Implant stability during osseointegration using osteotome technique

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1 中国组织工程研究第 19 卷第 16 期 出版 Chinese Journal of Tissue Engineering Research April 16, 2015 Vol.19, No.16 Implant stability during osseointegration using osteotome technique Zhang Xiao-dong, Yang Yong-qin, Shi Sa-sa, Ma Rui-zhao, Liao Li-fei Department of Stomatology, the 521 Hospital of China North Industries Group Corporation, Xi an , Shaanxi Province, China Abstract BACKGROUND: Implant stability is the basic requirement of osseointegration and also one of important parameters to judge whether the implant is implanted successfully. Generally, the implant stability is closed related to bone quality (bone hardness and bone density) in the implant zone, implant shape, diameter and length. OBJECTIVE: To continuously monitor the changing trend of implant stability during early healing period due to the utilization of osteotome technique by resonance frequency analysis. METHODS: Twenty patients with class IV defects in the posterior maxilla who underwent implant restoration (4.8 mm 12 mm) from 2010 to 2011 at the Department of Stomatology, the 521 Hospital of China North Industries Group Corporation were recruited. Resonance frequency analysis was used to measure the implant stability at implant insertion, 1, 2, 3, 4, 6, 8 and 12 weeks postoperatively. RESULTS AND CONCLUSION: All the implants achieved osseintegration uneventfully within 12 weeks. At implant installation, the mean implant stability quotient value was 69.66±4.75. An increase trend in implant stability quotient values was visible within 1 week, and the implant stability quotient value reached the peaked at 1 week, and then decreased to the lowest point at 2 weeks, which were significantly different from that at implant installation (P < 0.05). In the secondary stability phase, the increasing slope of implant stability quotient values reached a plateau by the 8 th week. The resonance frequency analysis can estimate the quantitative change of implant stability after applying the osteotome technique, and the osteotome technique can promote the implant initial stability. Zhang Xiao-dong, Associate chief physician, Department of Stomatology, the 521 Hospital of China North Industries Group Corporation, Xi an , Shaanxi Province, China Corresponding author: Yang Yong-qin, Department of Stomatology, the 521 Hospital of China North Industries Group Corporation, Xi an , Shaanxi Province, China Accepted: Subject headings: Dental Implants; Denture Retention; Synostosis; Dental Implantation, Endosseous Zhang XD, Yang YQ, Shi SS, Ma RZ, Liao LF. Implant stability during osseointegration using osteotome technique. Zhongguo Zuzhi Gongcheng Yanjiu. 2015;19(16): doi: /j.issn INTRODUCTION Good implant stability is the basic requirement of osseointegration and an important parameter to judge the success of dental implantation [1-2]. Primary implant stability is considered to be related to bone quality (bone hardness and bone density) in the implant zone, implant shape, diameter and length [3-5]. How to preserve the residual alveolar bone and to choose suitable an implant that can raise the primary implant stability is crucial for the successful dental implantation [6-7]. Osteoporosis in the posterior maxilla is mainly classed as Lekholm & Zarb classification types III-IV [8], which is more difficult for dental implantation adjacent to the maxillary tuberosity than the other zones. The osteotome technique, which was firstly applied for the dental implantation at osteoporosis zones by Prof. Summers [9] in 1994, is still in the stage of animal experiments for the qualitative and quantitative determination, and there is, however, no clinical research on the changing trend of implant stability after implantation using the osteotome technique. Therefore, in this study, resonance frequency analysis was utilized to evaluate the changes in the implant stability during the early healing period after dental implantation using the osteotome technique, providing fundamental basis for its clinical application. SUBJECTS AND METHODS Design Contemporary non-randomized controlled observation. Time and setting The trial was completed at the Department of Stomatology, the 521 Hospital of China North Industries Group Corporation, China from 2010 to Subjects Patients with class IV dentition defects were collected at the Department of Stomatology, ISSN CN /R CODEN: ZLKHAH 2551

