Clinical Applications of an Atraumatic Osteotome
Benjamin A. Baptist, DDS, FAGD, FICOI, FAAID, DABOI/ID
Osteotomes have long been used in the formation of osteotomies for the placement of dental implants. Their ability to manipulate and compress existing bone without generating heat makes them particularly useful for expanding narrow ridges, elevating delicate sinus membrane, and increasing relative bone density around the osteotomy. Common concerns with these devices include the traumatic force communicated to the patient during use and difficulty controlling force vectors. A new type of osteotome has been developed that is designed to enable the clinician to eliminate the concerns found with traditional osteotomes yet it preserves the best qualities and functionality of this class of device. This article will present several case reports that illustrate the usefulness of this instrumentation in clinical settings.
Osteotomes can be used as an alternative to drills to prepare osteotomies for the placement of dental implants. These instruments come in many forms to accommodate different protocols, including ridge splitting and expansion, osteocondensing, and maxillary sinus augmentation.1-4 Osteotomy preparation with osteotomes results in densification of the bone through compression, which can result in increased stability at the time of implant placement.5-7 Additionally, stress to the bone during preparation results in regional acceleratory phenomenon with an adaptive change in bone, which has been shown to improve bone-to-implant contact after osseointegration.8,9 Osteotomes have been shown to reduce overall clinical treatment times by 6 to 9 months for sinus augmentation while maintaining long-term clinical success equal to or better than that of traditional techniques.10-12
Most osteotomes are either cylindrical or semi-round rods that are driven into the bone through mallet strikes. Many providers have unfavorably perceived the traumatic impact on the patient during the use of these instruments.2,13 Using osteotomes requires considerable skill and experience to control the trajectory, depth, and rate of advancement during osteotomy preparation to achieve acceptable outcomes.1
Newer inceptions have sought to control the depth and rate of advancement of the osteotomy by creating a tapered screw that can be advanced into the bone using a socket and ratcheting wrench.2,7,13 Screw expansion improves the rate of advancement and bone expansion; however, it creates a situation in which the clinician cannot predictably redirect the trajectory of the osteotomy, such as in immediate socket placement.
The case reports presented here provide a clinical introduction to a new manually driven osteotome (Rototome®, Janus Dental Industries Inc., janusdentalindustries.com) (Figure 1). This instrumentation combines the ridged, elongated handheld form of a traditional osteotome with the rotational threaded form of the screw-expansion devices. These features are intended to enable improved control of trajectory, depth of preparation, and rate of advancement to create the possibility for greater predictability of outcomes in the placement of immediate implants, ridge expansion, and sinus elevation.
Case 1: Extraction and Immediate Placement With Provisional Restoration
A 53-year-old woman with a noncontributory medical history presented with a chief complaint of pain associated with tooth No. 9 (Figure 2 and Figure 3). A diagnosis of vertical root fracture of the tooth was made. Adjacent and opposing teeth and periodontal support were determined to be favorable. The findings were reviewed with the patient and treatment options and reasonable alternatives were discussed. Single-tooth implant (STI) therapy was agreed upon. The risks and benefits of the therapy were reviewed and written informed consent was obtained from the patient.
First, the mouth was lavaged with chlorhexidine oral rinse (CHG 0.12% suspension, Patterson Dental, pattersondental.com) for 30 seconds before administering local anesthetic. Tooth No. 9 was atraumatically extracted, and the socket was mechanically debrided and irrigated with sterile saline. No fracture or bony dehiscence was detected.
An initial penetration of the palatal cribriform plate was made approximately 2 mm to 3 mm from the apex of the extraction socket with a #701 surgical bur. The first Rototome was inserted in an apical-palatal orientation and advanced 4 mm before being gently redirected vertically to the desired final long access of the implant and driven to depth (Figure 4). The osteotomy was sequentially enlarged with Rototome instruments to the final diameter required. Mineralized ground cortical bone (MGCB) allograft (OraGraft®, Salvin Dental, salvin.com) was placed firmly in the socket around the final osteotome instrument (Figure 5) before the instrument was removed.
The dental implant (ReActive™ SBM, 4.3 mm x 13 mm, Implant Direct, implantdirect.com) was placed with 45-Ncm torque (Figure 6), and an undercontoured immediate nonocclusal load (INOL) provisional was fabricated (Figure 7). Home-care and postoperative instructions were reviewed with the patient verbally and in writing.
Case 2: Maxillary Ridge Splitting
A 60-year-old woman presented with a nonrestorable fractured tooth No. 10 (Figure 11). The patient reported smoking 20 cigarettes per day and demonstrated fair oral hygiene. Her medical history was otherwise unremarkable. Additional dental treatment needs were identified and reviewed with the patient in addition to the fractured tooth. Treatment options, risks, benefits, and alternatives were reviewed. The patient elected to have tooth No. 10 extracted and proceed with ridge preservation before STI therapy.
