Comparative evaluation of osseodensification drilling versus conventional drilling technique on dental implant stability: A systematic review

Abstract

Aim:

The present systematic review compares the stability, crestal bone levels and efficacy of osseodensification (OD) drilling techniques for dental implant placement to traditional drilling methods.

Settings and Design:

The Cochrane online library, PubMed, Scopus, and other well-known online resources are used in the research. Using a systematic review design, the current study examines published qualitative studies with an emphasis on analysis.

Materials and Methods:

Using precise keywords, a thorough search of pertinent databases was carried out in accordance with PRISMA standards. Studies testing dental implant stability, crestal bone levels and clinical results using both OD and traditional procedures were covered by the inclusion criteria.

Statistical Analysis Used:

The risk of bias and quality of included studies was assessed using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for randomized controlled trials.

Results:

A total of 170 patients and 334 implants from Egypt, India, and Brazil were included in eight papers that made up the systematic review. In several clinical situations, osseodensification outperformed standard drilling in terms of implant durability, bone development, and torque data. Statistical analysis presented the lowest risks, while blinded outcome assessment, allocation concealment, random sequence generation, incomplete outcome data and experimental technique revealed higher risks. Bias assessment found various risks across different components.

Conclusion:

The thorough examination of eight papers demonstrates that osseodensification is a technique with great promise in the field of dental implants. It exhibits superior torque values, bone development, and stability when compared to traditional drilling. The overall results highlight the potential of osseodensification to improve clinical outcomes and advance the science of dental implantology, even in the face of variances in bias concerns.

INTRODUCTION

The introduction of osseointegrated titanium implants marked a revolutionary advancement in addressing tooth loss and providing patients with functional and esthetically pleasing dental restorations, significantly enhancing their overall quality of life.[1] A pivotal factor that governs the success of dental implants lies in the establishment of a stable and long-lasting connection between the bone and the implant. This connection is an essential prerequisite for the successful process of osseointegration which is also related to implant stability.[2] Implant stability is affected by several variables, including surgical technique, bone quality, and implant design, and is classified as primary stability or mechanical stability between bone and implant and secondary stability or biological stability that happens as an outcome of osseointegration.[3]

Conventional osteotomies are done using the traditional drilling technique, a subtractive method where the bone is drilled away and to ensure primary stability, the last drill had a smaller diameter than the implant. It has been shown in early literature that an increase in insertion torque is associated with higher implant survival rates.[4,5]

Implant stability can be augmented through carefully regulated bone compaction such as novel methods such as osseodensification (OD) which have evolved because of advances in the understanding of bone plastic and elastic properties where bone is autografted into the walls of the osteotomy and open marrow spaces in outwardly expanding directions. The surrounding bone is densified using specifically made drills to prepare the implant site, especially helpful in situations of poor bone quality.[6]

A correlation between implant stability and bone remodeling is found in the investigation of static bone strain, illuminating the biomechanical factors that influence implant success.[3] Studies on the role of drilling dimension and its impacts on torque used for implant insertion and osseointegration phases, found the crucial function of surgical parameters in implant stability.[6] The resonance frequency analysis (RFA) is suggested to be a promising method for evaluating implant stability.[7]

Studies have been done to assess the impact of OD on implant stability[8] and also to compare OD to osteotome for elevation of the sinus floor, demonstrating its applicability in various clinical circumstances.[9] These findings highlight the value of researching cutting-edge methods to improve implant stability and give clinicians evidence-based information for making wise decisions.

The present systematic review compares the stability and efficacy of OD drilling techniques for dental implant placement to more traditional drilling/osteotomy methods. To produce a thorough study of the advantages, restrictions, and potential clinical consequences of OD, this systematic review was conducted through a critical assessment of the literature, ultimately directing clinicians toward evidence-based treatment options.

METHODOLOGY

The present systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to confirm rigor, transparency, and reproducibility in the review process.

Research question

The research question guiding this systematic review was: “What is the comparative impact of OD drilling technique versus conventional drilling technique on dental implant stability?” The PICO question (patients requiring implant placement [P: Patients]; OD drilling technique [I: Intervention]; conventional drilling technique [C: Comparison]; and dental implant stability and crestal bone levels [O: Outcome]).

