Investigation and Prevention of Intraosseous Temperature Rise in Guided Implant Surgery: An in Vitro Study

doi:10.21203/rs.3.rs-3330379/v1

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Investigation and Prevention of Intraosseous Temperature Rise in Guided Implant Surgery: An in Vitro Study

https://doi.org/10.21203/rs.3.rs-3330379/v1

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Background

In this study; the temperature changes in the implant preparation sites using a surgical guide and using the traditional method on sheep iliac crest bones imitating D3 density in in-vitro conditions were compared. In addition, the effects of the temperature of the solution used while cooling with the irrigation solution during the preparation of the implant site and the effects of performing osteotomy at low speed without cooling on the temperature formed in the bone were also evaluated in the study.

Methods

A surgical guide was prepared using stereolithographic technology. Temperature changes were measured using a K-type thermocouple. On 40 sheep iliac bone specimen; using a surgical guide, four implant sites with dimensions of 2.9 mm x 8.5 mm, 2.9 mm x 13 mm, 3.8 mm x 8.5 mm, 3.8 mm x 13 mm were prapared as experimental groups; and a 3.5 mm x 10 mm implant site was prepared as a control group with the traditional method.

Results

A statistically significant rise was observed in the temperature as the bur diameter increased in all groups. Temperature rise in the implant sites prepared using surgical guide at high speed under irrigation was statistically significantly higher than the traditional method. The temperature rise in the group irrigated with solution cooled to 10°C was found to be significantly lower than in the group irrigated with solution at 24°C and in the group in which the implant sites were prepared at low speed without cooling.

Conclusions

The use of a surgical guide causes an increase in intraosseous temperature by preventing the coolant from reaching the surgical area but the intraosseous temperature can be kept within safe limits with external irrigation, which is applied effectively in accordance with the patient-specific conditions.

dental implant

surgical guide

bone necrosis

revolution

thermal change

Oral and maxillofacial surgery studies in recent years; focused on the development of techniques that can provide maximum function and aesthetics with a minimally invasive surgical approach. In order to meet this need, guided implant surgery has been advocated by many physicians (1).

To ensure adequate osseointegration between a dental implant and bone, certain conditions must be met: The implant material must be biocompatible; The implant surface must be composed of microstructures created by special surface treatment methods such as sandblasting and etching to drive bone cell growth and osseointegration, and the osteoblastic cells surrounding the implant must have sufficient cellular activity. When bone is heated above 53°C, irreversible tissue damage occurs, while exposure to 47°C for 1 minute is considered the limit for bone damage. Therefore, osseointegration may not be successful if the temperature is not controlled (2).

Dental implant surgery using a surgical guide has been advocated by physicians over the traditional approach because of its significant advantages in restorative focused implant placement, ensuring consistency between treatment planning and surgical procedure, time efficiency and reduction in surgical errors. However, the use of this technique prevents direct contact of the irrigation fluid with the burs and implant seat. As a result, bone tissue temperature rises during implant site preparation, which may adversely affect osseointegration.

40 iliac crest bodies were obtained from 20 sheep to be used in the study. Iliac crest bones were obtained from dead animals and the animals were not sacrificed for use in the study.

Evaluation of Bone Structure of Sheep Iliac Crests

CBCT images were taken from iliac crest bones and bone densities were determined with the Morita One Volume Viewer Manager program. The mean value of Houndsfield Unit values was determined as 696 HU (highest 848 HU, lowest 638 HU) and it was observed that all bones were D3 density bones (3).

