Sinus Lifting techniques: direct (Caldwell Luc) and indirect (Summer’s), Anatomy, Technique, Complications of sinus lift                                 

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Anatomy

1. Solar P, et al. Blood supply to the maxillary sinus relevant to sinus floor elevation procedures. Clin Oral Implants Res. 1999 Feb; 10 (1):34-44.

2. Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G. Incidence and suggested surgical management of septa in sinus-lift procedures. Int J Oral Maxillofac Implants. 1995 Jul-Aug;10(4):462-5.

3. Pommer B, Ulm C, Lorenzoni M, et al. Prevalence, location and morphology of maxillary sinus septa: systematic review and meta-analysis. J Clin Periodontol. 2012 Aug;39(8):769-73.

Technique

• Misch, Resnik, Misch-Dietsh. Maxillary Sinus Anatomy, Pathology and Graft Surgery. (CH 38) pp 1055-1072. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.

1. Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T. Maxillary sinus elevation by lateral window approach: evolution of technology and technique. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-71.

2. Romero-Millán J, et al. Indirect osteotome maxillary sinus floor elevation: an update. J Oral Implantol. 2012 Dec;38(6):799-804.

3. Zhen F, Fang W, Jing S, Zuolin W. The use of a piezoelectric ultrasonic osteotome for internal sinus elevation: a retrospective analysis of clinical results. Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):920-6.

Complications

• Part IV Complications Associated with Lateral Window Sinus Elevation. pp 135-169. Surgical complications in oral implantology : etiology, prevention, and management Louie Al-Faraje. Quintessence Pub., c2011.

• Wallace, S. Complications in lateral window sinus elevation surgery. (CH16) pp 284-309. Dental Implant Complications: Etiology, Prevention, and Treatment. Froum, SJ. 2010. Wiley-Blackwell.

• Rosen P. Complications with the bone-added osteotome sinus floor elevation: etiology, prevention, and treatment. (CH 17) pp 310-324/

1. van den Bergh JP, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res 2000;11(3):256-265

2. Penarrocha-Diago, M et al: Benign Paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: A study of 4 cases. Int J Oral Maxillofac Implants 2008:23:129-132

3. Fugazzotto PA, Vlassis J. A simplified classification and repair system for sinus membrane perforations. J Periodontol. 2003 Oct;74(10):1534-41.

4. Froum SJ, Khouly I, Favero G, Cho SC. Effect of maxillary sinus membrane perforation on vital bone formation and implant survival: a retrospective study. J Periodontol. 2013 Aug;84(8):1094-9.

5. Proussaefs P, Lozada J, Kim J, Rohrer MD. Repair of the perforated sinus membrane with a resorbable collagen membrane: a human study. Int J Oral Maxillofac Implants. 2004;19(3):413-420.

6. Cho SC, Wallace SS, Froum SJ, Tarnow DP, Influence of anatomy of Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis. Pract Proced Aesthet Dent 2001; 13:160-163.

7. Vlassis JM, Fugazzotto PA. A classification system for sinus membrane perforations during augmentation procedures with options for repair. J Periodontol 1999;70(6):692-699.

8. Jensen SS, Eriksen J, Schiodt M. Severe bleeding after sinus floor elevation using the transcrestal technique: a case report. Eur J Oral Implantol. 2012 Autumn;5(3):287-91.

9. Testori T, Weinstein RL, Taschieri S, Del Fabbro M. Risk factor analysis following maxillary sinus augmentation: a retrospective multicenter study. Int J Oral Maxillofac Implants. 2012 Sep-Oct;27(5):1170-6.

10. Manor Y, Mardinger O, et al. Late signs and symptoms of maxillary sinusitis after sinus augmentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jul;110(1):e1-4.

11. Moreno Vazquez JC, et al. Complication rate in 200 consecutive sinus lift procedures: guidelines for prevention and treatment. J Oral Maxillofac Surg. 2014 May;72(5):892-901

12. Najm SA, Malis D, Hage ME, Rahban S, Carrel JP, Bernard JP Potential adverse events of endosseous dental implants penetrating the maxillary sinus: Long-term clinical evaluation. Laryngoscope. 2013 Dec;123(12):2958-61. doi: 10.1002/lary.24189. Epub 2013 Oct 2.

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Topic: Maxillary sinus arteries

Authors:Solar P, et al.

TitleBlood supply to the maxillary sinus relevant to sinus floor elevation procedures

Source: Clin Oral Implants Res. 1999 Feb; 10 (1):34-44.

Type: Clinical

Keywords: sinus floor elevation, maxillary artery, posterior superior alveolar artery, infraorbital artery, blood supply

Purpose: To evaluate maxillary arteries relevant to sinus floor elevation surgery and examine the vascularization of the lateral maxillary after tooth loss.

Material and methods: The vessels of the lateral maxilla of 18 maxillary specimens (10 males, 8 females, mean age 67 years) were prepared anatomically and the local main arties, the number of macroscopically discernible branches and anastomoses, their calibers, and the distance between the caudal main branches and the alveolar ridge recorded.

Results:  The lateral maxilla is supplied by branches of the posterior superior alveolar artery (PSAA) and the infraorbital artery (IOA)that form an anastomosis in the bony lateral antral wall, which also supplies the schneiderian membrane.

This intraosseous anastomosis was found in ALL of the specimens.

8/18 (44.4%) also showed an extraosseous anastomosis between PSAA and IOA.

PSAA had a mean caliber of 1.6mm and exhibited an average of 2 endosseous and 1 extraosseous branches.

IOA had a mean diameter of 1.6mm and showed an average of 1 endosseous and 3 extraosseous branches.

The mean distance between the intraosseous anastomosis and the alveolar ridge was 19mm and in 2 defined measuring sites. Mean length was 44.6mm.

The epiperiosteal vestibular anastomosis was situated further cranially, at a mean distance of 23-26mm from the alveolar ridges and had a mean length of 46mm.

Conclusion:Large caliber of the vessels supplying the lateral antral wall seems to be crucial to the fact that the periosteal blood supply is maintained even in severe maxillary atrophy and after complete disappearance of the centro-medullary vessels.

Topic: Maxillary sinus

Authors: Ulm CW, Solar P, Krennmair G, Matejka M, Watzek G.

Title:Incidence and suggested surgical management of septa in sinus-lift procedures.

Source: Int J Oral Maxillofac Implants. 1995 Jul-Aug;10(4):462-5.

Type:Cross sectional study

Rating: Good

Keywords: sinus, septum, septa

Background: A variable number of septa, also referred to as Underwood’s septa, divide the floor of the maxillary sinus into several recesses and may thus cause various complications during sinus-lift procedures.

Purpose: To examine the incidence, location, and height of Underwood’s septa.

Methods: 41 edentulous maxillas obtained from the collection of the Department of Anatomy of the University of Vienna were examined. The mean age of the deceased was 76 years. The maxillary sinus was exposed from the cranial aspect by a horizontal section below the floor of the orbits, then the alveolar recess of the antrum was examined. Only those bone lamellae were considered as septa that showed a height of at least 2.5 mm were recorded.

Results: In 13 of these maxillas (31.7% of the cases), sinus floors with at least one septum were observed. 26.8% showed one septum, whereas 4.9%) exhibited two septa. Most of the septa were located in the region between the second premolar and the first molar. The mean height of the septa was 7.9 mm, with the highest septum showing a height of 17 mm.

Conclusion:One third of the the maxillas studied had a septa. A possible cause of septal formation could be the variable phases of maxillary sinus pneumatization of the empty alveolar process followind tooth extraction.

Topic:Maxillary sinus septa

Authors:Pommer B, Ulm C, Lorenzoni M, et al.

Title:Prevalence, location and morphology of maxillary sinus septa: systematic review and meta-analysis.

Source:J Clin Periodontol. 2012 Aug;39(8):769-73.

Type:Meta-analysis

Rating:Good

Keywords:dental implants, maxillary sinus floor elevation, radiographic diagnosis, sinus anatomy, sinus membrane perforation.

Purpose:To examine the literature regarding prevalence, predominant location, and morphologic variability of maxillary sinus septa.

Method:Literature search (electronic and hand) of English literature from 1995-2011. Only septa 2-4 mm or higher were included. 33 publications made the final selection.

Results:8923 sinuses were examined, septa were present 28.4% of the time. Prevalence was slightly higher in atrophic sinuses when compared to dentate sinuses. Septa were more common in the molar region (54.6%) than the premolar (24.4%) and retromolar (21.0%) regions. Orientation of the septa was most often transverse (87.6%). Average septa height was 7.5mm. Complete septa (dividing entire sinus) was rare (0.3%). Multiple septa in one sinus only occurred 4.2% of the time and bilateral septa was found 17.2%. Panoramic diagnosis of septa was found to be incorrect 29% of the time.

