The use of various instruments for alveolar bone augmentation and sinus grafting has played a pivotal role in modern regenerative dentistry. Many tools such as cone beam computed tomography (CBCT) have greatly improved the clinician’s ability to diagnose and treatment plan cases with optimal accuracy and predictability in implant dentistry. Other devices such as Osstell’s implant stability quotient (ISQ) tool can be utilized to accurately monitor implant stability over time.
Furthermore, radio- frequency, Piezosurgery (Mectron), and osseodensification (OD) burs have greatly improved surgical outcomes for the clinician. This chapter provides an overview of the various instruments most frequently utilized by the author on a daily basis within his private practice and institute. Furthermore, a brief overview of their technologies and uses in alveolar ridge augmentation and sinus grafting is presented.
CBCT
In the last decade, the use of 3D CBCT has dramatically increased. When computed tomography was first intro- duced (mainly in implantology), its use was limited to a small number of specialists, due primarily to its limited indications, high costs, and elevated dose of radiation. In the late 1990s, a new technology using a “cone beam” and a reciprocat- ing detector, which rotates around the patient 360 degrees, entered the dental implant field, making high-definition 3D scans easily accessible to dentists and their patients.
By 2005, I began utilizing CBCT technology in my own private practice and teaching institution. Because my prac- tice has been limited to implant reconstruction for the past 25 years, I require ALL of my patients to have a CBCT scan, as this 3D technology plays an integral role in overall diag- nosis and treatment planning. CBCT has seen widespread use in all fields of dentistry, including implantology, oral surgery, endodontics, and orthodontics.
One of the major breakthroughs in CBCT technology was the ability to use significantly smaller doses of radia- tion when compared to conventional films.1,2 The establishment of sensitive radiographic techniques for assessing dentoalveolar structures led to its more frequent use owing to its higher safety standards. Today, all patients within my practice requiring implant dentistry or bone augmenta- tion procedures must have a CBCT image taken prior to implant therapy, bone augmentation, or sinus augmentation in order to fully characterize anatomical features/abnor- malities and diagnose potential pathology. Furthermore, the use of CBCT for postgraft evaluation prior to implant placement has become routine.
Carestream Dental provides a high-quality CBCT system with state-of-the-art features3 (Fig 1-1). Advantages of the system include the ability to perform all necessary exam- inations with one system (CS 9600 family). Image reso- lution can reach up to 75 μm (sizes up to 16 × 17 cm), ideal for a wide range of applications from implantology to oral surgery, orthodontics, and endodontics (Fig 1-2).These features will only further improve over time. Low-dose imaging modes are also possible with 3D image quality, utilizing lower doses of radiation when compared to tradi- tional panoramic radiographs. Box 1-1 provides a list of relevant features of the system.
Hand Instruments
Hand instruments are widely utilized within any dental office, with various companies now promoting sales of their indi- vidual items. Salvin Dental has been recognized as one of the leaders in the field, and together we have codeveloped many specific trays for implant surgery (Fig 1-3), soft tissue grafting (Fig 1-4), block grafting (Fig 1-5), and sinus grafting (Fig 1-6). Each kit contains various useful instruments that have assisted our team in surgery. Nevertheless, each instrument must be chosen according to the treating surgeon’s preference. For example, one instru- ment used specifically when dealing with full-arch cases is the right-angle torque wrench (Salvin AccessTorq Right AngleVariable Torque Driver), with adjustable Ncm features from 10 to 35 Ncm (Fig 1-7). This instrument is valuable for hard-to-reach areas. Another tool frequently utilized in large bone augmentation procedures is the Pro-fix Preci- sion Fixation System (Osteogenics).4,5 This system includes self-drilling membrane fixation screws, self-drilling tent- ing screws, and self-tapping bone fixation screws (Fig 1-8), shown in a number of bone augmentation procedures in chapter 4.
Osstell IDx
The value of the Osstell system is that it helps clinicians objectively determine implant stability and assess the progress of osseointegration6–12 (Fig 1-9), with many peer- reviewed research articles supporting its use. It is a fast, easy, and reliable way to provide accurate and objective informa- tion needed to proceed with implant loading. My cases are routinely tested for ISQ values to assess implant stability. ISQ values may potentially reduce treatment time, better manage risk, and offer an ability to better communicate findings with patients. The Osstell system allows for the quick and easy identification of which implants are ready for loading and which need additional healing time in an objective way, with hundreds of publications now supporting its use.
Radiosurgery Device
A radiosurgical energy source (Fig 1-10) delivers advanced radiowave technology and provides outstanding surgical control, precision, and versatility.15,16 Unlike lasers, the high frequency of the 4-MHz Surgitron Dual 120 surgical device minimizes heat dissipation, and thus cellular alteration, while cutting and coagulating soft tissues.Approximately 50 watts of power is utilized with the ability to micro-coagulate pinpoint locations.This favors minimal charring or tissue necrosis and is ideal for the oral maxillofacial region with critical anatomy. Advantages include reduced postoperative discomfort and minimal scar formation. Typical radiosurgery systems come with the following four waveforms. 
• Used for performing deep surgical incisions.
• Waveform mimics the cut of a scalpel blade with only minimal coagulation.
• When used with a varied-tip straight-wire electrode, produces the most delicate of incisions.
