“Osseodensification”

By

Dr. Milind Waddar

Library Dissertation
Submitted in partial fulfillment of the requirements for

The degree of

MASTER OF DENTAL SURGERY

IN

PERIODONTOLOGY

Under the guidance of

Dr. Sandeep Katti M.D.S

PROFESSOR

DEPARTMENT OF PERIODONTOLGY

MARATHA MANDAL’S NATHAJIRAO G. HALGEKAR INSTITUTE OF

DENTAL SCIENCES AND RESEARCH CENTRE

BELAGAVI, KARNATAKA

2022-2025
 S. TOPIC PAGE
NO. NUMBER

1 Introduction

2 History

3 Rationale for dental implant

4 Bone quantity and quality

4.1 Bone quality and quantity classification
4.2 Bone density classification

5 Bone density classification

6 Dental implant stability

6.1 Factors affecting primary stability
6.2 Methods to measure implant stability

7 Osseointegration
7.1Factors affecting osseointegration
7.2Bone remodeling around dental implants

8 Osseodensification
8.1 Rationale of osseodensification
8.2 Unique Characteristics
8.3 Characteristics of osseodensification drills
8.4 Densah® BurMarking
8.5 Technology behind the Densah® burs
8.6 The Densah® Bur Kit
8.7 Mechanism of the osseodensification procedure
8.8 Advantages of osseodensification
8.9 Disadvantages of osseodensification
 8.10 Indications
8.11 Contraindications
8.12 Protocol for the use of Densah® bur in different
bone qualities
(a) Protocol I- Osseodensification facilitates
medium and soft bone density
(b)Protocol II- Osseodensification in dense
bone quality in the mandible
(c) Protocol III- Osseodensification facilitates
lateral ridge expansion
(d) Protocol IV- Osseodensification facilitates
vertical ridge expansion
(e) Protocol V- Instructions for maintenance
of Densah™burs kit
9 Osseodensification versus conventional osteotomy

10 Limitations

11 Healing of the osteomy by osseodensification

12 Conclusion

13 Bibliography
 OSSEODENSIFICATION

INTRODUCTION
A dental implant is one of the treatments to replace missing teeth. The most common cause of
teeth loss is periodontitis, and other causes include dental caries, trauma, developmental
defects, and genetic disorders. The use of dental implants to rehabilitate the loss of teeth has
increased in the last 30 years1.

Before dental implants, dentures or bridges were used for cosmesis in edentulous patients. A
removable denture (false teeth) is a prosthesis composed primarily of acrylic resin or
porcelain seated in a plastic mount and supported by the surrounding hard and soft tissues of
the oral cavity. A denture may be partial or complete depending on whether a patient is
missing some or all of his or her teeth in a single arch. A bridge is a fixed (non-removable)
partial denture that is used to replace a missing tooth or several missing teeth. A bridge
consists of an artificial or “dummy” tooth or teeth composed of gold, porcelain, or
porcelainfused- to-metal. A crown is used to anchor a bridge to the adjacent normal teeth.

Dental implants have a number of advantages over conventional fixed partial denture. A high
success rate (above 97% for 10 years), a decreased risk of caries and endodontic problems of
adjacent teeth, improved maintenance of bone in edentulous site, decreased sensitivity of
adjacent teeth3. The overall high success rate and predictability of the process, and with the
relatively small percentage of complications during and after implantation, have made this
procedure highly accessible to the general population.2

A dental implant is an alloplastic biomaterial that is surgically inserted into the jaw bone to
solve functional and/or esthetic problems. Most dental implants today are made from
commercially pure titanium (CP-Ti grade 4) or from titanium alloy Ti-6Al-4V ELI (extra low
interstitial). A typical dental implant, as shown in Figure 1, includes the implant body which
is the part of the implant designed to be surgically placed into the bone. Root form implants
are the common implant body form, with a screw design aimed to strongly fix the implant to
the bone. The abutment is the part of the implant that serves to support and/or retain the
suprastructure (i.e., fixed or removable prosthesis)2.

The success of dental implants is largely attributed to what is known as “osseointegration,” a

term originally defined by Branemark in 1952. Osseointegration is defined as a direct
structural and functional connection between ordered, living bone and the surface of a load
carrying implant. Primary stability of dental implants has been considered as an important
factor for achievement of successful osseointegration3.
Primary stability has a direct relationship with density of bone. It is the measure of the
anchorage quality of an implant in the alveolar bone. Implant stability can occur at two
different stages: primary and secondary. It has been proven to affect the process of
osseointegration, the pattern of implant loading, and, finally, the success of an implant.
Primary stability of an implant mostly comes from mechanical engagement with cortical
bone. Thus, it prevents the formation of a connective tissue layer between implant and bone,
ultimately ensuring bone healing. Secondary stability, on the other hand, offers biological
stability through bone regeneration and remodeling4.

The key factors in enhancing implant primary stability are bone density, surgical protocol,
implant thread type and geometry. Increased primary stability and maintaining the bulk of
bone mineral and collagen material has been shown to accelerate the healing process after
surgery. Therefore, it is necessary to preserve bone bulk during the preparation of an
osteotomy4.

There have been many techniques tried in the past to increase the implant primary stability in
areas of low bone density. A few among them included bi-cortical fixation, under preparation
for the implant bed, stepped osteotomy of the implant bed and the use of osteotomes and
condensers5. Traditionally this has been achieved through under preparation of the implant
site which is achieved by using a one or more size smaller as the last drill than selected
implant diameter, and in an in vitro study, a 10% under preparation of the implant site was
considered sufficient to improve primary stability whereas, additional decrease does not
improve primary stability values in poor bone quality 8,9.Studies on stepped osteotomy of
implant bed, which is another variant of the under preparation method, have reported greater
implant stability in terms of insertion torque than conventional osteotomy in soft bone.
Another approach to increase primary implant stability in poor bone quality is by using
osteotomes to condense and compress bone apically and laterally creating a layer of compact
bone at the implant interface. The osteotome technique, uses hand driven devices and
compresses the surrounding bone by gradual expansion leading to enhanced insertion torque
values5.
The conventional implant site preparation techniques are subtractive in nature that use
successively increasing-diameter drills rotating in a clockwise direction under copious
irrigation to excavate bone and prepare the implant bed.But the imprecise cutting of the
osteotomy drills makes the design elliptical or elongated, which will reduce the torque during
implant placement. This ultimately contributes to poor implant stability. Osteotomies tend to
fracture the bony trabeculae, resulting in long remodeling time and delayed secondary
implant stability. Also, osteotomies prepared in deficient bone or narrow ridges may produce
buccal or lingual dehiscence that necessitates additional bone graft increasing the healing
period and cost.

However, these techniques have presented limitations during surgery. The repeated impacting
of a mallet is required to advance the Summers osteotome, which is a traumatic technique
that may be difficult for the surgeon to control and in some cases can result in fracture, or
patient side effects such as vertigo.

Recently, a new technique to increase the density of osteotomy site has been introduced by
Salah Huwais in 2013 known as Osseo densification (OD) which is a novel, biomechanical,
non-excavation technique. This bone condensation technique makes use of specially designed
burs to increase the density of the bone as they expand in an osteotomy. The procedure is
characterized by low plastic deformation of bone that is created by rolling and sliding contact
using a densifying bur that is fluted such that it densifies the bone with minimal heat
elevation6.

Densifying burs has the advantage to control the tactile and speed of drills. The reason behind
ossedensification concept is that autologous bone contacts through an endosteal device which
accelerate osseointegration because of osteoblasts nucleating on instrumented bone adjacent
to the implant and have increased primary stability because of interlocking between the
device and bone7.

Compared with conventional drilling, OD was reported to result in higher insertion and
removal torque, increased primary and secondary stability, higher bone-to-implant contact
(BIC) and higher bone volume (BV) around implants15, this favorable outcome is possible
because of the drills that have many lands with large negative rake angles which work as a
noncutting edge to expand the implant site and increase the density of the bone. This library
dissertation aims on osseodensification, its techniques, advantages, disadvantages, indications
and contraindications in detail.

Fig 1: Implant components

Dental implantology has witnessed remarkable advancements in recent years, with the quest
for enhanced treatment outcomes and patient satisfaction being a constant driving force.
Among the innovative techniques that have emerged, osseodensification has garnered
significant attention as a transformative approach to preparing implant sites and optimizing
osseointegration—the process by which dental implants integrate with the surrounding bone.
This dissertation aims to delve into the concept of osseodensification, exploring its principles,
applications, and potential benefits in dental implantology.

Traditional implant site preparation methods relied on drilling or cutting into the bone to
create space for the implant. While effective, these methods often resulted in bone loss,
compromised stability, and extended healing periods. In contrast, osseodensification
represents a paradigm shift by focusing on bone preservation and augmentation during the
implant placement process.
The core principle of osseodensification lies in the controlled compression and densification
of the bone rather than its removal. This technique utilizes specialized drills or osteotomes
with uniquely designed flutes and non-cutting tips. As these instruments engage with the
bone, they gently compact and densify the surrounding bone, effectively increasing its
density and strength. This enhanced bone quality not only provides a stable foundation for
implant placement but also facilitates faster and more reliable osseointegration.

One of the primary advantages of osseodensification is its ability to preserve the existing
bone structure. By minimizing bone removal, this technique helps maintain the volume and
integrity of the surrounding bone, which is critical for long-term implant success. The
densified bone also offers improved primary stability, reducing the risk of implant failure and
enabling immediate or early loading protocols.