Conclusion:3D radiographic imaging should be used to help reduce complication rates in the presence of maxillary sinus septa

Topic: Sinus Lift

Authors:Wallace SS, Tarnow DP, Froum SJ, Cho SC, Zadeh HH, Stoupel J, Del Fabbro M, Testori T.

Title: Maxillary Sinus Elevation by Lateral Window Approach: Evolution of Technology and Technique

Source: J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):161-71.

Type: Review

Rating: Good

Keywords: Maxillary sinus augmentation, maxillary sinus elevation, sinus augmentation technique, sinus bone grafts, xenografts, piezosurgery, DASK

Purpose: To follow the evolution of the 2 most important trends in lateral window sinus augmentation surgery: the transition from autogenous bone to bone replacement grafts as a donor material and the desire to develop a surgical technique that is simpler to perform and has the least chance for complications.

Method: Data on grafting materials and implant survival rates came from 10 published evidence-based reviews that include all relevant published data from 1980 to 2012. Supporting clinical material comes from the experience of the authors.

Results: The evidence-based reviews report and compare the implant survival rates utilizing various grafting materials, implant surfaces, and the use or non-use of barrier membranes over the lateral window. Clinical studies report on complication rates utilizing piezoelectric surgery and compare them to complication rates with rotary instrumentation.

Conclusion:The utilization of bone replacement grafts, rough-surfaced implants, and barrier membranes result in the most positive outcomes when considering implant survival. Further, the utilization of piezoelectric surgery, rather than rotary diamond burs, for lateral window preparation and membrane separation leads to a dramatic reduction in the occurrence of the intraoperative complications of bleeding and membrane perforation.

Topic: Maxillary Sinus

Title: Indirect osteotome maxillary sinus floor elevation: an update

Author: Romero,  et al

Source: Journal of Oral Implantology. 2012 Dec;38(6):799-804.

Type: Literature Review

Rating: Good

Keywords:indirect sinus elevation, osteotome technique, osteotome sinus floor elevation

B:Indirect osteotome maxillary sinus floor elevation (OMSFE) is generally employed when the

residual bone height is equal to or greater than 6 mm; in cases with higher resorption, the direct sinus elevation technique is used. Advantages: the surgery is more conservative, sinus augmentation is localized, there is a low rate of postoperative morbidity, a shorter time to implant loading is possible than with the direct technique, and high survival rates of around 90% are obtained.

P: To review publications reporting on indirect OMSFE; to evaluate the influence of the graft material, the gain in bone height, and the amount of bone resorption; to assess the complications

of this surgical technique and the survival rates of implants placed in these areas.

M&M: Studies published between 1999 and 2010 on patients with a minimum of 1 year of follow-up were analyzed. Ninety-seven articles were identified, of which 83 studies were excluded; Fourteen studies were included. Indirect OMSFE is indicated for a bone height of 6-8 mm.

R: More bone height was gained when graft material (deproteinized bovine bone, autologous bone with xenograft and or allograft) was used. Schneiderian membrane perforation was the most frequent complication. Survival rates varied between 93.5% and 100%. 

BL:Osteotome sinus membrane elevation is a predictable and effective procedure for placing implants in areas of the posterior maxilla with low bone height.

CR:It is a good systematic review with carefully screened articles and briefly outlines the surgical procedure, grafts and post op complications. However, there is a need for larger pool of articles for review.

Topic:sinus lift with piezo osteotome

Authors: Zhen F, Fang W,

Title:The use of a piezoelectric ultrasonic osteotome for internal sinus elevation: a retrospective analysis of clinical results

Source:Int J Oral Maxillofac Implants. 2012 Jul-Aug;27(4):920-6

Type:retrospective analysis

Rating: good

Keywords: dental implants, internal sinus elevation, maxillary sinus, piezoelectric ultrasonic osteotome

Purpose:To evaluate the clinical outcome of maxillary internal sinus floor augmentation with the use of piezoelectric osteotome, in conjuction with implant placement.

Methods:Patients needing implant in post maxilla with pneumatization of the maxillary sinus were enrolled. Sinus augmentation with piezo osteotomes and implant placement (immediate or delayed) were performed.

Results:30 patients in need of 36 implants with insufficient alveolar bone height in maxilla were selected. 28 immediate and 8 delayed implants were placed. Systemic antibiotics prescribed. Only 1 membrane perforated (2.78%, which is much lower than what the literature shows, ranging from 5% to 85%) and one implant lost. No mobility or rapid bone loss seen in the rest of the implants. (5-27-month follow-up)

Discussion:Precautions;

• Pressure control: cutting efficacy of the piezo is not increased by applying additional pressure. The pressure may be transferred into heat and damage the tissue. Different bone modes and frequencies should be chosen according to the density and thickness of the bone.

• Directional control: both the tip and side walls of OT4 and OP4 are cutting. Therefore, pressure should be directed toward the bottom of the cavity.

• Use of negative pressure:

Conclusion: Application of a piezoelectric osteotome for internal sinus elevation simplified manipulation of the membrane and greatly reduced the chance of perforation.

Critique:small number of cases.

Topic:Anatomy of Maxillary Sinus

Author:van den Bergh JP

Title:Anatomical aspects of sinus floor elevations

Source:Clin Oral Implants Res 2000;11(3):256-265

Type:Review

Rating: Good

Keywords:anatomy, maxillary sinus, sinus lifting, sinus floor elevation, bone grafting

Purpose:To review the anatomical considerations in regards to the maxillary sinus.

Discussion:

Anatomy of the maxillary sinus

• A pyramidal shaped cavity in the facial skull, with its base at the lateral nasal wall and its apex extending into the zygomatic process.

• Sinus is internally lined with a thin mucosa of “ciliated” respiratory epithelium, which is continuous with that of the nose. This ciliated epithelium has a transport function for fluids like pus and mucus towards the internal ostium.

• Pneumatization seems to complete at the end of the growth to approximately 12-15 cm^3

• Average dimension of adult maxillary sinus:

  • Width: 25-35mm

  • Height: 36-45mm

  • Length: 38-45mm

• Convex sinus floor usually reaches its deepest point at the first molar region.

• At the edentulous stage of life, the size of the maxillary sinus will increase further. The process of Pneumatization can vary from person to person and side to side. Apart from inner expansion of the sinus, the outer aspect of the alveolar process is also thinned.

• Blood supply of maxillary sinus: Infra-orbital artery, the greater palatine artery and the posterior superior alveolar artery

• The two most important walls in regards to sinus floor elevation:

  • Anterior/Buccal wall: thin compact bone, containing neurovascular canals to the ant teeth

  • Internal/Nasal wall: covered by musculo-periosteal tissue, containing the facial artery and vein, the lymphatic system and the infra orbital nerves.

• Internal wall has a rectangular shape and forms the bony septum between the nasal and maxillary sinus.

• The inferior portion of the internal wall corresponds with the inferior meatus of the nasal cavity.

• In the middle of the internal wall is the sinus hiatus

Surgical considerations with regard to the anatomy

• The flap design: incision is made on the top of the alveolar ridge, or slightly palatal.

• The sinus floor: Shape of the door should ideally follow the inner shape=curved. Rounded corners with a usually wide cranial hinge based are used. Rounded corners reduces the chance of damaging the Schneiderian membrane

• Lateral sinus wall preparation: If the lateral sinus wall consists of thick bone the whole lateral sinus wall should be thinned out. Too thick of bone makes it extremely difficult to release the membrane from the inner aspect of the bony sinus. Door luxation is best performed with finger pressure.

  • Healthy membrane= dark greyish-blue

  • Smoker membrane= atrophic and be extremely thin and fragile to touch

  • Chronic sinusitis membrane=thick and spongy

• The Schneiderian membrane: Freeing the membrane from bone floor using instruments designed by Tatum. Starts at the caudal edge slowly and carefully working towards the mesial and distal sides of the sinus. Overfilling with grafting materials may cause necrosis of the Schneiderian membrane. Previous sinus surgery results in scar tissue formation, and might be a contraindication for sinus lift procedures.

• Schneiderian membrane perforations: Most likely to happen at sharp edges and ridges like Underwoods septa and at spines.

  • Small perforation and located in an area where elevated mucosa folds together when lifting the door: no need for further measurements

  • Large and unfavorable areas: Perforation needs to be closed and covered with a resorbable membrane and bioglues. Re-entry might be considered, but must wait 6-8 weeks.

