Biologically Adapted Drilling for Dental Implant Placement – Nik Sisodia

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  Posted by: Dental Design      12th May 2019

Primary stability is closely associated with successful osseointegration of dental implants. Various studies have shown that the achievement of primary stability depends on various factors, including implant design, surgical technique and density of the surrounding bone.[i]

Focusing on the latter, higher bone densities have been associated with greater primary stability.[ii][iii]The challenge dental surgeons face is that bone density varies from patient to patient and site to site within the same mouth. For example, the softest bone is generally found in the posterior maxilla, followed by that in the anterior maxilla – the bone is usually much denser in the mandible.

It is important to keep this in mind when planning a case in terms of size and number of dental implants to be used. Combining knowledge of these general patterns with CBCT information can enhance the procedure being prepared for.

However, the ultimate test of bone quality is the first drill pass – this is when you receive tactile feedback as to the bone quality present.With experience, that first drill pass will allow you to make very quick and intuitive decisions about the way in which you should prepare the osteotomy and achieve the best bone-to-dental implant contact with good primary stability.

Most of us were taught to follow a pre-determined drilling protocol provided by the manufacturer. With the evolution of digital technology, though, we are able to virtually simulate surgery and practice the procedure on artificial typodont models. In some cases, this helps to eliminate any surprises and improve the predictability of treatment. It also provides an opportunity to check that the proposed treatment plan is the most suitable option for the patient and that satisfactory function and aesthetics are likely to be achieved.

However, this approach doesn’t take the quality of the bone into account, which can leave us with unpredictable primary stability. As such, additional techniques should be employed in order to manipulate the bone and increase the chance for surgical success.

There are many different procedures that enable us to modify the osteotomy preparation in terms of bone density, depending on the existing bone quality and quantity. For example, there are tools such as osteotomes that work well, but these are often not the easiest or quickest instruments to use.

There are also various surgical techniques that can be used to develop and enhance the dental implant recipient site, encouraging primary stability and successful osseointegration. The developed and refined procedures we use today, combined with and supported by cutting-edge technologies and instruments, allow us to create the best possible environment for dental implant placement, even in the most complex clinical situations.

Over the years, I have tried a variety of methods and during my ADI Study Club in November, I will share when and where each technique can be used to expand, widen, modify or otherwise improve and simplify the surgical aspect of dental implantology. Alongside the principles of osseodensification, techniques covered will include Bone Spreaders, Bone Condensers, Versah Drills, End Cutting Drills, Piezosurgery and Mectron Sentineri Spreaders that allow us to take a biologically driven approach to prepare each individual site optimally, based on the tactile feedback at pilot osteotomy. This should result in more predictable primary stability and greater insertion torque. I’ll discuss the advantages of each and offer some very quick, simple and intuitive ways to achieve surgical objectives without a complex or protracted workflow.

Some of these approaches, such as when using Versah drills with a Biologically Adapted Osteotomy, afford benefits in addition to enhanced primary stability. They encourage a quicker surgery and facilitate safer flapless surgery in some situations. They also provide an opportunity to perform crestal sinus lifts in far more cases than was previously possible, requiring minimal investment in equipment and a much less invasive surgery, affording reduced morbidity for the patient.

Nik Sisodia, Co-Principal of Ten Dental + Facial in London, will be discussing “BAD Implant Placement”in his ADI Study Club presentation in November. He will outline various approaches for bone manipulation depending on the existing bone quality and quantity, and share his wealth of experience to help colleagues improve the predictability and primary stability achieved in dental implant treatment, even in cases with limited bone available.


For information on upcoming ADI Study Clubs, or to book, please visit

 ADI Study Clubs are free to members. Join online today.


The views expressed in this article are those of the author, and not necessarily those of the ADI.


Author bio:

After graduating from Bristol University in 1995 and spending a year as a Senior House Officer in Restorative Dentistry and several years in general practice in London, Nik went into partnership with Martin Wanendeya to create Ten Dental + Facial. Nik’s special interest in dental implants has led him to become a lecturer and mentor for various leading dental implant companies. He is a Fellow of the International Congress of Oral Implantology, a Member of the International Team for Implantology and a Member of the Association of Dental Implantology. A member of the British Academy of Aesthetic Dentistry and a past President of the British Academy of Cosmetic Dentistry, Nik also lectures nationally and internationally on all aspects of dental implant and restorative dentistry.



[i]Javed F, Ahmed HB, Crespi R, Romanos GE. Role of primary stability for successful osseointegration of dental implants: Factors of influence and evaluation. Interv Med Appl Sci. 2013;5(4):162-7.


[ii]Farre-Pages N et al. Relation between bone density and primary implant stability. Med Oral Patol Oral Cir Bucal. 2011; 16(1):e62-7


[iii]Salem WS, Mahmoud MR, Zaharia WM, Araby YA. The correlation between peri-implant bone density and the biological implant stability: A two years follow up. Inter J Dent Sci Res. 2018; 6(2):48-52

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