­Ultrasonic implant site preparation vs conventional drilling: in vitro evaluation of implant site diameter.

doi:10.21203/rs.3.rs-3233116/v1

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Ultrasonic implant site preparation vs conventional drilling: in vitro evaluation of implant site diameter.

https://doi.org/10.21203/rs.3.rs-3233116/v1

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published 01 Mar, 2024

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Objective

The aim of this study is to evaluate implant site diameter after bony preparation using either conventional drilling (CD) or ultrasonic implant site preparation (UISP).

Materials and Methods

On bovine ribs, 3mm x 10mm implant sites were prepared using two different ultrasonic protocols, UISP1 (n = 16) and UISP2 (n = 16) and a conventional drilling protocol CD (n = 16). Implant sites were then filled with resin and both cortical and cancellous horizontal sections were made in order to measure the bucco-lingual (D1) and the mesio-distal (D2) diameters of each site. Also, implant sites were prepared on bovine ribs following UISP1 (n = 12), UISP2 (n = 12) and CD (n = 12) protocols and final insertion torque (IT) was measured for each preparation. The results were statistically analyzed using the Kruskal Wallis test.

Results

Statistically significant differences were found between UISP1 (mean diameter = 3.161) and CD (mean diameter = 3.012) for D1 (P = 0.041), between UISP1 (mean diameter = 3.328) and CD (mean diameter = 3.039) for D2 (P = 0.001), between UISP1 (mean diameter = 3.328) and UISP2 (mean diameter = 3.005) for D2 (P < 0.001). No statistically significant differences were noted between UISP1 (mean diameter = 3.161) and UISP2 (mean diameter = 2.995) for D1 (p-value = 0.08), between CD (mean diameter = 3.012) and UISP2 (mean diameter = 2.995) for D1 (p-value = 0.290), and between CD (mean diameter = 3.039) and UISP 2 (mean diameter = 3.005) for D2 (p-value = 0.650). A significant difference was noted between UISP1-IT values (mean torque = 17.96 N/cm) and both UISP2-IT values (mean torque = 37.48 N/cm) (P < 0.001) and CD-IT values (mean torque = 40.99 N/cm) (P < 0.001). No statistically significant difference was noted between CD-IT (mean torque = 40.99 Ncm) and UISP2-IT (mean torque = 37.48 Ncm) (p-value = 0.488).

Conclusion

By following proper protocol UISP can be used as precisely as CD to prepare implant bed.

ultrasonic implant site preparation

insertion torque

conventional drilling

ultrasound

piezosurgery

drills

Research in oral implantology focused on improving the ability of an implant to achieve osseointegration by modifying either surface topography (Davies, 2003) or implant design (Abuhussein et al., 2010). Nevertheless, implant site preparation protocols, which traditionally use drills, did not show any major changes since Branemark’s early studies (Branemark, 1985). In fact, atraumatic implant site preparation that preserves bone to implant interface is an essential condition for achieving proper osseointegration (Albrektsson et al., 1981; Sharawy et al., 2002).

Piezosurgery, that in the last decades enhanced bone surgery procedures was applied to implant site preparation, introducing the new concept of “Ultrasonic Implant Site Preparation Technique” (UISP) (Vercellotti, 2009). The UISP technique showed important biological and clinical advantages that allowed the introduction of the new concept “Ultraosseointegration” (Vercellotti et al., 2014).

Piezoelectric technique, takes advantage of ultrasonic technology to perform a less traumatic and more precise implant site preparation when compared to drills (Scarano et al., 2014), without neglecting the cavitation effect that cleans the trabeculae from any debris allowing a better blood supply thus a faster healing from histo-chemical and histological points of view (Maglione et al., 2019). As a result, topographic analysis of the inner bone surfaces following ultrasonic cuts, observed through Scanning Electron Microscopy (SEM), revealed a rough bone surface, clean, without trabecular destruction or signs of cortical fracture (Maurer et al., 2008). Furthermore, implant sites prepared with ultrasonic instruments showed significantly less micro cracks in the cortical part of the bone (Scarano et al., 2014).