Furthermore, osseodensification demonstrates potential benefits in challenging clinical

scenarios. It has shown promising results in cases with compromised bone quality, low bone
density, or previously failed implant placements. By densifying the bone and promoting
better osseointegration, osseodensification opens doors to implant treatment for patients who
might have been considered poor candidates in the past.

The impact of osseodensification reaches beyond the surgical phase of dental implantology.
Faster healing times and improved bone quality may lead to enhanced patient experiences,
allowing for expedited restoration of oral function and improved overall treatment outcomes.
Additionally, this technique's potential for reduced morbidity, such as decreased post-
operative pain and complications, contributes to the overall patient-centric approach of
modern implantology.

As the field of dental implantology continues to evolve, it is essential for clinicians and
researchers to explore novel techniques and their potential implications. This dissertation
aims to critically evaluate the concept of osseodensification, analysing available evidence,
discussing clinical applications, and highlighting its impact on implant success rates, bone
preservation, and patient satisfaction.

This library dissertation seeks to contribute to the existing body of knowledge and provide
insights into the field of dental implantology. Through a comprehensive examination of the
principles, techniques, and clinical outcomes associated with osseodensification, this library
dissertation strives to shed light on the potential benefits of this innovative approach and its
role in shaping the future of dental implant treatment.

HISTORY

The history of the evolution of dental implants is a rich and fascinating travelogue through
time. Since the beginning of mankind, humans have used dental implants in one form or
another to replace missing teeth. In approximately 2500 BC, the ancient Egyptians tried to
stabilize teeth that were periodontally involved with the use of ligature wire made of gold.
Their manuscripts and texts allude to several interesting references to toothaches. About 500
BC, the Etruscans customized soldered gold bands from animals to restore oral function in
humans; they also fashioned replacements for teeth from oxen bones. At about the same
period, the Phoenicians used gold wire to stabilize teeth that were periodontally involved;
around 300 AD, these innovative peoples used teeth creatively carved out of ivory which
were then stabilized by gold wire to create a fixed bridge. The first evidence of dental
implants is attributed to the Mayan population roughly around 600 AD where they excelled in
utilizing pieces of shells as implants as a replacement for mandibular teeth. Radiographs
taken in the 1970’s of Mayan mandibles show compact bone formation around the implants-
bone that amazingly looks very much like that seen around blade implants! Moreover, around
800 AD, a stone implant was first prepared and placed in the mandible in the early Honduran
cultured8.

In the middle of the 1600’s periodontally compromised teeth were stabilized in Europe with
various substances. From the 1500’s to about the 1800’s, teeth in Europe were collected from
the underprivileged or from cadavers for the use of allotransplantation. During this period,
Dr. John Hunter came on to the scene; for many years he worked with “resurrectionists”-
people who acquired corpses underhandedly through the robbing of graves. By doing so, he
was able to observe and document with great detail the anatomy of the mouth and jaw. In the
1700’s, Dr. Hunter suggested transplanting teeth from one human to another; his experiment
involved the implantation of an incompletely developed tooth into the comb of a rooster. He
observed an extraordinary and astonishing event: the tooth became firmly embedded in the
comb of the rooster and the blood vessels of the rooster grew straight into the pulp of the
tooth. In 1809, J. Maggiolo inserted a gold implant tube into a fresh extraction site. This site
was allowed to heal and then a crown was later added; unfortunately, there was extensive
inflammation of the gingiva which followed the procedure9

Dr. EJ Greenfield, in 1913, placed a “24-gauge hollow latticed cylinder of iridio platinum
soldered with 24-karat gold” as an artificial root to “fit exactly the circular 10 incision made
for it in the jaw-bone of the patient”. In the 1930’s, two brothers, Drs. Alvin and Moses
Strock, experimented with orthopedic screw fixtures made of Vitallium (chromium-cobalt
alloy). They carefully observed how physicians successfully placed implants in the hip bone,
so they implanted them in both humans and dogs to restore individual teeth. The Vitallium
screw provided anchorage and support for replacement of the missing tooth. These brothers
were acknowledged for their work in selecting a biocompatible metal to be used in the human
dentition. The Strock brothers were also thought to be the first to place the first successful
endosteal (in the bone) implant. (Incidentally, Dr. Alvin Strock not only worked with implant
materials, he also established the use of antibiotics for shipboard treatment of periodontal
infections like trench mouth). In 1938, Dr. P.B. Adams patented a cylindrical endosseous
implant that was threaded both internally and externally; it had a smooth gingival collar and a
healing cap. A post-type endosseous implant was developed by Formiggini (“Father of
Modern Implantology”) and Zepponi in the 1940’s. The spiral stainless-steel design of the
implant allowed bone to grow into the metal. This spiral implant was made by constructing a
stainless-steel wire on itself. Dr. Perron Andres from Spain modified Formiggini’s spiral
design to include a solid shaft in the construction10

Dr. Raphael Chercheve from France added to the spiral design by creating burs to ease the
insertion of the implant for a best fit. As the progression of implant discovery continued, the
subperiosteal (on the bone) implant was developed in the 1940’s by Dahl in Sweden. Dahl’s
original implant design involved flat abutments and screws which lay over the crest of the
alveolar ridge. Dahl’s work was carried on by Gershkoff and Goldberg as well as Weinberg
in the United States from 1947-1948. Gershkoff and Goldberg produced a cobalt-chromium-
molybdenum implant with an extension of Dahl’s design to include the external oblique
ridge11. The subperiosteal implant design was further researched and elaborated upon by
Lew, Bausch, and Berman in 1950. Lew utilized a direct impression method which used
fewer supports over the ridge crest.

Various implant designs expanded in the 1960’s. Dr. Cherchieve crafted a double helical
spiral implant; it was made of cobalt and chromium. Many of these were screw shaped and in
a single piece. The spiral shaft was further enhanced during this decade by Dr. Giordano
Muratori by the addition of internal threading to the shaft of the implant. The basic spiral
design was turned into a flat plate with various configurations by Dr. Leonard Linkow in
1963.12 In 1967, there were two variations of the blade implant that were introduced by
Linkow, making it possible to place it in either the maxilla or the mandible. Linkow
developed the Ventplant implant. The blade implant is now recognized as an endosseous
implant. Further on, Dr. Sandhaus in the mid-60’s developed a crystallized bone screw whose
composition was mainly that of aluminum.13

As the 1960’s came to a close and the 1970’s began, doctors Roberts and Roberts began the
development of the Ramus Blade endosseous implant. This implant was made of surgical
grade stainless steel; according to them, it was to serve as a “synthetic third molar”. They also
developed the ramus frame implant which received its stability by anchoring in the ramus
bilaterally as well as in the symphysis area. The 1970’s brought in the placement of vitreous
carbon implants by Grenoble. Weiss and Judy made popular the use of intramucosal inserts
during this time; the inserts helped in the retention of removable maxillary prostheses. In
1975, an implant device placed through a submental incision and attached to the mandible
was introduced by Dr. Small; this was known as the first transosteal implant called the
mandibular staple implant. This would help those individuals who had an edentulous
mandible that was atrophic in nature14

In 1978, Dr. P. Branemark presented a two-stage threaded titanium root-form implant; he

developed and tested a system using pure titanium screws which he termed fixtures. These
were first placed in his patients in 1965 and were the first to be well documented and the
most well-maintained dental implants thus far. Branemark’s first patient had severe
deformities of the jaw and chin, congenitally missing teeth and misaligned teeth. Four
implants were inserted into the mandible. These implants integrated within a period of six
months and remained in place for the next 40 years15. He found this discovery accidentally in
1952 when he was studying blood flow in rabbit femurs by placing titanium chambers in their
bone; over time the chamber became firmly affixed to the bone and could not be removed.
The bone actually bonded to the titanium surface. In fact, if a fracture occurred, it always
occurred between bone and bone, never between the bone and the implant. He carried over
this idea into the realm of dentistry. With his implant came the concept of “osseointegration”
and the confidence that dental implant education could be introduced into dental school
curricula. This term was further refined and defined by Branemark as “a direct structural and
functional connection between ordered, living bone, and the surface of a load carrying
implant”. The original Branemark implant was created as a cylindrical one; later on, tapered
forms appeared. Many other types of implants were introduced after the Branemark implant
which included the ITI-sprayed implant, the Stryker implant, the IMZ implant and the Core-
Vent implant16

Two other ground-breaking persons of modern implantology were Dr. Schroder and Dr.
Straumann of Switzerland. They experimented with metals utilized in orthopedic surgery to
help fabricate dental implants. Beginning in the middle of the 1980’s, the customary implant
used by many dental clinicians was the endosseous root-form implant. The major factors that
determined which endosseous implant system was chosen over another included the design,
the surface roughness, prosthetic considerations, ease of insertion into the bone, costs and
how successful they were over a period of time. Dr. Tatum introduced the omni-R implant in
the early 1980’s; it had horizontal fins made up of titanium alloy. Dr. Niznick introduced the
Core-Vent implant in the early part of the 1980’s. It was a hollow basket implant with a
threaded piece in it which helped to engage the bone; he also manufactured the Screw-Vent
implant which had a hydroxyapatite coating on it. This surface coating was to allow for more
immediate adaptation of the bone to the implant surface. The Core-Vent company also
designed the Swede-Vent implant which used an external hexagonal interface to hold the
abutment. Dr. Niznick continued to develop other systems including the Bio-Vent and the
Micro-Vent17

Soon after, Dr. Driskell in the 1980’s introduced the Stryker “root form” endosseous implant;
there are two versions of this-one made with a titanium alloy and another coated with
hydroxyl apatite18. The IMZ implant which was introduced by Dr. Kirsch towards the end of
the 1970’s, was widely used in many countries in the 1980’. The IMZ implant had some
distinctive features; it had a titanium surface spray to increase interface surface area and it
also had an intra-mobile element in it to duplicate the mobility of natural teeth. The Calcitek
Corporation in the early 1980’s started making a synthetic polycrystalline ceramic hydroxyl
apatite called calcite. In 1985 it produced the Integral Implant System. The ITI implant
system introduced in 1985 by the Straumann Company has exclusive plasma sprayed
cylinders and screws which are designed to be placed in a one-stage operation. The most
recent dental implant innovations involve the use fluoride, antibiotics, growth factors and
laminin.

