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Advanced surgery II

Biological aspects, including materials. Histological results.

Success/Survival rate of implants in grafted maxilla.

Short Implants and Tilted Implants, Implant survival

1. Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC. Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodontics Restorative Dent. 2000 Apr;20(2):117-25.

2. Corbella S, Taschieri S, Del Fabbro M. Long-Term Outcomes for the Treatment of Atrophic Posterior Maxilla: A Systematic Review of Literature. Clin Implant Dent Relat Res. 2013 May 8.

3. Schmitt C, Karasholi T, Lutz R, et al. Long-term changes in graft height after maxillary sinus augmentation, onlay bone grafting, and combination of both techniques: a long-term retrospective cohort study. Clin Oral Implants Res. 2012 Oct 17. doi: 10.1111/clr.12045. [Epub ahead of print]

4. Del Fabbro M, Corbella S, Ceresoli V, Ceci C, Taschieri S. Plasma Rich in Growth Factors Improves Patients’ Postoperative Quality of Life in Maxillary Sinus Floor Augmentation: Preliminary Results of a Randomized Clinical Study. Clin Implant Dent Relat Res. 2013 Nov 12. doi: 10.1111/cid.12171. [Epub ahead of print]

5. Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB, Triplett RG.  De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation. J Oral Maxillofacial Surg 2005; 63(12):1693-1707.

6. Maiorana C, Sommariva L, Brivio P, Sigurta D, Santoro F. Maxillary sinus augmentation with anorganic bovine bone (Bio-Oss) and autologous platelet-rich plasma: preliminary clinical and histologic evaluations. Int J Periodontics Restorative Dent 2003; 23:227-235.

7. Schmitt CM, Doering H, et al. Histological results after maxillary sinus augmentation with Straumann® BoneCeramic, Bio-Oss®, Puros®, and autologous bone. A randomized controlled clinical trial. Clin Oral Implants Res. 2013 May;24(5):576-85.

8. Mardinger O, Chaushu G, et al. Factors affecting changes in sinus graft height between and above the placed implants. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Jan;111(1):e6-11.

9. Cha HS, Kim A, Nowzari H, Chang HS, Ahn KM. Simultaneous Sinus Lift and Implant Installation: Prospective Study of Consecutive Two Hundred Seventeen Sinus Lift and Four Hundred Sixty-Two Implants. Clin Implant Dent Relat Res. 2012 Nov 15. [Epub ahead of print]

10. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003; 8:328-343.

11. Del Fabbro M, etc. Systematic review of survival for implants placed in the grafted maxillary sinus. Int J Periodont Restorative Dent 2004; 24:565-77.

12. Del Fabbro M, Wallace SS, Testori T. Long-term implant survival in the grafted maxillary sinus: a systematic review. Int J Periodontics Restorative Dent. 2013 Nov-Dec;33(6):773-83.

13. Felice P, Pistilli R, Piattelli M, Soardi E, Pellegrino G, Corvino V, Esposito M. 1-stage versus 2-stage lateral maxillary sinus lift procedures: 4-month post-loading results of a multicenter randomised controlled trial. Eur J Oral Implantol. 2013 Summer;6(2):153-65.

14. Nooh N. Effect of Schneiderian Membrane Perforation on Posterior Maxillary Implant Survival. J Int Oral Health 2013; 5(3):28-34 

15. 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.

16. Fugazzotto PA. Shorter implants in clinical practice: rationale and treatment results. Int J Oral Maxillofac Implants. 2008 May-Jun;23(3):487-96.

17. Pommer B, Frantal S, Willer J, Posch M, Watzek G, Tepper G. Impact of dental implant length on early failure rates: a meta-analysis of observational studies. J Clin Periodontol. 2011 Sep;38(9):856-63.

18. Maló P, Nobre Md, Lopes A. Immediate loading of ‘All-on-4’ maxillary prostheses using trans-sinus tilted implants without sinus bone grafting: a retrospective study reporting the 3-year outcome. Eur J Oral Implantol. 2013 Autumn;6(3):273-83.

19. Esposito M, Felice P, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev. 2014 May 13;5:CD008397.

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Topic:sinus floor elevation with/without barrier membrane    maxillary sinus augmentation

Authors:Tarnow DP, Wallace SS, Froum SJ, Rohrer MD, Cho SC.

Title:Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study

Source:Int J Periodontics Restorative Dent. 2000 Apr;20(2):117-25.

Type:Prospective study (Abstract ONLY)

Rating: Good

Keywords:Sinus elevation, barrier membrane

Purpose:To evaluatethe effect of barrier membrane placement on the creation of vital bone in the grafted sinus cavity.

Materials and methods:

• In 1993 the Department of Implant Dentistry at New York University College of Dentistry began a long-term clinical, histologic, histomorphometric, and radiographic study of the sinus elevation procedure

• 12 patients who underwent bilateral sinus elevation surgery. In each of these 12 patients the same grafting material was used in both sinuses, making the presence or absence of an expanded polytetrafluoroethylene (e-PTFE) barrier membrane the only controlled variable.