Preparation of Surgical Guide

Silicone impression material (Silect Putty Type C Silicone, Silect Light Type C Light Body, Müller-Amicron Dental) was used on the iliac crest bone using a half impression tray. The impression was scanned with an intraoral scanner (Carestream CS 3600, Carestream Dental LLC) and the three-dimensional model was transferred to the digital media. A plaster model was obtained from the impression. A guiding prosthesis was prepared by aligning the teeth on the plaster model obtained. In order to maximize the anatomical compatibility of the surgical guide to be prepared, another impression was taken over the iliac crest using the guiding prosthesis and a light bodied impression material (Betasil Light Type 3 Light Body, Müller-Amicron Dental). The guiding prosthesis was scanned with an intraoral scanner (Carestream CS 3600, Carestream Dental LLC) and the three-dimensional model was transferred to digital media. CBCT images of the iliac crest and guide prosthesis were taken and saved in DICOM format. All these digital data obtained were brought together in Real Guide 5.0 (3Diemme Bioimaging Technologies, Biomec Italy) software and the design of the surgical guide was completed by making implant planning on the iliac crest using stereolithographic technology. Oxy Guided Surgery (Biomec Italy) set that is registered with the Real Guide 5.0 software and developed by the same manufacturer was determined to be used, and the metal cylindrical bracelets placed in the surgical guide were produced in accordance with the burs in this set. The designed surgical guide was produced using a Free Shape 120 3D Printer (Accuretta Taiwan) (Fig. 1).

Implant Site Preparation and Temperature Change Observation

The experiments were carried out in the same room, the temperature of which was controlled at 24°C. The bone specimens were kept in a 24°C saline solution, which was the same as room temperature, before the experiment was carried out in order to have the same initial temperature. The surgical guide is fixed on the iliac crest with 4 mini screws. 2 mm diameter K-type thermocouple (Ser Resistans, Turkey) and a single-channel temperature control unit (Redbox TCS 01) with a sampling time of 100 ms were used to measure the temperature changes during the preparation of the implant sites. In order to prevent the detection of room temperature, isolation is provided with a silicone impression material. For the placement of thermocouples into the bone, sockets of the length size as the length of the implant were prapared with the pilot drill with a diameter of 2 mm, located 1 mm away from the areas where the implant site will be prepared. The thermocouple was placed in these sockets and its stabilization was checked. In order to stabilize the iliac crest bone, the bone was fixed with two vices (Fig. 2)

Experimental groups in the study was determined as;

Group A: Implant sites were prepared with surgical guide and traditional method using external cooling, at high (900 rpm/min) speed,

Group B: Implant sites were prepared with surgical guide and traditional method, at low (300–600 rpm/min) speed without cooling.

Group C: Implant sites were prepared with surgical guide and traditional method using external cooling, at high (900 rpm/min) speed, with external cooling of high (24°C) and low (10°C) temperature.

On the same bone specimen; using a surgical guide, four implant sites with dimensions of 2.9 mm x 8.5 mm, 2.9 mm x 13 mm, 3.8 mm x 8.5 mm, 3.8 mm x 13 mm were prapared as experimental groups; and a 3.5 mm x 10 mm implant site was prepared as a control group with the traditional method. Continuous external cooling was provided from the surgical unit with an irrigation fluif of 24°C for group A and 10°C for group C, and the irrigation fluid flow was kept constant at 100 ml/min. Implant sites; in accordance with the manufacturer's instructions, was prepared in two moves by 900 rpm/min, by applying up-down movement and by pulling back the bur at half of the bur length. Following the use of the pilot bur, the working length of the relevant site was prepared with a 2.3 mm diameter bur, and then the final bur was used. In each implant site, the initial temperature from the deepest point of the relevant working length, the temperature value after using the 2.3 mm diameter bur, and the temperature value after using the last bur were recorded.

Statistical Analysis

Descriptive data are expressed as median (minimum-maximum). Kolmogorov Smirnow and Shapiro Wilk tests were used to evaluate the normality of the data. Mann Whitney U test was used to compare two-category data, Kruskal Wallis test was used for group comparisons of three or more, and Mann Whitney U test with Bonferroni correction was used post-hoc. Wilcoxon signed-rank test was used for temperature changes of 2.3 and 2.9/3.8 according to the initial temperature values. Mixed Anova Greenhouse - Geisser test was used for the difference in temperature changes according to the working groups and in the study group, where the implant site was prepared using a surgical guide, without serum cooling, at low speed. p < 0.05 was accepted for statistical significance. SPSS 16.0 package program was used in the analysis of the data.