Over the course of time to improve the condition of bone at implant sites various surgical
techniques has been introduced to preserve the remaining volume of bone and increase its
density, chiefly in low density bone areas. Summers RB in 1994 used bone condensation
procedure with osteotomes which is different surgical approach to enhance density of bone
via mechanical action of cylindrical instruments alongside the osteotomic walls. This method
comprises a small pilot hole along the compression of osseous tissue with implant shaped
instrument or spreader apically or laterally. Many times, this treatment creates fracture of
trabeculae with debris which leads to hindrance of osseointegration process

Rationale for dental implant

A dental implant is an alloplastic biomaterial that is surgically inserted into the jaw bone to
solve functional and/or esthetic problems. Most dental implants today are made from
commercially pure titanium (CP-Ti grade 4) or from titanium alloy with well-established
properties of biocompatibility and corrosion resistance of those materials that are attributed to
the native surface oxide19.
Over the past 30 years, dental implant placement has evolved towards a predictable and
routine treatment option for the restoration of missing teeth and various edentulous cases,
with reported success rates exceeding 95%. There are many variables and clinical conditions
reported to have some potential influence on implant success, including local and systematic
disease condition, smoking habits, intravenous medications interacting with bone metabolism
and radiotherapy. Considering that all these variables and conditions may directly or
indirectly affect bone conditions, attention should be paid to the local bone quantity and
quality during the pre-surgical planningphase.20
Bone quantity and quality
Bone quantity can be defined as the amount of bone (height and the width) of the alveolar
bone at an edentulous site20. Bone quality has been suggested as one of the main factors
influencing implant therapy success. Areas of lesser bone quality have exhibited higher
failure rates and weaker primary stability values. Quality of cortical as well as cancellous
bone may affect primary implant stability and therefore success of treatment20. Bone quality
is often referred to as the amount (and their topographic relationship) of cortical and
cancellous bone in which the recipient site is drilled. A poor bone quantity and quality have
been indicated as the main risk factors for implant failure as it may be associated with
excessive bone resorption and impairment in the healing process. Clinical studies have
reported dental implants in the mandible to have higher survival rates compared to those in
the maxilla, especially for the posterior maxilla. It has been shown that achieving optimum
primary stability in soft bones is difficult and is also related to a higher implant failure rate
for the implants placed in such bones. Thus, the density of the surrounding bone seems to
play an essential role in high occlusal forces21.
The success rate obtained with dental implants depends to a great extent on the volume and
quality of the surrounding bone. Therefore, it is important to know the bone quantity and
quality of the jaws when planning implant treatment22

Bone quality and quantity classification

Sufficient bone density and volume are therefore crucial factors for ensuring implant
success23.Bone quality is broken down into four groups according to the proportion and
structure of compact and trabecular bone tissue24.

Lekholm and Zarb, 1985classified bone quality into four groups24:

Type 1: Large homogenous cortical bone.
Type2: Thick cortical layer surrounding a dense medullar bone.
Type3: Thin cortical layer surrounding a dense medullar bone.
Type4: Thin cortical layer surrounding a sparse medullar bone.
 Fig 2: Bone quality classification23

Bone quantity of jawbone is classified into five groups (from minimal to severe, A–E), based
on residual jaw shape and different rates of bone resorption following tooth extraction.

Fig 3: Bone
quantity classification23

The classification system presented by Lekholm & Zarb had several reasons23 24;
(1) It is well known
(2) It describes jawbone tissue from both qualitative and quantitative aspects and
(3) It results indicate a good correlation with bone mineral content

Bone density classification

Misch classified bones of the dental arches in five bone density classes, ranging from D1 to
D5: D1 bone is dense cortical bone, D2 bone is thick dense-to-porous cortical bone that
wraps a coarse trabecular bone, D3 bone is thin porous cortical bone that wraps a fine
trabecular bone, D4 is fine trabecular bone within the ridge and minimal or no cortical bone
on the crest, whereas D5 is immature, non-mineralized25,26.
The quality of bone depends on the anatomical location. The densest bone type is found in
the anterior mandible, being followed by the posterior mandible, the anterior maxilla, and the
posterior maxilla. An important leap in bone quality estimation was made using computed
tomography (CT), by characterizing bone density in terms of the CT number (or
radiodensity), expressed in Hounsfield units (HU). Misch classified the cancellous bone
density into five grades based on number of Hounsfield units (HU). D1: >1250 HU; D2: 850
to 1250 HU; D3: 350 to 850 HU; D4: 150 to 350 HU; and D5: < 150 HU10327.
D1 bone: is more often found in anterior mandibles with moderate to severe resorption. The
percentages of light microscopic contact of bone at the implant interface is greatest in
D1bone and greater than 80%. This bone density exhibits greater strength than any other
density. The strongest bone also benefits from the greatest BIC. Less stresses are transmitted
to the apical third of the implants than other bone densities. D1 bone has fewer blood vessels
than the other three densities, and therefore it is more dependent on the periosteum for its
nutrition. The cortical bone receives the outer one third of all its arterial and venous supply
from the periosteum. This bone density is almost all cortical and the capacity of regeneration
is impaired because of the poor blood circulation. In addition, greater heat is often generated
at the apical portion of the D1bone26.
D2 bone: is a combination of dense-to-porous cortical bone on the crest and coarse
trabecular bone on the inside. The D2 bone trabeculae are 40% to 60% stronger than D3
trabeculae. It occurs most frequently in the anterior mandible, followed by the posterior
mandible. Sometimes, it is observed in the anterior maxilla, especially for a single missing
tooth. D2 bone provides excellent implant interface healing, and osseointegration is very
predictable24,26.

D3 bone: is composed of thinner porous cortical bone on the crest and fine trabecular bone
with in the ridge. The trabeculae are approximately 40%to60% weaker than those in D2 bone.
It is found most often in the anterior maxilla and posterior regions of the mouth in either arch.
The D3 anterior maxilla is usually of less width than its mandibular D3 counterpart. The D3
bone is not only 50% weaker than D2 bone, BIC is also less favorable in D3 bone. The
additive factors can increase the risk of implant failure24,26.
D4 bone: has very little density and little or no cortical crestal bone. It is the opposite
spectrum of D1 (dense cortical bone). The most common locations for D4 are the posterior
region of the maxilla. It is rarely observed in mandible. The bone trabeculae may be up to 10
times weaker than the cortical bone of D1. After initial loading, BIC is often less than 25%.
Bone trabeculae are sparse and, as a result, initial fixation of any implant design presents a
surgical challenge.

Fig 4: Bone density classification26

Dental implant stability

One of the prerequisites for clinical success of the implant treatment is the stability of the
implant.
The stability of the implant can be classi_ed as:
1. Mechanical stability (primary stability) between implant and bone.
2. Biological stability (secondary stability) that occurs as a result of osseointegration. Primary
stability is a crucial factor to achieve implant osseointegration. It is obtained as the threads of
the implant interlocking with the bone upon insertion, holding the implant in place. Primary
stability is vital to the healing process, as it prevents the implants’ micro-movements during
the initial bone remodeling process.
Factors affecting primary stability
They include:
1. The bone quality, quantity and density surrounding the implant.
2. The macro and micro-geometric parameters of the implant, which uniquely interlock with
the surrounding bone.
3. The surgical protocol.
Methods of measurement of dental implant stability
Successful osseointegration is a prerequisite for functional dental implants, and primary
implant stability is a prerequisite for successful osseointegration. Measuring implant stability
supports making good decisions about when to load, allows advantageous protocol choice on
a patient-to-patient basis, indicates situations in which it is best to unload, supports good
communication and increased trust and provides better case documentation.
There are different methods to assess implant stability. They can be grouped as
invasive/destructive methods and noninvasive/ nondestructive methods as follows:
a. Invasive/destructive methods
1. Histologic/histomorphologic analysis
2. Tensional test