• A histologic and histomorphometric evaluation of healing with and without the placement of an e-PTFE barrier membrane over the lateral window at the time of sinus grafting.

Results:

(1) Placement of the barrier membrane tends to increase vital bone formation

(2) Placement of a barrier membrane has a positive effect on implant survival

(3) Membrane placement should be considered for all sinus elevation procedures.

Topic: Posterior maxilla

Authors:Corbella S, Taschieri S, Del Fabbro M.

Tittle: Long-Term Outcomes for the Treatment of Atrophic Posterior Maxilla: A Systematic Review of Literature.

Source:Clin Implant Dent Relat Res. 2013 May 8.

Type: Systematic review

Rating: Good

Keywords:maxilla, implants

Purpose:to estimate the implant survival rate in different types of techniques for the rehabilitation of posterior atrophic maxilla, after at least 3 years of follow-up.

Methods:MEDLINE database and hand searching of the relevant journals was searched using a combination of specific terms. All retrospective and prospective studies evaluating short implants in posterior maxilla, osteotome sinus floor elevation and lateral approach sinus floor elevation, and having a follow-up of at least 3 years, were included.

Results:Forty-four articles were included in the review. In four studies reporting on a total of 901 short implants (less than 10mm long, mean length around 8mm), the implant survival rate varied from 86.5% to 98.2% with up to 5 years follow-up. For the osteotome technique, 1,208 implants in eight studies were considered, showing a survival rate varying from95.4% to 100%after 3-year follow-up. Twenty-nine studies, accounting for 6,940 implants placed in 2,707 sinuses augmented through lateral techniquewere considered. Implant survival rate varied from 75.57% to 100%. Only three comparative studies were found that showed no significant difference in clinical outcomes between lateral approach and osteotome technique.

Conclusions:Sinus floor elevation with the lateral approach and with the osteotome technique is an effective and well- documented therapeutic option for the rehabilitation of atrophic posterior maxilla. The use of short implants is promising but needs further investigation to be considered as effective as the other techniques in the long term. However, the indication for the three different techniques is not perfectly equivalent and the treatment choice should be based on a careful evaluation of the individual case, in particular on the available residual bone.

Topic:Maxillary sinus augmentation                               need for KG around implants

Authors: Schmitt C, Karasholi T, Lutz R, Wiltfang J, Neukam F-W, Schlegel KA

Title: Long-term changes in graft height after maxillary sinus augmentation, onlay bone grafting, and combination of both techniques: a long-term retrospective cohort study.

Source: Clin Oral Implants Res. 2012 Oct 17. doi: 10.1111/clr.12045.

Type:Long-term retrospective cohort study

Reviewer:Evan Santiago

Rating:Fair

Keywords:autologous bone, bone augmentation, bone resorption, dental implant, keratinized gingiva, onlay bone grafting, sinus lift

Purpose:To examine long-term changes in graft height, implant survival rate, and peri-implant tissue conditions of dental implants place din alveolar ridges after augmentation procedures with a follow-up of 10 years

Method:25 patients with edentulous severe atrophic maxillary situations who received vertical augmentation procedures with autologous bone prior to implant placement. Patients were divided into groups (sinus elevation, onlay grafting, or a combination of both techniques). Patients were allowed to heal for 4 months and 127 implants were placed and allowed to heal for 6 months before loading. These patients were followed up clinically and radiographically followed up 1, 5, and 10 years later.

Results:Seven implants lost during observation period (94.48% 10 year survival rate). Significant bone loss occurred in the first 12 months and slowed afterwards and stabilized. After 10 years the total vertical bone loss was 27.51% after onlay grafting, 28.14% after sinus elevation, and 30.24% in the combination group (NSSD between groups). Signification positive correlations between PD and the degree of peri-implant inflammation. KG showed a statistically negative correlation to the degree of peri-implant inflammation.

Conclusion:Treatment does not impact vertical bone loss following augmentation using autologous grafts. This approach results in long term stability of dental implants. A sufficient width of keratinized peri-implant mucosa is important to prevent peri-implant bone loss and inflammation.

Topic:Growth Factors                         PRGF

Authors: Del FabbroM, Corbella S, Ceresoli V, Ceci C, Taschieri S

Title:Plasma Rich in Growth Factors Improves Patients’ Postoperative Quality of Life in Maxillary Sinus Floor Augmentation: Preliminary Results of a Randomized Clinical Study.

Source:Clin Implant Dent Relat Res. 2013 Nov 12. doi: 10.1111/cid.12171

Type:Clinical

Rating: Good

Keywords:growth factors, maxillary sinus augmentation, platelet concentrate, quality of life, sinus grafting

Purpose:The purpose of the present preliminary report was to assess if the use of autologous platelet concentrate during maxillary sinus augmentation may have a favorable impact on pain and other factors related to patient’s quality of life in the first week after surgery.

