Clinical Protocols - Osseodensification

Osseodensification

Clinical Protocols

Osseodensification

Facilitated Ridge Expansion Protocol*

Ridge Expansion Protocol

Overview: Osseodensification will not create the tissue, it may only optimize and preserve what already exists. 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 + 1 mm cortex on each side). This protocol is indicated to expand a ridge with a narrow crest and wider base. It is not indicated in resorbed ridge with a narrow base.

• DIAGNOSE AND ASSESS THE AMOUNT OF THE TRABECULAR BONE USING A CBCT

• CREATE INTRA-BONY TROUGH IN NARROW RIDGE < 4 MM

• NO NEED FOR VERTICAL SIDE CUTS

• USE DENSAH® BURS IN SMALL INCREMENTS

• OVER-SIZE THE OSTEOTOMY TO BE ≥ IMPLANT MAJOR DIAMETER

• OSTEOTOMY 1 MM DEEPER THAN IMPLANT LENGTH ESPECIALLY IN THE MANDIBLE

• PERFORM HARD & SOFT TISSUE VENEER CONTOUR GRAFT TO DEVELOP TISSUE THICKNESS AROUND IMPLANTS

Diagnose & assess the amount of the trabecular bone available using a CBCT to evaluate the bone composition needed to perform a predictable plastic expansion. Flap the soft tissue using instruments and technique normally used.

Step 1:

Create intra-bony trough in narrow ridge < 4 mm. the ridge contains ≤ 2 mm of trabecular-bone core or high cortical bone ratio, an intrabony ridge-split is needed; ridge-split to be made by a Piezosurgery 0.3 - 0.5 mm tip. Ridge-split is recommended to be as deep as the planned implant length. No vertical side cuts are needed. ridge-split is to allow more buccal wall elasticity during the expansion procedure. This intra-bony split is contra-indicated in resorbed ridge with a narrow base.

Step 2:

Use the Densah® Bur in small increments, depending upon the implant type and diameter. After a narrow pi lot osteotomy, change the surgical motor to Densifying Mode (counterclockwise, drill speed 800-1500 rpm with copious irrigation). Start with the narrowest Densah® Bur, in Densifying Mode, until reaching the desired depth (be gin by introducing the running bur into the osteotomy When feeling the haptic feedback of the bur pushing up out of the osteotomy, lift off and reapply pressure with a pumping motion until reaching the desired depth). As the bur diameter increases, the bone will slowly expand to the planned final diameter.

Clinical Versahtility of Osseodensification

Step 2 Continued...

The osteotomy may be expanded with minimal bone dehiscence, which may allow for total implant length placement in autogenous bone without thread exposure.

Step 3:

Oversize the osteotomy to be slightly wider than the implant major diameter (especially in the mandible) to prevent the implant threads from over-straining the expanded bony walls. Mandibular osteotomies need to be planned and performed to 1 mm deeper than the implant length.

Step 4:

Place an implant with a diameter that is equal or slightly larger than the initial ridge width. If using the surgical motor to tap the implant into place, the unit may stop when reaching the placement torque maximum. Finish placing the implant to depth manually with a torque indicating wrench.

Step 5: Perform hard and soft tissue veneer contour-graft to augment around the implant to develop tissue thickness that may enhance long term stability.

Step 5

Osseodensification

Facilitated Densah® Lift Protocol I*

Densah® Sinus Lift Protocol I

Minimum residual bone height ≥ 6 mm. Minimum alveolar width needed = 4 mm

Overview: Use Densah® Burs in full step increments. For example: 2.0 mm, 3.0 mm, 4.0 mm, 5.0 mm.