3. Push-out/pull-out test and

4. Removal torque analysis.

1. Histomorphometric analysis, Histomorphometric method, quantitatively assesses the bone
contact and bone area within threads. This technique generally requires a light microscope
with microvid computers. Ultrastructural studies are mostly performed on the decalcified
specimens
sectioned for transmission electron microscopy. But due to the invasive and destructive
nature of this techniques, its use has only limited to non-clinical and experiments studies. It is
used in the nonclinical studies and experiments. It is assessed at pre-, intra-, and postsurgical
time points.
2. Tensional test.
The interfacial tensile strength was originally measured by detaching the implant plate from
the supporting bone. Later on, it was modified by applying the lateral load to the cylindrical
implant fixture. However, there were difficulties in translating the test results to any area-
independent mechanical properties.
3. Push-out/Pull-outtest.
The ‘push-out’ or ‘pull-out’ test is the most commonly used approach to investigate the
healing capabilities within the bone-implant interface. In the typical push-out or pull- out test,
a cylinder-type implant is placed trans cortically or intramedullary in bone structures and then
removed by applying a force parallel to the interface. The maximum load capability (or
failure load) is defined as the maximum force on the force- displacement plot, and the
interfacial stiffness is visualized as the slope of a tangent approximately at the linear region
of the force displacement curve prior to breakpoint. However, the push-out and pull-out tests
are only applicable for non-threaded cylinder type implants, whereas most of clinically
available fixtures are of threaded design, and their interfacial failures are solely dependent on
shear stress without any consideration for either tensile or compressive stresses.
4. Removal Torque Analysis.
In this technique, osseointegration is tested at second stage surgery. During the test, a counter
clock wise (reverse) torque is applied to implant up to level of 20 Ncm as removaltorque
value of clinically Osseo integrated implant ranged from 45 to 48 Ncm.
Osseo integrated implants resist this torque, while failed implants unscrew. However, torque
load can result in plastic deformation, even at low levels of torque, and implant surface in the
process of osseointegration may fracture under the applied torque stress. This test is
considered one of the crudest tests as it gives little information about implant bone interface
and provides result only by all or none rule i.e., Osseo integrated or failed, thereby not able to
discriminate the degree of bone healing or bone formation around implants. Reverse torque
assessment; pull-out and push-out techniques are generally used only in preclinical
applications and may be of value as research techniques. The clinical usage of
destructive tests is limited due to ethical concerns associated with invasive nature of these
methodologies.
b. Noninvasive/nondestructive methods
1. The surgeon’s perception
2. Radiographical analysis/imaging techniques
3. Cutting torque resistance (for primary stability)/ Insertion torque measurement
4. Reverse torque
5. Seating torque test
1. The surgeon’s perception.
The clinical perception of primary implant stability is frequently based on the mobility
detected by blunt ended instruments. It’s a very unreliable and nonobjective method. It can
also be checked by the cutting resistance of the implant during its insertion. The feeling of
“good” stability may be accentuated if there is the sense of an abrupt stop at the seating of the
implant. Root forms of tapered implants often have a geometry that will provide a firm stop
and perhaps a false perception of high stability.
2. Radiographical analysis/imaging techniques.
Radiographic evaluation is a noninvasive method that can be performed at any stage of
healing. Bitewing view is used to measure crestal bone level, which has been suggested as an
important radiographic indicator for implant success. It has been reported that 1.5 mm of
radiographic crestal bone loss can be expected in the first year of loading in a stable\ implant,
with 0.1 mm of subsequent annual bone loss. Numerous limitations exist with the use of a
conventional radiograph alone in making an accurate, independent assessment of implant
stability. Conventional periapical or panoramic views do not provide information on a facial
bone level, and bone loss at this level precedes mesiodistal bone loss. At last, neither bone
quality nor density can be quantified with this method. Even changes in the bone mineral
cannot be radiographically detected until 40% of demineralization had occurred. Computer-
assisted measurement of crestal bone level change may prove to be the most accurate
radiographical information. However, this method is not convenient to use in clinical
practice.
3. Cutting torque resistance analysis / Insertion torque measurement. In cutting resistance
analysis (CRA), originally developed by Johansson and Strid and later improved by Friberg
et al in in vitro and in vivo human models, the energy (J/mm3) required for a current- fed
electric motor in cutting off a unit volume of bone during implant surgery is measured. It
determines areas of low-density bone and quantifies bone hardness during implant osteotomy
at the time of implant placement. It determines areas of low-density bone and quantifies bone
hardness during implant osteotomy at the time of implant placement. CRA can be used to
identify any area of low-density bone (or poorquality bone) and to quantify bone hardness
during the low-speed threading of implant osteotomy sites. The major limitation of CRA is
that it does not give any information on bone quality until the osteotomy site is prepared.
CRA also cannot identify the lower “critical” limit of cutting torque value (i.e., the value at
which an implant would be at risk).
Advantages and Disadvantages of CRA
Advantages:
Detect bone density
High correlation between cutting resistance and bone quality
Reliable method to assess bone quality
Identify bone density during surgery
Can be used in daily practice
Disadvantages:
Can only be used during surgery

4. Reverse torque test.

The reverse torque test (RTT), proposed by Roberts et al and developed by Johansson and

Albrektsson, measures the “critical” torque threshold where bone- implant contact (BIC) was

destroyed. This indirectly provides information on the degree of BIC in a given implant. It is

used to assess the secondary stability of the implant. Implants that rotate when reverse torque

is applied indicate that BIC could be destroyed. Further, it cannot quantify the degree of

osseointegration as threshold limits vary among patients, implant material, bone quality and

quantity. The studies showed, the stress of the applied torque may in itself be responsible for

the failure. It also does not measure lateral stability that is a useful indicator for successful

treatment outcome

Fig 5: Reverse torque test

Fig 6: Stability analysis for oral implant osseointegration (a- Tensional test, b- Pushout
method, c-Pull out method, d-Insertion/removal method, e-Periotest, f-Resonance frequency
analysis

5. Seating torque test.

Like insertion torque, the final seating torque gives some information about the
primary stability of the implant when the implant reaches its final apico-occlusal
position. It is done after implant placement.

c. Modal analysis
Theoretical Modal Analysis
1. Finite element method
Experimental Modal Analysis
1. Percussion test
2. Impact hammer method (Periotest, Siemens, Bensheim, Germany; Dental Mobility
Checker, J. Morita, Suita, Japan)
3. RFA (Osstell, Integration Diagnostics, Göteborg, Sweden; Implomate, Bio Tech
One, Taipei, Taiwan)
4. Others (pulsed oscillation waveform by Kaneko)
Modal Analysis.
Modal analysis measures the natural frequency or displacement signal of a system in
resonance, which is initiated by external steady-state waves or a transient impulse force.
Modal analysis, in other words, is a vibration analysis. Modal analysis can be performed in 2
models: theoretical and experimental. Two or 3-dimensional finite element modeling (FEM)
is an example of computer-simulated theoretical modal analysis. Experimental or dynamic
modal analysis, on the other hand, measures structural changes and dynamic characteristics
(e.g., natural characteristic frequency, characteristic mode, and attenuation) of a system that
is excited in an in vitro model via vibration testing (e.g., impactor or hammer). This in vitro
approach provides a more reliable assessment of an object than a theoretical model.
1. Percussion test.
A percussion test is one of the simplest methods that can be used to estimate the level of
osseointegration. This test is based upon vibrational acoustic science and impactresponse
theory. A clinical judgment on osseointegration is made based on the sound heard upon
percussion with a metallic instrument. A clearly ringing “crystal” sound indicates successful
osseointegration, whereas a “dull” sound may indicate no osseointegration. However, this
method heavily relies on the clinician’s experience level and subjective belief. Therefore, it
cannot be used experimentally as a standardized testing method.

2. Pulsed Oscillation Waveform.

Kaneko et al described the use of a pulsed oscillation waveform (POWF) to analyze the
mechanical vibrational characteristics of the implant-bone interface using forced excitation of
a steady-state wave. POWF is based on estimation of frequency and amplitude of the
vibration of the implant induced by a small pulsed force. This system consists of
acoustoelectric driver (AED), acoustoelectric receiver (AER), pulse generator, and
oscilloscope. Both the AED and AER consist of a piezoelectric element and a puncture
needle. A multifrequency pulsed force of about 1 kHz is applied to an implant by lightly
touching it with 2 fine needles connected with piezoelectric elements. Resonance and
vibration generated from bone-implant interface of an excited implant are picked up and
displayed on an oscilloscope screen. An in vitro study showed that the sensitivity of the
POWF test depended on load directions and positions. Sensitivity was rather low for the
assessment of implant rigidity.
3. Impact hammer method.
Impact hammer method is another example of transient impact as a source of excitement
force during experimental modal analysis. It is an improved version of the percussion test
except that sound generated from a contact between a hammer and an object is processed
through fast Fourier transform (FFT) for analysis of transfer characteristics. By enhancing the
response detection using various devices, such as a microphone, an accelerometer, or a strain
gauge, and by processing the detected response with FFT, it becomes possible to quantify and
qualify the response wave in the form of dislocation, speed, acceleration, stress, distortion,
sound, and other physical properties. Periotest (Siemens, Bensheim, Germany) and Dental
Mobility Checker (DMC; J. Morita, Suita, Japan) are currently available mobility testers
designed according to the impact hammer method. The former has an electromagnetically
driven and electronically controlled tapping head that hammers an object at a rate of 4 times
per second. Contact time between the tapping head and the object is also measured. DMC
utilizes the same
principle of tapping a tooth or implant with a dental hammer. A frequency response function
is built-in to detect bone-quality–dependent sound. DMC and Periotest are based on the
impact hammer method, in which impact force is used as the excitation force.
Dental Mobility Checker:
The DMC, which was originally developed by Aoki and Hirakawa measures tooth mobility
with an impact hammer method using transient impact force. Aoki and Hirakawa successfully
detected the level of tooth mobility by converting the integration (i.e., rigidity) of tooth and
alveolar bone into acoustic signals. A microphone was used as a receiver. The response signal
transferred from the microphone is processed by FFT for conversion for analysis in the time
axis. Hence, the duration of the first wave generated by the impact was detected. DMC uses a
small impact hammer as an excitation device. It is easily used even in molar regions. DMC
may provide quite stable measurement for Osseo integrated implants. There are some
problems, however, such as the difficulties of double-tapping and difficulty in attaining
constant excitation. Furthermore, the application of a small force to an implant immediately
after placement may jeopardize the process of osseointegration.
Periotest:
The Periotest was introduced by Schulte to perform measurements of the damping
characteristics of the periodontal ligament, thus assessing the mobility of natural tooth.
Periotest uses an electromagnetically driven and electronically controlled tapping metallic rod
in a handpiece. Response to a striking or “barking” is measured by a small accelerometer
incorporated into the head. The contact time between the test object and tapping rod is
measured on the time axis as a signal for analysis. The signals are then converted to a unique
value called the Periotest value (PTV), which depends on the damping characteristics of
tissues surrounding teeth or implants.
The instrument includes a tapping rod that impacts the abutment/implant assembly. The rod is
drawn by a propulsion coil toward the impacting surface and essentially moves at a constant
velocity from the moment it leaves the hand piece until it impacts the surface. This means
that over a certain distance (approximately 4 mm), the tapping rod is moving at the same
velocity and is designed to impact the surface at any time during this constant velocity travel.
The end of the rod inside the hand piece is rigidly connected to an accelerometer, which
produces an output proportional to its acceleration. The readings are from _8 to +50 and are
interpreted as in Table 1.

