A Randomized Controlled Clinical Study Comparing Implant Stability Using Osteotome vs. Conventional Drilling Techniques by Resonance Frequency Analysis

With the emergence of one stage surgical approach to implant placements with immediate loading (IL), the importance of achieving uncompromised primary stability, especially in poor bone density (D3, D4), cannot be underestimated. Degidi et al. showed that poor quality bone was related to increased marginal bone loss and inferior clinical outcomes for IL implants. In a 5 year retrospective study, Elkhoury et al. found that one of the significant clinical parameters, associated with success of plasma-sprayed cylindrical dental implants was higher bone density (P<0.0001). Hermann et al evaluated 487 implants randomly selected from a research created database that used different implant placements protocols placed over a 5 year period and found out that implant failures were primarily associated with negative bone-related patient factors: jawbone quality and shape.

Two bone types that fall in the negative bone-related factors are types D3 and D4. D3 type bone, which consists of thin porous cortical and fine trabecular bone, according to the Misch bone density classification, is most prevalent in anterior maxilla and posterior regions of maxilla and mandible. In a review of 73 published articles, by Esposito et al., biological factors that contribute to failures of osseointegrated oral implants, the authors confirmed that maxillas, due to their poor bone density, have almost 3 times more implant failures than mandibles.

In planning the case, it is very important to differentiate between bone quality and bone density. Bone quality comprises bone metabolism, cell turn over, mineralization, maturation, intercellular matrix, and vascularization and while all of these factors influence implant success, it is valuable to be able to isolate them in order to be able to investigate their individual contributions to implant outcomes.

The development of three-dimensional imaging, such as Computed Tomography (CT) and Cone Beam Computed Tomography (CBCT) has recently became the standard of care during pre-surgical phase, at implant planning stage. It enables an implant team to provide the most precise and reliable diagnostic information on the patient's vital anatomy, bone quality and bone quantity at the proposed implant sites. In 95% of cases that use CT, bone quantity determination is to +/- 1 mm of accuracy, compared to only 30% of cases that use panoramic radiology.

A comprehensive review of 45 manuscripts by Molly that investigated and discussed the relationship between bone density and primary implant stability concluded that there is a significant correlation exists between bone density, primary stability, and implant outcomes.