• Maxillary sinus septa: Especially more prominent in younger adults. Divide the caudal part of the sinus in multiple compartments known as recesses. These septa act as a masticatory force carrying struts during the dentate phase of life. These septa seem to disappear slowly when teeth have been lost.

  • Septum located at the bottom of the sinus: door can be of normal shape

  • Septum located higher: door must either follow the contour making a W-shape or two trap doors, or it must be located on one side of the septum (usually mesial)

• The narrow sinus: A narrow sinus is rare. One option is to do an antrostomy on the lateral sinus wall instead of a door preparation.

• Hemorrhages:Hemorrhages during sinus grating are rare, since the main arteries are not within the surgical area.

• Bone grafting, bone healing and remodeling: Healing and remodeling of the graft material depends on the vascularization of the Schneiderian membrane, buccal muco periosteal flap, the bone segments of the former sinus floor, and the elevated sinus wall. Therefore its an advantage to save the bony trapdoor (Tatum, 1986).

• Primary alveolar bone height and width: Primarily stability of the implant determines if one or two stage surgery should be used with sinus lift procedures

  • One stage: at least 4mm of bone height of the original alveolar process

  • Two stages: less than 4mm of bone height. Implant should be placed 4 to 6 months after sinus floor grafting.

Topic: Maxillary implants

Authors:Penarrocha-Diago, M et al

Title: Benign Paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: A study of 4 cases

Source: Int J Oral Maxillofac Implants 2008:23:129-132

Type: Case study

Rating: Good

Keywords: benign paroxysmal positional vertigo, dental implants, osteotomes

Purpose: To discuss the etiology, diagnosis, treatment, and prevention of benign paroxysmal positional vertigo (BPPV) following osteotome prepatation of implant beds.

Methods: 812 implants were placed on 320 patients between 1996 and 2004. 4 of these patients developed BPPV (1.25%).

Clinical cases of BPPV:
Case	Age	Sex:	Eduntulism:	No. implants:	Hx of vertigo:	Onset of vertigo:	Treatment:	Evolution:
			Total			Following Sx	rest/antivertigo
			Total			Following Sx	rest/antivertigo/Epley maneuver
			Total			1 week after Sx	rest/antivertigo
			Partial (max L)			Following Sx	rest/antivertigo/Epley maneuver

Conclusion: BPPV is characterized by short, recurrent episodes of vertigo initiated by certain head lateralization and extension movements toward the affected side. It usually presents in middle age and could have a degenerative component. The most accepted theory as to mechanism of BPPV is canalithiasis- free-floating particles detach from the macula and gravitate into the endolymph of the semicircular canal. Treatment consists of maneuvers to restore the calcic carbonate crystals from the anomalous location in the semicircular canal to their correct place in the utricle (Epley maneuver). During placement of maxillary implants using the osteotome technique, trauma induced by the percussion along with hyperextension of the neck during the procedure can displace otoliths and produce BPPV. Minimizing trauma when using this technique is advised to reduce the incidence of BPPV, especially in older patients.

Topic:Complications

Authors:Fugazzato & Vlassis

Title:A Simplified Classification and Repair System for Sinus Membrane Perforations

Source:JOP October 2003, vol. 74, No. 10; 1534-1541

Type:Classification & case series

Rating:

Keywords:Maxillary sinus/surgery; maxillary sinus augmentation

Purpose:Present a classification and repair system for management of sinus perforations based on their location and severity

Background: The efficacy of sinus augmentation therapy and the attainment of an increased bone volume in the maxillary posterior region has been documented through animal and human histologic evaluations and clinical case reports.Implant success rates in these augmented areas are comparable to the success rates of implants placed in non-regenerated bone, both in the maxillary posterior regions and other areas of the mouth.However, the presence of preexisting Schneiderian membrane perforations, or the creation of a membrane perforation at the time of sinus augmentation, may cause clinicians to pause and reevaluate the feasibility of performing the planned augmentation therapy, and implant placement, during the same visit.

CLASSIFICATION FIRST BY LOCATION

CLASS I Perforations: occur at any point along the most apical wall of the prepared sinus window

CLASS II Perforations: occur along the lateral or crestal aspects of the prepared sinus window, further subdivided according to their relative positions to the most mesial, distal, or crestal extension of the underlying sinus

CLASS III Perforations: occur at any location within the body of the prepared sinus window.

*Upon discovery of any perforation, AVOID MANIPULATION of the membrane to ascertain the size of the tear. Will likely have to extend mesial and distal releasing incisions to fully visualize and access the extent of perforation.

Classification	Description	Affect of tx seq.
I	See above	NONE; place implant after sealing the perforation if 1 stage was planned.
II	See above	Dependent upon position of membrane perforation with relation to bordering walls of the sinus cavity to be augmented.
IIA	Perforation anywhere in the lateral or coronal walls of the prepped sinus window, when sinus cavity to be augmented extends a 4-5 mm minimum beyond the membrane perf.	Repair perforation and place implant as planned
IIB	When the prepared aspect of the sinus window approxi- mates the extension of the sinus cavity in this area, no additional space exists for performance of a fur- ther osteotomy to uncover intact sinus membrane beyond the perforated area.	Only sinus augmentation performed that day.
III	Preexisting or iatrogenic membrane tear causing oro-antral fistula	Treated as class IIB

*MATERIAL MODIFICATION BASED ON MATERIAL SELECTION:

–Non-autogenous particulate – first mixed with microfibrillar collagen.

-Osseous coagulum +non-autogenous particulate or bone blocks: no need to add microfibrillar collagen

– Use of PRP obviates need for microfibrillar collagen.

*Post op Therapy: CHx rinses bid for 21 days, amoxicillin 500X30 tid for 10days; don’t blow nose for 10 days. No removable prosthesis prior to suture removal @ 10-12 days.

If implants placed at time of augmentation – wait 8 months for uncover. If 2^nd stage surgery, placement is at 8 months post augmentation.

Materials and Methods:

Results:

Nineteen patients were treated for detectable sinus membrane perforations that were noted during sinus augmentation therapy. The classification of these perforations, the course of therapy, and the subse- quent treatment outcome are noted in Table 1. All patients eventually received implants that were restored and are functioning successfully accord- ing to the Albrektsson et al. criteria9 as confirmed through clinical and radiographic evaluation at the time of statistical compilation. The following short case reports are indicative of patient experiences.

Conclusions: There is no doubt that an intact Schneiderian membrane pro- vides a significant containing func- tion for inserted graft materials and the subsequent forming blood clot. Presence of a torn Schneiderian membrane encoun- tered during sinus augmentation therapy should not be viewed as a contraindication to either pro- ceeding with planned augmenta- tion with or without simultaneous implant placement, or to the attain- ment of satisfactory sinus aug- mentation results. Utilization of a repair and classification system, which directly relates to sinus membrane perforation location and treatment options, enhances the delivery of pre- dictable sinus augmentation therapy. Regardless of the

type and severity of sinus membrane perforation encountered, acceptable augmentation results are obtainable.

Topic: Sinus Membrane Perforations

Author: Froum SJ

Title: Effect of maxillary sinus membrane perforation on vital bone formation and implant survival: a retrospective study

Source: Journal of Periodontology, August 2013, Vol. 84, No. 8, Pages 1094-1099

Type: Retrospective Study

Rating: Good

Keywords: Bone grafting, dental implant, histology; sinus floor augmentation

Purpose: to evaluate the effect of the maxillary sinus membrane perforation (MSMP) on the percentage of vital bone and implant survival obtained after the sinus augmentation procedure (SAP).

Methods: Data were obtained retrospectively from an Institutional Review Board–approved anonymous database at New York University, Kriser Dental Center, Department of Periodontology and Implant Dentistry, New York, New York, from 23 patients (10 males, and 13 females; The age range of patients included was 46 to 75 years and the mean was 59 years) who had undergone SAP with a total of 40 treated sinuses. Sinuses were grafted with mineralized cancellous bone allograft (MCBA), anorganic bovine bone matrix (ABBM), or biphasic calcium phosphate (BCP). Perforation complications occurred in 15 sinuses with 25 non-perforated sinuses. All perforations were repaired during surgery with absorbable collagen membrane barriers. Histologic cores were taken from all treated sinuses 26 to 32 weeks after surgery. The implant success rate of 79 placed implants was recorded.

Results:

1. The implant success rate in perforated sinuses was 100% (35 of 35) compared with the non-perforated sinuses with 95.5% (43 of 45).

