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Clinical and radiographic evaluation of osseodensification versus osteotome

for sinus floor elevation in partially atrophic maxilla: A prospective long term
study

Article · January 2019

DOI: 10.21608/edj.2015.71261

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 EGYPTIAN Vol. 65, 189:195, January, 2019
DENTAL JOURNAL I.S.S.N 0070-9484

Oral Surgery
www.eda-egypt.org • Codex : 189/1901

CLINICAL AND RADIOGRAPHIC EVALUATION OF

OSSEODENSIFICATION VERSUS OSTEOTOME FOR SINUS
FLOOR ELEVATION IN PARTIALLY ATROPHIC MAXILLA:
A PROSPECTIVE LONG TERM STUDY

Shereen W Arafat* and Mohamed A Elbaz**

ABSTRACT
Objectives: The current study was conducted to evaluate crestal sinus floor elevation with
either osteotome or osseodensification in posterior atrophic maxilla.

Material & methods: 24 crestal sinus floor elevations were performed for 24 patients with at
least 5mm residual bone height. 12 randomly selected patients received osteotome sinus elevation
(group 1), and 12 received osseodensification sinus elevation (group 2). The treatment outcome was
evaluated at 6, 12 months of healing clinically and radiographicaly. Implant 1ry and 2ry stability,
marginal bone loss, and bone gain were recorded and statistically analyzed.

Results: group 2 showed significantly higher ISQ values immediately postoperatively and at
6 months. There was significant increase of bone height (bone gain) in both groups (P=0.001), and
bone gain was 2.79±0.30 mm and 3.33±0.25 mm in group 1 &2 respectively.

Conclusion: Osseodensification sinus floor elevation was superior to osteotome elevation

regarding the 1ry & 2ry stability, and bone gain.

KEY WORDS: osseodensification , osteotome, sinus lift, atrophic maxilla

INTRODUCTION area. Maxillary sinus lift is one of the most common

surgical techniques used for increasing the available
The rehabilitation of the edentulous posterior
bone volume to place implants and restore function
maxilla using osseointegrated implants is often
and esthetics. Lateral approach for sinus lift is
challenging due alveolar bone resorption, low bone usually indicated when residual bone height is less
density and maxillary sinus pneumatization. Thus, than 5 to 6 mm. (1,2) While transcrestal approach can
an augmentation procedure is often indicated in this be successfully adopted when residual bone height

* Associate Professor of Oral & Maxillofacial Surgery, MSA University.

** Lecturer of Oral & Maxillofacial Surgery, MSA University.
(190) E.D.J. Vol. 65, No. 1 Shereen W Arafat and Mohamed A Elbaz

is at least 5 mm.(3,4) Osteotome sinus floor elevation The current study sample comprised 24 patients.
was 1st introduced by Summers (5,6)1994, and proved 17 patients of the 24 were male (70.8%), while 7
to be less invasive, more conservative, less time patients were female (29.2%) with age range 23-65
consuming, and reduces postoperative discomfort to years.
the patient. (7,8) Moreover, this technique was found
Surgical protocol
to yield predictable results, with success rates of at
least 95%. (9, 10) Prior to surgery, radiographic evaluation through
panoramic radiographs and cone-beam CT scan
Osseodensification is a new surgical technique
was performed to identify the residual bone height,
of biomechanical bone preparation performed for
dental implant placement where bone is compacted width, the bone quality at the surgical site, and to
and autografted into open marrow spaces and determine the sequence of bone drills for implant site
osteotomy site walls in outwardly expanding preparation. Local anesthesia articaine chloridrate
directions. (11) It was reported that Osseodensification 4% with adrenaline 1:100.000 (Alfacaina N, Weimer
increases the bone-implant contact, bone density, Pharma, Rastat, Germany) was administered. A full-
and primary stability. (12) Moreover, The insertion thickness mucoperiosteal flap was elevated.
torque peak is directly related to implant primary Patients were randomly divided into 2
stability and host bone density. (13) Furthermore, groups. Group 1 received osteotome sinus lift
Ottoni et al. (14) showed a reduction in failure rate and simultaneous implant placement, and group
of 20% in single‑tooth implant restoration for every 2 received osseodensification sinus lift and
9.8 N cm of torque increased. simultaneous implant placement. In osteotome
The objective of this study was to evaluate sinus lift cases, bone drilling was performed
crestal sinus elevation using ossedensification with conventional drills with working length 1
versus osteotomy clinically and radiographically in mm shorter than the residual bone height. Then
terms of marginal bone loss, primary and secondary osteotome (Straumann AG) was used with Light
stability and bone gain around the implant. careful tapping using a mallet to elevate the
Schneiderian membrane. The osteotomy was
MATERIALS AND METHODS subsequently enlarged. A Valsalva maneuver was
This prospective clinical study was conducted at performed to verify the sinus membrane integrity,
Oral Surgery and Anesthesia Department, Faculty and tapered Screw Plant* implants were inserted. For
of Dentistry, MSA University. Patients of at least osseodensification group, drilling was performed
18 years old requiring 1–2 Implants in the atrophic within an approximate safety zone of 1.0 mm from
posterior maxilla with at least 5 mm residual bone the sinus floor using a pilot drill, then the narrowest
height were enrolled. Patients were excluded from Densah® Bur (2.0). The motor was then changed to
the study if they presented one of the following reverse – Densifying Mode (Counterclockwise drill
exclusion criteria: inability to maintain proper level speed 800-1500 rpm with copious irrigation), and
of oral hygiene throughout the study, any medical osteotomy was created. Pressure with a pumping
condition, or medication that might compromise motion was performed to reach the sinus floor. The
bone healing, and inability to return for follow- next wider Densah® Bur (3.0) was then used and
up visits. Every subject has signed an informed advanced into the previously created osteotomy
consent before entering the study. with modulating pressure and a pumping motion.