2 the 521 Hospital of China North Industries Group Corporation from 2010 to Inclusion criteria: (1) Age > 18 years and no systemic disease. (2) Time of tooth loss is 6 months. (3) No bone augmentation in the scheduled implant zone. (4) There is sufficient bone mass in the scheduled implant zone to ensure the primary stability of the implant. (5) Patients can be regularly reviewed and sign the informed consent. Exclusion criteria: (1) Poor oral conditions that could not be improved. (2) Acute and chronic systemic diseases that may affect the surgical process, secondary treatment and re-treatment. (3) A history of tooth extraction or surgical experience in the scheduled implant zone within 6 months. According to inclusion and exclusion criteria, 20 adult patients with class IV defects in the posterior maxilla were enrolled for implantation of Strauman implants (4.8 mm 12 mm) using the osteotome technique, one implant per patient. There was plenty of bone marrow without sinus elevation, and the corresponding initial stability (implant stability quotient) values and final torque were recorded. The experiment was approved by the ethics committee of the 521 Hospital of China North Industries Group Corporation. Materials ITI SLA implants were purchased from Straumann AG, Switzerland. ITI implants are made from titanium, covered with plasma coating, and there are holes in the walls of the empty tube. Two notable features of the system are transgingival system and Morse taper. Transgingival system can omit the stage II surgery, and further avoid bone resorption because the inevitable gap between the implant and the abutment is located above the alveolar crest. Morse taper connection implants can withstand cyclical pressures, which can effectively prevent abutment rotation and loosening. Implants, 4.8 mm 12 mm, were used. Main instruments for implant insertion and evaluation using the osteotome technique: Instrument Dental implant machine Methods Dental implantation using osteotome technique Patients were under local anesthesia, and ITI implantation surgery was carried out according to standard surgical procedures followed by conventional surgery disinfection. The specific procedures are as follows: (1) Primary bone drill preparation: After positioning and orientation using round bur and pioneer bur, respectively, the desired depth 2552 Source NOUVAG, Switzerland Implantation instruments, ITI transfer rod Straumann AG, Switzerland OSSTELL Integration AB, Sweden was determined. A 2.0 reamer was used to prepare a dental implant socket until it reached the predetermined depth. The type of bone was determined with hand, class III or IV defects. Afterwards, the combination of whole-course and local bone condensing was chosen, that is, an osteotome was used for preparation of implant socket following the usage of the reamer. (2) Bone condensing step-by-step: The osteotome was used stepwise to prepare the implant socket with a progressively increased depth to prevent bone necrosis due to excessive heat and resistance. When reaching the desired depth, each osteotome was rotated and shaken gently to make the socket smooth and further expansion, in order to wedge another osteotome. If it is partial to class III defects, the round bur or neck shaping drill was employed to enlarge the neck of implant socket, thereby avoiding cortical bone fracture. (3) Dental implantation: Class III or IV defects were characterized as low bone density. In this experiment, implant screws were used and inserted into the implant socket. The osteotome used finally had a diameter mm less than the implant screw, namely differential preparation. After implantation, the implants and implant sockets were tightly sealed in all cases. Then, the diameter, length and bone insertion torque of implants as well as bone quality grading were recorded. In order to ensure consistent evaluation, all implantation surgeries were implemented by the same person. Resonance frequency analyzer to measure implant stability Resonance frequency analyzer was used to measure implant stability at implant insertion, 1, 2, 3, 4, 6, 8, 12 weeks after implantation. First, the cap was unscrewed and the special connecting rod for ITI SLA was inserted and mounted on the