• MEASURE BONE HEIGHT TO SINUS FLOOR

• PILOT DRILL 1 MM BELOW THE SINUS FLOOR

• DENSAH® BUR (2.0) IN OD MODE TO SINUS FLOOR

• ENTER WITH DENSAH® BUR (3.0) IN OD MODE UP TO 3MM PAST THE SINUS FLOOR

• DENSAH® BUR (4.0), (5.0) OD MODE UP TO 3 MM PAST THE SINUS FLOOR, IF NEEDED

• USE DENSAH® BURS IN FULL STEP INCREMENTS FOR EXAMPLE: 2.0 MM, 3.0 MM, 4.0 MM, 5.0 MM

Step 1

Step 1: Measure bone height to the sinus floor. Flap the soft tissue using instruments and technique normally used.

Densifying crust in osseodensification mode due to compaction autografting

Compaction autografting in the apex of the osteotomy facilitates sinus grafting

Step 2: Pilot drill 1 mm below the sinus floor. In cases where posterior residual alveolar ridge height is ≥ 6.0 mm, and additional vertical depth is desired, drill to the depth determined within an approximate safety zone of 1.0 mm from the sinus floor using a pilot drill (clockwise drill speed 800-1500 rpm with copious irrigation). Confirm pilot drill position with a radiograph.

Step

2

Clinical Versahtility of Osseodensification

Step 3

Step 4

Step 3: Densah® Bur (2.0) OD mode to sinus floor. Depending upon the implant type and diameter selected for the site, begin with the narrowest Densah® Bur (2.0). Change the surgical 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 reaching the dense sinus floor, stop and confirm the first Densah® Bur vertical position with a radiograph.

Step 4: Enter with Densah® Bur (3.0) OD mode up to 3 mm past the sinus floor. Use the next wider Densah® Bur (3.0) in densifying-mode (counterclockwise drill speed 800-1500 rpm with copious irrigation) and advance it into the previously created osteotomy with modulating pressure and a pumping motion. When feeling the haptic feedback of the bur reaching the dense sinus floor, modulate pressure with a gentle pumping motion to advance past the sinus floor in 1 mm increments. Maximum possible advancement past the sinus floor at any stage must not exceed 3 mm. As the next wider Densah® Bur advances in the osteotomy, additional autogenous bone will be pushed toward the apical end to achieve additional vertical depth and a maximum membrane lift of 3.0 mm. Confirm the bur vertical position with a radiograph.

Step 5: Place Implant. Place the implant into the osteotomy. If using the surgical 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 indication ratchet wrench.

Step 5

Osseodensification

Facilitated Densah® Lift Protocol II*

II

Minimum residual bone height 4-5 mm. Minimum alveolar width needed = 5 mm

Overview: Use Densah® Burs in full step increments. For example: 2.0 mm, 3.0 mm, 4.0 mm, 5.0 mm.

• MEASURE BONE HEIGHT TO SINUS FLOOR

• AVOID USING A PILOT DRILL

• DENSAH® BUR (2.0) OD MODE TO SINUS FLOOR

• ENTER WITH DENSAH® BUR (3.0) OD MODE UP TO 3 MM PAST THE SINUS FLOOR

• DENSAH® BUR (4.0), (5.0) OD MODE UP TO 3 MM PAST THE SINUS FLOOR TO FURTHER EXPAND THE OSTEOTOMY

• USE DENSAH® BURS IN FULL STEP INCREMENTS FOR EXAMPLE: 2.0 MM, 3.0 MM, 4.0 MM, 5.0 MM

• USE THE LAST DENSAH® BUR IN LOW SPEED TO GENTLY PROPEL WELL HYDRATED ALLOGRAFT

Step 1:

Measure bone height to sinus floor. Flap the soft tissue using instruments and technique normally used.

Step 2:

Densah® Bur (2.0) OD Mode to sinus floor. Avoid using a pilot drill. Depending upon the implant type and diameter selected for the site, begin with the narrowest Densah® Bur (2.0). Change the surgical motor to reverse (counterclockwise drill speed 800-1500 rpm–Densifying Mode with copious irrigation). Begin running the bur into the osteotomy until reaching the dense sinus floor. Confirm Bur position with a radiograph.

