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Review Article

Osseodensification – A novel approach in implant dentistry

Umesh Y. Pai, Shobha J. Rodrigues, Karishma S Talreja, Mahesh Mundathaje
Department of Prosthodontics, Manipal College of Dental Sciences, Manipal University, Mangalore, Karnataka, India

Abstract Primary stability in dental implants is an essential factor for achieving successful osseointegration. Surgical
procedure and bone quality are among the most common factors that affect primary stability. It is also
crucial to achieve high‑insertion torque which is important for obtaining primary stability. Maintaining
sufficient bone bulk and density is essential to achieve necessary bone‑to‑implant contact for obtaining
a biomechanically stable implant. A new concept for osteotomy called osseodensification (OD) has been
at the forefront of changes in surgical site preparation in implantology. This relatively new concept with
universally compatible drills has been proposed to help in better osteotomy preparation, bone densification,
and indirect sinus lift and also achieve bone expansion at different sites of varying bone densities. This
procedure has also shown improvement in achieving better implant primary stability and better osteotomy
than conventional implant drills. A systematic review was undertaken to analyze if OD procedure had any
advantages over conventional osteotomy on bone density and primary stability. An electronic database
search was conducted in PubMed using keywords such as “OD,” “implant primary stability,” “implant bone
density,” and “implant osteotomy.” A total of 195 articles were collected and subjected to screening using
inclusion and exclusion criteria. A literature review was done, following which it was seen that the use of
versah drills for bone OD resulted in undersized osteotomy compared to conventional drills. It also resulted
in improved bone density and increase in percentage bone volume and bone‑to‑implant contact, thereby
improving implant stability.

Keywords: Implant stability, osseodensification, osteotomy

Address for correspondence: Dr. Umesh Y. Pai, Department of Prosthodontics, Manipal College of Dental Sciences, Manipal Academy of Higher Education,
Manipal, Mangalore-575001, Karnataka, India.
E‑mail: pai.umesh@manipal.edu
Received: 13th November, 2017, Accepted: 24th May, 2018

INTRODUCTION osteotomy. The insertion torque peak is directly related

to implant primary stability and host bone density;[5]
Primary stability in implant placement is one of the high‑insertion torque could significantly increase the
most critical factors determining the outcome of implant initial bone‑to‑implant contact percentage  (%BIC)
therapy. The key factors in enhancing implant primary compared to implant inserted with low‑insertion torque
stability are bone density,[1,2] surgical protocol,[3] and values.[6] Ottoni et al.[7] showed a reduction in failure rate
implant thread type and geometry.[4] Primary stability of 20% in single‑tooth implant restoration for every
is provided by the mechanical friction between the 9.8 N cm of torque increased.
external implant surface and walls of the implant
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DOI: How to cite this article: Pai UY, Rodrigues SJ, Talreja KS, Mundathaje M.
10.4103/jips.jips_292_17 Osseodensification – A novel approach in implant dentistry. J Indian Prosthodont
Soc 2018;18:196-200.

196 © 2018 The Journal of Indian Prosthodontic Society | Published by Wolters Kluwer - Medknow
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Pai, et al.: Osseodensification in implant dentistry

Osseodensification (OD) is a new method of biomechanical

bone preparation performed for dental implant placement.
The procedure is characterized by low plastic deformation
of bone that is created by rolling and sliding contact using
a densifying bur that is fluted such that it densifies the bone
with minimal heat elevation. OD, a bone nonextraction
technique, was developed by Huwais 2013[8] and done using
specially designed burs (Densah™ burs) that help densify
bone [Figure 1] as they prepare an osteotomy.[9] These
burs provide advantages of both osteotomes combining
the speed along with improved tactile control of the drills
during osteotomy. Standard drills excavate bone during
implant osteotomy, while osteotomes tend to induce Figure 1: Versah Kit with densification drills
fractures of the trabeculae that requiring long remodeling
time and delayed secondary implant stability. The Densah
burs allow for bone preservation and condensation through
compaction autografting during osteotomy preparation,
thereby increasing the bone density in the peri‑implant
areas and improving the implant mechanical stability.[10]
The bone‑remodeling unit requires more than 12 weeks
to repair the damaged area created by conventional drills
that extract substantial amount of bone to let strains in
the walls of osteotomy reach or go beyond the bone
microdamage threshold. Hence, OD will help preserve
bone bulk and increase density, thereby shortening the
healing period.[11]

