Ridge split with Piezo and Versah burs

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Posted on By Isaac Tawil In Implants

After Dr Nieva's excellent presentation on osseodensification I was asked to expand on his last case using these burs for ridge splitting.
I have found them to be a improvement on bone expanders for ridge splitting. While it is still new to me as I've only been using them for the last 6 months they seem to densify and expand the ridge simultaneously. I've been very impressed as the osstel readings start hiigh around 75-85 and upon exposure at 3 months they are the same if not higher.

This case was difficult as the IA is only 9.7 mm from the crest. I used 10mm implants and placed them lateral the the canal.

Piezo horizontal cut used to start then 3 versah burs for osteotomy and expansion. Any ridge implants were then used to complete the expansion torque values between 50-80ncm. Bioss and CGF(PRF) closure with PTFE sutures.
Case completed at 4 months using ZR abutments and crowns.




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13 Comments

Good technique. thanks for sharing. Maurice


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Isaac. Nice work! Could you please explain why the Versah burs are better for ridge split expansion in the mandible. How do you manage torque values in already dense bone. Thank you for sharing. Best regards. Chuck


Reply

Good question chuck, I assume you are referring to torque intra operatively.
Before I get into to that let me say these burs are wonderful as everyday burs. You are seeing posts from emil and others about adjunctive uses during sinus and mine on ridge expansion but primarily they are densification burs when used in reverse saving bone width. If you have expanders and sinus burs than you can continue your current procedures at your comfort level. If you are considering adding ossedenfication to your toolbox than these are additional pros to switching.

Now getting back to your question:
I use the aseptic motor which goes up to 80 ncm. I start at 45 for insertion during the ridge expansion procedure and have my assistant increase as needed. The highest torque was 76 I believe in this case.
If you are referring to post op high torque values I believe in the process of osseodenification and was convinced during Alan Meltzers lecture at ICOI orlando this past January.
These burs can be a replacement for expanders. If used in reverse which for this procedure I set at 50rpm reverse they can densify the bone while expanding. Densification is new to all of us as we are doing something counter intuitive . In the past if I were to do the same processes I would find pain and bone loss by over torquing (pressure necrosis). To compensate I would torque the implant in high than reverse and place back in at what I thought was a reasonable torque of 35-45. However, after using these burs I believe in conjunction with the densification process implants can be torqued in higher. I do have a wrench that goes up to 100ncm but I am timid to go that high at this time. But as time goes by I may start to increase.
Better Im not sure as I was having great success with my old protocol, different and simpler I would say.
-isaac


Reply

Isaac
I watched the presentation and really enjoyed it. However, I was thinking how much torque is to much ?

Can there be to much to prevent the osteoblasts to move around and do there job? And a point where the osteoclastic activity moves into the danger zone???

Just some simplistic thoughts...

Thanks

Rocco


Reply

Rocco,
That's a good question. Im not really sure how much is too much. As of now I've been staying under 80ncm but I am aware of a few docs going unto 100ncm. My torque wrench goes up to 100ncm.
Im not taking core samples although I've been in touch with the CEO frequently and the samples they are concluding that densifying the bone doesn't inhibit proliferation. In fact new osteocytes have been shown to form faster around the densified bone.

So to answer your question I dunno know

I'm going to ask the experts to weigh in.

Thanks for your question, I hope this sparks a great debate.
-isaac


Reply

Dear Roco and Isaac:

The question of how much insertion torque is too much is frequently being asked. I will try to answer it within the literature.
The term pressure osseonecrosis (bone pressure necrosis) has never been clearly defined in the literature, other than being viewed as generally limited to cortical bone.(1)
The theory is that high insertion Torque (IT) values for implant placement above 40 to 45 N/cm may create pressure ischemia and microcirculation disturbances to osteocytes, leading to bone resorption. Compression of bone beyond its physiologic limits may result in ischemia, leading to osseous necrosis.(2,3) There is no scientific data or evidence to support these opinions.
On the other hand, both animal histological and human controlled clinical studies have shown that high IT does not induce bone necrosis.
Trisi and colleagues demonstrated that high IT in dense bone does not induce bone necrosis or implant failure. In fact, histologically, high IT increased initial BIC (bone to implant contact) and promoted primary healing and remodeling for weeks one through six when compared with low IT placed implants.(4)
A study by Ottoni and colleagues correlated high IT with increased survival rate of single tooth implants under functional loading. For every 9.8 Ncm of torque added, the risk of implant failure was reduced by 20%.(5)
Khayat and colleagues concluded that the use of high IT up to 176 N/cm did not prevent or inhibit osseointegration.(6)
Perren and colleagues inserted compression plates in the tibia of sheep and observed that pressure of about 40 MPa at the screw sites did not result in pressure necrosis, but rather in a gradual decrease in pressure due to bone viscoelasticity.(7)
In summary, there is a slow, gradual decline in bone stress produced with implant insertion. This gradual decline or creep is the result of two phenomena: viscoelastic relaxation of bone, and normal remodeling by basic multicellular units, whereby pre-stressed bone is replaced by new bone through internal remodeling rather than surface resorption.(8,9) Thus, higher IT combined with enhanced bone densification of the implant site is highly desired.(10)