Step 3:

Enter with Densah® Bur (3.0) OD mode up to 3 mm past the sinus floor.

Use the next wider Densah® Bur (3.0) and advance it into the previously created osteotomy with modulating pressure and a pumping motion. When feeling the haptic feedback of the bur reaching the dense sinus floor, modulate pressure with a pumping motion to advance past the sinus floor in 1 mm increments, up to 3 mm. Maximum bur advancement past the sinus floor, at any stage, must not exceed 3 mm. Bone will be pushed toward the apical end and will begin to gently lift the membrane and autograft compacted bone up to 3 mm. Confirm the bur vertical position with a radiograph.

Step 2

Step 3

Step 1

Densah® Sinus Lift Protocol

Step 4: Densah Bur (4.0), (5.0) OD mode up to 3 mm past the sinus floor.

Use the sequential wider Densah® Burs in Densifying Mode (Counterclockwise drill speed 800-1500 rpm) with copious irrigation with pumping motion to achieve additional width with maximum membrane lift of 3 mm (in 1 mm increments) to reach final desired width for implant placement. Densah® Burs must not advance more than 3 mm past the sinus floor at all times regardless of the Densah® Bur diameter.

Step 5: Propel allograft.

After achieving the final planned osteotomy diameter, fill the osteotomy with a well hydrated, mainly cancellous, allograft. Use the last Densah® Bur used in step 4 in Densifying Mode (Counterclockwise) with low speed 150-200 rpm with no irrigation to propel the allograft into the sinus. The Densah® Bur must only facilitate the allograft material compaction to further lift the sinus membrane, and not to advance beyond the sinus floor more than 2-3 mm. Repeat the graft propelling step to facilitate additional membrane lift as needed according to implant length.

Step 6: Place implant. Place the implant into the osteotomy. If using the surgical 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.

Osseodensification

Immediate Implant Placement*

• ATRAUMATIC TOOTH EXTRACTION WITHOUT OR MINIMAL FLAP REFLECTION.

• CHOOSE IMPLANT DIAMETER TO BE SLIGHTLY WIDER THAN THE TOOTH APEX.

• USE DENSAH® BURS IN FULL INCREMENTS AND CCW OSSEODENSIFICATION MODE.

• FINAL DENSAH® BUR APICAL DIAMETER TO BE ≥ TO THE APICAL DIAMETER OF TOOTH APEX.

Immediate Implant Placement Protocol

• USE A WELL HYDRATED COMPOSITE ALLOGRAFT OF 70/30 CANCELLOUS//CORTICAL TO FILL THE SOCKET.

• USE DENSAH® BUR THAT IS ONE STEP SMALLER THAN THE LAST USED BUR TO DENSIFY ALLOGRAFT.

• IMPLANT STABILITY MUST BE MAINLY PROVIDED BY THE APICAL PORTION OF THE SOCKET.

Step 1:

After atraumatic tooth extraction without or minimal flap reflection and socket degranu lation, use the pilot drill in clockwise mode to achieve implant trajectory.

Step 2a:

Choose implant diameter based on the tooth or its socket apical diameter. Implant needs to be slightly wider than the tooth apex. This will allow the implant stability to be mainly provided by the apical portion of the socket.

Step 2b:

Choose a Densah® Bur to be the last preparation bur based on its diameter relative to the tooth or its socket apical diameter. Final Densah® Bur needs to be ≥ to the apical diameter of the tooth or its socket.

Step 3:

Use Densah® Burs in full increments, depending upon the implant type and diameter. After the pilot os teotomy, change the surgical motor to Densifying Mode (CCW, 800-1500 rpm with copious irrigation). To prep the site, start with the narrowest Densah® Bur, in OD Mode, until reaching the desired depth (begin by intro ducing the running bur into the osteotomy.) When feel ing the haptic feedback of the bur pushing up out of the osteotomy, lift off and reapply pressure with a pumping motion until reaching the desired depth.

