The bone matrix Osteotensor® was first developed clinically by surgeons. Despite the lack of related literature on what began as an empirical approach, most of the ideas and concepts behind this instrument are substantiated by numerous earlier studies on mechanobiology3, tensegrity4, fracture healing5,6, corticotomy7,8, bone matrix growth factors9, bone remodeling10,11, distraction osteogenesis12, angiogenesis13 and stem cells.
Initially, practical clinical experience guided our steps. However, this situation is changing as molecular biology provides an understanding of the factors involved in osteogenesis following use of bone matrix Osteotensors®. In particular, research over the past decade has shown that numerous growth factors are found in bone matrix (BMP, IGF-I and II, IGF-beta, etc.)14.
Analysis of the effects of mechanically-induced, spatially-targeted osteogenic activation led to replacement of the standard dental instruments originally used (drills, burs, probes, needles, etc.) by specific tools and protocols for each clinical application. This novel armamentarium drastically improves the reproducibility and predictability of clinical results. Since 2005, activation of accelerated bone remodeling using Osteotensors® has become an integral part of our implant treatment planning.
Early work on periosteal stimulation by "needling”16 and, later on, endosteal stimulation using drills17 revealed that mechanically induced micro-trauma of the periosteum and/or the bone matrix can drastically improve the quality of the bone site prior to implant installation. However, the commercial burs and drills available at the time did not offer an adequate state of surface, dimensions or profile to insure biocompatibility and efficiency. These methods thus never gained widespread acceptance. Furthermore, medical imaging and molecular biology had not reached their current state of development. Recent advances in stem cell research renewed our interest in this approach, and in particular their application for immediate fixed rehabilitation in extremely atrophic jaws15.
The osteogenic process is initiated with a bone matrix Osteotensor® (Fig. 1). The zone to be activated is determined by analysis of CT data and clinical findings. Calibrated as a function of the diameter and shape of the osteon, the mirror-polished, surgical steel Osteotensor® is coated with diamond-like carbon (DLC) to avoid metal contamination during use19. The ultrafine tapered profile and mirror-polished, DLC-coated surface also prevent the seeding of undesirable cellular elements and bacteria within the bone tissue.
MECHANISM OF ACTION
Osteotension is a mechano-biological factor involved in the regulation of bone homeostasis. On a cellular level, modification of bone matrix osteotensions corresponds to selectively-oriented molecular mechanotherapy. Flapless surgical trauma of the cortical bone produces a burst of localized hard tissue remodeling termed the regional accelerated bone remodeling phenomenon (RAP) by Frost5. Furthermore, the micro-cracks created cause the release of bone matrix growth factors that have a range of biologic properties, including chemotactic, mitogenic, differentiation and osteolytic activities14. More recently, it has been shown that osteo-inductive proteins are able to recruit stem cells at a distance from the micro-cracks. Flapless application of the Osteotensor® prior to implant treatment improves bone quality at the recipient site. When bone grafting is scheduled, both the future donor site and the recipient site are activated 18 to 21 days before surgery.
Passage of the Osteotensor® through the various osteogenic compartments (periosteum, bone matrix, endosteum, vascular walls, bone marrow) instantly modifies the bone matrix tensions. Each impact site is the point of departure of accelerated reparative osteogenesis with bone gain following mineralization of the subperiosteal blood clot. This mechanism of action is in agreement with recent literature reports on the complex interactions between bone matrix tensions and signaling (extracellular matrix - bone cells - cell nuclei) and osteo-regulation processes based on mechanotransduction20, 21. A reparative bone callus forms after 45 days. There is no exception to this rule, which is constant for the consolidation of closed bone fractures without displacement22.
Type IV bone is transformed into active type II bone after 45 to 90 days. In contrast, hyperdense, type I reparative bone will be "softened” into active type II after 18 to 21 days, which marks the end of the post-trauma catabolic phase. This is the optimal time to perform therapeutic procedures such as implant placement, distraction, bone grafting, etc. in highly dense type I bone.
The aim of osteogenic activation is improvement of the initial bone site by promoting angiogenesis, the recruitment of progenitors, and finally, the formation of a bone callus. It is not an emergency procedure and should be used only for healthy patients without any local and/or general pathologies that might affect the bone tissue.
The most common indications are: evaluation of bone density, evaluation of the depth of bone penetration, osteogenic activation, implantology, parodontology, orthodontics, difficult tooth extractions.