2. There was no statistical significance in implant failure between non-perforated sinuses and implant failure in the perforated group.

3. There was a statistically significant difference in the vital bone percentage between the non-perforated (19.1%) and perforated (26.3%) sinuses. There was no statistically significant effect for treatment.

4. The average percentage of vital bone was 28.25% for MCBA, 12.44% for ABBM, and 30.6% for BCP.

Conclusion:treated sinuses that exhibited MSMPs that occurred during the SAP (which were treated during surgery) showed statistically significant greater vital bone percentages compared with the non-perforated sinus group. However, there were no statistically significant differences in implant survival in the non-perforated versus perforated sinus groups.

Topic: Repair of perforated sinus membrane

Authors: Proussaefs P, Lozada J, Kim J, Rohrer MD.

TitleRepair of the perforated sinus membrane with a resorbable collagen membrane: a human study

Source: Int J Oral Maxillofac Implants. 2004;19(3):413-420

Type: Clinical

Keywords:artificial membranes, collagen, dental implants, maxillary sinus, sinus augmentation, sinus membrane.

Purpose:to evaluate the results of the repair of perforated sinus membrane with resorbable collagen membrane.

Materials and methods:

• A split-mouth design was followed of 12 patient requiring bilateral sinus grafting were included.

• One site had been “accidentally” perforated during sinus augmentation, and the other site had not been perforated.

• The perforation was repaired with a resorbable collagen membrane.

• Dental implants were placed during a second surgery 6-9 months after graft, and biopsy samples were harvested from both sinuses during implant placement.

• New bone formation was measured for all sites. Implant survival was recorded at second-stage surgery. Panoramic radiographic were taken before/after sinus grafting and after implant placement.

Result:

	Nonperforated sites	Perforated sites	P value
Bone formation	33.58% ± 7.45%	14.17%± 7.06%	<.0001
Soft tissue formation	48.5% ± 12.57%	63.58% ± 12.96%
Residual graft particles had their surface in contact with bone.	40.17% ± 14.92%	14.5% ± 12.03%	<.0001
Implant survival rate at second stage surgery		69.56%	.0028

Conclusion:Repairing the perforated site of the sinus membrane with resorbable collagen membrane may result in reduced bone formation and implant survival rate.

BL:perforation and repair of the sinus membrane may compromise new bone formation and implant survival.

Critics:

• Small sample size.

• The authors didn’t mention the size and the severity of the perforation. It was only mentioned larger than 2mm.

• Only placing a collagen membrane without being using tacks for stability (Pikos technique) for a larger perforation may not be adequate for the repair.

Topic:  Maxillary sinus

Authors: Cho SC, Wallace SS, Froum SJ, Tarnow DP

Title: Influence of anatomy of Schneiderian membrane perforations during sinus elevation surgery: three-dimensional analysis.

Source: Pract Proced Aesthet Dent 2001; 13:160-163.

Type: Cross sectional study

Rating: Good

Keywords: sinus, Schneiderian, membrane

Purpose: o determine if variations in sinus anatomy influenced the perforation rate of the Schneiderian membrane .

Methods: Residents under the supervision of faculty performed 49 randomly selected sinus elevation procedures on 34 patients. Preoperative radiographic evaluation included panoramic Xray and CT scan. Three anatomic variations were selected for evaluation. Each of these variables consisted of the angle formed by intersection of bony walls relating to the inverted pyramid-shaped maxillary sinus. For purpose of comparison each angle was divided into three groups. Group I: specimens with an angle of 30 degrees or less. Group II: Angles between 31 to 60 degrees. Group III: Angles of 61 degrees of greater.  These measurements were analyzed to investigate any correlation between the anatomic variables and the experienced perforation rate.

Results: Of the 49 sinus elevation procedures, nine resulted in visible perforations of the Schneiderian membrane. If perforation occurred an absorbable barrier membrane would be use to occlude the perforation. Only the different groups within angle A demonstrated a significant correlation with the observed perforations. The perforation rates were Group I: 37.5%, Group II: 28.6% and Group III: 0%

Conclusion:The greatest risk of perforation is when the sinus is narrow, mostly on the anterior portion of the sinus.

Topic:Classification for sinsus membrane perforation

Authors:Vlassis JM, Fugazzotto PA.

Title:A classification system for sinus membrane perforations during augmentation procedures with options for repair.

Source:J Periodontol 1999;70(6):692-699.

Type:Case study

Rating:Good

Keywords:Alveolar ridge augmentation, dental implants, endosseous, grafts, bone, maxillary sinus/injuries, Schneiderian membrane

Purpose:To propose a classification for sinus membrane perforation during sinus augmentation and options for repair.

Method:Case study of five perforations, classify them, and make recommendations for repair.

Results:Classification was determined by both position and extent. Be sure to isolate the area to maintain a clear field.

Class 1: Often are sealed off as a result of folding of the membrane across itself. If this occurs no further steps need to be taken other than being delicate when packing membrane material. If perforation still evident after reflection, collagen tape is placed over the area to cover the perforation 3 mm in all directions. Graft is placed in the location of the collagen tape last. If the collagen tape does not suffice a resorbable material can be sutured with the membrane to close the perforation.

Class II: Located in the mid-superior aspect of the osteotomy, extending mesiodstially for 2/3 the dimension of the osteotomy. Typically happens when reflecting with the intact internal portion of the osteotomy rather than a detached window. To repair you can try reflecting the rest of the membrane to see if it folds over on itself. If this does not occur, collagen tape, a resorbable membrane, or freeze-tried human lamellar bone sheets can be used to cover the perforation. Suturing is also an option.

Class III: Located in the inferior border of the osteotomy at its mesial or distal sixth. This is the most common perforation, and often results from inadequate osteotomy design or improper membrane reflection. Round edged osteotomy helps to reduce this risk. You may attempt to relieve the margins of the tear and then follow up by suturing them together and cover with a lamellar bone sheet. Graft material must first be placed on the borders of the lamellar bone sheet to stabilize the sheet over the perforation and then over the bone sheet. This is difficult and not always practical. A final attempt to repair a Class III is to trim a lamellar bone sheet and place it within the osteotomy site so that a pouch is created over the perforation. Graft material is then placed all around the bone sheet to stabilize it but this approach is not as stable as the others.

Class IV: Located in the central two thirds of the inferior border of the osteotomy site and often enlarges dramatically as management is attempted. This is relatively rare but can be seen in improper septal elevation. If both margins around the tear can be elevated then the tear should be sutured and covered with a lamellar bone sheet. If suturing is not feasible, an attempt may be made at enlarging the osteotomy site (may not be possible depending on the position to the crest of the alveolar ridge). Again if these attempts fail a pouch can be made with a lamellar bone sheet.

Class V: Perforation that results in inadequate residual bone between the most inferior border of the sinus and alveolar crest. A prior oral-antral fistula may have been a contributing factor. Perforation is often only evident following flap reflection.

Class 1 and Class II perforations are more easily repaired. Class IV perforations is the most difficult to successfully treat.

Conclusion:When classified and managed appropriately, sinus membrane perforations are not an absolute indication for aborting the augmentation procedure while in progress.

Topic: Sinus Lift

Authors:Jensen SS, Eriksen J, Schiodt M.

Title: Severe bleeding after sinus floor elevation using the transcrestal technique: a case report.

Source: Eur J Oral Implantol. 2012 Autumn;5(3):287-91.

Type: Case Report

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 rhBMP with wire mesh, sonic weld, block grafts, titanium reinforced membranes. Nerve transposition

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Implant success/survival. Complications

1. Proussaefs P, Lozada J, Kleinman A, Rohrer MD. The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement: a pilot study. Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):238-48

2. Proussaefs P, Lozada J. The use of intraorally harvested autogenous block grafts for vertical alveolar ridge augmentation: a human study. Int J Periodontics Restorative Dent. 2005 Aug;25(4):351-63.

3. Merli M, Lombardini F, Esposito M. Vertical ridge augmentation with autogenous bone grafts 3 years after loading: resorbable barriers versus titanium-reinforced barriers. A randomized controlled clinical trial. Int J Oral Maxillofac Implants. 2010 Jul-Aug;25(4):801-7.

4. Urban IA, Lozada JL, Jovanovic SA, Nagursky H, Nagy K. Vertical ridge augmentation with titanium-reinforced, dense-PTFE membranes and a combination of particulated autogenous bone and anorganic bovine bone-derived mineral: a prospective case series in 19 patients. Int J Oral Maxillofac Implants. 2014 Jan-Feb;29(1):185-93

5. Guze KA, Arguello E, Kim D, Nevins M, Karimbux NY. Growth factor-mediated vertical mandibular ridge augmentation: a case report. Int J Periodontics Restorative Dent. 2013 Sep-Oct;33(5):611-7.

6. Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA. Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement. J Oral Maxillofac Surg. 2008 Feb;66(2):235-45.

7. Louis PJ. Vertical ridge augmentation using titanium mesh. Oral Maxillofac Surg Clin North Am. 2010 Aug;22(3):353-68

8. Todisco M. Early loading of implants in vertically augmented bone with non-resorbable membranes and deproteinised anorganic bovine bone. An uncontrolled prospective cohort study. Eur J Oral Implantol. 2010 Spring;3(1):47-58.

9. Lorean A, Kablan F, et al. Inferior alveolar nerve transposition and reposition for dental implant placement in edentulous or partially edentulous mandibles: a multicenter retrospective study. Int J Oral Maxillofac Surg. 2013 May;42(5):656-9.

10. Friberg, G et al: Inferior Alveolar Nerve Transposition in Combination with Branemark Implant Treatment. I nt. J Perio Rest Dent 12:441-450, 1992

11. Proussaefs P. Inferior alveolar nerve transposing in a situation with minimal bone height: a clinical report. J Oral Implantol. 2005;31(4):180-5.

12. Chiapasco M et al: Vertical distraction osteogenesis of edentulous ridges for improvement of oral implant positioning: A clinical report of preliminary results. Int J Oral Maxillofac Implants 16:43-51,2001

13. Spagnoli DB, Marx RE. Dental implants and the use of rhBMP-2. Dent Clin North Am. 2011 Oct;55(4):883-907

14. Simion M et al: Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1-5 year follow-up. Clin Oral Implants Res: 12:35-45, 2001

15. Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading. Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):502-10.

16. Clementini M, Morlupi A, Canullo L, Agrestini C, Barlattani A. Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: a systematic review. Int J Oral Maxillofac Surg. 2012 Jul;41(7):847-52.

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Authors: Proussaefs P, Lozada J, Kleinman A, Rohrer MD.

Title: The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement:

Source: Int J Oral Maxillofac Implants. 2002 Mar-Apr;17(2):238-48

Type: a pilot study.

Rating: Good

Keywords: block graft, vertical ridge augmentation

Purpose:This study presents a clinical, radiographic, laboratory, and histologic/histomorphometric analysis of the use of mandibular ramus block autografts for vertical alveolar ridge augmentation and implant placement.

Materials and Methods: pts (2 men and 6 women, mean age 65) participated in this study.Autogenous block autografts were fixed at the recipient site with fixation screws while a mixture of autogenous bone marrow and inorganic bovine material (Bio-Oss) was used at the periphery. All grafts appeared well incorporated at the recipient site during re-entry surgery.

Results:

• Radiographic measurements revealed an average of 6.12 mm vertical ridge augmentation 1 month after surgery and 5.12 mm 4 to 6 months after surgery.

• Laboratory volumetric measurements revealed an average of 0.91 mL alveolar ridge augmentation 1 month after surgery and 0.75 mL 6 months postoperatively. Linear laboratory measurements revealed 6.12 mm of vertical ridge augmentation 1 month postoperatively and 4.37 mm 4 to 6 months after surgery.

• Histologic evaluation indicated signs of active remodeling in all the specimens.

• Histomorphometric analysis of the peripheral particulate bone indicated bone present at 34.33% of the grafted area, while 42.17% of the area was occupied by fibrous tissue and 23.50% by residual Bio-Oss particles.

Conclusion:

1. Mandibular block autografts can maintain their vitality when used for vertical alveolar ridge augmentation.

2. An average of 5.12 mm of vertical ridge augmentation was achieved and 17% resorption was seen 4 to 6 months after bone grafting.

3. Late graft exposure may not necessarily result in graft necrosis, while early exposure may result in compromised healing and partial graft necrosis.

4. Inorganic bovine mineral (Bio-Oss) can be used at the periphery of the block graft when mixed with autogenous bone marrow. This mixture resulted in an average of 34.33% bone formation in this series.

Topic: Vertical Augmentation

Authors:Proussaefs P, Lozada J

Tittle: The use of intraorally harvested autogenous block grafts for vertical alveolar ridge augmentation: a human study.

Source: Int J Periodontics Restorative Dent. 2005 Aug;25(4):351-63.

Type: Clinical study

Rating: Good

Keywords: Vertical Augmentation

Purpose: This study presents a clinical, radiographic, laboratory, and histologic/histomorphometric analysis of the use of mandibular block autografts for vertical alveolar ridge augmentation.

Methods: 12 patients received autogenous block autografts. These were fixated at the recipient sites with screws, and a mixture of autogenous bone marrow and inorganic bovine mineral (Bio-Oss) was used at the periphery.

Results:

• At re-entry surgery, all the grafts appeared well incorporated at the recipient sites.

• Radiographic measurements revealed an average of 5.75 ± 1.29 mm vertical ridge augmentation at 1 month after surgery and 4.75 ± 1.29 mm at 4 to 6 months after surgery. This indicated 17.4% resorption.

• Histologic evaluation of the block autografts indicated signs of active remodeling activity in 10 of the 12 specimens.

• In one case the block graft became exposed and infected, and in another case the block autograft became dislodged during implant placement surgery.

• Histomorphometric analysis of the peripheral mixture of particulate results in an aver- age of 33.99% bone formation, while 42.43% of the area was occupied by fibrous tissue and 23.89% was made up of residual Bio-Oss particles. Residual Bio-Oss particles were in tight contact with newly formed bone along 58.57% of their perimeter.

Conclusions: Mandibular block autografts can maintain their vitality when used for vertical alveolar ridge augmentation.

 

Topic: Resorbable barrier vs titanium-reinforced barriers

Authors: Merli M, Lombardini F, Esposito M.

Title: Vertical ridge augmentation with autogenous bone grafts 3 years after loading: resorbable barriers versus titanium-reinforced barriers. A randomized controlled clinical trial.

Source: Int J Oral Maxillofac Implants. 2010 Jul-Aug;25(4):801-7.

Type: Clinical study

Rating: Fair

Keywords: dental implants, guided bone regeneration, peri-implant bone levels, vertical augmentation

Purpose: To compare vertical bone regeneration at implant placement results using resorbable collagen membranes versus non-resortable titanium reinforced membranes.

Method: 22 patients requiring vertical bone augmentation were split into two groups, resorbable and non-resorbable membranes. Prosthetic and implant failures, complications, the amount of vertically regenerated bone, and peri-implant marginal bone levels were recorded by independent and blind assessors. Follow-up time ranged from provisional loading to 3 years after loading.

Result: No prosthetic or implant failures or complications occurred after loading. There was NSSD in bone loss between the two groups at 1 or 3 years. Both groups had gradually lost a SS amount of peri-implant bone at 1 and 3 years. At year 3, patients treated with resorbable membranes lost a mean of 0.55 mm of bone and those treated with non-resorbable membranes lost 0.53 mm.

Conclusion: Vertically regenerated bone can be successfully maintained after functional loading at 3 year follow up. There is no difference between the resorbable and non-resorbable barriers for this application.

Topic: Vertical ridge augmentation

Authors: Urban IA, Lozada JL, Jovanovic SA, Nagursky H, Nagy K.

Title:Vertical ridge augmentation with titanium-reinforced, dense-PTFE membranes and a combination of particulated autogenous bone and anorganic bovine bone-derived mineral: a prospective case series in 19 patients

Source:Int J Oral Maxillofac Implants. 2014 Jan-Feb;29(1):185-93

Type: Case Series

Rating: Good

Keywords:anorganic bovine bone-derived mineral, case series, guided bone regeneration, nonresorbable membrane, verticial augmentation.

Purpose: This prospective case series evaluated the use of a new titanium-reinforced nonresorbable membrane (high-density polytetrafluoroethylene), in combination with a mixture of anorganic bovine bone-derived mineral (ABBM) and autogenous particulated bone, for vertical augmentation of deficient alveolar ridges.

Method: A mixture of ABBM and autogenous particulated bone was used for vertical ridge augmentation and covered with a new titanium-reinforced nonresorbable membrane. Ridge measurements were obtained before and after the procedure, complications were recorded, and biopsy specimens were taken for histologic examination.