* Spectra-System®, ScrewPlant, Implant DirectTM LLG, Malibu hills, USA

CLINICAL AND RADIOGRAPHIC EVALUATION OF OSSEODENSIFICATION VERSUS (191)

When feeling the haptic feedback of the bur reaching 6 months after surgery for the definitive prosthesis
the dense sinus floor, modulating pressure with a and stability 2nd record, and 6 months after loading
pumping motion was continued to advance past the for radiographic evaluation.
sinus floor in 1 mm increments. Maximum possible
Clinical and Radiological Parameters
advancement past the sinus floor at any stage did
not exceed 3 mm. Bone was pushed toward the The implant survival rate was recorded according
apical end and began to gently lift the membrane to Buser et al (15) and Cochran et al (16) which are
and autograft compacted bone. Tapered Screw Plant no pain or any subjective sensation, no clinically
implants then were inserted. (Fig 1) detectable implant mobility, no continuous
radiolucency around the implant, and no recurrent
At the time of implant placement, resonance
peri-implant infection.
frequency analysis was performed to record
the implant stability quotient (ISQ) value. The Cone beam CT was performed at 6 months
transducer (Smartpeg; Integration Diagnostics AB, postoperatively and at 6 month after loading. The
G€oteborg, Sweden) was connected to the implant, residual bone height before surgery was measured
and the analyzer probe was located close to the for each planned implant site and was compared
Smartpeg, and ISQ value was given by the Osstell with the height attained at 6 months postoperatively.
device. The flap then was repositioned and sutured Bone height gain was calculated as the difference
with 3-0 non-resorbable sutures. between the bone height at 6 months and the residual
bone height. Marginal bone height at the mesial and
The surgical area was maintained prosthesis
distal aspects were measured and averaged at 6
free. Postsurgical instructions were provided to
months postoperatively and 6 months after loading
avoid infection, control bleeding and to avoid
as the distance from alveolar bone crest to the
suture detachment during the first healing period.
implant end. (Fig 2) The difference between the 2
Final prosthesis was delivered after 6 month healing
measurements represented the marginal bone loss.
period.
Implant Stability Quotient (ISQ) was measured
Follow-up visits were scheduled after 10 days at the time of implant placement and at 6 months
for suture removal, 1 month for clinical observation, postoperatively.

Fig. (1) A) Universal Densah Bur Kit used for osseodensification sinus elevation in group 2, B) drilling the osseodensification site
with copious irrigation at the maxillary 1st molar site, C) the prepared osseodensification site after sinus elevation, D) the
implant in place at the prepared site after sinus elevation.
(192) E.D.J. Vol. 65, No. 1 Shereen W Arafat and Mohamed A Elbaz

Evaluation was obtained by Scanora 3D, with RESULTS

OnDemand 3D App 1.0.10.4304 viewer. Measure-
All implants osteointegrated successfully in both
ments were calculated by an oral radiologist who
groups and were clinically stable during abutment
was blinded to the surgical procedure and the evalu-
tightening at six months postoperatively. Thus,
ation were made twice with 10 days period interval.
Implant survival rate was 100% at 6 months from
Statistical analysis implant loading. No patient complained of pain, and
there were no signs of inflammation or Schneiderian
Independent t-test used to compare between
tested groups. Dependent t-test used to compare membrane perforation.
between follow-up period for each group (α=0.05). The pre-surgical bone height in group 1 (os-
Data analysis done using SPSS (IBM Corp. teotome group) was 7.14±0.47 mm and in group
Released 2015. IBM SPSS Statistics for Windows, 2 (osseodensification group) was 7.38±0.52 mm.
Version 23.0. Armonk, NY: IBM Corp.) The Student’s t-test found statistically non-signif-
icant difference of pre-surgical bone height be-
tween groups (P = 0.260). At 6 months postopera-
tively, there was significant increase of bone height
(bone gain) in both groups (P=0.001). Comparing
the bone gain at 6 months postoperatively between
the study groups showed that bone gain in group 2
was significantly higher than bone gain in group 1.
(P≤0.001) which was 3.33±0.25 mm and 2.79±0.30
mm respectively. (Fig 3) There was no statistically
significant difference between the 2 groups regard-
ing the marginal bone loss at 6 months after loading
Fig. (2) CBAT image showing the measurement of alveolar
which was 0.93±0.15 mm in group 1 and 0.98±0.15
bone height mesial and distal to the implant 6 months
postoperatively with reference to the implant end for a mm in group 2. (P=0.501) as shown in table (1)
case of osseodensifcation group.