References

1. Winwood K, Zioupos P, Currey JD, et al. The importance of the elastic and plastic components of strain in tensile and compressive fatigue of human cortical bone in relation to orthopaedic biomechanics. J Musculoskelet Neuronal Interact. 2006;6(2):134-141.
2. Bashutski JD, D’Silva NJ, Wang HL. Implant compression necrosis: current understanding and case report. J Periodontol. 2009;80(4):700-704.
3. Haider R. Histomorphometric analysis of bone healing after insertion of IMZ-1 implants independent of bone structure and drilling method. Z Stomatol. 1991; 88:507-521.
4. Trisi P, Todisco M, Consolo U, Travaglini D. High versus low implant insertion torque: a histologic, histomorphometric, and biomechanical study in the sheep mandible. Int J Oral Maxillofac Implants. 2011;26(4):837-849.
5. Ottoni JM, Oliveira ZF, Mansini R, Cabral AM. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants. 2005;20(5):769-776.
6. Khayat PG, Arnal HM, Tourbah BI, Sennerby L.Clinical outcome of dental implants placed with high insertion torques (up to 176 Ncm). Clin Implant Dent Relat Res. 2013;15(2):227-233.
7. Perren SM, Huggler A, Russenberger M, et al. The reaction of cortical bone to compression. Acta Orthop Scand Suppl. 1969;125:19-29.
8. Halldin A, Jimbo R, Johansson CB, et al. The effect of static bone strain on implant stability and bone remodeling. Bone. 2011;49(4):783-789.
9. Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002;84(8):1093-1110.
10. Trisi P, Perfetti G, Baldoni E, et al. Implant micromotion is related to peak insertion torque and bone density. Clin Oral Implants Res. 2009;20(5):467-471.

Salah


Reply

Dr. Salah: Thanks for your explanation!
and the literature that supports your explanation.
Jorge.


Reply

Dr.Salah,
Thanks for the very interesting and complete observations. We often believe to have objective data in many areas and sometime find out data are incomplete and upgrades are highly desired.
Again thanks for sharing your research.
Armando


Reply

Isaac,

Nice presentation and great success.
It's good to know we can perform ridge split with Versah burs instead of expanders.
One question.
Do you have experiences of ridge split in type I bone with Versah burs and obtain the same result as in type II bone?

Thanks for sharing.

Best Regards, Vincent


Reply

Vincent,
I have not encountered many type 1 cases in posterior mandible. When I do see type one bone I am often very cautious and prefer to graft prior to implant placement. Usually in posterior mandible the crest may be type one but once the piezo cut is made we often find good blood supply similar to type 3 bone but not as soft.
Hopes this answers your question
-isaac


Reply

Isaac;
thanks for presentation.It's great to have a new and alternative option in your innovative ridge splitting technique.

Salah;
lots of thanks for sharing your enlightening research. Masuod


Reply

Thank you Masuod


Reply

Dear Drs. Campos, Ponzi and Adeli:
Thank you for your kind remarks. Please allow me to explain why we think that Osseodensification is a paradigm shift as Rodrigo has called it in his presentation.
Osseodensification is an applied science of bone plasticity. The philosophy of this technique runs counter to the outcome of bone excavation drilling. We believe that healthy bone should be maintained, especially in regions where the density is already compromised.
The quality and quantity of bone at the implant interface is linked to the success rate of osseointegration (Todisco and Trisi, 2005). The mechanical properties of bone are related not only to the mineral density, but also to the architectural distribution, and collagen integrity (Lang et al., 2002; Javinen et al., 2005). Collagen gives bone its toughness and its ability to dissipate energy (Ritchie et al., 2009), and therefore, collagen integrity is directly linked to bone plasticity (Wang et al., 2002). The plastic deformation of bone occurs as a gradual change, which is time and strain rate dependent (Panjabi et al., 1973; Carter and Hayes, 1989). Due to its viscoelasticity, it reacts to stress with rate dependent strain, Meaning if you shock it with a hammer, it will react with increased stiffness and may fracture but if you apply a time dependent load, bone will expand without fracturing. The osseodensification preparation technique preserves bone bulk in two ways; compaction of cancellous bone due to viscoelastic and plastic deformation, and compaction autografting of bone particles along the length and at the apex of the osteotomy. Orthopedic literature has showed that bone preservation will enhance the host and its healing (Frost et al., 1998). Our biomechanical and histological data will be revealed this fall and will scientifically confirm that.
Please preserve this beautiful dynamic tissue we call bone!

REFERENCES:
1- Todisco, M. and Trisi P. Bone mineral density and bone histomorphometry are statistically related. Int J Oral Maxillofac Implants. 2005;20(6):898-904.
2- Lang TF, Guglielmi G, van Kuijk C, De Serio A, Cammisa M, Genant HK. Measurement of bone mineral density at the spine and proximal femur by volumetric quantitative computed tomography and dual-energy X-ray absorptiometry in elderly women with and without vertebral fractures. Bone, 2002;30(1):247-250
3- Jarvinen TL, Sievänen H, Jokihaara J, Einhorn TA. Revival of bone strength: the bottom line. J Bone Miner Res. 2005;20(5):717-720.
4- Ritchie RO, Buehler MJ, Hansma P. Plasticty and toughness in bone. Physics Today, 2009;62(6):41-47.
5- Wang X, Shen X, X Li, Mauli CA. Age-related changes in the collagen network and toughness of bone. Bone. 2002;31(1):1-7.
6- Panjabi MM, White AA, Southwick WO. Mechanical properties of bone as a function of rate of deformation. J Bone Joint Surg Am. 1973;55(2):322-330.
7- Carter DR, Hayes WC. The compressive behavior of bone as a two-phase porous structure. J Bone Joint Surg Am. 1977;59(7):954-962
8- Frost HM. A brief review for orthopedic surgeons: fatigue damage (microdamage) in bone (its determinants and clinical implications). J Orthop Sci. 1998;3(5):272-281.
Salah


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