Search strategy

A comprehensive search strategy was done to recognize relevant studies. The following databases were searched: PubMed, Scopus, Embase, Cochrane Library, and Web of Science were searched up to and including July 2023. The search will include a combination of keywords and controlled vocabulary terms (MeSH terms) related to dental implants, implant stability, OD, and drilling techniques. The search terms were included with variations and synonyms of the following keywords: “Osseointegration,” “Implant stability,” “Osseodensification,” “Conventional drilling,” and “Osteotomy technique.” The strategy of search based on the algorithm developed for MEDLINE: “(Osseodensification OR densification) AND (conventional drilling OR osteotomy technique) AND (Dental implants [MeSH] OR dental implantation) (MeSH) OR (osseointegration [MeSH] OR implant stability).” A gray literature search in OpenGrey and Google Search was also conducted [Figure 1].

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses flowchart for the review

Previous relevant studies related to dental implant stability and their outcome related to OD are placed in Table 1.

Table 1.

Previous relevant studies and their outcomes

Author names		Year		Place of study		Methodology		Sample selection		Study outcomes		Whether included in systematic review (yes/no), reasons for exclusion
Esposito et al.[2]		2014		Various		The Cochrane database of systematic reviews		Meta-analysis of different dental implants		Explored various dental implant interventions, highlighting different implant types and their effectiveness		No, Cochrane review
Raghavendra et al.[10]		2005		N/A		Review of literature		N/A		Reviewed early wound healing around endosseous implants and factors influencing the process		No, review of literature
Halldin et al.[3]		2011		Sweden		Experimental study		Rabbit bone samples		Investigated the effects of static bone strain on implant stability and bone remodeling		No, experimental study on rabbits
Campos et al.[6]		2012		Brazil		Experimental study		Dogs		Explored the effect of drilling dimension on implant placement torque and early osseointegration stages		No, experimental study on dogs
Szmukler-Moncler et al.[11]		1998		N/A		Review of experimental literature		N/A		Reviewed experimental literature to explore the effects of timing of loading and micromotion on the bone-dental implant interface		No, review of experimental literature
Pagliani et al.[7]		2013		Italy		Experimental study		Bovine bone specimens		Investigated the relationship between RFA and lateral displacement of dental implants		No, experimental study in fresh bovine bone specimens
Trisi et al.[4]		2011		Italy		Experimental study		Sheep mandibles		Compared high and low implant insertion torque, assessing histologically, histomorphometrically, and biomechanically		No, a histologic, histomorphometric, and biomechanical study in the sheep mandible
Ottoni et al.[5]		2005		Brazil		Controlled clinical trial		Patients receiving single-tooth implants		Correlated insertion torque with implant survival, emphasizing the significance of high insertion torque		No, the study evaluated the survival parameters of single-tooth implants through clinical and radiographic analysis
Degidi et al.[12]		2015		Italy		Experimental study		Fresh humid bovine bone samples		Explored the influence of under preparation on the primary stability of implants in poor-quality bone sites		No, experimental study on fresh humid bovine bone
Sultana et al.[13]		2020		India		Clinical study		Patients receiving implants		Compared stability and crestal bone loss of implants placed using OD and traditional drilling protocol		Yes
Ibrahim et al.[8]		2020		Egypt		Clinical trial		Patients receiving implants		Evaluated the effect of the OD technique on implant stability		Yes
Aloorker et al.[14]		2022		India		Split-mouth study		Patients receiving implants		Investigated the effect of OD on bone density and crestal bone levels in a split-mouth study		Yes
Bandela et al.[15]		2022		India		Ex vivo study		Fresh iliac bone of the sheep		Compared OD with conventional osteotomy technique on dental implant primary stability		No, ex vivo study on fresh iliac bone of the sheep
Bergamo et al.[16]		2021		Multicenter		Controlled clinical trial		Patients receiving implants		Compared the insertion torque and temporal implant stability quotients of implants placed via OD or subtractive drilling		Yes
Chatru et al.[17]		2023		N/A		Clinical-radiographic study		Patients receiving implants		Compared drill technique in assessing crestal bone loss and implant stability		Yes
Gaspar et al.[18]		2021		Multicenter		Systematic review		Evaluated OD studies		Summarized implant stability of OD drilling versus conventional surgical technique, using systematic review methodology		No, systematic review
Mohammad and Ahmed[19]		2023		N/A		Clinical study		Patients receiving maxillary overdentures		Investigated OD versus conventional drilling technique on bone height changes of implant-retained maxillary overdentures		Yes

N/A: Not available, RFA: Resonance frequency analysis, OD: Osseodensification

Study selection criteria

Inclusion criteria

• Studies comparing OD drilling technique with conventional drilling technique for dental implants

• Randomized clinical trials and nonrandomized studies of interventions

• Studies reporting implant stability outcomes, such as insertion torque, RFA, or any other relevant stability assessment methods.

