The Osteotome Technique: Modifications to the Original Approach

Howard J. Drew, DMD; Tat Chiang, DMD; and Barry I. Simon, DDS, MSD

Excellent long-term success has been achieved with the use of endosseous root-form implants; however, when the bone is deficient in quality and volume, the survival rate of these implants decreases. After a tooth is lost, rapid horizontal and vertical bone loss occurs.¹ This results in significant loss of bone volume. This rate of resorption is most rapid in the posterior maxilla.²

When using endosseous implants in the posterior maxilla, the maxillary sinus is often a frequent anatomical restriction. Reports have demonstrated that there are two basic techniques advocated to raise the sinus for the acceptance of implants. In the 1980s both Tatum³ and Misch⁴ reported success with the elevation of the sinus floor through the lateral wall of the maxilla (the Caldwell-Luc procedure). Tatum had also tried a crestal approach but felt this approach was too limiting and made the Caldwell-Luc operation his norm for sinus lifting. In 1994, Robert Summers, using a special set of matched and tapered osteotomes, proposed a method for inserting implants in the posterior maxilla (Figure 1).⁵ Summers’ method has made the crestal approach less traumatic and invasive when placing implants coronal to the sinus floor.

A multi-center retrospective study of 101 consecutively treated patients with a total of 174 implants placed showed an implant survival rate of 96% or greater.⁶ In these cases the osteotome technique was performed when a pretreatment height (sinus floor to crestal bone) was 5 mm or greater. In addition to the osteotome sinus lift having comparable success rates to the lateral window procedure, the technique is less invasive and has less chance of postoperative complications and morbidity. The authors have also noted greater patient acceptance for the osteotome technique compared to the lateral window procedure.

Summers had noted that the maxillary posterior bone had primarily type III or type IV bone.⁷ Using his custom osteotomes, Summers proposed that his osteotomes would "compact the osseous layer around the osteotomy, which will form a denser bone interface with the implant."⁵ In 2001 Nkenke showed in an animal model that the osteotome technique when compared to conventional drilling had a significantly higher bone-to-implant contact ratio.⁸

The original Summers technique has been modified for additional applications. Summers proposed using the osteotomes with the addition of bone for bone-added osteotome sinus-floor elevation,⁹ ridge expansion osteotomy,¹⁰ and future site development.¹¹ In 2004, Toffler reported that when the residual sub-sinus bone height was 4 mm or less, his success rate for simultaneous sinus lift and implant placement dropped significantly.¹² Toffler felt a two-stage procedure or a crestal core approach would be more predictable.¹³

In the following cases the authors propose modifications to increase the success rates of the osteotome sinus-floor elevation, site development, and ridge expansion.

PROCEDURE

With Summers’ original approach, tapered osteotomes with concave tips shaved bone from the walls of the osteotomy and pushed the shavings toward the sinus floor. These authors have added several modifications to the osteotome technique to ensure success. The authors feel it is imperative to use a surgical guide for the osteotome technique. This guide is actually more critical for osteotomes than for drilling the osteotomy. After completion of a diagnostic wax-up, the restorative dentist fabricates the surgical guide template. This guide will give the surgeon the ideal location for fixture placement. Not only is the guide critical for the drilling sequence, but it also may be important for site development, sinus elevation, and ridge expansion cases. In the authors’ experience, there are cases where site development, sinus elevation, and ridge expansion need to be done as two-stage procedures or, in rare instances, when one-stage procedures are aborted due to such factors as: large sinus-membrane perforations, not achieving primary stabilization, or fracture and/or dehiscence of buccal or palatal plates. It is imperative that when this is done the precise location of the lift and expansion are known. The best way to ensure accuracy in these cases is to use the surgical guide during second-stage surgeries. It is critical that the surgeon returns to the exact location that sinus elevation and/or ridge expansion was achieved. The surgical template must be sturdy enough to ensure reutilization and resterilization.

Additionally, the authors have custom fabricated countersink/pilot osteotomes (BIOMET 3i, Palm Beach Gardens, FL) (Figure 2). The problem the authors found with the Summers’ osteotomes were that a significant vertical depth (approximately 10 mm) had to be achieved before the next osteotome could enter the cortical crestal bone osteotomy. The problems encountered when this vertical height was not achieved were that the subsequent osteotomes did not always follow the initial path and that additional crestal cortical bone could be compromised. These problems also are encountered in ridge expansion cases where the width is deficient. The new osteotomes ensure that the path is followed and that crestal bone is widened rather than destroyed.