Readings Interpretation

-8.0 to 0.0 Good

loaded.
osseointegration, implant can be
+0.1 to +9.9 Examination is required; implant loading is
not possible in many cases

+10.0or Examination is required; implant loading is

Higher not possible in many cases

Table 1: Interpretation of Periotest readings

The factors that influence the periotest value are the quality of the hard tissue in the region
of the implant, so that no specific values can be deemed as appropriate for higher or lower
degrees of integration. It is a function of the distance from the implant flange to the point at
which the rod impacts the abutment. The measurements are significantly affected by
excitation conditions such as direction and position. The measurements must be made in the
mid buccal region and be perpendicular to the implant axes. Considering the intra oral
environment, it is considerably easy to make measurements on anterior implants whereas it is
not possible for molars owing to the buccal mucosa. The periotest cannot diagnose a
“borderline” case or “an implant in the process of osseointegration.” It does not reflect the
level of peri-implant bone and therefore cannot be substituted for radiography.
The main limitation of the Periotest® is a lack of sensitivity in evaluating osseointegration,
whereby the range of PTV in Osseo integrated implants falls to a narrow zone (_5 to +5)
within a wide scale (_8 to +50). This could be accounted for by physical differences between
periodontium and the bone-implant interface, because bone is much stiffer and does not allow
3for significant deformation as compared to the soft tissue of the periodontium. Moreover,
results may also be influenced by the position and direction of the percussion rod.
 Fig 7: Periotest® (Siemens AG, Benshein, Germany) measures tooth mobility
and implant stability by Periotest value. (a) Periotest®, (b) Periotest®M

4. Resonance Frequency Analysis.

It was suggested by Meredith in 1998. It is a noninvasive diagnostic method that measures
implant stability and bone density at various time points using vibration and a principle of
structural analysis. RFA utilizes a small L-shaped transducer that is tightened to the implant
or abutment by a screw. The transducer comprises of two ceramic elements, one of which is
vibrated by a sinusoidal signal (5–15 kHz) while the other serves as a receptor. The
transducer is screwed directly to the implant body and shakes the implant at a constant input
and amplitude, starting at a low frequency and increasing in pitch until the implant resonates.
High frequency resonance indicates stronger bone-implant interface. It also provides baseline
reading for future comparison and postsurgical placement of the implant. RFA has been
widely used for clinically assessing osseointegration, as well as for prognostic evaluation.
Classically, the ISQ has been found to vary between 40 and 80, the higher the ISQ, the higher
the implant stability. The factors affecting the readings are effective implant length, bone
quality and quantity, implant length, diameter and shape. The most recent version of RFA is a
wireless gadget. A metal rod is attached to the implant with a screw connection. The rod has
a small magnet attached to its top that is stimulated by magnetic impulses from a handheld
electronic device. The rod mounted on the implant has two fundamental resonance
frequencies; it vibrates in two directions, perpendicular to each other. One of the vibrations is
in the direction where the implant is most stable and the other is in the direction where the
implant is least stable.
Currently, two RFA machines are in clinical use: Osstell® (integration diagnostics) and
Implomates® (Bio TechOne).
ELECTRONIC TECHNOLOGY RESONANCE FREQUENCY ANALYSIS
(OSSTELL™)
It was the first commercially available product for measuring implant stability. The electronic
technology combines the transducer, computerized analysis and the excitation source into one
machine. Implant stability quotient (ISQ) is the measurement unit (ISQ of 0 to 100) used.
When used at the time of implant placement it provides baseline reading for future
comparison and postsurgical placement of the implant. Currently, Osstell (Integration
Diagnostic AB, Goteborg, Sweden), a commercialized product utilizing the concept of RFA,
has translated the resonance frequency ranging from 3000 to 8500 Hz as the ISQ of 0–100.

MAGNETIC TECHNOLOGY RESONANCE FREQUENCY ANALYSIS

(OSSTELL™MENTOR)
The transducer has a magnetic peg on top and is fixed to implant or abutment. On activation
by magnetic resonance frequency probe the peg is activated, which vibrates and induces
electric volt sampled by magnetic resonance frequency analyzer. Values are expressed as ISQ
of 0 to 100. At the time of implant placement, it provides baseline reading for future
comparison and postsurgical placement of the implant. However, this method is expensive
and technique sensitive as it requires respective transducer and magnetic peg. It should
maintain a distance of 1–3 mm, angle of 90°, and should be 3 mm above the soft tissue
otherwise the measured value will be affected. The drawbacks with this technology are that
the transducer is limited to a set of 60 measurements, thus making the method rather
expensive. In order to perform the RFA, a transducer is fixed to the implant. This excludes
monitoring all implants that support a cemented restoration.
 Fig 8: principle of electronic resonance frequency analyzer.

Fig 9: Principle of the Osstell Mentor™. Magnetic peg (smart peg™) works like a
tuning fork and Osstell ISQ™
 METHODE ADVANTAGES DISSADVANTAGES

Histologic analysis Good objectivity Destructive and Invasive

method
Limited to Non-clinical/
Experimental studies

Percussion test Non-invasive Not Reliable method -

No costly equipment Subjective method
Easy to use Depends upon clinician
Perception

Removal Torque No costly equipment Osseointegration is tested in

Easy to use second stage
Provide result only in
osseointegration or/ failed
implant
Radiographs Good objectivity Destructive and Invasive
method
Limited to Non-clinical/
Experimental studies

Cutting resistance Reliable method Can only be used during

High Correlation between Surgery
Cutting Resistance and bone
quality
Detect bone density
Periotest Non-Invasive Poor Sensitivity
Quantitative method Lack of resolution
Can be used clinically

RFA Non-Invasive Expensive Equipment

Quantitative method No Critical value to suggest
Can be used clinically implant success or/ failure

Table 2: Advantages and disadvantages of methods used to measure implant stability

Osseointegration
Osseointegration is defined as a direct structural and functional connection between ordered,
living bone and the surface of a load carrying implant. Osseointegration is crucial for implant
stability, which determines the long-term success of dental implants.
The process of osseointegration leads to bone formation on the implant surface and
contributes to implant secondary stability between bone and dental implant. Osseointegration
is the basis of a successful endosseous implant. The process itself is quite complex and there
are many factors that influence the formation and maintenance of bone at the implantsurface.
Factors affecting osseointegration.
In 1981, Albrektsson et al. demonstrated the six major parameters of osseointegration,
mainly:
the implant material, the implant surface, the implant design, the condition of the bone at the
host bed, the surgical technique and the loading conditions. However, as research revealed
more on the role of these factors, it is more useful to categorize them by their determinants
into the following factors:
1. Implant related factors: The biocompatibility of the material, the topography, the
composition, the coating of the surface, the shape, the design of the implant and the
dimensions of the fixture.
2. Host bed factors: The bone volume, density and vascularity.
3. Surgical factors: Achieving primary stability, mechanical trauma, thermal trauma or
infection.
4. Biomechanical factors: Loading conditions.
5. Patient related factors: Systemic disease, systemic medication, radiotherapy and
parafunctional habits. Primary stability of the implant is, however, of utmost importance as it
is related to the parameters of all five categories. It is influenced by the shape and design of
the implant, the quality and quantity of the bone, the surgical technique and skills of the
surgeon, whilst its maintenance is depended on the loading conditions, the presence of
parafunctional habits and the healing capacity of the host. The absence of movement
immediately after implant insertion is one of the most important factors affecting implant
osseointegration118. Different surgeons have different preparation protocols, depending on
the patient bone densities. Among the surgical factors that influence osseointegration, implant
bed preparation is of critical importance. Drilling the implant bed not only causes mechanical
damage to the bone but also
increases the temperature of the bone directly, adjacent to the implant surface.
Bone remodeling around dental implants
Shortly after dental implant placement, a sequence of immuno- inflammatory responses,
followed by angiogenic and osteogenic events, takes place. This sequence is primarily
influenced by the implant surface characteristics, including surface topography, chemistry
and material composition, which either facilitate or prevent the adsorption of proteins onto
the implant surface.
Within the first 5 days, thrombin and fibrinogen adsorb to the implant surface and play a key
role in the early homeostasis as the release of cytokines and growth factors stimulates future
collagen matrix deposition around the titanium oxide layer of the implant, leading to newly
formed woven bone.
In about 8 to 12 weeks, lamellar bone initiates the biological stability, namely
osseointegration.
Twelve weeks afterwards, as with natural dentition, implants are subject to soft and hard
tissue remodeling where the average biologic width around dental implants has been reported
at approximately 3.5 mm.
The process of osseointegration continues to increase the bone mineral density close to the
implant body for up to 2 years. A steady state of osseointegration is achieved where there is
nearly equal gain and loss of minerals, without substantial change in volumetric bone mass.

