating the effects of treat- implant secondary stability. However, in a literature review
ment, time, and grafted/native bone on ISQ. We found a by Huang et al., ISQ is not a one-time measurement substi-
statistical interaction between treatment and time, with no tute for insertion torque.27 Therefore, both measurements
significant effect of grafted/native bone. A statistical inter- may facilitate determining the implant’s stability at the
action between treatment and time indicates that the effect time of placement and throughout healing.
of drilling type on ISQ varies over time. In the present Possible limitations of the present study include non-
study, OD has significantly greater ISQ at placement com- blinded recordings by a single examiner for ridge expan-
pared to SD; however, the difference in ISQ between the sion, implant torque, and implant ISQ readings under the
two groups over time is not constant. Therefore, we inde- supervision of two investigators. However, data recorded
pendently evaluated the effect of time on ISQ values within by one person ensure consistent data collection through-
each group and found significant differences in ISQ over out the study. Moreover, the extent of ridge width changes
time. Despite the significant differences, we noticed that following SD and OD may vary depending on implant
the mean ISQ intervals at each timepoint for the OD group location (anterior vs. posterior and maxilla vs. mandible)
remained above 70, while the mean ISQ for SD approaches (see Table S5 in online Journal of Periodontology). There
70 at 6 weeks and above 70 at 12 weeks. According to the were insufficient sites in each group to assess the effect
manufacturer, an ISQ of 70 or greater indicates HIS. Hick- of implant location on ridge expansion appropriately. In
lin et al. evaluated implant survival utilizing early loading addition, marginal bone level was not measured in the
protocols. In their study, implants with ISQ of 70 or greater present study, as no standardized periapical radiographs
at 3 weeks were restored with provisional reconstruction were obtained during implant placement; future studies
in occlusion. Their results noted a continual increase in may evaluate differences in implant marginal bone level
ISQ values from placement to 6 months post loading and stability following both drilling protocols. The study was
marginal bone level stability at 3 months.23 Kokovic et al. performed in a university setting, with multiple residents
reported a 100% implant survival rate for immediately performing surgeries, while a single resident treated a
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
746 SAQR et al.

majority of the subjects. Despite the variance in treat- Srinivas Ayilavarapu https://orcid.org/0000-0002-1899-
ment and surgeon experience, all providers followed the 8900
same protocol and obtained consistent results. Finally, Kavan Gandhi https://orcid.org/0009-0006-5900-4251
when obtaining CBCT measurements around implants, Chun-Teh Lee https://orcid.org/0000-0001-7812-5637
significant beam-hardening artifacts can affect the abil- Popi Stylianou https://orcid.org/0009-0006-1762-2721
ity to measure BBT accurately. Future studies should
include ultrasound imaging to accurately evaluate BBT by REFERENCES
overcoming any beam-hardening artifacts. 1. Cochran DL. A comparison of endosseous dental implant sur-
faces. J Periodontol. 1999;70(12):1523-1539. doi:10.1902/jop.1999.
70.12.1523
5 CONCLUSION 2. Buser D, Broggini N, Wieland M, et al. Enhanced bone apposi-
tion to a chemically modified SLA titanium surface. J Dent Res.
2004;83(7):529-533. doi:10.1177/154405910408300704
In areas where bone grafting is indicated at implant place- 3. Albrektsson T, Wennerberg A. Oral implant surfaces: part
ment, clinicians can avoid additional procedures by using 1–review focusing on topographic and chemical properties of dif-
OD and expect 0.84 mm in crestal ridge width expansion ferent surfaces and in vivo responses to them. Int J Prosthodont.
and 0.62 mm expansion 5 mm from the crest. Clinicians 2004;17(5):536-543.
can also expect a 6.24% increase in BBT 1.5 mm from 4. Huwais S, Meyer EG. A novel osseous densification approach
the implant platform and an 8.21% increase 5 mm from in implant osteotomy preparation to increase biomechanical
the implant platform, preserving the BBT 6 months fol- primary stability, bone mineral density, and bone-to-implant
contact. Int J Oral Maxillofac Implants. 2017;32(1):27-36. 10.