Exclusion criteria

• Studies not directly comparing OD and conventional drilling techniques

• Studies not available in English

• Animal studies, case reports, and reviews.

Study selection process

After the initial search of the database, duplicate records were eliminated. Two independent reviewers (SB and DD) then examined the titles and abstracts of the remaining studies based on the inclusion and exclusion criteria. Full texts of possibly eligible studies were retrieved and assessed for eligibility. Discrepancies were eliminated through discussion with third, fourth, and fifth reviewers (NP, DP, and UG) when necessary.

Data extraction

The following information was extracted:

• Study characteristics: Author, publication year, sample size, and study design

• Participants: Patient characteristics and number of implants

• Interventions: OD technique and conventional drilling technique

• Outcomes: Implant stability assessment methods and crestal bone level measurements.

Risk of bias assessment

The risk of bias and quality of included studies was assessed using the Newcastle–Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for randomized controlled trials. Due to anticipated heterogeneity in study designs and outcomes, a meta-analysis may not be feasible.

RESULTS

Table 2 summarizes the details of the eight corresponding studies that were included in the present systematic review after following the PRISMA guidelines. The table depicts the type of studies analyzed, the type of implants used in these studies, the sample size and measurement tool used, and the final outcome of the studies. The included eight studies comprised an overall sample of 170 patients and 334 implants [Table 2]. These studies were four from Egypt, three from India, and one from Brazil. Seven studies placed implants in the maxilla and one study in both the maxilla and mandible with the OD drilling and compared with conventional drilling.

Table 2.

Summary of the articles included in the systematic review

Author		Type of study		Site of study		Implant type		Sample size		Measurement tool		Result
Arafat and Elbaz[9]		Comparative prospective study		Maxillary posterior with sinus lift		Straumann AG		24 patients 24 implants		CBCT		PO ISQ in TD (52.83±6.29), OD ISQ (65.17±4.39) 6 months ISQ in TD (67.83±4.78), OD ISQ (75.92±2.94) PO 6 months the study showed that bone gain in OD group was significantly higher than bone gain in the conventional group
Aloorker et al.[14]		Comparative split-mouth study		Maxillary posterior region		SLA implants		10 patients 20 implants		CBCT		The width of the residual bone increased after OD after 3 months and 6 months of PO
Bergamo et al.[16]		Multicentric control trial		Maxilla (anterior as well as posterior)		Unspecified		56 patients 150 implants		IT with a torque indicator ISQ with RFA		The statistical analysis of IT as a function osteotomy indicated that OD (60±3.4 N.cm) presented higher IT compared to TD (35±3.4 N.cm), approximately 41% difference (P<0.001) Overall, ISQ data showed significantly higher values for OD compared to SD
Chatru et al.[17]		Comparative study		Both maxilla and mandible		Unspecified		16 patients 16 implants		CBCT and RFA		No statistical difference between primary stability and crestal bone level OD compared to TD
Ibrahim et al.[8]		Split mouth clinical trial		Maxillary posterior region		Dentium Co Ltd		10 patients 20 implants		RFA		The mean value ISQ readings for implants drilled in OD was 74.25±4.95, whereas that of the TD was 59.65±5.39. The secondary stability mean value for implants drilled by OD was 76.90±4.05 while that of the TD was 68.25±5.14
Mohammad and Ahmed[19]		Split mouth comparative study		Anterior maxilla		Vitronex implant system		10 patients 40 implants		CBCT		Statistically insignificant difference in the marginal bone height loss between the two studied groups during the follow-up period The average mean value of marginal bone height changes measured from prosthetic loading to 12 months after implant loading for TD group was found to be 1.115±0.137 mm After 6 months, the least bone loss around the implants was reported in OD group. The mean difference of bone height changes was (0.4±0.097) and (0.460±0.0119) for group OD and TD respectively. While from 6 to 12 months, the mean difference of bone height changes was (0.61±0.174) and (0.655±0.219) in group OD and TD, respectively
Sultana et al.[13]		Comparative study		Maxillary anterior		ADIN Touareg S		20 patients 20 implants		CBCT and RFA		The mean values of implant stability in OD group RFA1 (baseline) and RFA2 (6 months) were 65.6 N.cm and 66 N.cm, respectively, and in TD the mean values RFA1 and RFA2 are 57.6 N.cm and 64.8 N.cm. No statistical significance in crestal bone levels
El-Hawary[20]		Comparative study		Posterior maxilla		Dentium		24 patients 44 implant		CBCT		The mean immediate postoperative Ostell reading in OD group was 50.62±15.88, after 6 months the mean was 65.96±15.02 The mean immediate postoperative ostell reading in TD group was 61.70±4.78, after 6 months there was a significant increase in the mean reading (71.33±2.02) (P=1.22e-5)