Unlike traditional osteotomy, OD does not excavate bone

Figure 2: Role of densification Drills (image source: Versah LLC
but simultaneously compacts and autografts the particulate product catalogue, www.versah.com)
bone in an outward direction to create the osteotomy,
thereby preserving vital bone tissue. This is achieved using
specialized densifying burs [Figure 2]. When the specialized
drill is used at high speed in an anticlockwise direction with
steady external irrigation  (Densifying Mode), the dense
compact bone tissue is created along the osteotomy walls.[12]
The pumping motion (in and out movement) creates a
rate‑dependent stress to produce a rate‑dependent strain
and allows saline solution pumping to gently pressurize
the bone walls. This combination facilitates an increased
bone plasticity and bone expansion  [Figure 3]. Huwais
demonstrated that OD helped ridge expansion while
maintaining alveolar ridge integrity, thereby allowing
implant placement in autogenous bone, also achieving
adequate primary stability. OD helped in preserving bone
bulk and shortened the waiting period to restorative Figure 3: Osteotomy preparation using the densification drills
phase.[13]
implant bone density, and implant osteotomy. An electronic
A systematic review was undertaken to analyze if database search in PUBMED was conducted for articles up
OD procedure had any advantages over conventional to 2017 using MeSH and keywords such as “OD,” “implant
osteotomy on bone density and primary stability. An primary stability,” “implant osteotomy,” and “implant
electronic database search was conducted in PUBMED bone density.” A total of 195 articles were identified and
using keywords such asOD, implant primary stability, scrutinized for full‑text articles, and after screening, finally,
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Pai, et al.: Osseodensification in implant dentistry

Total articles
is critical in immediate loading protocols, and it was
(electronic search) n = 195 reported that an implant micromotion above 50–100
Duplicates removed um potentiated peri‑implant bone resorption or implant
n=4
failures.[15‑17] Trisi et al. in in vivo study found a statistically
significant correlation between peri‑implant bone density,
Total articles remaining
n = 191
insertion torque, and micromotion [Table 1]. A significant
Articles not related to dentistry increase in insertion torque and a concomitant reduction in
n = 22
micromotion was noted with an increase in bone density
values.[18] Berardini et al.[19] and Li et al.[20] in a review reported
Articles screened and no significant difference in crestal bone resorption and
selected n = 169
Aricles not satisfying failure rate between implants inserted with either high‑ or
inclusion/exclusion
Criteria n = 166
low‑insertion torque values. They also demonstrated the
ability of OD drills to increase the % of BV and % of
BIC for dental implants inserted into poor density bone
Articles selected n = 3 compared to conventional osteotomies, which may help in
Figure 4: Diagram showing search results enhancing osseointegration,[21,22]

