CLINICAL

Comparison of Crestal Bone Loss and

Implant Stability Among the Implants
Placed With Conventional Procedure
and Using Osteotome Technique:
A Clinical Study
Thallam Veer Padmanabhan, MDS*
Rajiv Kumar Gupta, MDS

To overcome the limitations of implant placement in knife-edge ridges, Summer introduced the
osteotome technique in 1994. It has been claimed that using bone condensing to prepare the
implant site in soft maxillary bone avoids the risk of heat generation, and implants can be placed
precisely with increased primary stability. The purpose of this clinical study was to evaluate the
crestal bone loss exhibited by the bone around early nonfunctionally loaded implants placed with
conventional implant placement technique and with Summer’s osteotome technique and to
evaluate whether the bone-compression technique provides better primary stability than the
conventional technique. A total of 10 Uniti implants were placed in the maxillary anterior region of
5 patients. One implant site was prepared using the conventional technique with drills (control
group A), and second site was prepared using the osteotome technique (experimental group B)
and an MIS bone compression kit. Resonance frequency measurements (RFMs) were made on each
implant at the time of fixture placement and on the 180th day after implant fixture placement. The
peri-implant alveolar bone loss was evaluated radiographically. Differences between the alveolar
crest and the implant shoulder in radiographs were obtained immediately after implant insertion
and on the 180th day after implant placement. The RFMs demonstrated a significantly higher
stability of implants in control group A than in experimental group B on the day of surgery
(P 5 .026). However, no statistically significant difference in stability was found between both
groups on 180th day after implant placement (P 5 .076). A significant difference was found in the
crestal bone levels after 180 days of surgery between two groups (P 5 0) with less crestal bone loss
with group A. Within the limitations of this study we concluded that the osteotome technique is
good for the purpose for which it was introduced, that is, for knife-edge ridges, and it should not be
considered a substitute for conventional procedures for implant placement.

Key Words: crestal bone loss, implant stability, osteotome technique, resonance
frequency analysis, dental implants

Department of Prosthodontics and Implantology, Sri Ramachandra Dental College, Chennai, India.
* Corresponding author, e-mail: tvpadu@gmail.com
DOI: 10.1563/AAID-JOI-D-09-00049

Journal of Oral Implantology 475

Crestal Bone Loss and Implant Stability Using Conventional and Osteotome Techniques
INTRODUCTION
T
he replacement of missing teeth
is carried out frequently with the
help of implants in most surgi-
cally indicated cases. Dental re-
habilitation of partially or totally
edentulous patients with dental implants has
become common practice in recent decades
and has reliable long-term results.1–6 After
loss of tooth, the remaining alveolar and
basal bone provides anchorage to the
endosteal implants for retaining and sup-
porting prosthesis. Current trends and de-
mands have revealed the need for faster
restoration of dental function using implants,
which led to the introduction of early and
immediate loading protocols.
The success rate obtained with dental
implants in various clinical situations depends
to a great extent on the volume and quality of
the surrounding bone.7–10 Successful osseoin-
tegration of an endosseous titanium implant
requires adequate stability at the time of
placement.8,11–13 Achieving stability depends
on the bone density, the surgical technique,
and the microscopic and macroscopic mor-
phology of the implant used. In bone that is
not very dense, it is often difficult to obtain
implant anchorage.14 Sufficient density and
appropriate volume of the bone are therefore
crucial for successful implant treatment.15,16
To achieve better primary stability and
expand the range of indications with inferior
bone quality, a procedure known as the
osteotome technique for bone condensing
was developed by Summer in 1994.17–20 The
objective of this procedure is to retain the
bone that would otherwise be removed by
compressing it laterally and axially to create a
precisely formed implant site. Biomechanical
research on peri-implant bone loading has
shown that a maxillary implant surrounded
with firm bone is more desirable than reliance
on bicortical anchorage with inferior bone
quality.21,22 The osteotome technique is used
primarily for type III and type IV bone that is
476 Vol. XXXVI/No. Six/2010
typically found in maxilla. This technique can
be used if ridge expansion and condensation
of spongious bone of reduced density is
required to improve the primary stability of
the implant.23
It has been claimed that using Summer’s
technique of bone expansion and simulta-
neous implant placement results in less
chance of heat generation and increases
initial stability because of lateral condensa-
tion of bone. It is also claimed that this
approach gives better primary stability,
results in less chance of crestal bone loss
around the implant, and so leads to less fear
and anxiety related to implant failure.17–20
Because there are no clinical studies to
date comparing the conventional approach
of implant placement with the osteotome
technique in the same patient, the aim of
this in vivo study was to evaluate the crestal
bone loss exhibited by the bone around
early nonfunctionally loaded implants placed
with conventional approach and with the
osteotome technique and to examine the
effect of osteotome technique on the
stability of the implants. Conventional im-
plant site preparation with drills served as a
control group. Stability was measured using
a resonance frequency analysis (RFA) device.
MATERIALS AND METHODS
The total number of patients was 5 (2
women with a mean age of 29 years and 3
men with a mean age of 23 years), and they
had a minimum of 2 teeth missing in the
maxillary anterior region (Figure 1). Patients
were excluded if they had a history of
immune disease, uncontrolled diabetes, on-
going chemotherapy, radiation treatment to
the head and neck, alcohol or drug abuse, or
psychological instability. Patients were given
oral and written information regarding the
risks of surgery, and their written informed
consent was obtained. All surgical work was
performed at the Department of Prostho-
 Padmanabhan and Gupta