Multiple studies confirm the efficacy of piezoelectric devices for implant site preparation. One of the biological advantages related to this technique is the reduction of thermal variation on bone tissue that contributes to maintain a better bone vitality and a superior osteoblastic turnover leading to a better postoperative bone response (Scarano et al., 2018). Furthermore, this technique allows a better preservation of the soft tissues and of any noble anatomical structures (nerve or Schneiderian membrane) adjacent to the drilling site (Stacchi et al., 2020). Besides studies revealed that implant placement using piezoelectric technique cause less post-operative pain and swelling when compared to conventional technique (Maglione et al., 2019).

During implant placement, insertion torque values can be predicated by implant geometry and bone density (Makary et al., 2011) but also by implant site preparation technique (Tabassum et al., 2009). Drilling dimension can significantly affect implant stability and implant osseointegration at later healing periods (Campos et al., 2012).

In the present study, final IT values were measured to monitor implant site preparation accuracy between ultrasonic preparation and conventional drilling.

The aim of this study is to compare implant site diameter in cortical and cancellous bone, and implant insertion torque, while using two ultrasonic implant site preparation protocols or the conventional drilling technique, allowing the establishment of a protocol for UISP leading to similar results as conventional drilling.

Twelve bovine bone ribs, freshly taken from the butchery, were used. The choice of these ribs was done due to their biomechanical characteristics. The cortical thickness and the trabecular density are similar to those of the human bone. In fact, those ribs have an external dense cortical bone with a thickness of 2 mm approximately, and an internal part formed by a trabecular bone with a mean density of D2 of Misch classification (Misch, 2008).

The samples were cleaned and rid of all soft tissue residues, then submerged in a saline and ethanol solution (1:1), according to the methodology described by Tricio et al. (1995). In order to diminish alterations in bone mechanical and thermophysical properties, the specimens were stocked frozen in sterile saline solution (-10°C), according to previous publication (Harder et al., 2009). Before implant site preparation, they were maintained at room temperature for 3 h, wrapped with saline-soaked gauze for hydration.

Prior to implant site preparations, the lower parts of the bovine ribs were leveled and set on a horizontal table. All bony preparations were perpendicular to the horizontal plane and conducted by the same clinician (Fig. 1).

Cortical wall thickness may vary from the mesial to the distal region of the bone rib. This anatomical variation could have a direct impact on implant site preparation, as well as on insertion torque measurement. To encounter this bias, the preparations made during this experiment were spread on bovine ribs alternately allowing their equal distribution. Like so, on the same bovine rib, the conventional drilling sites and the UISP sites were performed in similar anatomical conditions.

For the conventional drilling group, implant sites were prepared with a W& H drilling motor at 900 rpm speed, using conventional rotary instrumentation as per the standard protocol recommended by the manufacturer (round bur followed by 1.5, 2.0 and 3.0 diameter drills) (Fig. 2a).

For the ultrasonic implant site preparation groups, Piezosurgery Touch unit (Mectron spa., Carasco, Italy) along with the special implant site preparation inserts were used. Two different protocols were tested. UISP1 protocol: 3 inserts were used. IM1 as pilot, IM2 cylindrical tip, equipped with teeth at the end and internal irrigation, used to expand the osteotomy diameter to 2mm and final insert IM3 used to finalize the implant site at 3 mm diameter (Fig. 2b).

For UISP2 protocol, 5 tips were used. Between IM2 and IM3, OT4 (cylindrical, rounded end and diamond coated tip), and IP2-3 conical diamond coated tip with a diameter increasing from 2 to 3mm). During all preparations, the bovine ribs were maintained at room temperature and hydrated at humid gauzes with saline solution (Fig. 3).

A total of 84 sites (Ø = 3mm; L = 10 mm) were prepared, divided into 6 groups depending on the measured parameters (Table 1).

Table 1

Distribution of the 84 site preparations
Group	Acronym	Number of preparations
Conventional Drilling	CD	16
Ultrasonic Implant Site Preparation - protocol 1	UISP 1	16
Ultrasonic Implant Site Preparation - protocol 2	UISP 2	16
Conventional Drilling – Insertion Torque	CD-IT	12
Ultrasonic Implant Site Preparation 1- Insertion Torque	UISP 1-IT	12
Ultrasonic Implant Site Preparation 2 - Insertion Torque	UISP 2-IT	12

Preparation sites for groups CD, UISP 1 and UISP 2 were manually injected with Pattern resin (GC, Japan), with an established retraction rate of 0.37%. Standard amounts of liquid and powder were mixed to a light consistency, allowing it to be easily injected with minimal air bubbles. All the preparations were injected by the same mixture.