Step 2b

Step 2a

Step 3 Continued: Use the following wider Densah® Burs until reaching the designated bur in Step 2B. As the bur diameter increases, the apical bone will slowly expand to accommodate the designated implant diameter.

Step 4: Loosely fill the osteotomy with well hydrated allograft in the socket. Allograft preferably to be a combination of 70/30 cancellous/cortical.

Step 5:

Densified allograft may enhance implant primary stability in the extraction socket. Use the Densah® Bur that is one step smaller than the last bur used in socket preparation. Use the bur in CCW direction, low speed 150-200 rpm with no irrigation to densify the allograft laterally into the socket walls. Follow the same implant preparation trajectory.

Step 6: Place the implant. Using the surgical motor to tap the implant into place, the unit may stop when reaching the placement torque maximum. Finish placing the implant to depth manually with a torque indicating wrench.

We believe innovative medical technology must be biologically viable and able to translate to predictable and reproducible procedures.

Step 6

Osseodensification

Guided Expansion Graft*

For cases with initial ridge width of ≤ 3.0 mm

• USE PILOT DRILL IN (CW) MODE AND DRILL TO IMPLANT DEPTH AND ANGULATION

Guided Expansion Graft Protocol

• USE THE SUBSEQUENT DENSAH® BURS IN SMALLER INCREMENTS TO EXPAND THE OSTEOTOMY AND TO INCREASE BONE PLASTICITY

• FINAL EXPANSION DIAMETER SHOULD NOT EXCEED THE PLUS ONE FORMULA (INITIAL RIDGE WIDTH + 1 MM)

• GRAFT THE NEWLY FORMED SOCKET WITH A 70/30 CANCELLOUS/CORTICAL COMBINATION ALLOGRAFT

• ALLOW HEALING FOR 3-6 MONTHS

• RE-ENTER THE SITE TO PREPARE FOR IMPLANT PLACEMENT USING OSSEODENSIFICATION WITH THE DENSAH® BURS

Step 1:

Flap the soft tissue using the technique indicated for the implant position. Drill to implant depth and angulation using a narrow Pilot Drill preferably 1.3 mm – 1.5 mm. (CWspeed 800-1500 rpm with copious irrigation).

Step 2:

Depending upon the implant type and diameter, follow the corresponding Implant System Drilling Protocol start ing with the smallest Densah® Bur to 1 mm deeper than the intended implant length. Run the Densah® Burs in OD mode (counterclockwise, drill speed 800-1500 rpm with copious irrigation). Use the subsequent Densah® Burs in smaller increments to increase bone plasticity and expand the osteotomy. For example, use Densah® Bur (2.0) after the pilot then expand with Densah® Bur (2.3) then move to Densah® Bur (2.5) before introducing the Densah® Bur (3.0).

Step 3:

Increase osteotomy diameter in small increments until reaching the intended expansion. As the bur diameter increases, the bone will slowly expand to the final expansion diameter. Final expansion diameter should not exceed the plus 1 formula (initial ridge width + 1 mm). For example, if you start with a 3 mm ridge, the maximum expected final osteotomy diameter is not to exceed (3+1) = 4 mm.

Step 4: Graft the newly formed socket/osteotomy including surrounding area with your preferred bone allograft materials, preferably a 70/30 cancellous/cortical ratio. Use membrane and try to achieve tension free primary closure. Allow healing for 3-6 months.

Step 5:

Re-enter the site and perform Osseodensification to facilitate further expansion if needed and place the implant. Use the Densah® Burs in smaller increments. Do not under-prep the osteotomy beyond 0.5 mm - 0.7 mm in the maxilla or 0.2 mm – 0.5 mm in the mandible.

Step 6:

If using the surgical 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.

Case courtesy of Dr. Salah Huwais