FIGURES 1–6. FIGURE 1. Preoperative intraoral view. FIGURE 2. Full-thickness flap raised after crestal incision.
FIGURE 3. Conventional osteotomy preparation. FIGURE 4. Osteotomy preparation with osteotome
technique. FIGURE 5. Implants in position. FIGURE 6. Impressions post in position for final impression.

dontics and Implantology, Sri Ramachandra
University, Chennai, India.
Implant design
In this study we used 10 Uniti (Equinox
Medical Technologies, Zeist, The Nether-
lands) screw-type self-tapping threads im-
plants with a length of 13 mm and a
diameter of 3.7 mm.
Surgical procedure
Preoperative antibiotics were prescribed to the
patients before surgery. All surgeries were
performed under aseptic conditions. Local
anesthesia was achieved by infiltrating ligno-
caine 2% containing 1:100 000 adrenaline. A
crestal incision was made, and a full-thickness
mucoperiosteal flap was raised (Figure 2).
Thereafter, the implants were placed in the
first quadrant using the conventional tech-
nique (group A) and in the second quadrant
using the osteotome technique (group B). For
group A, the implant sites were sequentially
enlarged to 3.7 mm in diameter with pilot and
spiral drills according to the standard protocol
of the manufacturer (Equinox Medical Tech-

Journal of Oral Implantology 477

Crestal Bone Loss and Implant Stability Using Conventional and Osteotome Techniques
nologies; Figure 3). When the osteotome
technique was performed, the implant sites
were prepared initially by a 2-mm diameter
pilot drill. This was followed by condensing the
bone using osteotomes of increasing diameter
(MIS bone compression kit, MIS Implants
Technologies Ltd, Shlomi, Israel) using a hand
ratchet (Figure 4). Extreme care was taken to
proceed as slowly as possible, and continuous
external saline irrigation was used to minimize
bone damage caused by overheating (Fig-
ure 4). After each half turn, there was a pause
of 20–30 seconds before turning the ratchet
another half turn. This is important because at
each half turn, as the osteotome sinks further,
the bone needs time to accommodate to the
expansion. It should be kept in mind that rapid
expansion would obviously result in fracture of
the labial bone plate and should be avoided.
After each osteotome had reached a depth
of 13 mm (this can be checked against the
black marks on the osteotome) it was allowed
to remain in the implant site for a minimum of
1 minute before the next diameter osteotome
was used. Once both osteotomy sites were
prepared, implants were inserted (Figure 5).
As we planned for early nonfunctional load-
ing, impressions were made using elastomeric
impression material after placing posts and
sutures (Figure 6). Patients were sent home
with gingival formers in place and recalled
after 5–7 days for suture removal and
prosthesis cementation (Figures 7 through
9). Temporary luting agent (RelyX Temp NE,
3M ESPE, Seefeld, Germany) was used to
ensure that the restoration could be removed
to facilitate monitoring and maintenance.
Resonance frequency measurements
Resonance frequency measurements (RFMs)
were made on each implant on the day of
fixture placement and on 180th day after
fixture placement by attaching a standard
transducer (Osstell, Integration Diagnostics,
Goteborg, Sweden) to each implant. The
frequency response of the system was
478 Vol. XXXVI/No. Six/2010
measured by attaching the smartpeg type
21 to the implant (Figure 11).24–26 The excita-
tion sign was given over a range of frequen-
cies (typically 5–15 KHz with a peak amplitude
of 1V), and the first flexural resonance was
measured.24–26
Radiographic monitoring
Radiographic examination was carried out
using Radio Visio Graphy taken with RINN X-
ray holders (Rinn Corp Com, Dentsply, Elgin, Ill)
using a paralleling long-cone technique (Fig-
ure 10). These examinations occurred on the
day of fixture placement and 6 months after
completion of the restoration. The radiopaque
implant length was used as a measuring
reference. The implant shoulder and the
alveolar crest were used as reference points.
Measurements of the distance between 2
reference points were performed at mesial
and distal aspects digitally, 3 times per implant,
using SOPRO digital imaging software (SOPIX,
La Ciotat, France; Figure 12). Mean values were
calculated and recorded for each implant.
Crestal bone loss was analyzed by calculating
the difference between measured bone levels
in radiographs on the day of surgery and
180 days after surgery.
STATISTICAL ANALYSIS
Descriptive statistics, including mean value
and standard deviation, were used to com-
pare the implant stability and crestal bone
loss over time for the conventional proce-
dure and the osteotome technique. Com-
parisons between both techniques were
performed using paired t tests. Difference
was considered significant when P , .05.
Calculations were performed using SPSS for
Windows (SPSS Inc, Chicago, Ill).
RESULTS
Clinical observation
A total of 10 implants were placed in 5
patients. At the end of 6 months all 10
 Padmanabhan and Gupta