After resin setting, bone ribs were cut into cubic blocks using a 0.5 mm metallic disc mounted on a steady rotary motor (Ray Foster high speed) at a speed of 24000 rpm, each block containing a preparation. From a lateral view, the two different bone block densities (cortical and cancellous) can be easily distinguished and measured. Each of the 48 blocks underwent 2 horizontal cuts at the middle parts of the cortical regions.

The obtained bone sections were then photographed using a digital camera equipped with a 100 mm macro lens (Canon Inc., Japan). The camera was fixed on a special horizontal support and all bone cuts were placed at a fixed position with graduated mm scales facing the camera, assuring maximum precision and measurement reproducibility, plus allowing digital measurement of preparation sites (Fig. 4).

Drilling diameters were measured on cortical bone section images using Adobe Photoshop cs4 (Adobe systems, San Jose, California, USA). Each image was cropped to fit the dimensions of the resin section. The corresponding quadrangle having four sides tangent to the red rounded form allowed the measurement of the two diameters D1 and D2 in pixels (Fig. 5).

In the cancellous bone sections, resin diffusion into bone trabeculae was observed, consequently the computer software was incapable of properly analyzing the images and set the two diameters D1 and D2 (Fig. 6). Thus, only cortical bone diameter measures were used in this work.

On the mm scale in each photo, 3 mm was measured on the software in order to obtain a conversion reference and convert D1 and D2 from pixel to mm.

On the other hand, using a digital torque meter (DTA, Italy), a 3.7mm diameter implant tapping device, simulating a cylindrical implant, was inserted into the 36 preparations and insertion torque was measured. The final insertion torque was noted for each site and CD-IT, UISP1-IT and UISP2-IT values were obtained.

Statistics

Kruskal-Wallis test was used for the statistical analysis to compare the preparation diameter in cortical section of the drilling to the piezoelectric techniques and to compare the insertion torque of the three groups.

Mean cortical diameter values for D1 were 3.012 mm for the conventional drilling protocol, 3.161 for UISP1 protocol and 2.995 for UISP2. D2 mean values were 3.039 for conventional drilling group, 3.328 for UISP1 and 3.005 for UISP2 (Fig. 7).

Statistically significant difference was noted in the values of D1 (p-value = 0.041) between the conventional technique CD (mean value 3.012mm) and UISP1 (mean value 3.161mm).

Statistically significant difference was noted in the values of D2 (p-value = 0.001) between the conventional technique CD (mean value 3.039mm) and UISP1 (mean value 3.328mm).

No statistically significant difference was noted in the values of D1 (p-value = 0.08) between UISP1 (mean value 3.161mm) and UISP2 (mean value 2.995mm).

Statistically significant difference was noted in the values of D2 (p-value < 0.001) between UISP1 (mean value 3.328mm) and UISP2 (mean value 3.005mm) (Table 2).

No Statistically significant difference was noted in the values of D1 (p-value = 0.290) between the conventional technique CD (mean value 3.012) and UISP2 (mean value 2.995mm), and in the values of D2 between CD (mean value 3.039mm) et UISP 2 (mean value 3.005 mm) (p-value = 0.650).

No Statistically significant difference was noted in the group of CD (p-value = 0.211) between the values of D1 (mean value 3.012mm) and D2 (mean value 3.039mm) and in the group of UISP2 between the values of D1 (mean value 2.995mm) and D2 (mean value 3.005mm) (p-value = 0.941).

Statistically significant difference was noted in the UISP1 group (p-value = 0.037) between the values of D1 (mean value 3.161mm) and D2 (mean value 3.328mm) (Table 2).