lowing implant placement utilizing OD. Implants placed
11607/jomi.4817
in osteotomies following OD achieve greater implant sta- 5. Frizzera F, Spin-Neto R, Padilha V, et al. Effect of osseodensifi-
bility compared to SD and can predictably achieve and cation on the increase in ridge thickness and the prevention of
maintain HIS throughout healing. Immediate loading of buccal peri-implant defects: an in vitro randomized split mouth
these implants could be considered according to clinician’s pilot study. BMC Oral Health. 2022;22(1):233. doi:10.1186/s12903-
preference. 022-02242-x
6. Koutouzis T, Huwais S, Hasan F, et al. Alveolar ridge expansion
by osseodensification-mediated plastic deformation and com-
AU T H O R CO N T R I B U T I O N S paction autografting: a multicenter retrospective study. Implant
Drs. Saqr, Ayilavarapu, Lee, and Stylianou contributed Dent. 2019;28(4):349-355. doi:10.1097/ID.0000000000000898
to the study design, data collection, data interpretation, 7. Cáceres F, Troncoso C, Silva R, et al. Effects of osseodensification
and drafting and revising of this manuscript. Dr. Gandhi protocol on insertion, removal torques, and resonance frequency
performed all CBCT analyses. analysis of BioHorizons R conical implants. An ex vivo study.
J Oral Biol Craniofac Res. 2020;10(4):625-628. doi:10.1016/j.jobcr.
2020.08.019
AC K N OW L E D G M E N T S 8. Alifarag AM, Lopez CD, Neiva RF, et al. Atemporal osseointegra-
The authors would like to thank Julian Holland, PhD (Uni- tion: early biomechanical stability through osseodensification. J
versity of Texas Health Science Center at Houston, School Orthop Res. 2018;36(9):2516-2523. doi:10.1002/jor.23893
of Dentistry) for his statistical analysis. The authors would 9. Lopez CD, Alifarag AM, Torroni A, et al. Osseodensification for
also like to thank the Dean’s Small Grant program at the enhancement of spinal surgical hardware fixation. J Mech Behav
University of Texas School of Dentistry at Houston and Biomed Mater. 2017;69:275-281. doi:10.1016/j.jmbbm.2017.01.020
10. Gaspar J, Proença L, Botelho J, et al. Implant stability of
the Schoor Research Award of the American Academy of
osseodensification drilling versus conventional surgical tech-
Periodontology Foundation for their financial support.
nique: a systematic review. Int J Oral Maxillofac Implants.
2021;36(6):1104-1110. doi:10.11607/jomi.9132
C O N F L I C T O F I N T E R E S T S TAT E M E N T 11. Al Ahmari NM. Osseo-densification versus conventional surgi-
All authors have no conflicts of interest to report and no cal technique in low density jaw bone: a split mouth in vivo
commercial relations to declare. study. Technol Health Care. 2022;30(5):1117-1124. doi:10.3233/
THC-220048
12. Arafat SW, A Elbaz M. Clinical and radiographic evaluation of
D A T A AVA I L A B I L I T Y S T A T E M E N T
osseodensification versus osteotome for sinus floor elevation in
The data that support the findings of this study are partially atrophic maxilla: a prospective long term study. Egypt
available from the corresponding author upon reasonable Dent J. 2019;65:189-195. doi:10.21608/EDJ.2015.71261
request. 13. Bergamo ETP, Zahoui A, Barrera RB, et al. Osseodensification
effect on implants primary and secondary stability: multi-
ORCID center controlled clinical trial. Clin Implant Dent Relat Res.