Osteotensor® application is indicated whenever radiologic analysis reveals a bone of inadequate quality, either because it is too fragile (type IV) or, on the contrary, too dense (type I). Similarly, when bone grafting, a sinus lift procedure, or bone distraction is planned, osteogenic preparation favors the sought-after result.
All of the temporary and/or absolute physical and/or psychological contra-indications of bucco-dental surgery must be respected concerning Osteotensor® application include.
Specific contra-indications include: children under 12 years of age, heavy smoking, bucco-dental infections (acute periodontal disease, dental abscess, etc.), maxillary sinusitis (if surgery is scheduled in this zone), insufficient oral hygiene, treatment by bisphosphonates, ongoing radiotherapy and/or chemotherapy.
A complete pre-therapy workup is essential (medical status, bucco-dental status, radiologic study, impressions, impact guide) to make sue there are no contra-ind
What does the minimally invasive bone matrix Osteotensor® procedure represent for the professional and for the patient?
First of all, this transparietal probe allows verification of the initial quality of the future recipient bone site (type I, II, III, IV). Combined with high-tech modalities such as robotic navigation systems, the Osteotensor® can be used both as a bone surface probe and a transmatrix depth gauge.
A manual Osteotensor® is always used first to test the bone quality at the intended site. As soon as dense bone is encountered and the tip of the instrument comes up against a hard surface, manual pressure on the instrument must be stopped to avoid damaging the DLC surface. A rotary Osteotensor® is then used (20,000 rpm under copious irrigation): diameter 0.8-1.0 mm for fragile and narrow bone sites, diameter 1.2-1.4 mm for wider bone sites.
When natural teeth are present, care must be taken to avoid injuring the periodontal ligament with the Osteotensor® (impacts must be located at least 1 mm away from the ligament).
For the maxilla, insert the Osteotensor® through the guide and apply pressure until resistance is felt. Avoid deforming the DLC tip of the instrument. When treating the region beneath the sinuses, perforation of the sinus floor and the sinus membrane is not a problem (Fig. 3). Any bleeding will take place underneath the membrane, between the bony floor of the sinus and the membrane. The blood will extravasate from the strongly irrigated connective tissue under the respiratory epithelial lining of the sinus cavities. A bone gain results thanks to the callus that forms at the concerned bone site 45 days after passage of the Osteotensor®.
For the mandible, the procedure is somewhat different due to the anatomy of the mandibular bone (the buccal and lingual plates both consist of dense cortical bone). All of the deep, intrabony impacts are made starting on the crest.
Passage of the instrument through the gingiva and the bone matrix using a flapless technique creates a channel that fills in with blood and fluid. The resultant osseo-distraction with micro-crack formation regenerates in the form of a bone callus after 45 days (this is the natural course of closed bone fractures without displacement). The outcome of future implant treatment is rendered more predictable, particularly in extremely atrophic jaws.
It is not necessary for patients to stop taking anticoagulant drugs (Plavix®, aspirin, etc.). The dimensions of the transgingival impacts at their tip are smaller than those of a perfusion needle. Little or no bleeding occurs. The risk of damaging sensitive and/or vital organs is less than with a needle for local anesthesia, i.e. practically null. Perforation of the sinus membrane is without consequence, for the reasons mentioned previously.
The postoperative course is uneventful. However, the Osteotensor® must never be used in an infected site. If there is any doubt, refer the patient to an ENT specialist to make sure the sinuses are healthy before performing the procedure.
Impact guides are recommended for accurate positioning and orientation of the impacts. Guides can also be used to check the efficacy of treatment during reapplication of the Osteotensor® during a second session. Modifications in bone density at each impact site are easily detected. A robotic navigation system can be used to pilot the Osteotensor® to the target sites determined by computer-assisted analysis of the region. A series of virtual projections of the final result can also be obtained as a function of the orientation of the Osteotensor®.
In light of the reproducible clinical results obtained with osteogenic activation over the past four years, even in extreme clinical conditions, this procedure is now part of our daily practice for root-form or disk type implants and for bone augmentation procedures. Training in use of Osteotensors® (indications, contraindications, determination of parameters, protocols and procedures) is obviously indispensable to assure the reproducibility of this minimally-invasive, natural therapeutic approach so as to safely guarantee patients optimum implant treatment performance and efficiency.
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