Table 2 Mean, std deviation and P-value of the cortical diameters

Group	Mean	Standard deviation	p- value
CD - D1	3.012	0.0653	p=0.041
UISP 1 - D1	3.161	0.1122	p=0.041
UISP 1 -D1	3.161	0.1122	p=0.08
UISP 2 - D1	2.995	0.0868	p=0.08
CD - D1	3.012	0.0653	p=0.290
UISP 2 - D1	2.995	0.0868	p=0.290
CD - D2	3.039	0.0766	p=0.001
UISP 1 - D2	3.328	0.1746	p=0.001
UISP 1 - D2	3.328	0.1746	p<0.001
UISP 2 - D2	3.005	0.0855	p<0.001
CD - D2	3.039	0.0766	p=0.650
UISP 2 - D2	3.005	0.0855	p=0.650
CD - D1	3.012	0.0653	p=0.211
CD - D2	3.039	0.0766	p=0.211
UISP 1 - D1	3.161	0.1122	p=0.037
UISP 1 - D2	3.328	0.1746	p=0.037
UISP 2 - D1	2.995	0.0868	p=0.941
UISP 2 - D2	3.005	0.0855	p=0.941

On the other hand, mean Insertion torque value for conventional drilling group was 40.99 Ncm, for UISP1 17.96 Ncm and for UISP2 37.48 Ncm (Fig. 8).

Statistically significant difference was noted in the insertion torque values (p < 0.001) between CD-IT (mean value 40.99 Ncm) and UISP1-IT (mean value 17.96 Ncm). And between UISP1-IT (mean value 17.96 Ncm) and UISP2-IT (mean value 37.48 Ncm) (p < 0.001).

No statistically significant difference was noted in the insertion torque values (p = 0.488) between CD-IT (mean value 40.99 Ncm) and UISP2-IT (mean value 37.48 Ncm). (Table 3).

Table 3- Mean, std deviation and p-value of the insertion torque values

Groupe	Mean	Standard Deviation	p- value
CD - IT	40.99	12.045	p<0.001
UISP1 - IT	17.96	4.479	p<0.001
UISP1 - IT	17.96	4.479	p<0.001
UISP2 - IT	37.48	7.7562	p<0.001
CD - IT	40.99	12.045	p= 0.488
UISP2 - IT	37.48	7.7562	p= 0.488

Following implant site preparation, bone tissue integrity is very important in achieving osseointegration. In fact, the delicate bone to implant interface may be damaged by surgical trauma which may impair osseointegration and eventually lead to implant failure (Albrektsson et al., 1981).

This study compared two different protocols for ultrasonic implant site preparation (UISP1-UISP2) and a conventional drilling (CD) technique. Since two different types of ultrasonic inserts (cutting and diamond) were evaluated, it was possible to monitor their effect on preparation site geometry and therefore on implant insertion torque.

Accurate measurements of preparation diameters were possible due to the color contrast produced by the red resin which allowed clear identification of site limits.

In order to avoid bone-resin gaps, a filling product with a minimum deformation coefficient is necessary. Pattern Resin (GC, Japan) with a stable retraction rate of 0.37% was used. Its liquid consistency allowed injection into the preparation sites using a syringe, and once set, bone-to-resin contact was maintained.

The integration of a graduated mm scale to each cut allowed a conversion reference to be obtained for each image when using the Adobe Photoshop cs4 software to minimize errors due to photographic distortion when measuring the diameter of the site preparation.

Statistically significant differences were noted in the diameter values of the preparations in the cortical bone, when comparing cutting inserts (UISP1) to diamond inserts (UISP2) or drills (CD). Indeed, an oval section preparation was observed when using inserts IM2 and IM3 (UISP 1 group). This ovalization is most likely related to the cutting technique of these inserts that entails a coupled clockwise and counter clockwise movement by the operator (Baker et al., 2012). For this reason, we found a slight difference even not significative between mean values of D1 and D2 only in UISP1 group and not in the others.

When the insert is working on cortical bone, a cutting resistance would lead to the application of additional pressure by the operator which, coupled to the rotational movement, may lead to increased ovalization. On the other hand, the use of diamond inserts (OT4, IP2-3) on the cortical bone preserved the rounded form of the preparation, which is closely comparable to the shape generated by the conventional drill. This is probably due to the less aggressive cutting technique of these inserts. This difference between cortical preparation diameters could have a direct impact on insertion torque and implant primary stability.These findings are in accordance with Vercellotti et al. (2009), who proposed a differential preparation technique of the implant site which advocates the use of different types of inserts, including diamond ones for cortical drilling.

