Implant stability following septal expansion in immediate mandibular molars: a pilot randomized clinical trial comparing piezoelectric surgery and osseodensification
It is demonstrated that PISP achieves comparable biomechanical stability to OD, establishing its clinical feasibility for immediate molar implant placement in anatomically complex posterior regions.
Abstract
Immediate implant placement (IIP) in mandibular molars is challenged by wide extraction sockets and limited septal bone support. This pilot feasibility randomized clinical trial evaluated primary and secondary implant stability following septal expansion using piezoelectric surgery (PISP) compared with osseodensification (OD) using Densah® burs. Twenty patients were randomly allocated (1:1) to either PISP group or OD group for immediate mandibular molar implant placement. The primary outcome was implant stability quotient (ISQ), measured immediately and at 3 months. Secondary outcomes included insertion torque, osteotomy preparation time, and postoperative pain assessed using a visual analogue scale (VAS) during the first postoperative week. Normality was evaluated using Shapiro–Wilk tests and Q–Q plots. Between-group comparisons were performed using independent t-tests, while VAS scores were analyzed using Mann–Whitney U and Friedman tests (α = 0.05). No statistically significant differences were observed between groups in primary or secondary ISQ (p > 0.05). Both groups demonstrated a significant increase in ISQ at 3 months compared with baseline (p < 0.001). The mean insertion torque was significantly higher in the PISP group (40.33 ± 3.24 Ncm; p = 0.004) compared to the OD group (35.00 ± 3.53 Ncm). Osteotomy preparation time was significantly longer in the PISP group (9.00 ± 0.94 min) than in the OD group (6.00 ± 0.82 min) (p < 0.001). Postoperative VAS pain scores were significantly lower in the PISP group throughout the first week (p < 0.05). All implants achieved clinical stability with no intra- or postoperative complications. The preliminary findings of this pilot feasibility trial demonstrated that PISP achieves comparable biomechanical stability to OD, establishing its clinical feasibility for immediate molar implant placement in anatomically complex posterior regions. NCT06957860 ; registered May 5, 2025.
AIM
To compare the clinical outcomes of digitally assisted immediate implant placement in the posterior mandible using immediate (Type A) and delayed (Type C) loading protocols.
METHODS
Eighty-two patients requiring five-unit fixed partial dentures supported by three implants were consecutively enrolled. All cases were planned using a fully digital workflow integrating CBCT, intraoral scanning, and static computer-guided surgery. Only implants achieving adequate primary stability (insertion torque ≥25 Ncm and/or ISQ ≥60) were included. Patients were assigned to either immediate or delayed loading protocols. Implant survival, marginal bone loss (MBL), plaque index (PI), bleeding on probing (BOP), and probing depth (PD) were evaluated over variable follow-up periods according to the timing of patient enrollment and treatment completion.
RESULTS
A total of 246 implants were placed, yielding an overall survival rate of 97.5% with no significant differences between loading protocols. Mean MBL was 0.7 mm and remained comparable between groups. Peri-implant parameters, including PI, BOP, and PD, were stable throughout follow-up. Regression analysis identified restorative angles >30° as the only significant predictor of increased MBL.
CONCLUSION
Digitally guided immediate implant placement in the posterior mandible demonstrated high survival rates and favorable peri-implant outcomes with both Type A and Type C loading protocols.
CLINICAL SIGNIFICANCE
Type A loading may provide a predictable and time-efficient alternative to conventional delayed loading without compromising clinical outcomes.
Mohammed A. Elsawy, Mohammed T. Khater, Islam Kandil et al.· E -journal of dentistry· 0 citations
Neither the choice of drilling technique nor the implant macrogeometry significantly influences insertion torque or stability levels in regions of low bone density in this randomized controlled clinical study.
Worood A Akram, S. Bede· The Journal of craniofacial...· 0 citations
The dissociation between insertion torque and 90-day stability indicates that secondary stability is governed by factors beyond initial mechanical engagement, and suggests a potential long-term biomechanical difference warranting further study.