Results: Twenty vertical ridge augmentation procedures were carried out in 19 patients. All treated defect sites exhibited excellent bone formation, with an average bone gain of 5.45 mm (standard deviation 1.93 mm). The healing period was uneventful, and no complications were observed. Eight specimens were examined histologically; on average, autogenous or regenerated bone represented 36.6% of the specimens, ABBM 16.6%, and marrow space 46.8%. No inflammatory responses or foreign-body reactions were noted in the specimens.

Conclusion: The treatment of vertically deficient alveolar ridges with guided bone regeneration using a mixture of autogenous bone and ABBM and a new titanium-reinforced nonresorbable membrane can be considered successful.

Topic:Ridge augmentation with growth factor

Title: Growth Factor Mediated Vertical Mandibular Ridge Augmentation: A Case report

Author: Guze, K et al

Source: International journal of periodontics and restorative dentistry 2013: 33, 5 611-620

Type: Case report

Rating: Good

Keywords: vertical ridge augmentation, growth factors, guided bone regeneration

Purpose: to demonstrate a proof of principle case report utilizing a composite freeze-dried bone allograft and recombinant human platelet-derived growth factor BB in conjunction with an overlying titanium mesh to regenerate well-vasculatized bone in significant posterior mandibular ridge defect prior to implant placement.

Methods and Materials: 44 year-old woman with left sided unilateral partially endentulous, moderately atrophic mandible with vertical deficiency. Surgery: FTF was reflected to expose ridge, a flexible 0.1mm thick titanium mesh was shaped and refined for graft site. Intramarrow penetrations completed. FDBA was saturated in rhPDGF-BB for 15 minutes and then carefully placed o permit optimal vertical and horizontal bone regeneration to occur. Mesh was then placed over graft and secured with screws. The flaps were closed with no reported tension. Patient was examined at 1, 2, 4, 8, 12, 24 weeks post op. CT scan was taken at 6 months and then a re-entry surgery was done at the same time to place implants. During implant placement bone cores were taken for histology.

Results: During the 24-week follow up no complications were seen. Direct linear measurements revealed an alveolar ridge width of 8mm and an approximately 10mm increase in ridge height. Histo: no native bone was present in the core samples. A number of residual graft particles seen surrounded by newly formed bone.

Conclusion: Within the boundaries of this study, the combination of FDBA, rhPDGF-BB, and titanium mesh may provide a minimally invasive, alternative treatment modality for moderate/severely resorbed alveolar ridge.

Topic: Vertical Augmentation

Authors: Louis PJ, Gutta R, Said-Al-Naief N, Bartolucci AA.

Title: Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement

Source: J Oral Maxillofac Surg. 2008 Feb;66(2):235-45.

Type: Retrospective Study

Rating: Good

Keywords: titanium mesh, particulate bone graft, ridge augmentation

PURPOSE: The purpose of the study was to evaluate the magnitude of ridge augmentation with titanium mesh, overall graft success, anatomic location of ridge defects and their relationship to mesh exposure.

MATERIALS AND METHODS: This retrospective study evaluated 44 patients who received mandibular or maxillary reconstruction with autogenous particulate bone graft and titanium mesh for the purpose of implant placement. Autogenous bone graft was harvested from the iliac crest, tibia, and mandibular symphysis. A total of 45 sites were included in the study. Average augmentation bone heights were measured and compared. Statistical analysis was done with ANOVA and Student’s t test. Histomorphometric analysis was performed on the soft tissue specimen found between the mesh and the bone graft.

RESULTS:Twenty-nine sites underwent mandibular reconstruction and 16 underwent maxillary reconstruction. The mean augmentation in partial maxillary defects was 11.33 +/- 1.56 mm, and in complete maxillary augmentation, the height achieved was 14.3 +/- 1.39 mm. In themandible, mean increase in height for partial defects was 14 +/- 1.42 mm and for complete augmentation it was 13.71 +/- 1.14 mm. The mean augmentation for all sites was 13.7 mm (12.8 mm in the maxilla and 13.9 mm in the mandible). A total of 82 implants were placed in themaxilla and 92 implants were placed in the mandible. In the maxillary group, 7 sites had exposure of the titanium mesh and 16 sites were exposed in the mandible. The success of the bone grafting procedure was 97.72%.

CONCLUSIONS: Porous titanium mesh is a reliable containment system used for reconstruction of the maxilla and the mandible. This material tolerates exposure very well and gives predictable results.

Topic:Vertical ridge augmentation using titanium mesh

Authors: Louis PJ

Title:Vertical ridge augmentation using titanium mesh.

Source: Oral Maxillofac Surg Clin North Am. 2010 Aug;22(3):353-68, v. doi: 10.1016/j.coms.2010.04.005

Type: clinical

Rating: good

Keywords: vertical ridge augmentation; titanium mesh; reconstruction.

Purpose:All of techniques have advantages and disadvantages. This article focuses on augmentation procedures using titanium mesh, which acts as a barrier and physical support of the soft tissue over the bone graft.
Methods:management of edentulous maxilla: full thickness flap; 5 mm below the depth of the maxillary vestibule extending posterior. Superior extent: just below the infraorbital nerve. Sinus lift performed simultaneously. Precontoured titanium mesh is chosen based on desired augmentation. Further contouring if needed. Titanium mesh trays are filled with bone graft material and placed in position and secured with at least 2 screws in facial and at least one in palate. Then the wound can be closed in layers. Titanium mesh can be used on partially edentulous maxilla with a modification of this method.

Atrophic mandible can be augmented with titanium mesh with an intraoral and extraoral approach. In extra oral approach, the incision is made along the submental crease, sharply down to the inferior border of mandible where a subperiosteal dissection is performed. Using this approach, the mental nerves can be easily identified.

Results:

Advantages of titanium mesh:

• Height and width of augmentation, ideal shape.

• Nonresorbable and rigid: The rigidity allows for shape maintenance, which is important when attempting to extend the bony envelope. The soft tissue is placed under tension during an augmentation procedure, thus causing a flattening or deforming of nonrigid membranes and the associated graft. Titanium mesh is rigid and will maintain its shape.

• Biocompatible: can be place subperiosteally.

• Vestibuloplasty at the time of mesh removal

Disadvantages:

• Tendency to become exposed during healing. (although, the risk of infection remains low). The use of vestibular incisions may decrease the risk of exposure.

• Additional contouring needed.

Conclusion: the use of titanium mesh and bone graft is a successful technique in reconstruction of atrophic mandible and maxilla. The main advantage of is the rigidity of the material which prevents collapse and flattening of the graft during ridge augmentation.

Topic:Early implant loading

Author:Todisco M.

Title: Early loading of implants in vertically augmented bone with non-resorbable membranes and deproteinised anorganic bovine bone. An uncontrolled prospective cohort study

Source:Eur J Oral Implantol. 2010 Spring;3(1):47-58.

Type:Prospective cohort study

Rating: Fair

Keywords:bone regeneration; bone substitute; implants; membrane

Purpose: To evaluate the clinical and histological outcomes 1 year after loading of early-loaded implants placed in vertically augmented bone using deproteinised bovine bone (Bio-Oss) and a titanium-reinforced membrane (Gore-Tex)Results:A total of 23 out of 25 sties healed uneventfully. Two sites showed ehe surgery was repeated with success 2 months later. The mean vertical bone gain after GBR was 5.2mm. Histology of five samples showed a total percentage of xenograft and new bone of 52.6%, with dispersed graft particles surrounded by layers of bone. The density of regenerated tissue at drilling was found to be slightly less than the native bone. All implants were stable after 1 year of function (100% survival rate). SS peri-implant bone loss (0.95mm) was observed radiographically from baseline to the 1-year follow-up.

Conclusion: This study shows that by using deproteinised bovine bone and non-resorbable titanium-reinforced membrane, vertical bone gain can be obtained and implants can be loaded after 30 days. The vertical regenerated tissue exhibited good stability over 1 year of implant function.

Criticism: No control was evaluated in this study. The process of standardized radiographs seems to have a lot of room for error.

Topic: Inferior alveolar nerve transposition

Authors: Lorean A, Kablan F, et al.

Title: Inferior alveolar nerve transposition and reposition for dental implant placement in edentulous or partially edentulous mandibles: a multicenter retrospective study

Source: Int J Oral Maxillofac Surg. 2013 May;42(5):656-9.

Type: Retrospective Study

Rating: Good

Keywords: bone width; success; survival; alveolar bone; dental implantation; mandible

Purpose: To evaluate the success and complications following IAN transposition/reposition for dental implant placement in edentulous or partially edentulous mandibles.