Cortical sections led to accurate measurements, but analysis of cancellous sections was almost impossible due to resin leakage within bone trabeculae which was most probably due to the liquid consistency of the filling resin. Quantification of this infiltration could not be carried out accurately; however, observation of the cancellous cuts revealed a greater dispersion of the resin in the UISP groups. The infiltration differences were impossible to measure but were visually discernable between the section images. The cause of this discrepancy is probably due to the effect of the different implant preparation techniques on trabecular bone.

Indeed, conventional drilling is characterized by an accumulation of bone debris and obliteration of marrow spaces (Rebaudi et al., 2010). Implant sites prepared using ultrasonic techniques are characterized by clean trabecular bone areas as a direct result of cavitation (Rashad et al., 2011; Rebaudi et al., 2010). The difference in product diffusion is most probably due to this variation. In fact, Rebaudi et al. (2010), using a scanning electron microscope, described bone architecture preservation and the opening of Haversian and Volkman canals after the use of UISP, but that was not the case in sites prepared with the conventional technique. This reduction of the smear layer after using UISP can have positive effects on the early phases of bone healing by promoting angiogenesis and reducing edema (Atieh et al., 2018). Furthermore, Scarano et al. (2014), in an histologic study, found a significantly higher micro crack occurrence for implant sites preparations using conventional drills (p-value = 0.001) when compared to piezoelectric devices, and concluded that bone architecture is better preserved when using UISP.

Statistically significant differences were found in terms of insertion torque values between conventional preparation technique CD and UISP1 protocol and even between UISP1 and UISP2 protocols. This difference is due to the oval shape of the preparations obtained when using UISP1 protocol, which is not the case in the UISP2 and CD group.

On the other hand, no statistically significant difference was found in the insertion torque values, between CD and UISP2 protocol. This is due to the preparation diameters that are almost similar in both groups. These observations underline the importance of the cortical bone and the importance of implant site preparation technique on the primary stability of the implant.

Turkyilmaz et al. (2007) calculated the values of the insertion torque in different types of bone, and found a significant correlation between bone density and insertion torque. In a clinical study, Makary et al. (2011) showed a strong correlation between the values of insertion torque and bone volume. The cylindrical or conical geometry of the implant and the width of the thread, may also play a role in the variation of the insertion torque using any implant site preparation technique (Trisi et al., 2011). In this work using cylindrical tapping device has reduced the bias associated with the implant shape.

Furthermore, Shalabi et al. (2006),Tabassum et al. (2010) and Unsal and Turkyilmaz (2020) demonstrated higher IT values for implants using an undersized osteotomy technique compared with implants placed using standard drilling technique with a significant correlations between maximum insertion torque, and Implant stability quotient values. Miyamoto et al. (2005) found a strong correlation between implant site cortical bone thickness (digitally measured preoperatively) and primary stability. Friberg et al. (1999) compared cutting resistance values to implant primary stability and only found a correlation at implant neck, which suggests an interesting positive correlation between cortical thickness, implant insertion torque and primary stability. Additionally Li et al. (2020) in their systematic review and metanalysis, found that UISP and conventional technique give the same survival rate for the implants, but the piezoelectric group may achieve better stability.

This in vitro study allowed the establishment of an ultrasonic implant site preparation protocol leading to preparations similar to conventional drilling. A sequence of ultrasonic inserts adapted to the cortical and cancellous bone is presented. It allows the preservation of site architecture at the cortical level thus a better primary stability through a better insertion torque.

The preservation of primary stability sought in this work is essential in order to guide bone healing around implants. This results in a better planning of immediate and early loading protocols of dental implants, coupling the mechanical and biological benefits of ultrasonic technique. Other clinical and histological studies should be undertaken in the future to confirm the mechanical and biological benefits of ultrasonic techniques for implant site preparation.

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Not applicable

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Competing interests

Not applicable

Funding

No external funding

Authors' contributions

J.A.N P.L. C.M. did the experiment

P.L. and A.M. wrote the main manuscript

All the authors reviewed the manuscript

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No competing interests reported.

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Materials and Methods

Results

Conclusion

Figures

Introduction

Materials and Methods

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1

Ultrasonic implant site preparation vs conventional drilling: in vitro evaluation of implant site diameter.