TABLE (1) Residual bone height, bone gain, marginal bone loss, and implant stability quotient means and
standard deviations for the study groups.

Osteotome Osseodensification p-value

Mean SD Mean SD
Residual bone height (mm) Immediate 7.14 0.47 7.38 0.52 0.260 NS
6 Months 9.93 0.57 10.71 0.43 0.001*
p-value ≤0.001* ≤0.001*
Difference 2.79 0.30 3.33 0.25 ≤0.001*
Stability Immediate 52.83 6.29 65.17 4.39 ≤0.001*
6 Months 67.83 4.78 75.92 2.94 ≤0.001*
p-value ≤0.001* ≤0.001*
Difference 15.00 3.28 10.75 4.25 ≤0.001*
Marginal bone loss 0.93 0.15 0.98 0.15 0.501 NS

*=significant, NS=Non-significant
CLINICAL AND RADIOGRAPHIC EVALUATION OF OSSEODENSIFICATION VERSUS (193)

Fig. (3) bone gain in the study groups at 6 months postoperatively. Fig. (4) Implant Stability Quotient ISQ for the study groups
immediately after implant placement and at 6 months
postoperatively.

The mean ISQ value in both groups is shown in the drilling technique of osseodensification, which
figure 4. Both groups showed significant increase drives bone compaction in the osteotomy site wall,
in ISQ value from base line (immediately after and the presence of residual bone chips which form
implant placement) and at 6 months postoperatively an autograft wall around the osteotomy perimeter.
(P≤0.001). Comparing ISQ values in both groups This result is consistent with the findings of Jimbo
was significant at the baseline and at 6 months et al (18) in a sheep model. (19) This could be as well
postoperatively as group 2 showed significantly an explanation for the finding of significantly higher
higher ISQ values at the 2 time intervals. bone gain in group 2 than bone gain in group 1 at 6
months postoperatively. Moreover, It was concluded
DISCUSSION in the studies of Frost (20) and Mori et al (21) that
The main objective of this study was to evaluate the traumatic damage in bone caused by osteotome
crestal sinus floor elevation with either osteotome or sinus floor elevation delays the achievement of
osseodensification. A comparison was made of these secondary stability, as increased time needed for
two techniques regarding the bone gain, marginal the repair of the micro-damage, which stimulates
bone loss and implant stability. Considering the osteoclast activation.
results of this study, both sinus floor elevation The bone gain in the current study was 2.79±0.30
procedures showed 100% implant survival rate for mm in group 1, and 3.33±0.25 mm in group 2 which
6 months after loading. Literature reported that, is consistent with data reported in Antonaya-Mira
following use of osteotome technique without bone and colleagues (22) review of literature.
grafting material, the prognosis may become 97.2%
In the current study, no bone graft was used in
when the residual bone height is at least 5 mm. (17)
the 2 study groups with survival rate of 100%. This
In crestal sinus floor elevation, the achievement finding is consistent with Nedir et al (23) who reported
of satisfactory implant primary stability is a key osteotome sinus floor elevation without grafting for
factor for osseointegration. In the current study, sinus augmentation of 3mm. This was attributed
osseodensification group showed significantly to the osteogenic potential of the shenederian
higher ISQ values at the 2 study intervals representing membrane that may give origin for mesenchymal
1ry and 2ry stability. This could be explained by cells that start the osteogenic lineage. (1,24) Moreover,
(194) E.D.J. Vol. 65, No. 1 Shereen W Arafat and Mohamed A Elbaz

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10- Shalabi MM, Manders P, Mulder J, Jansen JA, Creugers NH.
Thus, from the results of the current study, it A meta-analysis of clinical studies to estimate the 4.5-year
could be concluded that osseodensification sinus survival rate of implants placed with the osteotome technique.
floor elevation was superior to osteotome elevation Int J Oral Maxillofac Implants 2007; 22:110–116.

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Moreover, the use of bone graft could not be approach in implant osteotomy preparation to increase
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12- B. Lahens, R. Neiva, N. Tovar, A.M. Alifarag, R. Jimbo,

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