CBCT: Cone beam computed tomography, PO: Postoperative, OD: Osseodensification, IT: Implant torque, RFA: Resonance frequency analysis, ISQ: Implant stability quotient, SD: Subtractive drilling, TD: Traditional, SLA: Sandblasted, large grit, acid-etched implant surface

Eight studies comparing OD with conventional drilling techniques in dental implant operations are thoroughly analyzed as part of the systematic review. Arafat and Elbaz[9] used Straumann AG implants in a prospective investigation of the maxillary posterior with a sinus lift. When compared to standard drilling, OD showed noticeably superior implant stability quotient (ISQ) values, with a notable increase in bone growth in the OD group. In the maxillary posterior region, Aloorker et al.’s[14] split-mouth study using sandblasted, large grit, acid-etched implant surface implants showed that OD increased residual bone width at 3 and 6 months after surgery. The superiority of OD over typical drilling was highlighted by Bergamo et al.’s[16] multicentric control study, which involved the anterior and posterior portions of the maxilla and demonstrated higher implant torque and ISQ values. In a study comparing OD with typical drilling to the maxilla and mandible, Chatru et al.[17] observed no statistically significant difference in primary stability and crestal bone levels. In comparison to standard drilling, OD produced greater ISQ readings and secondary stability in Ibrahim et al.’s[8] split-mouth clinical experiment in the maxillary posterior region using Dentium Co Ltd implants. The study done by Mohammad and Ahmed[19] compared the Vitronex implant system in the front maxilla. The results showed that there were no significant variations in the marginal bone height loss. However, after 6 months, the OD group had the least amount of bone loss surrounding the implants. In the maxillary anterior, Sultana et al.’s[13] comparative investigation using ADIN Touareg S implants revealed no statistically significant difference in crestal bone levels between OD and conventional drilling. In contrast to standard drilling, OD resulted in a considerable rise in Ostell reading after 6 months, according to El-Hawary’s[20] comparative investigation in the posterior maxilla using Dentium implants. All these results together show that OD is a procedure that holds great promise for improving implant stability, bone gain, and clinical outcomes in dental implantology.

A bias assessment of the present study is done providing insight regarding the significant aspects such as ethical statement, experimental procedure, blinding of outcome assessment, random sequence generation, allocation concealment, sample size, incomplete outcome data, statistical analysis, and financial conflict of interest [Figure 2]. Each risk of bias item was presented as a percentage wherein statistical analysis showed the lowest risk, whereas blinding of outcome assessment, random sequence generation, allocation concealment, incomplete outcome data, and experimental procedure showed quite high risk [Figure 3].

Figure 2.

Risk of bias assessment

Figure 3.

Summary of each risk of bias item presented as percentage

DISCUSSION

Primary implant stability is an important factor for successful osseointegration and its lacking can be linked with a higher implant failure rate.[21,22] Various techniques have been introduced to enhance primary implant stability, including implant design or macrogeometry and surface modifications or microgeometry, enhanced insertion torque,[23] placement of a larger diameter implant into an undersized osteotomy, osteotome techniques, use of screw type expanders, the bone spreader technique,[24] bicortical fixation, piezoelectric devices,[25] and the OD technique.