In this study, a total of 192 different lengths and diameters of implant sites were prepared in 3 groups. In all study groups and all implant sites, the initial temperature was recorded as 24°C. In group A, the temperature value was 28°C (25°C – 31°C) for 2.3 mm diameter, and 30.5°C (25°C − 33°C) for 2.9 mm and 3.8 mm diameters. In group B, the temperature value for 2.3 mm diameter was 29°C (24°C – 33°C), the temperature value for 2.9 mm and 3.8 mm diameter was 31°C (26°C – 36°C) °C. In group C, the temperature value was measured as 26°C (23°C − 28°C) for 2.3 mm diameter, 27°C (25°C − 31°C) for 2.9 mm and 3.8 mm diameter. A statistically significant increase was found in temperature values as the diameter increased in all study groups. The p value was found to be 0.001, 0.001 and 0.001, respectively (Table 1).

Temperature values of 2.3 mm and 2.9 mm/3.8 mm diameters in all study groups were found to be significantly higher than the initial temperature value (p = 0.001, 0.001, respectively).

The change in temperature increase between groups A and C and groups B and C was statistically significant (p = 0.001). The change in temperature increase between groups A and B was statistically insignificant at the border. Temperature increases in groups A and B were higher than those in group C (Table 2).

It was determined that the temperature increases in all study groups in group A were significantly higher than the control group. The temperature value of the 2.9 mm x 13 mm group was significantly higher than the 2.9 mm x 8.5 mm group (p = 0.005). The temperature value of the 3.8 mm x 8.5 mm group was significantly higher than the 2.9 mm x 8.5 mm group (p = 0.005). The temperature value of the 3.8 mm x 13 mm group was significantly higher than the 2.9 mm x 8.5 mm group (p = 0.005). There was no difference between 2.9 mm x 13 mm and 3.8 mm x 8.5 mm group, 2.9 mm x 13 mm and 3.8 mm x 13 mm group, 3.8 mm x 8.5 mm and 3.8 mm x 13 mm group temperature values.

It was determined that the temperature increases in all study groups at 600 rpm/min in group B were significantly higher than the control group. The temperature value of the 2.9 mm x 8.5 mm group was significantly higher than the 3.8 mm x 8.5 mm group (p = 0.005). The temperature value of the 2.9 mm x 13 mm group was significantly higher than the 2.9 mm x 8.5 mm and 3.8 mm x 8.5 mm group (p = 0.005). The temperature value of the 3.8 mm x 13 mm group was significantly higher than the 2.9 mm x 8.5 mm and 3.8 mm x 8.5 mm group (p = 0.005). There was no difference between the temperature values of 2.9 mm x 13 mm and 3.8 mm x 13 mm group, 3.8 mm x 8.5 mm and the control group with 3.5 mm x 10 mm size.

It was determined that the temperature increases in all study groups at 300 rpm/min in group B were significantly higher than the control group. The temperature value of the 2.9 mm x 8.5 mm group was significantly lower than the 2.9 mm x 13 mm and 3.8 mm x 13 mm group (p = 0.005). The temperature value of the 2.9 mm x 13 mm group was significantly higher than the 3.8 mm x 8.5 mm group (p = 0.005). The temperature value of the 3.8 mm x 8.5 mm group was significantly lower than the 3.8 mm x 13 mm group (p = 0.005). There was no difference between the temperature values of the 2.9 mm x 8.5 mm and 3.8 mm x 8.5 mm group, and the 2.9 mm x 13 mm and 3.8 mm x 13 mm group (Table 3).

In group C, the temperature value of the 2.9 mm x 8.5 mm group was significantly lower than the 2.9 mm x 13 mm and 3.8 mm x 13 mm group (p = 0.006, 0.006). The temperature value of the 2.9 mm x 13 mm group was significantly higher than the 3.8 mm x 8.5 mm group and significantly lower than the 3.8 mm x 13 mm group (p = 0.006, 0.036). The temperature value of the 3.8 mm x 8.5 mm group was significantly lower than the 3.8 mm x 13 mm group (p = 0.006). There was no difference between the temperature values of the 2.9 mm x 8.5 mm group and the 3.8 mm x 8.5 mm group.

