Drilling sequence in implants

The primary success metric of dental implants is achieving osseointegration, which is influenced by many factors including implant design, surface treatments, as well as treatment method. Implant drilling is also a major influential factor.

1. Drilling Sequence Dr. Nazia Yaseen II MDS Dept. of Periodontics

2. Contents Introduction Pre implant placement protocols Flap designs Generic drilling sequence Osseodensification Conclusion References 2

3. Introduction Albrektsson et al. (1981) suggested that there are 6 factors that determine the success of osseointegration , that is biocompatibility, design, surface, state of the host bed, surgical technique and loading conditions. Especially the effect of surgical procedures such as the drilling protocol has been sparsely explored, and clinicians basically follow the given instructions from the manufacturers. 3

4. 4

5. Pre-Implant Placement Protocols 5

6. 6 Hupp JR, Ellis E, Tucker MR. Contemporary Oral and Maxillofacial Surgery. 7th ed. Philadelphia: Elsevier; 2020.

7. Flap Design Type of tissue Full thickness Partial thickness and Flapless The number and type of incisions Envelope Papilla sparing Triangular Trapezoidal Vestibular, etc 7

8. 8 Partial Thickness Full Thickness Flapless

9. 9 Papilla sparing Envelope Flap

10. 10 Triangular Flap Trapezoidal Flap

11. 11

12. Template-guided drilling procedure leads to significantly enhanced accuracy. Significant results compared to free-handed drilling actions were achieved, irrespective of the clinical experience level of the operator. 12

13. Dental Implant Osteotomy Preparation 13

14. Implant drills 14 https://alpha-bio.net/global/products/surgical-tools/drills/

15. Platform Switching 15

16. 16

17. Driver 17 Ratchet Handpiece

18. 18

19. 19 https://alpha-bio.net/global/products/digital-solutions/guided-surgery-tool-kit/

20. Irrigation vs No irrigation Yacker and colleagues - without irrigation, drill temperatures greater than 100°C are reached within seconds of the osteotomy . Benington et al., reported that the osteotomy temperature may rise up to 130.1°C without irrigation after monitoring changes in bone temperature during the sequence of drilling for implant site preparation 50 mL /min of cooled irrigation of sterile saline (0.9% NaCl ) Distilled water should not be used because rapid cell death may occur in this medium. Barrak and colleagues reported that cooling the irrigation fluid to 10°C, no mean temperature change >1°C will occur. 20

21. Graduated versus One-Step Drilling The amount of heat produced in the bone is directly related to the amount of bone removed by each drill. 2mm ˃ 1.5mm The smaller incremental drill size allows the clinician to prepare the site faster, with less pressure and less heat generation. Reduces the drill shatter at the crestal opening, which can inadvertently fragment the bony crest in which complete bony contact is especially desired. Maintains the sharpness of each drill for a longer period, which also reduces the heat generation. 21

22. Drilling Speed Yeniyol et al., showed that excessively low drilling speeds (less than 250 rpm) increased the degree of fragmentation of the osteotomy edge. It has been shown that low speed drills will “ wobble ,” which leads to overpreparation of the osteotomy site. The clinician should allow the cutting surface of the drill to contact D1 and D2 bone fewer than 5 of every 10 seconds. Ideally, a pumping up-and down motion (i.e., bone dancing) is used to prepare the osteotomy and provide constant irrigation to the drill cutting surface. D1 and D2 = 1500 - 2000 rpm D3 and D4 = 1000 rpm 22

23. 23

24. Drilling Time The slower the rotations per minute (1225), the longer the bone temperature remained above the baseline. Because two to three drills are used to prepare an implant site, at 1225 rpm the first drill may increase the temperature to 41°C, the second drill to 45°C, and the third drill to 49°C, when the time between each sequence is not extended more than 1 minute. Therefore to reduce the preparation time within the bone to a minimum in D1 bone, the clinician should not apply constant pressure to the drill, but “bone dance” with intermittent pressure for 1 second in the D1 bone and 1 to 2 seconds out of the bone while the cooled irrigation is allowed to perfuse the site 24

