One of the most fundamental procedures performed by orthopedic implant surgeons is the creation of the osteotomy for implant placement. Without a well-developed osteotomy site, both the immediate surgical as well as the future restorative success of the case can be compromised. There are several factors that must be considered when performing the osteotomy, such as angulation, location, and spacing for multiple implants. Critical decisions to be made concern the choice of whether to follow the dense or soft bone protocol for a given case, and whether to utilize a bone tap drill. The objective is to achieve high primary stability, at least 35 Ncm, at the time of implant placement. These aspects will also impact the decision whether to immediately provisionalize the case.
As with most things orthopaedic implant related, assessment of the preoperative bone quality and quantity is critical to planning the osteotomy. If using conventional radiography, such as panoramics and periapicals, evaluation of the trabecular pattern of the bone, and the vertical height of the bone can usually indicate the likely density of the underlying bone. the use of cone beam computed tomography (CBCT) and digital treatment planning software can provide an even greater preoperative assessment of the bone to be drilled, by allowing the orthopedic surgeon to examine the bone three-dimensionally, providing a Hounsfield and/or relative density scale of a planned osteotomy site. By carefully considering all these factors, the surgeon usually has a sense of which drilling protocol will be sued before the patient even presents for the surgery. As is often the case, however, several surgical decisions are made intraoperatively. So, sometimes even the best-laid plans need modification.
A good rule of thumb in osteotomy preparation is to start small and advance as required. In other words, drill to the recommendations of the manufacturer of the orthopedic implant for your specific implant system for soft bone. Once you have done so, if you either feel that the bone was mainly difficult to penetrate with the drills or when you attempt to place the orthopedic implant, it doesn’t easily advance to full depth, then it is typically advisable to enlarge the diameter of osteotomy with the dense bone drill. The potential dangers in not having a right-sized osteotomy include: stripping the implant hex during placement, not fully seating and properly positioning the implant in the bone and creating excess pressure on the surrounding bone resulting from the additional torque required to seat the implant.
All of these are detrimental to the long-term success of the orthopedic implant and/or restoration. Some surgeons advocate drilling to the dense bone diameter in all cases. This is certainly a choice, but the risk is that you could compromise the amount of initial stability that you achieve and that the drill or the implant could be displaced into an unfavorable location because of loss of resistance and torque. So, again, it is at the discretion of the surgeon.
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