Informed consent was obtained from the patient and tooth No. 10 was extracted under local anesthesia without complication; a facial bony dehiscence was noted. The socket was irrigated with saline before site preservation with MGCB and a collagen sponge. The site was provisionalized with a vacuform retainer.
After 4 months (Figure 12), a second surgery was performed with local anesthetic. The patient rinsed with CHG, and a partial-thickness/full-thickness Z flap was prepared (Figure 13) as described by Anitua7 with a vertical releasing incision distal to tooth No. 11. An initial cortical penetration was made with a locator drill (Implant Direct), and a ridge-splitting osteotomy was made via sequential progression with the Rototome osteotome (Figure 14). A tapered implant (Legacy™3 SBM, 3.2 mm x 13 mm, Implant Direct) was placed, completing the ridge split (Figure 15). The facial ridge was overlaid with MGCB allograft and a porcine membrane (Renovix™, Salvin Dental). The periosteum was scored, and the site was closed primarily with 6-0 VICRYL® (Ethicon, ethicon.com) suture. The implant was allowed to integrate for 4 months (Figure 16) before being uncovered with a full-thickness mid-crestal flap, and an INOL provisional was constructed. At 6 months, the final restoration was fabricated (Figure 17).
Case 3: Sinus Elevation
A 66-year-old man with a history of coronary artery disease, who had a stent and a pacemaker placed, presented with a nonrestorable fracture of tooth No. 5. The patient was taking clopidogrel and a statin medication daily. He was informed of the findings and treatment options. The risks, benefits, and reasonable alternatives were reviewed. After informed consent was obtained from the patient, tooth No. 5 was extracted under local anesthesia without complication. The socket was debrided and irrigated with saline prior to ridge preservation with MGCB allograft and a collagen sponge.
After 4 months, the patient returned for placement of the implant. It was noted that the vertical height of bone was 6 mm to 7 mm from the crest to the floor of the maxillary sinus (Figure 18). The patient opted for implant placement with a crestal approach sinus elevation. Again, informed consent was obtained from the patient and, after chlorhexidine rinse for 30 seconds, the procedure was performed under local anesthetic.
A 3-mm tissue punch was used to expose the ridge, and a 2-mm deep pilot-hole penetration was made with the locator drill. An osteotomy was developed sequentially with Rototome instruments to a depth of 6 mm until the final diameter was advanced to 10 mm to elevate the Schneiderian membrane (Figure 19). MGCB allograft was placed and advanced with the second largest osteotome before the implant (InterActive™, 4.3 mm x 10 mm, Implant Direct) was placed and the tissue stabilized by a healing abutment (Figure 20). Five months after surgery, a layered zirconia crown was fabricated on a stock abutment (Figure 21).
In recent years, introduction of new techniques and protocols in dentistry have reduced the number of surgeries and the length of treatment, while enabling optimal esthetics to be achieved in the anterior esthetic zone.14-16 Advances include the placement of implants in fresh or partially healed extraction sockets, as well as fabrication of interim restorations, such as INOLs, to aid in the healing and maturation of tissue.14-17 As demonstrated in these cases, by carefully maintaining the residual socket, precisely placing the implant, and supporting the gingival architecture an optimal outcome was achieved. The osteotome devices created lateral and apical condensation of the osteotomies, allowing optimal insertion torque in native bone and promoting osseodensification via Wolff’s Law,8,9 as evidenced in the first case by the enhanced radiopacity of the lamina dura in the coronal aspect of the fixture (Figure 10). Because the socket wall could be penetrated and the noncutting instrument uprighted with class I lever mechanics as it was advanced, the trajectory was reoriented with more control than with a drill or a traditional mallet-type osteotome (Figure 6).
When considering ridge splitting and sinus elevation, the rate of advancement is critical to the success of the procedure. A slower rate of advancement during bone expansion allows for interstitial fluid pressure to dissipate and equalize, increasing the bone’s natural pliability and permitting a favorable green-stick fracture to be propagated in an ideal location. The same holds true when up-fracturing the floor of the maxillary sinus; by controlling the rate of advancement precisely, the sinus membrane can be more gently elevated, reducing the risk of perforation.
The development of a new osteotome, designed to improve control of dental implant osteotomy depth and trajectory, rate of expansion and advancement, bone density, and implant stability, allows for refinement of well-established techniques within implant dentistry. The instrumentation enables rapid integration for clinical applications by experienced implant surgeons.
Rototome® is a trademark of Benjamin A. Baptist.
About the Author
Benjamin A. Baptist, DDS, FAGD, FICOI, FAAID, DABOI/ID
Midwestern University College of Dental Medicine
Downers Grove, Illinois
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