implant. Then, a metal rod with a magnet was mounted on the implant abutment using a wireless analyzer, which could separate the abutment from the detector and resonance frequency analyzer. When measuring, magnetic pulse vibration waves were emitted from the detector close to the metal rod and generated the resonance. Meanwhile, the vibration frequency sensed by the induction coil within the detector was transmitted to the resonance frequency analysis system, which was converted into implant stability quotient. The implant stability quotient was measured respectively at the mesial and buccal sides of each implant. Material collection and recording were done by the same person. Main outcome measures The stability of implants. Statistical analysis Data were expressed as mean±sd and statistically analyzed by SPSS 16.0 (SPSS, Chicago, USA). Repeated analysis of variance was performed for difference at different time points (Bonferroni adjustment for confidence interval). A value of P < 0.05 was considered significant. P.O. Box 10002, Shenyang

3 Table 1 Clinical data of enrolled patients No. Sex Age (year) Time of tooth loss in the implant zone (month) Implant zone Final torque (N cm) Follow-up (month) 1 Female Upper left first molar Male Upper left first molar Female Upper left second molar Male Upper right first molar Male Upper right first molar Female Upper right first molar Female Upper right second molar Female 24 7 Upper left first molar Male 30 6 Upper left first molar Male Upper right first molar Male Upper right first molar Male Upper left second molar Male Upper right first molar Female Upper left second molar Female Upper right first molar Female Upper right second molar Male 32 8 Upper left first molar Male Upper right first molar Female 33 9 Upper right first molar Male Upper left first molar 35 3 Implant stability quotient values Time after implantation (week) Figure 1 Changing trend of the mean implant stability quotient values during osseointegration Note: The implant stability quotient values increased after implantation, reached the peak at the 1 st week, then decreased to the lowest at the 2 nd week, gradually increased at the 3 rd week, and became stable till the 8 th week. Table 2 Mean implant stability quotient values at all observation points during osseointegration Time after implantation (week) Implant stability quotient ±4.75 ( ) ±4.46 ( ) ±5.23 ( ) a ±4.12 ( ) ±4.49 ( ) ±4.17 ( ) ±4.37 ( ) ±4.07 ( ) a Note: a P < 0.05, vs. immediately after implantation (0 week). RESULTS Quantitative analysis of participants All patients were enrolled in result analysis with no implant loss. General information of participants is listed in Table 1. Variation of implant stability during osseointegration after usage of osteotome technique All implants achieved osseointegration within 12 weeks after implantation, and were successfully implanted. As shown in Table 2 and Figure 1, there were significant differences in the implant stability quotient values within the measuring time (P < 0.05). At implant insertion, the mean implant stability quotient value was 69.66±4.75, reached the peak at 1 week after implantation and touched the bottom at 2 weeks (P < 0.05). From the 3 rd week, the mean implant stability quotient gradually increased and reached a stable extension at 8 and 12 weeks, and there was no difference at 8 and 12 weeks (P > 0.05). The implant stability quotient values were significantly different at implant insertion and at 12 weeks after implantation (P < 0.05). Adverse reactions and complications during osseointegration All the participants did not appear with wound dehiscence, bleeding, sinus mucosa penetrating, gingivitis, progressive marginal bone resorption, implant mechanical breakage and other adverse reactions. DISCUSSION Currently experiments addressing the osteotome technique are mainly focused on quantitative and qualitative detection of animal experiments, and histological and radiological examinations have been used to explore the morphological changes of surrounding bone tissues in term of bone density after bone condensing. Stenport et al [10] used an osteotome to seed the implants into a rabbit femur, and researchers found that the osseointegration of cancellous bone was accelerated using the osteotome technique and furthermore, a ISSN CN /R CODEN: ZLKHAH 2553