25. Drilling Pressure The pressure exerted when preparing the osteotomy should not result in heat generation. Hobkirk and Rusiniak found that the average force placed on a handpiece during preparation of an osteotomy is 1.2 kg. Matthews and Hirsch found that increasing both speed and pressure allowed the drill to cut more efficiently and generated less heat. Sufficient pressure should be used on the drill to proceed at least 2 mm every 5 seconds. If this is not achieved, then new (sharper) or smaller diameter drills are indicated for each site preparation. The pressure on the drills should not reduce the rotations per minute, which makes the drill less efficient and increases heat. 25

26. Continuous Drilling When constant pressure is applied, irrigation cannot enter the osteotomy site; therefore this may result in heat-related damage. Bone debris is maintained within the flutes of the surgical burs, resulting in potential heat generation. This also leads to less efficient drilling. Intermittent Drilling Less heat generation is seen. Debris is removed, thus making the cutting process more efficient. Disadvantage of the bone dancing technique is the possibility of changing angulation or inadvertent widening of the osteotomy site. Care should be exercised in withdrawing and inserting the implant drill at the same trajectory or angulation . 26 Intermittent versus Continuous Drilling

27. Insertion Torque 27 The force used to insert a dental implant into a prepared osteotomy . Expressed in units of N/cm, which ultimately determines the loading protocol. IT is the primary most important factor in determining primary stability. Ideal for implant integration = 35 - 45 N/cm To standardize the amount of torque, calibrated torque wrenches, physiodispenser instruments with integrated electronic torque control settings, and preset torque settings on the implant electric motor systems should be used.

28. 28

29. 29

30. Generic Drilling Sequence 30

31. Step 1: Pilot Drill 31

32. Step 2: Position Verification 32

33. Step 3: Second Twist Drill 33

34. Step 4 : Final Shaping Drills 34

35. Step 5: Crest Module and Bone Tap Drills 35

36. Step 6: Implant Insertion 36

37. 37

38. 38

39. 39

40. 40

41. 41

42. 42

43. 43

44. 44

45. 45

46. Osseodensification 46

47. 47

48. Conclusion 48

49. 49 Misch’s Contemporary Implant dentistry – 4 th edition Block & Kent’s Endosseous Implants For Maxillofacial Reconstruction ADA council on scientific affairs Dental endosseous implants. An update. JADA, Vol. 135, January 2004. Shadid , R.M., Sadaqah , N.R. and Othman, S.A., 2014. Does the implant surgical technique affect the primary and/or secondary stability of dental implants? A systematic review.  International journal of dentistry , 2014. Sharawy , M., Misch , C.E., Weller, N. and Tehemar , S., 2002. Heat generation during implant drilling: the significance of motor speed.  Journal of Oral and Maxillofacial Surgery ,  60 (10), pp.1160-1169. References

50. 50 Tehemar , S.H., 1999. Factors affecting heat generation during implant site preparation: a review of biologic observations and future considerations.  Int J Oral Maxillofac Implants ,  14 (1), pp.127-136. Cavallaro Jr , J., Greenstein, B. and Greenstein, G., 2009. Clinical methodologies for achieving primary dental implant stability: the effects of alveolar bone density.  The Journal of the American Dental Association ,  140 (11), pp.1366-1372. Padhye , N.M., Padhye , A.M. and Bhatavadekar , N.B., 2020. Osseodensification ––A systematic review and qualitative analysis of published literature.  Journal of oral biology and craniofacial research ,  10 (1), pp.375-380. Scherer, U., Stoetzer , M., Ruecker , M., Gellrich , N.C. and von See, C., 2015. Template-guided vs. non-guided drilling in site preparation of dental implants.  Clinical oral investigations ,  19 (6), pp.1339-1346.

51. 51