Increasing the primary stability of an implant in low-density bone

During the past decades, many surgical techniques have been developed to increase the
primary stability of an implant placed in low-density bone.
One tapping: it was suggested that the stage of bone tapping should be omitted due to
invasiveness, especially in cases of low-density bone.
Bicortical anchorage: It was reported that bicortical anchorage significantly increases
primary implant stability.
Under preparation of the implant bed: which is achieved by using a one or more size
smaller as the last drill than selected implant diameter. In the presence of poor bone quality,
10% undersized implant bed preparation is sufficient to enhance primary stability whereas,
additional decrease does not improve primary stability values. Studies on stepped osteotomy
of implant bed, which is another variant of the under-preparation method, have reported
greater implant stability in terms of insertion torque than conventional osteotomy in soft
bone.
Bone condensation: Summers in 1994 described the use of osteotomes to condense bone
manually in case of low bone density. The principle behind the bone condensation at the
periphery of implant bed is to insert implant in a high- density bone matrix. The osteotome
technique, uses hand driven devices and compresses the surrounding bone by gradual
expansion leading to enhanced insertion torque values that is considered by the practitioners
as an indication of improved primary stability. Many studies recommend the bone
condensing technique as another method to increase the primary stability of an implant.
Recently a new technique of preparation the implant bed has been developed based on OD
drilling concept.

Osseodensification
Osseodensification (OD) is a new method of biomechanical bone preparation performed for
dental implant placement. The procedure is characterized by low plastic deformation of bone
that is created by rolling and sliding contact using a densifying bur that is fluted such that it
densifies the bone with minimal heat elevation. OD, a bone nonextraction technique, was
developed by Salah Huwais in 2013. For this purpose, Huwais invented specially designed
densifying burs called Densah™ burs that has many lands with a large negative rake angle,
which work as noncutting edges to increase the density of the bone as they expand an
osteotomy. These densifying burs have four or more lands and flutes that smoothly compact
the bone. Densifying burs are novel surgical devices as they are designed to have a cutting
chisel edge and a tapered shank, so as they enter deeper into the osteotomy, they have a
progressively increasing diameter that controls the expansion process. These burs are used
with a standard surgical engine and can densify bone by rotating in the noncutting direction
(counterclockwise at 800–1,200 rotations per minute) or drill bone by rotating in the cutting
direction (clockwise at 800–1,200 rotations per minute).

Fig 10: Densification drills

These burs provide advantages of both osteotomes combining the speed along with improved
tactile control of the drills during osteotomy. Standard drills excavate bone during implant
osteotomy, while osteotomes tend to induce fractures of the trabeculae that requiring long
remodeling time and delayed secondary implant stability. The Densah burs allow for bone
preservation and condensation through compaction autografting during osteotomy
preparation,
thereby increasing the bone density in the peri-implant areas and improving the implant
mechanical stability (fig). The bone-remodeling unit requires more than 12 weeks to repair
the damaged area created by conventional drills that extract substantial amount of bone to let
strains in the walls of osteotomy reach or go beyond the bone microdamage threshold. Hence,
OD will help preserve bone bulk and increase density, thereby shortening the healing period.

Fig 11: Versah Kit with densification drills

Rationale of Osseodensification
The rationale for the utilization of this process is that densification of the bone that will
immediately be in contact to the endosteal device will not only result in higher degrees of
primary stability due to physical interlocking (higher degrees of contact) between the bone
and
the device, but also in faster new bone growth formation due to osteoblasts nucleating on
instrumented bone that is in close proximity with the implant. This is performed in an attempt
to develop a condensed autograft surrounding the implant, making it valuable in clinical
settings where there is an anatomic paucity of bone126. Unlike traditional drilling protocols
(subtractive drilling), OD increases primary stability due to densification of the drilled
osteotomy site walls centrifugally by means of non- subtractive drilling. Gaspar et al. stated
that the bone expansion capacity of OD for predictable ridge expansion has been validated
with enhanced primary stability and higher insertion torque values. This may be clinically
relevant in minimizing implant dehiscence’s or fenestrations. OD can also be used
for crestal sinus lift in a simple, safe and predictable way with reduced morbidity.

Unique Characteristics
Regular twist drills or straight fluted drills have 2-4 lands to guide them through the
osteotomy.
Densah® Burs are designed with 4 or more lands, which precisely guide them through bone.
More lands mean less potential chatter. During Osseodensification, Densah® Burs produce a
controlled bone plastic deformation, which allows the expansion of a cylindrical osteotomy
without excavating any bone tissue.
1. Modes
Densah® Burs progressively increase in diameter throughout the surgical procedure and are
designed to be used with standard surgical engines, to preserve and compact bone (800-1500
rpm) in a counterclockwise direction (Densifying Mode), and to precisely cut bone if needed
(800-1500 rpm) in a clockwise direction (Cutting Mode).
 Fig 12: Dual use capability of densifying bur- a) Densifying mode- creates
Osseodensification; b) Cutting mode-precisely cuts bone.

1. Motion
The Densah® Burs are always to be used with copious irrigation in a Bouncing- Pumping
motion (vertical pressure to advance the drill into the osteotomy, then a minor pulls out for
pressure relief, then advance with vertical pressure again and so on in an in/out fashion). The
duration and number of bouncing-pumping episodes (in/out) are usually dictated by bone
density and desired length.
Fig 13: Bouncing- Pumping motion of Densah® Burs

Features of Osseodensification drills

A conically tapered body with a maximum diameter adjacent the shank and minimum
diameter adjacent the apical end. This taper design controls the expansion process, as the bur
enters deeper into the osteotomy.
The apical end includes at least one lip to grind bone when rotated in the counterclockwise/
non-cutting/burnishing direction and cut bone when rotated in the clockwise/cutting/drilling
direction.
Helical flutes and interposed lands are disposed about the body. Each flute has a burnishing
face and an opposing cutting face. The burnishing face burnishes bone when rotated in the
burnishing direction and the cutting face cuts bone when turned in the cutting direction.
At least one of the lips and the lands are configured to generate an opposing axial reaction
force when continuously rotated in a burnishing direction and concurrently forcibly advanced
into an osteotomy. This results in a push-back phenomenon, which provides the user
enhanced control over the expansion procedure.
 Figure 14: Characteristics of a densifying bur.
Technology behind the Densah® burs
1. These burs have a twist drills or straight fluted drills with four or more lands to guide them
through the osteotomy and smoothly compact the bone.
2. It has many lands with a large negative rake angle, which work as non-cutting edges to
increase the bone density as they expand an osteotomy in which the displaced bone is
compacted and compressed circumferentially. Therefore, increase in biomechanical stability.
3. The pattern of burs has a cutting chisel edge and a tapered shank, so as they easily enter
deeper into the osteotomy site, and controls the expansion process.
4. These burs can used as a densify bone by rotating in the non-cutting direction (counter
clockwise at 800 - 1,200 rotations per minute) or drill bone by rotating in the cutting direction
(clockwise at 800 - 1,200 rotations per minute.
Figure 15: Role of densification Drills

Armamentarium:
The Densah Bur kit includes 12 burs that are designed to create osteotomies for all major
dental implants in the market (Figure 10). Each Densah Bur is marked with depth markings
from 8-20 mm. They are designed to be used in a consecutive increasing order to achieve the
desired osteotomy diameter

Figure 16: Densah Bur kit

Densah Bur Marking

  They are marked with laser markings1 from 3-20 mm depth.
 Densah® Burs have a tapered geometry; catalog number is a reflection of their minor
and major diameter dimension. E.g., Densah® Bur VT3848 has a (minor-diameter) of 3.8
mm and a coronal (majordiameter
of 4.8 mm at 11.5 mm laser mark with an average-diameter of (4.3 mm) at
the 8 mm laser mark which becomes the crestal diameter for short implants length _
8mm.
 Drilling Depth: Measure the drilling depth of the Densah® Bur from the widest part
of its tip to the indication line. Regardless of the Densah® Bur diameter, the
maximum additional tip depth is 1.0mm.

Figure 17: Densah® Bur Laser Lines

Included in the Kit
Densah® Burs are designed to be used for Osseodensification in small increments (alternate
between VT5 and VT8) in dense trabecular bone to allow gentle expansion of the osteotomy.
In soft bone, the osteotomy final preparation diameter should be that measures 0.2-0.5 mm
smaller than the implant average diameter. With Osseodensification, bone preservation
creates a spring back effect.