In the similar studies in the literature, the majority of bone samples used only examined cortical bone layers with D1 bone density, while studies using subjects containing cortical and cancellous bones did not specify bone densities (1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13). Our study was carried out on bone blocks obtained from sheep iliac crest, which mimics the human jawbone in terms of bone morphology, bone density, cortical and cancellous bone amount and the relationship between bone layers and thermal conductivity in order to obtain the closest results while simulating the surgical operation in the human mandible. In order to report consistent results when comparing the temperature changes with the human mandible, the densities of the bone samples used were determined over the HU values.

In our study, a statistically significant increase in temperature increase was observed as the bur diameter increased in all study groups. Frösch et al. (7) reported in their study that as the diameter of the implant sites prepared using a surgical guide increases, the temperature increase increases significantly and the time exceeding the critical temperature of 47°C during the 4.2 mm osteotomy is more than one minute. For this reason, we think that special attention should be paid to working with smaller diameter burs and providing effective cooling in order to avoid heat generation and possible complications due to bone damage while performing guided surgery.

It was observed that the temperature increase in the implant sites prepared using the surgical guide at high (900 rpm/min) speed by providing cooling with the irrigation fluid was statistically significantly higher than the implant sites prepared by the traditional method. Dos Santos et al. (4) stated that guided surgery stimulates bone resorption earlier than the traditional method and has less adverse effects on cell viability immediately after the operation in the conventional method than guided surgery, and these results are probably related to the inadequate cooling caused by the use of surgical guides. Another result reported by the researchers is that the temperature increase in all study groups was below the threshold value of 47°C. Similarly, in our study, the temperature increase in all study groups in implant sites prepared at 900 rpm/min by cooling with irrigation solution with a surgical guide was found within the safe range to be below 10°C. Migliorati et al. (13), although significantly higher temperatures were observed during preparation with the surgical guide compared to conventional techniques, the measured temperatures remained well below the critical level of 47°C. Our study, in line with these data, shows that guided surgery is an equally safe method with a surgical guide, adequate cooling of the temperature changes that occur in all study groups, and a careful surgical technique in implant sites that are prepared with external cooling.

In the literature, the concept of preparing the implant site at low speed without cooling with irrigation fluids has been proposed as an alternative to the traditional procedure. It has been reported that low speed osteotomy has several advantages over high-speed osteotomy technique with irrigation. One of these advantages is the ability to collect the bone grafts with burs, which can be used for autograft, without contaminating it with saliva. Working at low speed provides a more controlled operation opportunity for the clinicians, while the surgeon's field of view in the operation area increases when irrigation solution is not used.

In our study, no statistically significant difference was found between the temperature increases in the implant sites prepared using a surgical guide at low speed, without cooling with irrigation solution, and in the implant sites prepared using a surgical guide at high speed, with cooling with irrigation solution. It is possible to report that there is no significant advantage in preparing the implant sites using surgical guide at low (300–600 rpm/min) speed without providing cooling with irrigation solution. The temperature increase in the implant sites prepared using surgical guide at 600 rpm/min without cooling with the irrigation solution, is statistically significantly higher than the temperature increase seen in the implant sites prepared using the traditional method at 600 rpm/min without cooling with the irrigation solution. As the implant sites depthens, the temperature increase difference in the implant sites was found to be statistically significant. The temperature increase in the implant sites prepared using surgical guide at 300 rpm/min without cooling with the irrigation solution, is statistically significantly higher than the temperature increase seen in the implant sites prepared using the traditional method at 300 rpm/min without cooling with the irrigation solution. As the implant sites depthens, the temperature increase difference in the implant sites was found to be statistically significant. The difference between the temperature increase in the implant sites prepared using the surgical guide at 600 rpm/min without cooling with the irrigation solution and the temperature increase in the implant sites prepared using the surgical guide at 300 rpm/min without cooling with the irrigation solution was not found statistically significant. The only publication in the literature examining the intraosseous temperature change caused by the preparation of the implant site at low speed without cooling is Oh et al.'s (14) study which they examined temperature changes in the implant sites prepared at 50 rpm/min with a surgical guide on an artificial bone block imitating D1 bone density. As a result of the study, the researchers reported that there was an average temperature difference of 1.2°C between the two groups, although the difference was significant, the temperatures observed in the experimental group were well below the critical threshold and the method could be considered safe. In our study, unlike the results reported by Oh et al., we observed that 8 subjects reached and exceeded the threshold of 10°C in the study group in which the temperature changes in the implant sites prepared at 600 rpm/min with the surgical guide, without cooling. In the study group, in which temperature changes in implant sites prepared at 300 rpm/min without cooling with irrigation solution with a surgical guide were examined, it was observed that 5 subjects reached the threshold of 10°C. Based on these findings, it is possible to say that there is no advantage in preparing the implant site without cooling with irrigation fluids at low speed when using a surgical guide, but further research is needed on the subject.