Methods: IAN lateralization: Nerve is exposed and traction is used to deflect it laterally while implants are placed. IAN transposition: Corticotomy is done about the mental foramen and the incisive nerve is transected, such that the mental foramen can be positioned more posteriorly. At follow up visits, nerve function was assessed with a 2-point discrimination test, Von Frey test (nociceptor stimulation), and pin prick with a sharp instrument. Findings were recorded.

Results: 68 repositions and 11 transpositions were performed in 57 patients (46 females and 11 males, avg. age 47). 3 patients reported smoking. 232 implants were placed. Average follow up time was 20 months. One implant was lost during the follow up period. 4 patients reported neural disturbances (1 transposition, 3 repositions) following surgery for 1-6 months. Some patients reported short-term disturbances (0-4 weeks). No symptoms were permanent.

Conclusion: IAN transposition and reposition are useful adjunct techniques for the management of severely atrophic posterior edentulous/partially edentulous mandibles, with very low risk of neural dysfunction.

Topic: Inferior Alveolar Nerve Transposition

Authors: Friberg, G et al
Title: Inferior Alveolar Nerve Transposition in Combination with Branemark Implant Treatment

Source:I nt. J Perio Rest Dent 12:441-450, 1992

Type: Technique article

Rating: Good

Keywords

Purpose: to present the surgical protocol for the inferior alveolar nerve transposition in combination with implant placement and evaluates the short-term outcome of the first procedures with this technique as used at the Branemark Clinic.

Method:ten nerve transpositions performed in one man and 6 women with mean age 60 years (range 41 to 82 years). Three of the treated jaws received three implants each, while the other seven received 2 implants each. In total, 23 implants were placed from Dec, 1990 to Dec, 1991. All patients were edentulous posterior to the mandibular canine or first bicuspid and had poor vertical bone as radiographs had shown. Patients were informed about the transposition procedure and possible long-term paresthesia/anesthesia. The patients were assessed postoperatively for pain, paresthesia/anesthesia, and/or other complications after 1,4 and 8 weeks after surgery, at abutment connection and after 6 months.

Results:Primary soft tissue healing was uneventful in all patients. However, after 7 weeks, an infection similar to osteomyelitis developed in one patient and the source was a necrotic canine close to the implant. This was managed by antibiotics which failed and explorative surgery was carried on 4 weeks later. 2 implants had to be removed along with two bone sequestra. Healing was normal and with minor sins of hypoesthesia. Complete bone regeneration of the defects was seen in all patients along with distal position of the foramen. Fixed partial dentures were connected and were in function for 1 to 12 months.

Conclusion:Strict patient selection criteria are necessary for the transposition of the inferior alveolar nerve together with implant placement. This can be beneficial for reconstructing severely resorbed edentulous posterior mandibles.

Topic: Inferior alveolar nerve transposing

Authors: Proussaefs P.

Title:Inferior alveolar nerve transposing in a situation with minimal bone height: A clinical report

Source: Journal of Oral Implantology: 2005; 31(4): 180-185.

Type: Clinical Report

Rating: Fair

Keywords:Nerve transposing, alveolar resorption, bone grafting, inferior alveolar nerve repositioning, neurosensory disturbance

Purpose:To describe treatment of a patient where minimal crestal bone was observed coronal to the canal of the Inferior alveolar nerve (IAN). For this purpose, an autogenous bone graft was placed around the implants and covered with a collagen membrane.

Materials and methods:

56-year-old woman with edentulism and extensive resorption at area of teeth 18-20, 30 and 31. Computerized tomography scan indicated that the IAN was 1 to 2 mm below the crest of residual alveolar ridge. Around mental foramen, the canal of the IAN was at the same level with the crest. A crestal incision was performed; full thickness labial and lingual flaps were reflected. Al lateral access window (LAW) was performed. Two horizontal and two vertical osteotomies were performed. The IAN was retracted. With an acrylic resin surgical stent, implants were placed in teeth 18-20, 30 and 31. The autogenous bone from the LAW was particulate and placed around the implants. Resorbable collagen membrane was placed above the graft material. Flaps sutured. Second stage surgery after 6 months of implant placement. Implants were osseointegrated and restored with cement retained metal ceramic restorations. Three years post loading; there was minimal marginal bone loss. The patient reported transient hypesthesia that lasted for 3 months but no further symptoms of neurosensory disturbance were observed.

Discussion: Previous studies suggest that a minimum of 6 to 8 mm of bone is needed above the canal of the IAN to provide implant stability, in most cases this means vertical ridge augmentation and implant placement simultaneously (1-stage bone grafting). In this case, application of this technique was not feasible because of the excessive resorption.

Mandibular block autografts: used for vertical ridge augmentation/ 5 mm, 6 months after graft

• In this case 10 mm vertical ridge would be needed. 2-stage bone grafting offers inadequate results in severely resorbed cases.

In this case, autogenous bone was particulated and placed around implants. Particulate graft was used to avoid mechanical trauma to the IAN from fixation process of the block.

Regarding transposing IAN, sensory disturbance should be considered and explained to the patient.

Conclusion: In a situation with minimal bone height above IAN, implant placement and TIAN may be considered in conjunction with autogenous particulated bone graft.

Topic: INTRAORAL VERTICAL DISTRACTION OSTEOGENESIS, RIDGE AUGMENTATION

Authors: Chiapasco

Title: Vertical Distraction Osteogenesis of Edentulous Ridges for Improvement of Oral Implant Positioning: A Clinical Report of Preliminary Results

Source: IJOMI

Type: clinical report

Rating: good results,Low number of paitents, low level evidence

Keywords: dental implants, distraction osteogenesis, implant-supported prosthesis, preprosthetic oral surgical procedures

Background: Vertically deficient edentulous ridges remain a challenge for implant placement. Vertical guided regeneration (GBR) with semipermeable barriers often yield unpredictable bone gain, membranes are at risk for exposure and infection, and autogenous grafts are associated with increased morbidity and are prone to unpredictable gain. Distraction osteogenesis was originally created for orthopedic purposes and was later applied to the maxillofacial region to correct severe malformations, sleep apnea and dento-facial manifestations of various syndromes. More recently it has been being used to improve bone volume to facilitate eventual implant placement.

Purpose: To present the experience of the authors in treating vertical defects in edentulous ridges by means of intraoral vertical distraction osteogenesis followed by implant placement in the distracted areas.

Materials and Methods: 8 patients w defects from various etiologies with minimum 5mm width of ridge but height that was deficient for implant placement and who didn’t present with common relative contraindications of implant placement were included. Intraoral photographs and panoramic radiographs taken intraoperatively, at time of distractor removal. and implant placement, 4 patients evaluated with CT.

The procedure was started with an intraoral incision in the buccal vestibule, without lateral releasing incisions. Careful subperiosteal dissection was per- formed to obtain adequate visibility of the underlying bone, but to preserve as much as possible the lingual or palatal pedicle after the osteotomy was performed. Preplating and adjustment of the intra- oral distractor was performed before starting the osteotomy. With an oscillating saw or a fissure bur, under irrigation with sterile saline, the bone seg- ment to be vertically distracted was completely separated from the basal bone. The vertical osteotomies were enlarged to allow movement of the segment with no interference. Once the osteotomy was completed, the intraoral distractor was fixed to both the basal bone and the ostetomized segment with 1.5-mm titanium miniscrews (Gebruder Mar- tin GmbH). The osteotomized segment to be distracted was immediately moved by activating the distractor to check the direction of distraction and freedom of movement. Finally, the osteotomized segment was repositioned at its initial position and the surgical access was sutured with 4/0 silk sutures. Healing by secondary intention is unavoidable, because a portion of the distractor must pass through the incision to activate the distractor. All patients received antibiotics and non- steroidal analgesics postoperatively. A soft diet for 2 weeks postoperatively and appropriate oral hygiene with 0.2% chlorhexidine mouthwash were pre- scribed. After a 7-day waiting period for closure of the surgical wound, sutures were removed and the activation was started. A distraction of 1 mm per day (subdivided into 2 activations of 0.5 mm every 12 hours) was performed with a specific device until the desired amount of distraction was obtained. The distractor was then maintained in position for 2 to 3 months to obtain maturation of the neocallus formed between the basal bone and the distracted segment. Once consolidation of the distracted seg- ments was obtained, the distractor was removed and endosseous implants were placed following the indi- cations of surgical templates.