three full‑text articles were selected for the review according Newer methods such as cutting torque resistance analysis
to the inclusion criteria [Figure 4]. developed by Johansson and Strid was also suggested as
a tool to evaluate implant primary stability,[23] but nothing
Inclusion criteria specific has been documented in the literature with regard
Only full‑text articles were considered. to OD.
• Implant site: Compact bone/cancellous bone
• Implant stability: Primary stability/secondary stability OSSEODENSIFICATION VERSUS
• Drills: Osteotomy preparation with conventional CONVENTIONAL OSTEOTOMY
drills/OD drills
Biomechanical capabilities of implants are affected by various
• Bone density: Bone volume percentage (%BV)/BIC.
factors, which include implant macro/microgeometry,
Exclusion criteria nanosurface modifications, and osteotomy techniques
• Case reports/case series employed. [22,24] Standard drills used in implant site
• In vitro studies. osteotomy excavate bone to facilitate implant placement.
They produce effective cutting of bone but lack the design
OSSEODENSIFICATION AND BONE DENSITY capability to create a precise circumferential osteotomy.
Osteotomies, therefore, become elongated and elliptical
The process of osseointegration leads to bone formation due to the imprecise cutting of the drills. This leads to a
on the implant surface and contributes to implant reduction of torque during implant insertion, leading to
secondary stability between bone and dental implant. poor primary stability and contributing to the potential
for nonintegration of implant. Furthermore, osteotomies
In areas of low bone density, such as maxillary posterior
prepared in deficient bone may produce either buccal or
region, the insufficient bone available could affect the
lingual dehiscence, which results in a reduction of primary
histomorphometric parameters such as %BIC and %BV
stability and necessitates an additional bone grafting adding
negatively, thereby affecting primary and secondary
to the total cost of treatment and increasing healing time.
implant stability. A layer of increased bone mineral
density has been shown by imaging around the periphery Undersizing the implant site preparation[25,26] and using the
of osteotomies using OD. The increase in bone density osteotomes for bone condensation[27,28] are some of the
achieved by OD has shown to have a potentiating effect surgical methods advised to increase primary stability in
on secondary stability. implants and % of BIC in poor density bone. Observations
OSSEODENSIFICATION AND PRIMARY were also made of different healing patterns and
STABILITY peri‑implant bone‑remodeling models.[29‑31] The alternative
to implant drilling procedures in the posterior maxilla is
The implant primary stability is a crucial factor to achieve the osteotome technique[27] that aims to compact the bone
implant osseointegration.[14] High primary implant stability with the mechanical action of cylindrical instruments along
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Pai, et al.: Osseodensification in implant dentistry

Table 1: Table with relevant studies on osseodensification

Author Type of study Sample Study conducted Outcome
size
Lahens, 2016 In vivo animal study 5 Effect of OD on the initial stability and early Significantly higher BIC to OD
osseointegration of conical and parallel techniques (P<0.05) was observed compared
walled implants in low‑density bone (total to regular drilling
implants=30; 15 parallel, 15 conical)
Erich Meyer, In vivo animal study 12 Three preparation techniques No differences in ISQ between the groups
Daniel Greenshields, i. SD with rotary bur 3°C increase during drilling and 6°C during OD
Salah Huwais ii. ED with Densah® bur Bone mineral density increased around
iii. OD with Densah® bur rotating in periphery and bottom of OD holes
reversed, noncutting direction (total Bone particles autografted into walls and
sites=72) bottom creating smoother OD holes
BIC was increased to 3 times for OD versus SD
Trisi P , In vivo animal study 2 Ten 3.8 mm ×10 mm implants were inserted No implant failures were observed after
Bernardini M, Falco A , in the left side using the conventional 2 months of healing
Podaliri Vulpiani drilling method (control group) Significant increase of ridge width
Ten 5 mm ×10 mm implants were inserted and (%BV) (approximately 30% higher) was
in the right side (test group) using the OD detected in the test group
procedure (Versah) Significantly better removal torque values and
micromotion under lateral forces (value of
actual micromotion) were recorded for the test
group in respect with the control group
SD: Standard drilling, ED: Extraction drilling, OD: Osseodensification, BIC: Bone–implant contact, ISQ: Implant stability quotient, %BV: Bone
volume percentage

the osteotomy walls. This procedure created trabecular literature evidence is inadequate to draw any concrete
fractures with debris, which caused an obstruction to the conclusions, and more studies are recommended in this
process of osseointegration.[32] field.

OD osteotomy diameters were found to be smaller than Financial support and sponsorship
conventional osteotomies prepared with the same burs Nil.
due to the springy nature and elastic strain of bone. This
increased the percent of bone available at the implant site Conflicts of interest
by about three times. Histomorphological analysis has There are no conflicts of interest.
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