The temperature increase observed in the group that was irrigated with saline solution cooled to 10°C was found to be significantly lower than that of the group that was irrigated with solution at 24°C and the group in which the implant sites was prepared at low speed without serum cooling. In the group that was irrigated with a solution cooled to 10°C, the temperature increase in the implant sites prepared at a depth of 8.5 mm was found to be significantly lower than in the sites prepared at a depth of 13 mm. Even in the sockets prepared with narrow-diameter burs, the increase in the depth of the slot increased the temperature significantly. The temperature increase seen with the increase in the diameter of the bur in the holes drilled at a depth of 8.5 mm in the group irrigated with a solution cooled to 10°C was not statistically significant. The only publication in the literature examining the effects of using a cooled irrigation solution during the process of preparing the implant site with a surgical guide was Barrak et al.'s study which they compared the effects of different irrigation solution temperatures (10°C, 15°C and 20°C) on intraosseous temperature increase in guided surgery in implant sites drilled with a diameter of 2.0, 2.5, 3.0 and 3.5 mm on bovine ribs. As a result of the study, it was reported that the average temperature change did not exceed 1°C when the irrigation solution cooled to 10°C was used, regardless of the implant site diameter, but the use of irrigation fluid cooled to 15°C did not provide a significant reduction in the temperature change. In our study, the temperature increase observed in the group irrigated with a solution cooled to 10°C was found to be significantly lower than in the group in which the solution was irrigated at 24°C and in the group in which the implant site was prepared at low speed without cooling. Based on these findings, irrigation with a solution cooled to 10°C is an effective method to control the increase in intraosseous temperature in guided surgery.

Our study is subject to some limitations as it is in vitro, but measuring bone temperature in vivo can be difficult. In addition, in our research, we foresee that the results found may be a reasonable parameter since the temperature increase at the deepest point of the implant site is observed through thermocouples at a reasonable distance from the area where the implant site is prepared in the experimental environment. Another strong point is that we measured the thermal results of the osteotomy procedure using a real surgical guide designed and produced in accordance with the morphological structure of the bone. Although the surgical guide prevents the irrigation solution from reaching the area prepared for the implant, in accordance with the results we obtained in our study we think that the intraosseous temperature can be kept within safe limits with external irrigation, which is applied effectively in accordance with the patient-specific conditions but we believe that further research is needed.

Ethics approval and consent to participate: Not applicable

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests: The authors declare that they have no competing interests

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions: A.B.Ç. and M.A.E. conceived the ideas; S.S. planned and designed digital works; G.G.U. and B.A. did the experiments and collected the data; and G.G.U. led the writing.