A total of 26 titanium screw-shaped endosseous implants were placed in the distracted segments; 4 patients received 15 Brånemark System implants (Nobel Biocare, Göteborg, Sweden), and 4 patients received 11

screw-type ITI implants (Straumann, Waldenburg, Switzerland). Four to 6 months later, abutments were connected to the implants, and prosthetic treatment was started. Implants were followed with clinical examinations and panoramic radiographs every 6 months. The following parameters were evaluated: (1)vertical bone gain obtained after distraction; (2)radiographic assessment of peri-implant bone resorption mesial and distal to each implant;(3) peri-implant soft tissue parameters (Modified Plaque Index [MPI], Modified Bleeding Index [MBI], and probing depth [PD]); and (4)implant success (Albrekson definition)

Results: Recovery after the distraction procedure was uneventful in all patients treated, and all patients regularly followed the recall program. In all patients, the desired bone gain was reached at the end of distraction, with a mean vertical bone gain of 8.5 mm (range: 6 to 15 mm). In all patients it was possible to place the previously planned number of implants with primary stability and with complete embedding of the implants in both native and newly generated bone at the level of the distracted area. The mean follow-up after initial prosthetic loading was 14 months (range: 12 to 18 months). None of the implants placed were lost during the follow-up period.

Conclusions: distraction osteogenesis provides the following advantages

1. It provides the opportunity to obtain a natural formation of bone between the distracted segment and basal bone in a relatively short time span.

2. It eliminates the need to harvest bone, with con- sequent shortening of operating times and reduction in morbidity.

3. Soft tissues can follow elongation of the underlying bone.

4. Frequently, the procedure can be performed under local anesthesia on an outpatient basis, and postoperative recovery is favorable.

5. The regenerated bone seems to resist resorption. 6. The newly generated bone seems to be able to withstand the functional demands of implant- supported prostheses

Critique: low number of patients, highly skilled surgeons. In my hands level of evidence

Topic: implants and the use of rhBMP-2

Authors: Spagnoli DB, Marx RE

Title: Dental implants and the use of rhBMP-2.

Source: Dent Clin North Am. 2011 Oct;55(4):883-907

Type: Discussion

Rating: Good

Keywords: rhBMP-2, Implants

• BMPs are members of the transforming growth factor-b superfamily of growth factors.They are key regulators of cellular growth and differentiation, and regulate tissue formation in both developing and mature organisms. Twenty unique BMP ligands have been identified and categorized into subclasses based on amino acid sequence similarity

• BMPs exposed within or secreted into a wound affect mesenchymal stem cell (MSC) accumulation through chemotaxis and proliferation. MSCs are influenced by BMP-2 to differentiate either directly into osteoblasts for intramembranous bone development or into chondrocytes, followed by cartilage development and removal for endochondral bone formation.

• BMP-induced vascular endothelial growth factor a (VEGF-a) production in osteoblasts plays an important role in the coupling of bone formation and angiogenesis by acting as a chemoattractant for neighboring endothelial cells and stimulating VEGF-a secretion by osteoblasts and endothelial cells.

• The only BMP currently available for grafting of maxillofacial implant sites is recombinant human BMP-2 (rhBMP-2)

• Histologic specimens were obtained with a trephine technique used at implant placement during the clinical trials. The findings of the histologic assessment showed development of native bone through a de novo intramembranous pathway that repli- cates native bone development. Preosteoblast condensations were observed in asso- ciation with blood vessels, and osteoblasts were observed forming new bone trabeculae through appositional secretion of osteoid and mineralized matrix. Osteo- clast remodeling of the trabeculae was also observed.

Case 1 – complete vertical augmentation of maxilla

Case 2 – continuity defect of the mandible salvaging a deficient-free vascular fibula graft.

Topic: Vertical ridge augmentation

Authors: Simion M

Tittle: Long-term evaluation of osseointegrated implants inserted at the time or after vertical ridge augmentation. A retrospective study on 123 implants with 1-5 year follow-up.

Source: Clin Oral Implants Res: 12:35-45, 2001

Rating: Good

Keywords: vertical ridge augmentation

Purpose To evaluate retrospectively, in 4 clinics, 123 implants consecutively inserted in alveolar ridges at the time or after vertical bone augmentation

Methods: 123 Brånemark implants consecutively placed in 53 vertically augmented ridges were evaluated after a period of functional loading varying from 16 to 69 months. The study comprehended 49 partially edentulous patients requiring vertical bone augmentation to improve the crown–implant ratio and the implant support, and/or the esthetic of the final prosthetic reconstruction. The age of the patients ranged from 34 to 66 (median 50.4) years. At the time of the implant surgery, 3 different techniques were used: the implants were allowed to protrude 2 to 7 mm from the 
bone level and a titanium reinforced expanded-polytetrafluoroethylene (e-PTFE) membrane was positioned to protect either the blood clot (Group A, 6 patients), or an allograft (Group B, 11 patients), or an autograft (Group C, 32 patients). Follow up at 1 year.

Results:

Only 1 implant failed immediately after the second stage surgery and after 1 month it was substituted with a new implant. All the remaining implants appeared clinically stable, no signs of radiolucency were present at the bone–implant interface, therefore, they could be defined successfully osseointegrated. The radiographic analysis showed stable bone crest levels with a mean bone loss of 1.35 mm for the Group A, of 1.87 mm for the Group B and of 1.71 for the Group C during the period of observation. Only 2 implants demonstrated an increased crestal bone loss of 3.5 mm and 4 mm respectively at the first year examination.

Conclusions: Vertically augmented bone 
with GBR techniques respond to implant placement like native, non-regenerated bone.

Topic:Vertical ridge augmentation using guided bone regeneration

Authors: Urban IA, Jovanovic SA, Lozada JL.

Title: Vertical ridge augmentation using guided bone regeneration (GBR) in three clinical scenarios prior to implant placement: a retrospective study of 35 patients 12 to 72 months after loading.

Source: Int J Oral Maxillofac Implants. 2009 May-Jun;24(3):502-10.

Type: Clinical study

Rating: Fair

Keywords: autogenous bone graft, barrier membranes, guided bone regeneration, sinus augmentation, vertical ridge augmentation

Purpose: To evaluate the results of vertical guided bone regeneration with particulate autogenous bone grafts, determine clinically and radiographically the success and survival rates of implants placed in such surgical sites after prosthetic loading for 12-72 months, and compare defects that were treated simultaneously with sinus augmentation and vertical GBR to other areas of the jaw with vertical GBR only.

Method: 82 implants were placed in 35 patients with 36 vertical bone defects. Patients were divided into three groups: A) single missing teeth, B) multiple missing teeth, C) vertical defects in the posterior maxilla only. All patients were treated with ePTFE membranes and particulated autografts. After removal of the ePTFE membrane, all sites received a collagen membrane.

Result: Mean vertical augmentation at membrane removal was 5.5 mm. At 12 months mean combined crestal remodeling was 1.01 mm and remained stable 6 year follow up. There was NSSD between the three groups in mean marginal bone modeling. Overall implant survival rate was 100% with cumulative success rate of 94.7%.

Conclusion: Vertical augmentation with ePTFE membranes and particulated allografts is safe and predictable. Implant success and survival rates of implants placed in vertically augmented bone are similar to those placed in native bone. Success and failure rates of implants placed into bone regenerated simultaneously with sinus and vertical augmentation techniques compare favorable to those requiring only vertical augmentation.

Topic:Success rate

Authors: Clementini M, Morlupi A, Canullo L, Agrestini C, Barlattani A

Title:Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: a systematic review

Source:Int J Oral Maxillofac Surg. 2012 Jul;41(7):847-52.

Type: Review

Rating: Good

Keywords:systematic review, ridge augmentation

Purpose:This study assessed the success rate of implants placed in horizontal and vertical guided bone regenerated areas

Method: A systematic review was carried out of all prospective and retrospective studies, involving at least five consecutively treated patients, that analysed the success rate of implants placed simultaneously or as second surgery following ridge augmentation by means of a guided bone regeneration (GBR) technique. Studies reporting only the survival rate of implants and studies with a post-loading follow up less than 6 months were excluded

Results: From 323 potentially relevant studies, 32 full text publications were screened and 8 were identified as fulfilling the inclusion criteria. The success rate of implants placed in GBR augmented ridges ranged from 61.5% to 100%; all studies, apart from three, reported a success rate higher than 90% (range 90–100%). The survival rate of implants, was reported in 6 studies to range from 93.75% to 100%. One study reported a survival rate lower than 99.2%.

Conclusion: The data obtained demonstrated that GBR is a predictable technique that allows the placement of implants in atrophic areas. Despite that, studies with well-defined implant success criteria after a longer follow-up are required.

DesignedBy StevenJ. Spindler, DDS, LLC