FIGURES 7–12. FIGURE 7. Intraoral view after 7 days of healing. FIGURE 8. Prepared abutments in place.
FIGURE 9. Final prosthesis in place. FIGURE 10. Digital radiographs using RINN device. FIGURE 11. Measuring
stability using RFA. FIGURE 12. Computer-assisted measurement of digitalized radiographs for bone level.

implants showed good primary stability of
the osseointegration at the clinical level. No
problems with soft-tissue healing were
observed.
Resonance frequency measurements
The RFA measurements (Table 1) showed an
implant stability quotient (ISQ) of 64.77 as a
mean value, indicating the high primary
stability for conventional procedure of im-
plant placement (group A) than osteotome
technique (group B), which showed ISQ of
59.60 as a mean value on the day of surgery.
So, RFA demonstrated a statistically signifi-
cant higher primary stability for implants
in group A than that of group B (P 5 .026;
n 5 5). However, RFA demonstrated no sta-
tistically significant difference between both
groups 6 months after the surgery (P 5 .076;
n 5 5). A decrease in RFM values were found

Journal of Oral Implantology 479

Crestal Bone Loss and Implant Stability Using Conventional and Osteotome Techniques
Implant stability quotients
Conventional Technique
Patient Day of Surgery After 180 Days
A 68.67
B 72.50
C 65.33
D 65.00
E 52.33
after 6 months with group A, that is, 55.40. In
contrast, in group B there was a slight
increase in RFM values after 6 months, that
is, 61.50. But this difference in RFM values
between the 2 groups failed to reach a level
of significance.
Crestal bone loss
A statistically significant difference was
found in the level of the crestal bone loss
after 6 months of surgery between both
groups (P 5 0; n 5 5) with less crestal bone
loss in group A (Table 2). The mean crestal
bone loss for group A and group B was
0.99 mm and 1.19 mm, respectively.
DISCUSSION
Compression of trabecular bone to improve
density has been successfully used in recon-
structive surgery and cleft palate surgery for
a long time.27–32 With modifications, this
method has been introduced to dental
implantology.17–20 The use of the osteotome
technique has been investigated in clinical
studies with emphasis given on the survival
rate of the implants.33–37 However, there is a
TABLE 2
Crestal bone loss (in millimeters)
Conventional Osteotome
Patient Technique Technique
A 1.00 1.19
B 1.02 1.26
C 0.95 1.09
D 0.98 1.18
E 1.04 1.25
480 Vol. XXXVI/No. Six/2010
TABLE 1
Osteotome Technique
Day of Surgery After 180 Days
57.33 62.00 64.17
47.33 70.67 62.67
62.00 55.33 63.00
60.67 62.67 66.33
49.67 47.33 51.33
lack of clinical studies that compare the
osteotome technique with the conventional
technique of implant placement in the same
patient. Therefore, the aim of this clinical
study was to evaluate the crestal bone loss
and biomechanical outcome of implant
placement in condensed bone. Conventional
implant placement was used as a control.
Various methods have been introduced
to measure implant stability, including prim-
itive methods, such as percussion and
mobility testing by applying lateral forces
with mirror handles, and more recent meth-
ods, such as measuring cutting torque
resistance, insertion torque values, reverse
torque tests, periotest, dental fine tester, and
histomorphometric and histologic analysis of
the bone-implant interface. All of these have
some disadvantages, including questionable
accuracy and reliability, lack of repeatability,
and an invasive or destructive nature, so
they are not practical in a clinical setting.38
The need for a user-friendly, noninvasive,
reliable, and clinically applicable technique
to measure implant stability led to the
development of RFA by Meredith and
coworkers in 1996.24 A commercially avail-
able electronic device, based on RFA, with
the trade name Osstell, is widely used for
experimental and clinical purposes. This
device measures implant stability and quan-
tifies it in ISQ values.25
Radiographic evaluation of the peri-im-
plant bone, in addition to assessment of
several clinical parameters, has become one
of prerequisite for estimating implant suc-