The following schematic sequence represents the authors’ modification. Initially, accurate radiographic measurements are made from the crestal bone to the base of the sinus (Figure 3). Using a surgical guide, the Summers No. 1 osteotome is tapped approximately 1 mm to 2 mm coronal to the sinus floor (Figure 4). At this point the countersink/pilot osteotome No. 1 is tapped through cortical crestal bone to ensure that the Summers osteotome No. 2 will engage the osteotomy (Figure 5). It should be noted that as soon as the osteotome gets to the initial hub the next Summers osteotome can be engaged. The surgical guide is used for the Summers osteotome No. 2 to be tapped to the measured distance (Figure 6). During this sequence the osteotomes should be lubricated with sterile water and rotated in the osteotomy during tapping. The authors also suggest irrigating the osteotomy to keep the bone hydrated. As the osteotomes are stepped up in size, the tapping or pushing should be done in a slow, gentle manner, allowing the bone time to expand.

At this time, a parallel pin is placed into the site and a periapical radiograph is taken to check the location. If necessary, adjustments can be made and measurements documented (Figure 7). If adjustments are made and the osteotomy is altered, an additional radiograph should be taken.

The osteotomy is next expanded with the countersink/pilot osteotome No. 2 (Figure 8). The Summers osteotome No. 3 is now tapped to the final length (assuming an approximate 4-mm fixture is being placed). This final length will remain for all subsequent procedures (Figure 9). The osteotomy is now filled with bone graft material and osteotome No. 3 is pushed or tapped to the prior length. In this way, it is the material and not the osteotome that is elevating the sinus (Figure 10). The addition of bone graft material is continued until the desired length is achieved (Figure 11). The authors recommend using a 3-mm wide parallel pin to check the elevation before implant selection and insertion (Figure 12). If an approximate 4-mm fixture is being used, the countersink/pilot osteotome No. 3 can be used to widen the osteotomy for the fixture (Figure 13). It should be noted that this technique can be altered for a narrow or wider fixture. Both sets of osteotomes are fabricated for narrow and wide implants (Figure 14). In this example, final implants were then inserted (Figure 15).

CASE REPORT 1

A 61-year-old man presented with a chief complaint of fillings falling apart and teeth that were grounded down. He was also very unhappy with his appearance. The patient had a nonsignificant medical history. The patient was taken through a comprehensive diagnostic workup (periodontal and prosthetic). Phase I therapy included oral hygiene instruction, scaling and root planing, root canal therapy, caries control, and extraction of hopeless and nonrestorable teeth. After this, the patient was temporized with a maxillary/mandibular reconstruction to restore vertical dimension (Figure 16). When using osteotomes it is imperative that the surgical guide is fabricated off of a mounted diagnostic wax-up. This ensures proper positioning for implant placement as well as site development. After adequate healing of extraction sites, the patient was scheduled for implants in site No. 14 and site No. 15 (Figure 17). Using the modified osteotome technique, the sites were prepared using a stent, parallel pins, and both sets of osteotomes described (Figure 18). The technique enabled the operators to elevate the sinus in site No. 15, ensure parallelism, compact the osteotomy, and preserve crestal cortical bone (Figure 19).

CASE REPORT 2

A 52-year-old woman presented with a chief complaint of her teeth shifting. She wanted implants to replace them and did not want anything removable. The patient had an uncomplicated medical history. The patient was taken through a comprehensive diagnostic evaluation (periodontal and prosthetic) (Figure 20). After Phase I therapy, which included oral hygiene instruction, scaling and root planing, root canal therapy, caries control, and extraction of hopeless teeth, the patient was temporized with maxillary/mandibular full-arch provisionals. It should be noted that in the maxilla only the cuspids were retained in the final prosthesis. The posterior maxillary abutments were used only to stage the case for sinus elevation and implant placement procedures. As mentioned, the patient was adamant about not wearing a removable prosthesis throughout all stages of treatment. After temporization, a CAT scan was taken with the patient wearing fixed acrylic temporaries with radiographic markers (Figure 21). Radiographic and clinical measurements indicated that osteotome ridge expansion would be necessary (Figure 22). The patient was informed that the possibility of a two-stage procedure (site development followed by implant placement) was possible. Using the discussed osteotome technique, the ridge was slowly expanded to accept fixtures in the lateral incisor areas (Figure 23).

CONCLUSION

The osteotome technique is an excellent technique for sinus elevation, site development, and ridge augmentation. The authors feel that to improve upon this technique, a surgical guide should always be used and the modified osteotome technique presented here will aid in cases where vertical and horizontal bone is limited.

ACKNOWLEDGMENTS

The authors would like to thank Ms. Sherri Lynn Moose, management assistant, and Mr. Richard Merkel, multimedia specialist, for their assistance in the preparation of this article.