Acknowledgements: Not applicable

Jeong SM, Yoo JH, Fang Y, Choi BH, Son JS, Oh JH. The effect of guided flapless implant procedure on heat generation from implant drilling. J Craniomaxillofac Surg. 2014;42(6):725-9.
Stocchero M, Jinno Y, Toia M, Ahmad M, Papia E, Yamaguchi S, Becktor JP. Intraosseous Temperature Change during Installation of Dental Implants with Two Different Surfaces and Different Drilling Protocols: An In Vivo Study in Sheep. J Clin Med. 2019;8(8):1198.
Seriwatanachai D, Kiattavorncharoen S, Suriyan N, Boonsiriseth K, Wongsirichat. Reference and Techniques used in Alveolar Bone Classification. J Interdiscipl Med Dent Sci. 2015; 3: 172
dos Santos PL, Queiroz TP, Margonar R, Gomes de Souza Carvalho AC, Okamoto R, de Souza Faloni AP, Garcia IR Jr. Guided implant surgery: what is the influence of this new technique on bone cell viability? J Oral Maxillofac Surg. 2013;71(3):505-12.
Boa K, Varga E Jr, Pinter G, Csonka A, Gargyan I, Varga E. External cooling efficiently controls intraosseous temperature rise caused by drilling in a drilling guide system: an in vitro study. Br J Oral Maxillofac Surg. 2015;53(10):963-7.
Fraguas de San José L, Ruggeri FM, Rucco R, Zubizarreta-Macho Á, Alonso Pérez-Barquero J, Riad Deglow E, Hernández Montero S. Influence of Drilling Technique on the Radiographic, Thermographic, and Geomorphometric Effects of Dental Implant Drills and Osteotomy Site Preparations. J Clin Med. 2020 11;9(11):3631.
Frösch L, Mukaddam K, Filippi A, Zitzmann NU, Kühl S. Comparison of heat generation between guided and conventional implant surgery for single and sequential drilling protocols-An in vitro study. Clin Oral Implants Res. 2019;30(2):121-130.
Sannino G, Gherlone EF. Thermal Changes During Guided Flapless Implant Site Preparation: A Comparative Study. Int J Oral Maxillofac Implants. 2018;33(3):671-677.
Barrak I, Joób-Fancsaly A, Varga E, Boa K, Piffko J. Effect of the Combination of Low-Speed Drilling and Cooled Irrigation Fluid on Intraosseous Heat Generation During Guided Surgical Implant Site Preparation: An In Vitro Study. Implant Dent. 2017;26(4):541-546.
Choi YS, Oh JW, Lee Y, Lee DW. Thermal changes during implant site preparation with a digital surgical guide and slot design drill: an ex vivo study using a bovine rib model. J Periodontal Implant Sci. 2022;52(5):411-421.
Misir AF, Sumer M, Yenisey M, Ergioglu E. Effect of surgical drill guide on heat generated from implant drilling. J Oral Maxillofac Surg. 2009;67(12):2663-8
Kim SJ, Yoo J, Kim YS, Shin SW. Temperature change in pig rib bone during implant site preparation by low-speed drilling. J Appl Oral Sci. 2010;18(5):522-7.
Migliorati M, Amorfini L, Signori A, Barberis F, Silvestrini Biavati A, Benedicenti S. Internal bone temperature change during guided surgery preparations for dental implants: an in vitro study. Int J Oral Maxillofac Implants. 2013;28(6):1464-9
Oh JH, Fang Y, Jeong SM, Choi BH. The effect of low-speed drilling without irrigation on heat generation: an experimental study. J Korean Assoc Oral Maxillofac Surg. 2016;42(1):9-12.

Table 1: 2.3 mm diameter and 2.9 mm - 3.8 mm diameter temperature values in study groups

Study Group	Diameter 2.3 mm (°C) (Median(min-max))	Diameter 2.9 mm/3.8 mm (°C) (Median(min-max))	p value
With saline cooling, at high (900 rpm/min) speed, with surgical guide (n=80)	28 °C (25 – 31 °C)	30.5 °C (25 – 33 °C)	0.001
Without saline cooling, at low (300-600 rpm/min) speed, with surgical guide (n=80)	29 °C (24 – 33 °C)	31 °C (26 – 36 °C)	0.001
With surgical guide, at high (900 rpm/min) speed, with high and low temperature saline cooling (n=36)	26 °C (23 – 28 °C)	27 °C (25 – 31 °C)	0.001

No competing interests reported.

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Investigation and Prevention of Intraosseous Temperature Rise in Guided Implant Surgery: An in Vitro Study

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Version 1

Abstract

Background

Methods

Results

Conclusions

Figures

BACKGROUND

MATERIALS AND METHODS

Evaluation of Bone Structure of Sheep Iliac Crests

Preparation of Surgical Guide

Implant Site Preparation and Temperature Change Observation

Statistical Analysis

RESULTS

DISCUSSION

CONCLUSIONS

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

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