• Produces an incision with concurrent coagulation
• Allows increased visibility due to enhanced coagulation
Partially rectified waveform
• Strictly a coagulating waveform
• Used in areas of bleeding or oozing
Bipolar radiosurgery
• Bipolar electrodes coupled with a radiosurgical wave form.
• Higher radiofrequency of 4 MHz versus bipolar electro- surgical signal of 1.8 MHz.
• Research has shown that high-frequency radiosurgery produces less tissue alteration and lateral heat to the surrounding tissue than does the low-frequency elec- trosurgical signal (Fig 1-11).
• The bipolar componentry of radiosurgery is a must for clinicians involved with implant surgery. This is true because it allows for cauterization in the presence of body fluids (blood and saliva).
Piezosurgery Device
One of the most widely utilized new tools in implant dentistry over the past decade has been the Piezosurgery device (Fig 1-12). More specifically, Mectron’s dual-wave technology has been frequently cited owing to its patented technology overcoming the limitations of single wave.17 Work pioneered by Professor Tomaso Vercellotti in Italy demonstrated that a primary wave between 24 and 36 kHz modulated by a secondary low-frequency wave from 30 to 60 Hz could be utilized to efficiently maximize bone cutting while preventing overheating and necrosis.18–21 The Piezo- surgery handpiece is therefore a high-frequency electrical impulse unit with micrometric movement of approximately 80 µm in the horizontal amplitude and 5 µm in the vertical direction (Fig 1-13).
The device comes with more than 100 different tips characterized by their ability to seamlessly and efficiently cut bone all while being capable of differentiat- ing between hard and soft tissues.These features have been demonstrated to decrease the risk of damage to important anatomical structures such as nerves and membranes. Piezo- surgery has been shown to clinically lower the rate of sinus membrane perforations and has also been frequently utilized during ridge split procedures and harvesting of bone blocks (Fig 1-14). The author utilizes piezosurgical technology on a daily basis for a variety of bone-based surgical procedures that include but are not limited to the following: sinus graft- ing, ridge splitting, harvesting autogenous bone blocks, and recipient site preparation for bone grafts.
Versah Burs
The use of OD burs has also substantially improved our ability to obtain primary stability in low-density bone (Fig 1-15).The biomechanical stability of implants has typically been dependent on several factors, including implant macro and micro design as well as the quality and quantity of surrounding bone.22 Several protocols have been identified to increase implant primary stability over the years:
• Drilling protocol: underpreparation of osteotomy
• Implant type: macrotexture and microtexture
• Longer implants providing greater bone-to-implant contact (BIC)
• Techniques for osseocondensation of bone
Bone has long been considered an ideal tissue in the body because it is flexible, changing shape via deformation (without necessarily breaking/cracking), can withstand and widen during compression, and is able to lengthen during tension.23 Bone is typically prepared prior to implant placement utilizing standard drill burs. Because fresh, hydrated trabecu- lar bone is a ductile material, it has a good capacity for plastic deformation. Osseodensification is essentially a burnishing process that redistributes bone material on the bony surface through plastic deformation.The counterclockwise rotation of OD burs causes the lands of the bur to slide across the surface of the bone via low plastic deformation; these burs are purposefully designed with a compressive force less than the ultimate strength of bone. As a result, OD burs have several reported advantages. First, they create live, real-time haptic feedback that informs the surgeon if more or less force is needed, allowing the surgeon to make instanta- neous adjustments to the advancing force depending on the given bone density.These burs rotate in a counterclockwise direction and do not “cut” as expected with conventional burs. They therefore densify bone (D3, D4) by rotating in the noncutting direction (counterclockwise at 800–1,200 rotations per minute). It has been recommended by the manufacturer that copious amounts of irrigation fluid be used during this procedure to provide lubrication between the bur and bone surfaces and to eliminate overheating.
OD burs have been shown to produce compression waves, where a large negative rake applies outward pressure that laterally compresses bone during the continuously rotating and concurrently advancing bur. This facilitates “compaction autografting” or “osseodensification.” During this process, bone debris is redistributed up the flutes and is pressed into the trabecular walls of the osteotomy24 (Fig 1-16).The auto- grafting supplements the basic bone compression, and the condensation effect acts to further densify the inner walls of the osteotomy. Trisi et al were one of the first to study the OD technique in an animal model.25 It was found that OD burs increased the percentage of bone density/BIC values around dental implants inserted in low-density bone compared with conventional implant drilling techniques25 (Fig 1-17).These burs are highlighted primarily in chapter 5 under sinus augmentation procedures.
Conclusion
The use of novel instruments has facilitated the ability of the clinician to perform more predictable and accurate bone augmentation and sinus grafting.Today, the use of CBCT has been shown to markedly improve diagnostics and treatment planning in implant dentistry, and it is something I consider a necessity and standard for the field. In addition to hand instruments that have been utilized and further refined over the years, new instrumentation has become available. This includes but is not limited to radiosurgery, Piezosurgery, Osstell ISQ implant stability devices, and OD burs, all of which can be utilized on a routine basis for alveolar ridge augmentation and sinus grafting in implant dentistry.While their introduction was brief in this chapter, their use is further highlighted in the clinical chapters of this textbook. Furthermore, as the field continues to advance rapidly, new devices will certainly be brought to market in the coming years. For a current list of the tools and instruments utilized for alveolar ridge augmentation in my practice and guidelines for their use, a detailed and up-to-date description is provided at www.pikosonline.com.
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