Fig 18: VT5, VT8, VS8 series

Soft Trabecular Bone — Tapered Implants

Indications:
:Densah® Burs are indicated for use to prepare osteotomies for dental implant placement
in the mandible or maxilla.
:The Pilot Drill is used to create the initial hole in bone to prepare an osteotomy for dental
implant placement and monitor the drilling depth.
:The parallel pin is for use as a paralleling guide with the Densah® Burs.
Contraindications
: Osseodensification does not work in cortical bone. In (Type I/Dense Bone); use the Densah
Burs in Cutting Mode (CW) and reverse-out (CCW) to re-autograft. (Densify- Preserve after
Cut Protocol).
:Traditional guided surgery may present a higher risk of implant failure due to its limitation
in allowing the needed bouncing technique and adequate irrigation.
: Avoid Densifying Xenograft.
Mechanism of the Osseodensification procedure.
In Osseodensification (OD) procedure, the densifying burs produce a controlled bone
deformation, which allows the expansion of a cylindrical osteotomy without excavating any
bone tissue. When the osteotome is removed, the spring-back effect is a response of
compacted bone that reduces the osteotomy to a smaller diameter. The spring-back
phenomenon is due to the viscoelastic deformation. To achieve bone compaction Viscoelastic
process is used. In this technique, residual strains are created in bone. To increase the boneto-
implant contact (BIC) and primary stability, the residual strain in the bone creates
compressive forces against the implant, which promote osteogenic activity. This reverse
compression applied to the implant by the bone is responsible for higher removal torques that
were generated with osseous densification. High insertion torque is an indication of good
primary stability. The bone deformation occurs through viscoelastic mechanisms.
Overheating is eliminated by irrigation fluid. This fluid is forced into the osteotomy which
facilitate autografting of bone particles along the inner surface of the osteotomy.
 Osseodensification (hydrodynamic bone preparation) mechanism.

Protocol for the use of Densah® bur in different bone qualities.

Protocol I-Osseodensification facilitates medium and soft bone density
1. Implant was placed and buried under the soft tissue using the technique indicated.
2. By using the Pilot Drill (Clockwise drill) at speed of 800 - 1500 rpm with copious
irrigation, drill to the desired depth.
3. Begin with the narrowest Densah™ Bur.
4. Change the drill motor to reverse (Counterclockwise) direction at speed of 800- 1500 rpm.
5. Running the bur into the osteotomy site in a densifying direction.
6. When there is a feeling of the bur pushing up out of the osteotomy, modulate pressure with
a pumping motion to achieve desired depth.
7. Ample irrigation is always required.
8. When there is a feeling of resistance, increase the pressure and the number of bouncing-
pumping motions to achieve desired depth.
9. Placement of the implant.
10. Placing the implant with a torque indicating ratchet wrench to the desired depth.

Protocol II- Osseodensification in dense bone quality in the mandible

1. Implant was placed and buried under the soft tissue using the technique indicated.
2. It is advised to prepare the osteotomy 1.0 mm deeper than the final implant length.
3. Begin with the narrowest Densah™ Bur (2.0).
4. Change the drill motor to reverse (Counterclockwise) direction at speed of 800- 1500 rpm
with irrigation.
5. Running the bur into the osteotomy site in a densifying direction.
6. When there is a feeling of the bur pushing up out of the osteotomy, modulate pressure with
a pumping motion to achieved desired depth.
7. In very dense bone, strong resistance may be felt.
8. Change the drill motor to forward-Cutting Mode (Clockwise) direction at speed of 800-
1500rpm.
9. Begin running the bur into the osteotomy.
10. To densify and auto-graft the cut bone back into the osteotomy walls change the drill to
reverse densifying mode.
11. Re-deposit the cut bone particles inside the osteotomy by not eliminating the bur between
cutting and densifying modes

Protocol III- Osseodensification facilitates lateral ridge expansion

Ridge expansion procedure
1. There is a need for _ 2 mm of trabecular-bone core and _ 1/1 trabecular/cortical bone ratio
to achieve a predictable plastic expansion. The more cortical bone there is, the more
trabecular core is needed to facilitate predictable expansion. The ideal minimum ridge to
expand is 4 mm (2 mm trabecular core + 1mm cortex on each side).
2. Diagnose and assess the amount of trabecular bone available using a CBCT to evaluate
bone composition needed to perform a predictable plastic expansion.
3. Flap the soft tissue using the technique indicated for the implant position.
4. Depending upon the implant type and diameter selected for the site, after a narrow pilot
osteotomy, begin with the narrowest Densah® Bur. Set the drill motor to reverse– Densifying
Mode (Counterclockwise drill speed 800-1500 rpm with copious irrigation). Begin running
the bur into the osteotomy. When feeling the haptic feedback of the bur lift off pressure and
reapply, repeatedly lift off and reapply pressure with a pumping motion until reaching the
desired depth.
5. Use the Densah® Burs in small increments. As the bur diameter increases, the bone may
gradually expand to the final diameter. The osteotomy may be expanded with minimal bone
dehiscence, which may allow for total implant length placement in autogenous bone without
thread exposure. Mandibular osteotomies need to be planned and performed to 1 mm deeper
than the implant length.
6. Place an implant with a diameter that is equal or slightly larger than the initial ridge width
(up to 0.7 mm larger). If using the drill motor to tap the implant into place, the unit may stop
when reaching the placement torque maximum. Finish placing the implant to depth with a
torque indicating wrench. The proper diameter implants should be included in the treatment
plan and on hand at the surgical appointment. 7. If < 1.5-2.0 mm of buccal bone thickness has
resulted after Osseodensification, perform hard and soft tissue veneer contour-graft to
augment around the implant to develop tissue thickness that may enhance long term stability.
Complete implant coverage may be considered for 2-stage healing protocol.

Fig 19: Ridge expansion procedure

Ridge Expansion with Modified Ridge Split:

1. In cases of an initial ridge width < 4mm that contains _ 2mm of trabecular-bone core, an
intra-bony ridge split is needed; ridge split to be made by a Piezo surgery 0.3-0.5 mm tip.
Ridge split is recommended to be as deep as the planned implant length. No vertical cuts are
needed. Ridge split is to allow more buccal wall elasticity during the expansion procedure.
This intra-bony split is contraindicated in resorbed ridge with a narrow base.
2. Depending upon the implant type and diameter selected for the site, after a narrow pilot
osteotomy, begin with the narrowest Densah® Bur. Set the drill motor to reverse– Densifying
Mode (Counterclockwise drill speed 800-1500 rpm with copious irrigation). Begin running
the bur into the osteotomy. When feeling the haptic feedback of the bur lift off pressure and
reapply, repeatedly lift off and reapply pressure with a pumping motion until reaching the
desired depth.
3. Use the Densah® Burs in small increments. As the bur diameter increases, the bone may
gradually expand to the final diameter. The osteotomy may be expanded with minimal bone
dehiscence, which may allow for total implant length placement in autogenous bone without
thread exposure.
4. Oversize the osteotomy to be slightly wider than the implant major diameter (especially in
the mandible) to prevent the implant thread from over-straining the expanded bony walls.
Mandibular osteotomies need to be planned and performed to 1mm deeper than the implant
length.
5. Place implant with a diameter that is equal or slightly larger than the initial ridge width (up
to 0.7 mm larger). If using the drill motor to tap the implant into place, the unit may stop
when reaching the placement torque maximum. Finish placing the implant to depth with a
torque indicating wrench. The proper diameter implants should be included in the treatment
plan and on hand at the surgical appointment. 6. If < 2.0 mm of buccal bone thickness has
resulted after Osseodensification, perform hard and soft tissue veneer contour-graft to
augment around the implant to develop tissue thickness that may enhance long term stability.
Complete implant coverage may be considered for 2-stage healing protocol.
7. If the resulted buccal bone thickness post expansion is _ 1 mm, do not place the implant
and allow for 2-stage approach (Guided Expansion Graft)
 Fig 20: Ridge expansion with Modified Ridge Split

Guided Expansion Graft: 2-Stage Approach

1. For cases with initial width of < 3.0mm
2. Flap the soft tissue using the technique indicated for the implant position.
3. Drill to the desired depth using the Pilot Drill (Drill speed 800-1500 rpm with copious
irrigation).
4. Begin with the narrowest Densah® Bur. Set the drill motor to reverse–Densifying Mode
(Counterclockwise drill speed 800-1500 rpm with copious irrigation). Begin running the bur
into the osteotomy. When feeling the haptic feedback of the bur pushing up out of the
osteotomy, repeatedly lift off and reapply pressure with a pumping motion until reaching the
desired depth.
5. Increase osteotomy diameter in small increments until reaching a final width _3.5- 4.0 mm.
As the bur diameter increases, the bone may gradually expand to the final diameter.
6. Graft the newly formed socket including surrounding area with your preferred bone
allograft materials, use membrane and achieve primary closer. Allow healing for 4-6 months.
7. Perform Osseodensification to facilitate further expansion if needed and place the implant.
Finish placing the implant to depth with a torque indicating wrench.