4 large-animal experiment was suggested. According to the findings from Al-Maseeh et al [11], dog s humeral samples were taken to prepare implant sockets, and the healing manner was observed when there was a gap using the osteotomy technique. In their study, the bone drill method and osteotomy technique were both used to prepare implant sockets with a diameter of 8 mm, which 6 mm implants were inserted into. Therefore, there was a 1 mm gap between the implant and surrounding tissues. The socket produced using the osteotomy technique was prepared based on a 5 mm socket made by the bone drill. The socket prepared by the bone drill had no changes in the diameter immediately after implantation, but the diameter of socket prepared using the osteotomy technique was reduced by 17%, and the trabecular bone that was shifted showed a significant rebound. The results show a marked increase in bone density immediately and 2 weeks after implantation using the osteotomy technique as well as osseointegration rate at 2 and 4 weeks after implantation. However, these methods for evaluation of bone density in the implant sockets are not tools to accurately and quantitatively analyze the effect of osteotomy technique, and meanwhile, they also cannot judge whether the bone condensing can impact osseointegration time and efficiency. Overall, there is still a lack of systemic quantitative comparisons of differential socket preparation and osteotomy techniques in clinical experiments. Can the osteotome technique improve implant success rate and accelerate osseointegration process? Summers [9] first proposed in 1994 to increase the implant stability using the osteotome technique. Bone condensing is a method to prepare sockets using implant-matched osteotmes step-by-step instead of traditional bone drills, which can laterally compress the cancellous bone effectively, and meanwhile raise the bone density around the implant socket to minimize the bone loss caused by drilling. Al-Maseeh et al [11] found that using the osteotome technique, the implant was more tightly bonded with the surrounding bone because of bone bounce, which accelerates osseointegration process. However, the experimental design of bone condensing was to insert an implant with a smaller diameter than that of the socket, and the diameter of the socket could restore to 83% of original size immediately after implantation, which was still larger than the diameter of implant, indicating there was no pressure on the bone tissue after implantation. Additionally, the bone condensing was done based on a socket with a diameter that was 3 mm less than the final diameter prepared by the bone drill. In clinic, implants with a diameter no less than the socket diameter are preferred, based on which, the bone condensing can inevitably lead to changes in the three-dimensional structure of the bone. The changes in bone structure may directly affect the blood circulation around the implant, thus influencing the blood supply of bone and bone healing process. Previous literature suggests that the success rate of maxillary dental implantation is slightly lower than that of the 2554 mandible, especially near the maxillary tuberosity area, which is mainly because the sclerotin of maxilla is looser than that of the mandible. In addition, due to changes in estrogen levels, osteoporosis induced by increased calcium loss is also very common in the middle-aged women after menopause [12]. Based on clinical experience, the osteotome technique has achieved good clinical effects in the maxilla. As a result of loose and fine fibers of the trabecular bone (osteoid IV), there is relatively little influence on the blood circulation under the bone condensing as well as a lower probability of adverse reactions. Currently, there is still a lack of proven and reliable experimental evidence for whether the bone condensing can improve the success rate of dental implantation and accelerate osseointegration process. For osteoid I and II with higher bone mineral density, the bone condensing cannot be used to squeeze the bone wall effectively, or even result in osteonecrosis because of excessive implant-bone interface stress. At present, choosing the appropriate implant is a necessary mean to improve the early stability and success rate of implants in patients with osteoporosis scheduled for osteotome treatment [13]. Resonance