Aziz M. Saqr https://orcid.org/0009-0007-3766-2832 2021;23(3):317-328. doi:10.1111/cid.13007
 19433670, 2025, 7, Downloaded from https://aap.onlinelibrary.wiley.com/doi/10.1002/JPER.24-0343 by University Of Manitoba, Wiley Online Library on [03/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
SAQR et al. 747

14. Althobaiti AK, Ashour AW, Halteet FA, et al. A comparative hydrophilic implant surface after 21 days of healing. Clin Oral
assessment of primary implant stability using osseodensification Implants Res. 2016;27(7):875-883. doi:10.1111/clr.12706
vs. conventional drilling methods: a systematic review. Cureus. 24. Kokovic V, Jung R, Feloutzis A, et al. Immediate vs. early load-
2023;15(10):e46841. doi:10.7759/cureus.46841 ing of SLA implants in the posterior mandible: 5-year results
15. Lekholm U, Zarb GA. Patient selection and preparation. In: of randomized controlled clinical trial. Clin Oral Implants Res.
Branemark PI, Zarb GA, Albrektsson T, eds. Tissue Integrated 2014;25(2):e114-e119. doi:10.1111/clr.12072
Prostheses: Osseointegration in Clinical Dentistry. Quintessence 25. Trisi P, Perfetti G, Baldoni E, et al. Implant micromotion is
Publishing Company; 1985:199-209. related to peak insertion torque and bone density. Clin Oral
16. R Core Team. R: A Language and Environment for Statisti- Implants Res. 2009;20(5):467-471. doi:10.1111/j.1600-0501.2008.
cal Computing. R Foundation for Statistical Computing; 2022. 01679
https://www.Rproject.org/ 26. Trisi P, Berardini M, Falco A, Podaliri Vulpiani M. Validation
17. Qu F, Huang YJ, Wang YY, et al. Cone-beam CT evalua- of value of actual micromotion as a direct measure of implant
tion of post-extraction alveolar bone changes at the maxillary micromobility after healing (secondary implant stability). An in
incisor sites in an East Asian population: a cross-sectional study. vivo histologic and biomechanical study. Clin Oral Implants Res.
Heliyon. 2024;10(11):e32027. doi:10.1016/j.heliyon.2024.e32027 2016;27(11):1423-1430.
18. Hartman GA, Cochran DL. Initial implant position deter- 27. Huang H, Wu G, Hunziker E. The clinical significance of
mines the magnitude of crestal bone remodeling. J Periodontol. implant stability quotient (ISQ) measurements: a literature
2004;75(4):572-577. doi:10.1902/jop.2004.75.4.572 review. J Oral Biol Craniofac Res. 2020;10(4):629-638. doi:10.
19. Vera C, De Kok IJ, Chen W, et al. Evaluation of post-implant 1016/j.jobcr.2020.07.004
buccal bone resorption using cone beam computed tomog-
raphy: a clinical pilot study. Int J Oral Maxillofac Implants.
2012;27(5):1249-1257. S U P P O RT I N G I N F O R M AT I O N
20. Spray JR, Black CG, Morris HF, et al. The influence of bone Additional supporting information can be found online
thickness on facial marginal bone response: stage 1 placement in the Supporting Information section at the end of this
through stage 2 uncovering. Ann Periodontol. 2000;5(1):119-128. article.
doi:10.1902/annals.2000.5.1.119
21. Cardaropoli G, Lekholm U, Wennström JL. Tissue alterations at
implant-supported single-tooth replacements: a 1-year prospec-
tive clinical study. Clin Oral Implants Res. 2006;17(2):165-171. How to cite this article: Saqr AM, Ayilavarapu S,
doi:10.1111/j.1600-0501.2005.01210.x Gandhi K, Lee C-T, Stylianou P. Ridge dimensional
22. Merheb J, Vercruyssen M, Coucke W, et al. The fate of buccal
changes and implant stability utilizing the
bone around dental implants. A 12-month postloading follow-
osseodensification protocol: A randomized clinical
up study. Clin Oral Implants Res. 2017;28(1):103-108. doi:10.1111/
clr.12767 trial. J Periodontol. 2025;96:739–747.
23. Hicklin SP, Schneebeli E, Chappuis V, et al. Early loading of https://doi.org/10.1002/JPER.24-0343
titanium dental implants with an intra-operatively conditioned