References

1. Carlsson GE, Thilander H, Hedegård B. Histologic changes in the upper alveolar process after extractions with or without insertion of an immediate full denture. Acta Odontol Scand. 1967;25(1):21-43.

2. Pietrokovski J. The bony residual ridge in man. J Prosthet Dent. 1975;34(4): 456-462.

3. Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30(2): 207-229.

4. Misch CE. Maxillary sinus augmentation for endosteal implants: organized alternative treatment plans. Int J Oral Implantol. 1987;4(2): 49-58.

5. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994;15(2):152-162.

6. Rosen PS, Summers R, Mellado JR, et al. The bone-added osteotome sinus floor elevation technique: multicenter retrospective report of consecutively treated patients. Int J Oral Maxillofac Implants. 1999;14(6):853-856.

7. Babbush CA. Dental Implants: Principles and Practice. 1st ed. Philadelphia, Pa; WB Saunders Company: 1991.

8. Nkenke E, Kloss F, Wiltfang J, et al. Histom-orphometric and fluorescence microscopic analysis of bone remodeling after installation of implants using an osteotome technique. Clin Oral Implants Res. 2002;13(6):595-602.

9. Summers RB. The osteotome technique: Part 3—Less invasive methods of elevating the sinus floor. Compendium. 1994;15(6): 698-710.

10. Summers RB. The osteotome technique: Part 2—The ridge expansion osteotomy (REO) procedure. Compendium. 1994;15(4):422-436.

11. Summers RB. The osteotome technique: Part 4—Future site development. Compendium. 1995;16(11):1090-1099.

12. Toffler M. Osteotome-mediated sinus floor elevation: a clinical report. Int J Oral Maxillofac Implants. 2004;19(2):266-273.

13. Fugazzotto PA. The modified trephine/osteotome sinus augmentation technique: technical considerations and discussion of indications. Implant Dent. 2001;10(4):259-264.

Figure 1 Summers Osteotome Kit. Note how osteotomes are tapered.		Figure 2 Custom fabricated countersink/pilot osteotomes. Note how osteotomes are tapered and the short length of tip enters the osteotomy.
Figure 3 Using radiographs, accurate measurements are made from the osseous crest to the sinus floor (the surgical guide should be used with radiographic markers).		Figure 4 Using a surgical guide, osteotome No. 1 is tapped approximately 1 mm to 2 mm from the sinus floor.
Figure 5 Using the countersink/pilot osteotome No. 1, the entrance of the osteotomy is widened to accept osteotome No. 2.		Figure 6 With the surgical guide in place, osteotome No. 2 is tapped to the desired measurement.
Figure 7 At this point a radiograph is taken with parallel pins in place. If necessary, modifications can be made.		Figure 8 The entrance of the osteotomy is widened and compacted to accept osteotome No. 3 with the use of countersink/pilot osteotome No. 2.
Figure 9 Osteotome No. 3 is now tapped or pushed to the final length. This final depth never changes.		Figure 10 Osseous graft material is now placed in the osteotomy and osteotome No. 3 is tapped or pushed to the final depth measurement.
Figure 11 With the addition of osseous graft material, the elevation continues to the desired final depth.		Figure 12 Using a radiograph with or without a parallel pin, final measurements are made to choose the proper implant size.
Figure 13 Depending on the crestal cortical plate, a countersink/pilot osteotome can be used to expand the entrance of the osteotomy.		Figure 14 Osteotome sets can be used for narrowand wide-fixture placement.
Figure 15 Implants are selected and placed into the osteotomy.
Figure 16 Case 1 is diagnosed and temporized before implant placement.		Figure 17 Preoperative and postextraction panorex showing inadequate vertical height for implant placement in site No. 15.
Figure 18 Using a surgical guide, the modified osteotome technique is incorporated.		Figure 19 Postimplant placement radiograph.
Figure 20 Case 2 pretreatment views and diagnostic wax-up.		Figure 21 Temporization and CAT scan views of the mandibular incisor area.
Figure 22 The flap is elevated. The guide is used to denote areas for ridge expansion and guide osteotomes.		Figure 23 The implants are placed. Note the ridge expansion with use of the modified osteotome technique.
About the Author
Howard J. Drew, DMD Clinical Associate Professor Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey
Tat Chiang, DMD Clinical Associate Professor Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey Private Practice Somerville, NJ
Barry I. Simon, DDS, MSD Professor and Vice Chairperson Department of Periodontics University of Medicine and Dentistry of New Jersey Newark, New Jersey