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 success and the future restoration of the case may be compromised. There are several factors that should be considered when performing the osteotomy, such as angulation, location and space for multiple implants. The critical decisions that must be made have to do with the choice of following the protocol of soft or dense bone for a given case, and whether a bone puncture drill should be used. The objective is to achieve a high primary stability, at least 35 Ncm, at the time of implant placement.
As with most things related to orthopedic implants , the evaluation of preoperative bone quantity and quality is essential to plan the osteotomy. If a conventional radiograph is used, such as panoramas and periapical radiographs, the evaluation of the trabecular bone pattern and the vertical height of the bone can usually indicate the probable density of the underlying bone. The use of cone beam computed tomography (CBCT) and digital treatment planning software can provide an even greater preoperative evaluation of the bone to be drilled, by allowing the orthopedic surgeon to examine the bone three-dimensionally, providing a Houns field and / or relative density Scale of a planned osteotomy site. By carefully considering all these factors, the surgeon usually has an idea of what piercing protocol will be demanded before the patient shows up for surgery. As is often the case, however, several surgical decisions are made intraoperatively. So, sometimes, even the best plans need modifications.
A good general rule in the preparation of the osteotomy is to start small and advance as necessary. In other words, get the orthopedic manufacturer’s recommendations for your specific soft-bone implant system. Once you have done so, if you feel that the bone was mainly difficult to penetrate with the drills or, when you try to place the orthopedic implant, it does not advance easily to the maximum depth, so it is generally advisable to extend the diameter of the osteotomy with the dense bone drill. The potential dangers of not having an osteotomy of the correct size include: removing the hexagon from the implant during placement, not fully seating and properly placing the implant in the bone and creating excessive pressure on the surrounding bone as a result of the additional torque required to settle the implant All this is detrimental to the long-term success of the implant and / or orthopedic restoration. Some surgeons advocate perforating the diameter of the dense bone in all cases. This is certainly an option, but the risk is that it could compromise the amount of initial stability it achieves and that the drill or implant could move to an unfavorable location due to loss of strength and torque. So, once again, it is at the discretion of the surgeon.