Fig 21: Guided Expansion Graft

Protocol IV- Osseodensification facilitates vertical ridge expansion

Maxillary sinus autografting
1. Implant was placed and buried under the soft tissue using the technique indicated for
the implant position.
2. In cases where posterior residual alveolar ridge height is 7.0 mm, drill to the depth
determined within an approximate of 1.0 mm from the sinus floor using a pilot drill.
3. With the help of radiograph confirm pilot drill position.
4. Begin with the narrowest Densah™ Bur.
5. Change the drill motor to reverse-Densifying Mode (Counterclockwise drill speed 800-
1500 rpm with copious irrigation).
6. Begin advancing the bur into the osteotomy site.
7. When there is a feeling of the bur reaching the dense sinus floor, modulate pressure with a
pumping motion to advance past the sinus floor.
8. Maximum advancement past the sinus floor must not exceed 1.0mm.
9. With the help of radiograph confirm the first Densah™ Bur vertical position.
10. As the next Densah™ Bur advances in the osteotomy, bone will be pushed toward the
apical end and will begin to gently lift the membrane and autograft compacted bone.
11. To achieve additional vertical depth and maximum membrane lift of 3.0 mm (in 1.0 mm
increments) use the burs in Densifying Mode.
12. Placement of the implant into the osteotomy.
13. Placing the implant with a torque indicating ratchet wrench to the desired depth

Protocol V- Instructions for maintenance of Densah™burs kit

1. Stage 1: Cleaning: Drills should be brushed and rinsed with detergent to remove any
remaining blood or tissue.
2. Stage 2: Ultrasonic Cleaning: Drills should be cleaned in an ultrasonic bath using
appropriate enzymatic detergent (10%solution).
3. Stage 3: Rinsing: Drills should be rinsed with running water to completely remove
detergent and then dried.
4. Stage 4: Sterilization: Drills should be sterilized in an autoclave at 132°C (269.6°F) at a
pressure of 315 Kpa for a4-minute.
5. Stage 5: During Use: Drills should be soaked in a sterile saline solution.
6. Stage 6: Storage: Burs can be used immediately upon opening after long-term storage.

Advantages of osseodensification131
1. It is a unique, highly controllable, fast and efficient bone preservation osteotomy
preparation technique which results in increased primary stability, BMD and percentage of
bone at the implant surface leading to faster wound healing and enhanced Osseointegration.
2. Healing process can be accelerated due to bone matrix, cells and biochemicals maintained
and autografted along the osteotomy surface site.
3. By OD technique, wider implant diameter can be inserted in narrow ridges without
creating bone dehiscence or fenestration.
4. Increased insertion and removal torque values have been reported with dental implants
placed into Osseodensified osteotomies.
5. The dual use capability of densifying bur in both cutting and noncutting direction may
enable the clinician to autograft the maxillary sinus and expands any ridge in maxilla and
mandible.
6. Huwais demonstrated that OD helped ridge expansion while maintaining alveolar ridge
integrity, thereby allowing implant placement in autogenous bone. OD helped in preserving
bone bulk and shortened the waiting period to restorative phase108.
7. Compaction auto grafting: Osseodensification maintains the bulk of bone by
condensation and compaction which results in higher bone to implant contact.
8. Enhances bone density: Osseodensification burs allow preservation of bone and
condensation through compaction autografting, thereby increasing the peri- implant bone
density, and the implant mechanical stability.
9. Residual ridge expansion: Studies shown that narrow bone expands along with
Osseodensification thus facilitating for placement of implants with larger diameter and also
avoiding fenestration and dehiscence.
10. Increase in Implant Stability: Huwais S concluded that, the densahTM bur technology
facilitates ridge expansion with maintained alveolar ridge. He also concluded that, despite
compromised bone anatomy, Osseodensification preserved bone bulk and promoted a shorter
waiting period to the restoration.
11. Increase in residual strain: The bouncing motion helps to create a rate dependent stress
to produce a rate dependent strain, and allows saline irrigation to gently pressurize the bone
walls. These together facilitate increased bone plasticity and bone expansion.
Disadvantages of Osseodensification
Case selection for using OD burs in counterclockwise mode is important as the procedure is
not recommended in dense bone (D1, D2) and more suitable for soft bone.
_ This can be explained by the fact that soft bone has wider marrow spaces between the bone
trabeculae, allowing for bone compaction, rather than the compact bone, leading to lateral
compression that exceeds the viscoelastic limit of the thick and dense bone trabeculae, with
subsequent damage and a weaker bone implant interface143. During bone compaction and
implant loading under high torque, bone is subject to a microdamage threshold. If the bone's
micro-damage threshold is exceeded, the bone remodeling cycle may require an additional 3
months or more to repair these damaged areas. This is particularly important in relation to
OD since over-compression may also unintentionally cause bone necrosis.

Indications
_ It facilitates lateral ridge expansion- Ridge with less than 3 mm of width.
_ It facilitates vertical ridge expansion in maxillary sinus.
Contraindications
_ Osseodensification does not work with cortical bone as cortical bone is a non- dynamic
tissue which lacks plasticity. Densification of xenografts should be avoided because they
behave biomechanically different than the bone tissue, as they have only inorganic content
and they just provide the bulk without any viscoelasticity.
_ Patients with various systemic disorders such as compromised immune system, bleeding
disorders and titanium allergy should be excluded.

Osseodensification versus conventional osteotomy

Osseodensification technique is a bone preservation method, whereas traditional drilling
method involves cutting and excavation of bone tissue. It has been demonstrated that
densifying drills increase the percentage of BV and the percentage of BIC area for implants
placed in low-density bone compared to traditional osteotomies, which may enhance
osseointegration. Drilled osteotomies may sometimes become elongated and elliptical due to
chatter of the conventional drills while OD drills produce a precise circumferential osteotomy
due to their geometric configurations, Lack of precise osteotomy may lead to reduced
insertion torque, leading to poor implant stability.
Heat generation during rotary cutting is one of the crucial factors influencing the
development
of osseointegration. During drilling, temperature rises due to the plastic deformation and
shear failure of bone and friction at the machining face, which may affect the viability as well
as the structure and mechanical properties. These circumstances may reduce the implant
insertion torque, leading to poor primary stability and potential lack of integration to bone.
External irrigation with copious amount of saline along with a bouncing motion of bur used
in OD technique seems beneficial in reducing the heat generated during the osteotomy
preparation in the same manner as the conventional drilling124. The diameter on an
osteotomy prepared by OD is found to be smaller than conventional osteotomies prepared
with the same burs. The percentage of BIC is reported to be increased by approximately three
times for implants placed with OD compared with standard drilling by creating a crust of
increased bone mineral density around the osteotomy site.
Many authors reported a significant increase in insertion torque and concomitant reduction in
micromotion by bone compaction techniques with that of standard drilling. High insertion
torque can significantly increase the initial BIC percentage and is found to be directly related
to implant primary stability and host bone density. High insertion torque is also important for
achieving a good clinical outcome with early or immediate loading. Higher removal torque
values are noted with implants placed by OD compared to drilling. This may be due to the
reverse compression applied to the implant by the compressed bone in osteotomy prepared by
OD.

Fig 22: (a) Regular drill (b) Versah drill

 Technique Ossiodensification technique Traditional drilling technique

Bone Non-excavation, bone Involves cutting and excavation of

excavation preservation bone tissue
method, allows compaction
- auto-grafting of bone with
minimal
Trauma

Bur design Taper design with more than four Regular twist drills have only two
lands to four lands to guide them
and flutes and through the osteotomy
a tip with flute/s to guide through
the
osteotomy and
eliminates potential chatter.
Osteotomy Creates precise circumferential May not always produce a precise
osteotomy Circumferential osteotomy. May
Diameter of osteotomy is 0.5mm become elongated and elliptical
smaller than traditional drilling due to chatter of the drills
osteotomy.

Heat generation Heat generation is reduced with Heat generation during rotary
copious cutting
amount of saline external is a crucial
irrigation factor influencing the development
along with a bouncing-pumping of
osseointegration.
motion of bur
Implant Higher (Compared to traditional Less (compared to
placement drilling Osseodensification
Insertion techniques) technique)
torque Facilitates expansion of narrow Larger diameter implant placement
Removal ridges in may result in
torque width. bone dehiscence or fenestration
% Bone Allows larger diameter implant
volume placement without creating bone
In narrow dehiscence or fenestration
ridges
Table 3: Difference between Osseodensification technique and traditional drilling
technique130.

Limitations130
1. Osseodensification (OD) does not work with cortical bone as cortical bone lacks plasticity.
2. Prevent the densification of xenografts.
Healing of the osteotomy by Osseodensification technique80
The most specific feature of the healing pattern is observed at the level of coronal area where,
the bone presented a granular aspect. In these zones, the bone trabeculae show outer side
lamellar bone layers and the specific granular layer in the inner side. The percentage of bone
surface lined by osteoid bands in the coronal area is much higher than that found in other
areas of the implants. The increase of bone density is particularly evident in the most coronal
implant region. Active bone remodeling is found to be directed more toward bone apposition
and bone density increase than toward bone resorption. This suggests that, in the long run, the
bone could still increase its density.
CONCLUSION

Preservation of bone bulk during implant osteotomy preparation is crucial for securing
primary implant stability, which is highly associated with successful osseointegration and
long- term successful clinical outcome. Most of the techniques proposed for implant
osteotomy site preparation involve excavation and removal of bone. Recently, a unique; fast
and efficient; bone preserving; biomechanical osteotomy preparation technique called
Osseodensification has been introduced, which enhances implant stability. The
Osseodensification technique reduces bone sacrifice that appears unavoidable with
conventional drilling procedures and prevents fracturing of trabeculae causing a delayed bone
growth, as reported with the osteotome technique. The concept of Osseodensification has
changed the paradigm of implant site preparation and is found to be beneficial in creating a
stronger expanded osteotomy for implant placement, through compaction and autografting
the surrounding bone particularly in areas with low- density bone. The Osseodensification
technique is shown to increase the primary stability, the bone mineral density, and the
percentage of bone at the implant surface.

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