For the purpose of placing dental implants, conventional drilling includes cutting and removing bone tissue to form an osteotomy. As opposed to this, OD uses specialized burs (such as Versah’s Densah burs) that when turned counterclockwise with irrigation, cause hydrodynamic compression to densify the bone. By expanding the bone, this procedure improves primary stability and provides implants with more direct bone contact. These burs are made to cut when rotated clockwise and compact bone tissue in a centrifugal direction when rotated counterclockwise. This causes the bone to gradually deteriorate in plasticity. The viscoelastic characteristics of the bone make this deformation possible, necessitating precise pressure during drilling to produce the best results.[26]

OD exhibits significant therapeutic efficacy when examined in different clinical settings. Superior ISQ values and enhanced bone gain were found by Arafat and Elbaz,[9] who emphasized the beneficial effects of OD in the maxillary posterior region with sinus lift against osteotome elevation. The advantage of OD was supported by Aloorker et al.[14] who noted higher radiographic bone density around the implant after OD in the maxillary posterior region which is maintained after 6 months improving primary stability. This was corroborated by Bergamo et al.,[16] who reported that OD drilling showed higher insertion torque and temporal ISQ values relative to traditional drilling.

Comparative research provides important information about the efficacy of OD. According to Chatru et al.,[17] there is no statistically significant difference between OD and conventional drilling in the maxilla and mandible regarding primary stability and crestal bone levels. Ibrahim et al.[8] observed higher primary and secondary stability using OD. Mohammad and Ahmed[19] observed a reduction in bone loss after 6 months in the OD group in the maxillary anterior region. Sultana et al.[13] showed no statistically significant difference in crestal bone levels between OD drilling and conventional drilling, whereas El-Hawary[20] noted a notable elevation in Ostell reading after 6 months in the posterior maxilla. These studies collectively demonstrate the diverse applications and effectiveness of OD in different clinical scenarios.

Mechanistic insights into OD are obtained from experimental investigations. Lahens et al.[27] looked at low-density bone mechanics and histology and came up with some findings that may be applied in the clinic. The work by Mohammad and Ahmed on implant-retained maxillary overdentures demonstrates how this experimental technique fills the gap between laboratory results and real-world outcomes.[19] The biomechanical and histological elements of OD are better understood thanks to these investigations, which support the procedure’s potential for successful implants.

Studies that look at how drilling diameters affect implant torque and how micromotion affects the contact between the implant and bone emphasize the biomechanical significance of OD.[6,11] Positive benefits on bone density and primary and secondary implant stability are highlighted in clinical trials by Chatru et al.,[17] Aloorker et al.,[14] and Bergamo et al.[16] A range of techniques and procedures are explored in studies by Jimbo et al.,[28] Oliveira et al.,[29] Lahens et al.,[27] and Huwais et al.[24] that demonstrate the adaptability and efficacy of OD in a variety of clinical settings. These studies demonstrate how it can enhance implant success overall, as well as primary stability and bone-to-implant contact (BIC).

OD offers improved implant stability and accelerated healing time by promoting BIC by autograft compaction and promoting osteoblast activity.[30] These investigations highlight the complexity of implantology and the influence of drilling techniques on clinical results. To improve implant success, OD arises as a procedure that takes biomechanical, histological, and clinical elements into consideration.[31] For wider implications in implant dentistry, it is imperative to acknowledge the subtle differences specific to a certain study. Notwithstanding the method’s potential, it is imperative to recognize the limitations of the existing literature, as methodological variances, disparities in sample sizes, and a narrow emphasis restrict the applicability of findings. More randomized controlled trials with longer follow-up periods are desirable to fill in these gaps and provide thorough proof of long-term advantages and safety. It is equally important to assess patient-reported outcomes and cost-effectiveness. Promoting active engagement from clinicians in well-planned studies adds to the growing corpus of OD research.

CONCLUSION

Within the limitation of this systematic review, it can be concluded that:

1. The systematic analysis of papers contrasting OD osteotomy with traditional osteotomy techniques clearly depicts that OD offers a potential method for boosting implant stability and general success which will be essential in cases of poor bone quality

2. OD’s potential to enhance primary stability, maximize bone integration, and lessen crestal bone loss, all of which are essential components of long-term implant results

3. OD has the potential to become a common procedure in implant dentistry as more information and experience are gathered, providing patients with enhanced stability and better long-term results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.