Ahmed Elkattan, Mónica Blázquez-Hinarejos, H. Assiri et al.· European Journal of Dentistr...· 0 citations
The clinically meaningful esthetic advantages of IIP support its preferential use in the anterior zone when anatomical conditions permit and when combined with guided protocols and customized healing abutments, IIP and EIP yield comparable 12-month marginal bone outcomes.
Sara N. El Touliani, Ahmed M. Abdel-Hamid, Nada M. H. Fahmy et al.· Frontiers in Dental Medicine· 0 citations
Background and Clinical Significance: Immediate implant placement in mandibular molars represents a clinical challenge due to lower trabecular bone density and anatomical limitations of the interradicular septum. Osseodensification has been proposed as an alternative to improve primary stability in sites with low bone quality. Case Presentation: This report describes the case of a 54-year-old female patient with a mesial root fracture in the lower right first molar, treated by atraumatic extraction followed by immediate implant placement using a densifying drilling protocol. After careful root removal, the interradicular septum was expanded using Versah burs at 1200 rpm, allowing placement of a 4.0 × 7 mm Implacil Duecone implant with a final insertion torque of 25 Ncm. The residual gap was filled with a xenogeneic bone substitute and covered with a dense polytetrafluorethylene membrane for alveolar preservation. Healing progressed uneventfully and, after four months, adequate bone formation was observed, enabling prosthetic rehabilitation with a single ceramic crown. After 4 postoperative years we could find peri-implant tissue stability. Conclusions: The clinical outcome supports current evidence indicating that osseodensification may enhance initial stability and predictability of immediate implants placed in posterior mandibular regions.
Márcio de Carvalho Formiga, Jucielly Santos Lesnik de Souza, Gustavo Dos Santos Coura et al.· Reports· 0 citations
Horizontal ridge deficiencies in the anterior maxilla frequently compromise ideal implant positioning and esthetic outcomes. This randomized controlled clinical trial evaluated the clinical performance of customized CAD/CAM zirconia membranes compared with conventional collagen membranes for guided bone regeneration (GBR) performed simultaneously with early implant placement. Twenty systemically healthy patients requiring single-tooth replacement in the anterior maxilla underwent early implant placement (4–8 weeks after tooth extraction) combined with simultaneous contour augmentation using a composite graft of autogenous bone and deproteinized bovine bone mineral (1:1). Participants were randomly assigned to receive either a customized CAD/CAM zirconia membrane (test group, n = 10) or a double-layer collagen membrane (control group, n = 10). The primary outcome was horizontal bone gain (HBG) at 6 months, assessed by standardized CBCT superimposition. Secondary outcomes included soft tissue healing evaluated using the Modified Wound Healing Index (MWHI), membrane exposure (wound dehiscence), and patient-reported postoperative pain assessed using a visual analogue scale (VAS). All implants survived during the 6-month follow-up period (100% survival rate). Mean HBG was 6.18 ± 0.60 mm in the test group and 5.85 ± 0.37 mm in the control group, with no statistically significant difference between groups (p = 0.158). Membrane exposure occurred in all patients receiving customized zirconia membranes (10/10, 100%), whereas no membrane exposure was observed in the collagen membrane group (0/10, 0%). Despite the higher exposure rate, graft stability and horizontal bone regeneration were not adversely affected. Soft tissue healing was significantly more favorable in the collagen membrane group. Postoperative pain decreased significantly over time in both groups, with no significant intergroup differences. Customized CAD/CAM zirconia membranes achieved horizontal bone augmentation comparable to conventional collagen membranes when used for simultaneous GBR during early implant placement. Although customized zirconia membranes were associated with a substantially higher membrane exposure rate, regenerative outcomes and implant survival remained unaffected, indicating that customized rigid barriers may represent a predictable alternative for horizontal ridge augmentation while offering potential advantages in surgical precision and procedural efficiency. Trial registration: ClinicalTrials.gov NCT06987149.
Mohammed Mashhout Anas, A. M. Gabr, Yasser El‐Makaky et al.· International Journal of Imp...· 0 citations
