How to increase primary stability with cylinder implants without osteotomes?

If I don’t have osteotomes, what is the best technique for increasing the primary stability of cylinder implants in poor quality bone?  Is undersizing the osteotomy a viable option?  Is drilling an osteotomy 2-3mm short of the desired implant depth an option?  

19 thoughts on: How to increase primary stability with cylinder implants without osteotomes?

  1. Fernando Viek says:

    The best way to have good primary stability in a low bone quality is to use tapered implants with a very aggressive thread design, instead of cylinder implants. Nobel active is a good example. You can google it to see the implant design and you will understand the principle. You can use another brand, for sure, but please look for this kind of aggressive thread design. Just by doing less osteotomy a cylinder implant is not that predicteble to achieve good primary stability, specialy at the posterior maxila.

    All the best

  2. Alejandro Berg says:

    aaaahhhhh to be young again, cylinder or parallel wall implants are the origin of implant dentistry, Branemark style implants and or pressure fit cylinder implants like IMZ.
    To obtain better initial stability, yes undersized osteotomy would be the choice if no osteotomes are available. Just remember to prepare for the platform expansion, i am guessing you are going to use a 3.75 with a 4.1 prosthetic platform so that needs to be addressed. Just remember that external hexes are sensitive to exceeded insertion torque, which could become a problem at a later date.
    Good luck

  3. implant guy says:

    our founder, Gerry Niznick patened the idea of placing a tapered implant into a straight undersized osteotomy. Our most popular implants the Legacy and Interactive are tapered bone level implants and by using soft bone protocol get very high initial stability. Type in Achieving Osseointegration in Soft Bone……and read his article. Good luck

  4. Ninja says:

    Think of what you would do if you had to place a screw into a softwood like pine. You would not use a fine thread for sure. Check out implants made by MegaGen. They are not designed for butter but softwood for sure. Hope nobody is laughing because the wood industry solves these problem in an identical way. It is nothing but physics.

  5. Afshin Danesh says:

    In addition to what our colleagues said I personally place some bone materials into the osteotomy site to get a better primary retention as well in a poor class IV bone like in upper maxilla when needed.

  6. Nicholas Busuttil Dougall says:

    Apart from the physics for achieving good primary stability, you also have to think about biology. Undersizing your osteotomy will give you good mechanical retention but there is risk of necrosis due to increased heat generation and pressure necrosis when inserting the implant. Also the quality of bone you are mentioning means probably increased medullary spaces with less bone quality resulting in less bone to implant contact.
    Check out the densah drills mentioned by colleagues earlier. Combine their advantages with a taper type implant and you should be sorted! But don’t think of bone as simple wood. There is biology involved….

    • Ninja says:

      Obviously there is biology but that does not contradict the physical principals. All implants I assume underwent some scrutiny’s to their acceptability in live bone not wood and therefore that should not be an issue. Nobody suggests that one should go down to local hardware store to pick up a screw. There is o need to complicate things more than it deserves just to justify the fee and ego. If medicine took the same approach with regard to making simple things complicated, we would be dying at the age of forty because all the efforts would be dedicated to one subject with an intensity it does not deserve. Let us be real and realize that we try to reinvent problems that have been long resolved in orthopedics. We are dentists not scientists.

      • Nicholas Busuttil Dougall says:

        Dear NInja,

        Didn’t mean to irk you by my comment. I am merely stating that undersizing a site might lead to bone necrosis. Something which does not happen in wood! I speak from experience of course which led me to research more the matter and better myself both academically and clinically. If by striving to always give the best quality work to patients, you think we are over complicating matters, I beg to differ. Implantology is not simply inserting an implant in bone. There are a lot of things to consider both in terms of biology as well as in terms of physics. I cannot agree more with trying out the Versah system and see what I am talking about.
        Other techniques would be lateral grafts (Blocks or particulate) or ridge splitting.
        Good luck to the poster and hope to see a follow up to the case.

  7. Daniel P. Camm says:

    This has been mentioned: Versah drills have revolutionized the way osteotomies are formed. They were brilliantly engineered by Dr. Salah Huwais. By running them clockwise, like a regular drill, they cut bone. But runnifng them counterclockwise, they condense bone in the osteotomy. You can use them for ridge expansion, internal sinus lift during implant placement, condensing trabecular bone.
    I use these drills exclusively for preparing osteotomies now, no matter what implant system that I am using. They are quickly becoming a standard of care and are revolutionizing implant dentistry.
    Go on the website,, where you can see how they work and see examples of clinical cases. Do yourself a favor……get on the cutting edge.
    If you would like to talk to me about them, give me a call at 440-655-6512, I have no financial interest in the company. I just recognize when something truly special comes along.
    Daniel Camm
    Brunswick, Ohio

  8. Robin Rother says:

    Yes. Lateral packing of the site’s own bone is a possibility but it you’re talking about very low density bone then underdrilling may help too, maybe even just the ‘apical’ part of the site.. I was once mentoring a colleague who placed AstraTech implants. She was always very thorough with her planning and assessment. When she told me that she had the correct implant, and a choice of implants too I took it at face value that she had what she needed. She was completely reliable to date. Come the moment to prep the lower molar site she started off with everything under complete control. A cylindrical site was quickly prepared using the system drills in low density bone. Then the implant was produced. For those of you who don’t know, AstraTech have an implant that is partly tapered and partly cylindrical. We were looking at one of these. The implication was that it would be the correct length for the prepared site but would only fit at the crest surface and would leave a space elsewhere. The solution was to underdrill 2 mm deeper and laterally pack BioOss into the site as well. Healing and follow-up were uneventful. The implant followed and the stability was pretty good. The patient still has the molar implant and crown in place more than ten years later.

  9. CRS says:

    I learned on the old press fit Calcitec implants, that said if a “spinner” implant is buried and does not move it may integrate based on the healing ability on the patient. We are not putting in wood screws here and actually during the healing process the threads cut in the bone resorb and change according to the blood supply. An understanding of fracture healing and bone physiology is helpful vs mechanics. Yes a stable implant will heal primarily is more predictable and is something you should strive for. Condensing bone either with a burr or osteotome are good methods along with thread pattern but each indication is a clinical judgement call based on the patient’s ability to heal, well that’s medicine.

  10. Dr. Gerald Rudick says:

    A lot of good comments are made… I have experience with Calcitek, and because the press fit design had no threads to grip the bone….., they certainly had no stability at the time of insertion….but if left undisturbed for 4 months, chances were that they would become Osseointegrated, and this is due to the patient’s ability to heal….just as CRS spelled it out.
    Ridge expansion, and Osteotomes are great to form an ideal osteotomy….. but someone above mentioned Pressure necrosis….which may lead to failure and lack of integration…….. as well some dormant bad cells that have been left behind following the extraction of a tooth that had periapical pathology……..flare up and you lose the implant!!
    The new Versah drills are getting a lot of positive feedback, and I am one who will try them very shortly…… but I am sure they too have their failures…….

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