frequency analysis of the osteotome technique effects on implant stability during osseointegration In the past, X-ray, CT and bone densitometry were used to predict the primary stability of implants based on the bone substance in the implant region, and to develop an implanting plan before surgery. During the socket preparation, the appropriate implants were chosen based on sclerotin classification in order to obtain a higher stability. The most commonly used method for bone type classification is Lekholm and Zarb classification. This method refers to a relatively rough classification of clinical bone types, which cannot objectively predict the exact stability of implants immediately after implantation as well as variation trends of the implant stability in the late stage, and thus there is a certain restriction in the clinical application. Resonance frequency analysis is a new kind of implant stability measurement tool developed in recent years, and its value is determined by the hardness of the bone around the implant and distance from bone sensing cantilever to the first-contacted bone. This tool is more objective to measure the clinical implant stability, which is non-invasive, convenient and accurate for long-term monitoring of implant stability [14]. The value of resonant frequency is generally converted into implant stability coefficient that can be used to analyze the expression value of implant stability. Resonance frequency analysis using OSSTELL device can be used to monitor the osseointegration during the healing process of implant and assist clinicians to determine when the upper structure can be loaded. The implant stability can be divided into primary implant stability (immediately after implantation) and biostability (after bone healing). Poor primary stability can lead to the formation of fibrous P.O. 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5 connective tissue between the bone and implant; inversely, too much emphasis on the primary stability may lead to excessive pressure on the bone, damaging the local micro-circulation and bone metabolism as well as impacting the biostability formation [15-20]. In this study, the resonant frequency analyzer was used to monitor the implant stability quotient for 12 consecutive weeks following bone condensing, and the results showed significant differences existed in the implant stability quotient during the measurement period. The implant stability quotient reflected the rigid relationship between implant and bone. At dental implantation, the value of implant stability quotient was 69.66±4.75. Bone condensing caused the formation of a high-density peri-implant area, indicating the osteotome technique is effective to improve the primary implant stability. After implantation, the implant stability quotient had an increase trend within the 1st week, which may be interpreted as an increase in bone mineral density around the implant due to bone condensing, and afterwards, the socket had the ability to restore the original volume due to bone viscoelasticity. An increase in the rigidity between implant and surrounding bone tissue led to the rise of the implant stability quotient. At 2 weeks after implantation, the implant stability quotient reached the lowest point, indicating the bone resorption process, and then, it began to rise gradually at 3 weeks. This may be a process of mature lamellar bone instead of woven bone, and the rigidity between the implant and surrounding bone tissue became larger followed by an increase in the implant stability quotient [21-28]. At 8-12 weeks after implantation, the implant stability quotient (biostability) was at a plateau stage. Histological observation showed that the implant interface and surrounding bone tissue were completely replaced by mature lamellar bone tissues. At the same time, the rigidity between the implant and surrounding bone had no changes. Therefore, the implant stability quotient kept smooth at this stage [29-32]. Findings from the present study have demonstrated that the osteotome technique can bring out a higher implant stability quotient in the preosseous tissue of maxillary posterior teeth. The resonant frequency analysis can preliminarily reflect the changes in the implant stability quotient due to bone condensing quantitatively, and it is confirmed that it takes a relative prolonged time for biostability that can plateau. Generally, a relative prolonged time for implant restoration is recommended for IV osteoid area to ensure the implantation success. In this study, we only preliminarily investigated the changing trend of implant stability quotients due to osteotome technique, and bigger sample size and better stability data are needed for further understanding. REFERENCES [1] Albrektsson T, Brånemark PI, Hansson HA, et al. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthop Scand. 1981;52(2): [2] Meredith N, Friberg B, Sennerby L, et al. Relationship between contact time measurements and PTV values when using the Periotest to measure implant stability. Int J Prosthodont. 1998;11(3): [3] Chavez H, Ortman LF, DeFranco RL, et al. Assessment of oral implant mobility. J Prosthet Dent. 1993;70(5): [4] Meredith N. Assessment of implant stability as a prognostic determinant. Int J Prosthodont. 1998;11(5): [5] Beer A, Gahleitner A, Holm A, et al. Correlation of insertion torques with bone mineral density from dental quantitative CT in the mandible. 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6 [21] Schenk RK, Buser D. Osseointegration: a reality. Periodontol ;17: [22] Triplett RG, Frohberg U, Sykaras N, et al. Implant materials, design, and surface topographies: their influence on osseointegration of dental implants. J Long Term Eff Med Implants. 2003;13(6): [23] Albrektsson T, Zarb GA. Current interpretations of the osseointegrated response: clinical significance. Int J Prosthodont. 1993;6(2): [24] Sykaras N, Iacopino AM, Marker VA, et al. Implant materials, designs, and surface topographies: their effect on osseointegration. A literature review. Int J Oral Maxillofac Implants. 2000;15(5): [25] Favero GA. Submersible and nonsubmersible osseointegration systems: comparative evaluations. Minerva Stomatol. 1993;42(10): [26] Koka S, Vance JB, Maze GI. Bone growth factors: potential for use as an osseointegration enhancement technique (OET). J West Soc Periodontol Periodontal Abstr. 1995;43(3): [27] Berglundh T, Abrahamsson I, Lang NP, et al. De novo alveolar bone formation adjacent to endosseous implants. Clin Oral Implants Res. 2003;14(3): [28] Wiskott HW, Belser UC. Lack of integration of smooth titanium surfaces: a working hypothesis based on strains generated in the surrounding bone. Clin Oral Implants Res. 1999;10(6): [29] Brunski JB. In vivo bone response to biomechanical loading at the bone/dental-implant interface. Adv Dent Res. 1999; 13: [30] Kuboki T. Needs and current research directions of biological regenerative medicine in prosthodontic practice--to attain reliable and sophisticated dental implant therapy. Nihon Hotetsu Shika Gakkai Zasshi. 2005;49(4): [31] Marx RE, Garg AK. Bone structure, metabolism, and physiology: its impact on dental implantology. Implant Dent. 1998;7(4): [32] Jahangiri L, Devlin H, Ting K, et al. Current perspectives in residual ridge remodeling and its clinical implications: a review. J Prosthet Dent. 1998;80(2): 骨挤压后种植体愈合期稳定性变化的趋势 张晓东, 杨永勤, 石飒飒, 马瑞朝, 廖丽斐 ( 中国兵器工业五二一医院口腔科, 陕西省西安市 ) 张晓东, 男,1974 年生, 山西省垣曲县人, 汉族,1998 年西安医科大学毕业, 副主任医师, 主要从事口腔医学方面的研究 通讯作者 : 杨永勤, 中国兵器工业五二一医院口腔科, 陕西省西安市 文章亮点 : 文章的特点在于利用共振频率分析仪连续监测骨挤压后种植体骨愈合期稳定性, 发现上颌后牙植入 ITI 种植体 8 周后已达到延期稳定期, 且采用骨挤压可获得较高的种植体初期稳定性 关键词 : 生物材料 ; 口腔生物材料 ; 骨挤压 ; 种植体初期稳定性 ; 共振频率分析 ; 骨结合 ; 骨密度 ; 共振频率测量仪 ; 初期稳定性 ; 种植体主题词 : 牙种植体 ; 义齿固位 ; 骨结合 ; 牙种植, 骨内摘要背景 : 种植体稳定性是骨结合的基本条件及判断种植体成功的重要参数之一 一般认为种植体初期稳定性与种植体受植区骨质量 ( 骨硬度及骨密度 ) 种植体外形 直径和长度等因素密切相关 目的 : 利用共振频率分析仪连续监测骨挤压后种植体骨愈合期稳定性变化的趋势 方法 : 收集于 2010 至 2011 年在中国兵器工业五二一医院口腔科进行治疗的 Ⅳ 类骨牙列缺损患者, 上颌后牙植入 ITI 种植体 (4.8 mm 12 mm) 植入时以及植入后第 1,2,3,4,6,8,12 周利用共振频率分析仪测量种植体的稳定性 结果与结论 : 所有种植体在 12 周均实现骨结合, 并成功完成种植修复 在种植体植入时, 平均种植体稳定系数为 69.66±4.75 植入后种植体稳定系数均上升, 植入后 1 周到达最高点后又呈下降趋势, 至植入后第 2 周时达到最低点, 与植入时差异有显著性意义 (P < 0.05) 从植入后第 3 周开始种植体稳定系数逐渐上升,8 周时已达到延期稳定期 提示通过共振频率测量仪连续监测可以定量反映出骨挤压后种植体稳定性的变化, 且采用骨挤压可获得较高的种植体初期稳定性 作者贡献 : 第一作者和通讯作者构思并设计试验, 并与第二 第三 第四 第五作者共同实施 评估 收集资料, 第一作者成文, 经通讯作者审校, 第一作者和通讯作者对文章负责 利益冲突 : 文章内容不涉及相关利益冲突 伦理要求 : 试验获得患者及家属的知情同意, 并得到中国兵器工业五二一医院医学伦理学委员会的批准 学术用语 : 骨挤压 - 是利用与种植体匹配的各级骨挤压器, 逐级挤压取代传统系列钻备洞的方法, 使松质骨得到有效的侧向压缩, 在挤压的同时提高了种植窝周的骨密度, 也最大限度地减少了钻孔所造成的骨质丢失 作者声明 : 文章为原创作品, 无抄袭剽窃, 无泄密及署名和专利争议, 内容及数据真实, 文责自负 中图分类号 : R318 文献标识码 : A 文章编号 : (2015) 张晓东, 杨永勤, 石飒飒, 马瑞朝, 廖丽斐. 骨挤压后种植体愈合期稳定性变化的趋势 [J]. 中国组织工程研究,2015, 19(16): (Edited by Yu ST, Qu Z/Wang L) 2556 P.O. Box 10002, Shenyang