cess.1,39 Grondahl and Lekholm40 showed a
high predictive value of radiographs for the
identification of implant stability using the
Branemark system. Bone-level determination
based on evaluation of radiographs lacked
sufficient precision because of the method-
ologic difficulties in obtaining standardized
and reproducible radiographs, excentric
beam guiding, and inaccessibility of the
labial and lingual or palatal aspects. These
methodologic limitations may result in false
diagnosis and measurement errors.41 The
method of computer-assisted measurement
of digitalized radiographs was associated
with similar problems. The amount of
distortion of the measuring scale could be
determined taking into account the known
length and diameter of the radio-opaque
implant, thus serving as a measuring refer-
ence. Several options for optimizing the
images in contrast and brightness made it
easier to evaluate and measure the radio-
graph. Use of the Rinn device also helps
standardize radiographs.
Endosseous implant placement using a
bone condensing and expansion technique
is not new, and several studies have shown
excellent bone response and implant survival
using osteotomes for placement of dental
implants in the maxilla. The key to proper
expansion is a slow, gradual technique with
controlled force application that leads to
gradual expansion and minimal site trau-
ma.42 There are no reports available on heat
generation during the preparation of the
implant site by the osteotome technique.43
Although alveolar ridge expansion can be
achieved by the osteotome technique, this
kind of preparation seemed to put pressure
on the crestal cortical bone layer, causing a
significant peri-implant marginal bone loss.44
The results of our investigation showed a
significant mean crestal bone loss of 1.19 mm
measured after 6 months of fixture placement
using the osteotome technique. This decrease
in marginal bone height of maxillary implants
Padmanabhan and Gupta
is comparable with results published by De
Wijs and Cune in 1997 on implants inserted
with the bone-splitting technique, which
revealed a peri-implant ridge height reduc-
tion ranging from 0.8 to 1.3 mm.45
In our study we found less RFMs for
implants placed with osteotome technique
than for implants placed using a conven-
tional approach. This is in accordance with
the removal torque values and histologic
findings of Buchter et al46 in 2005, who
demonstrated significantly impaired implant
stability in terms of a reduced removal
torque values when the osteotome tech-
nique was used. Buchter and colleagues also
demonstrated that trabecular fractures ac-
company the osteotome technique. Trabec-
ular fractures were observed on day 7 in all
specimens of condensed bone, whereas
conventionally inserted implants failed to
damage bone trabeculae. At later stages of
osseointegration (28 days) peri-implant his-
tology resembled the histologic findings of
control implants.46 This could explain why
there was no significant difference between
RFMs of both the groups after 6 months.
No controlled clinical longitudinal studies
are available on the prognosis of the
implants inserted using the osteotome
technique. Although the power of the results
of the present investigation is limited be-
cause of the short investigation period and
the small sample size, our data suggest that
the use of osteotome technique should be
restricted to its indications. Further investi-
gations including a large number of patients
and considering long-term evaluation of
peri-implant alveolar bone loss are necessary
to enhance the power of the conclusions
concerning use and predictability of osteo-
tome technique.
CONCLUSION
The use of the osteotome technique for
implant placement in normal ridge cases
Journal of Oral Implantology 481
Crestal Bone Loss and Implant Stability Using Conventional and Osteotome Techniques
revealed an average crestal bone loss of
1.19 mm compared to 0.99 mm bone loss
with conventional procedure. The osteo-
tome technique also showed lower RFM
than the conventional approach on the day
of surgery. Within the limitations of this
study we concluded that the indications for
the use of osteotome technique should be
limited to those for which it was introduced,
that is, knife-edge ridges and for bone with
less density. It should not be considered a
substitute or replacement for the conven-
tional procedure of implant placement. Local
anatomy and density of the implant site
should be considered in the indication for
and planning of implant-bed preparation by
osteotome technique.
ABBREVIATIONS
ISQ: implant stability quotient
RFA: resonance frequency analysis
RFM: resonance frequency measurement
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