Method:This is an interim report of a randomized single-blind study. Fifteen patients with atrophic edentulous posterior maxilla underwent maxillary sinus augmentation using deproteinized bovine bone matrix (DBBM) as the grafting material (control group). In other 15 patients (test group), autologous plasma rich in growth factors (P-PRP) was added to DBBM, then a P-PRP clot was applied to covering the graft before suturing and finally P-PRP was placed over the suture in liquid form. During the first week postsurgery, all patients filled in a questionnaire for evaluation of main symptoms and daily activities. The outcomes of the questionnaires of the two groups were statistically compared.

Results:In the first days postsurgery, the group using P-PRP reported significantly less pain, swelling, and hematoma, and improved functional activities with respect to the control group.

Conclusion:The adjunct of P-PRP to the maxillary sinus augmentation procedure produced a beneficial effect to patients’ quality of life in the early postsurgical phase.

Topic:Sinus floor augmentation

Title: De novo bone induction by recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillary sinus floor augmentation.

Author: Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB, Triplett RG. 

Source: J Oral Maxillofacial Surg 2005; 63(12):1693-1707.

Type:Clinical trial

Rating:Good

Keywords:sinus lift, bone graft, BMP

Purpose:This phase II study was designed to evaluate 2 concentrations of recombinant human bone morphogenetic protein-2 (rhBMP-2) for safety and efficacy in inducing adequate bone for endosseous dental implant in patients requiring staged maxillary sinus floor augmentation.

Materials and Methods:Patients were treated with rhBMP-2 (via an absorbable collagen sponge [ACS]), at concentrations of 0.75 mg/mL (n = 18), 1.50 mg/mL (n = 17), or with bone graft (n = 13). Bone induction was assessed by alveolar ridge height, width, and density measurements from computed tomography scans obtained before and 4 months after treatment and 6 months post-functional loading of dental implants (density only).

Results:Mean increases in alveolar ridge height at 4 months after treatment were similar among the groups; 11.3 mm, 9.5 mm, and 10.2 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups. Mean increases in alveolar ridge width (buccal to lingual) at the crest of the ridge were statistically different among the treatment groups; 4.7 mm, 2.0 mm, and 2.0 mm, respectively, in the bone graft, 0.75 mg/mL, and 1.50 mg/mL treatment groups (P <or= .01 vs 0.75 mg/mL; P < .01 vs 1.50 mg/mL). At 4 months postoperative new bone density was statistically different among the treatment groups; 350 mg/cc, 84 mg/cc, and 134 mg/cc for the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups, respectively (P = .003 vs 0.75 mg/mL, P = .0137 vs 1.50 mg/mL, P = .0188; 1.50 mg/mL vs 0.75 mg/mL). Core bone biopsies obtained at the time of dental implant placement confirmed normal bone formation. The proportion of patients who received dental implants that were functionally loaded and remained functional at 36 months post-functional loading was 62%, 67%, and 76% in the bone graft, 0.75 mg/mL, and 1.50 mg/mL rhBMP-2/ACS treatment groups, respectively.

Conclusion:This study is the first randomized controlled trial demonstrating de novo organ tissue growth in humans from a recombinant human protein. rhBMP-2/ACS safely induced adequate bone for the placement and functional loading of endosseous dental implants in patients requiring staged maxillary sinus floor augmentation.

Topic:Maxillary sinus

Title: Maxillary sinus augmentation with anorganic bovine bone (Bio-Oss) and autologous platelet-rich plasma: preliminary clinical and histologic evaluations

Author: Maiorana C et al

Source:Int J Periodontics Restorative Dent 2003; 23:227-235.

Type:Clinical Study

Rating:Good

Keywords:PRP, BioOss, maxillary sinus augmentation

P:To describe clinical and histological evidence derived from the use of bovine bone and autologous PRP in a two stage surgical technique for maxillary sinus augmentation to avoid the use of autologous bone grafting technique.

M&M: 10 pts with posterior max atrophy recruited for bone augmentation. Eleven sinus elevation procedures were procedure according to 2 stage technique. Whole blood drawn and two centrifugation was performed and kept in continuous motion at 20 degrees Celsius until the time of surgery. BioOss and PRP gel mixed together and grafted into the sinus.

R:In all 11 cases, continuity of maxillary lateral wall was restored with tissue macroscopically similar to cortical bone in which some superficial particles of BioOss were identifiable. 3 months later CT scans showed presence and volume of graft. 6 months later, the scan showed graft to be more homogenous with reduce/resolved mucosal hypertrophy. Histomorphometric examination in 2 samples showed 40 % of the specimen composed of BioOss and newly formed bone and ratio between newly formed bone and total bone was in favor of bone regeneration. This results demonstrate osteoconductive properties of BioOss and suggest effective amplification of the bone regeneration and maturation processes evident only at 6 months after grafting procedures. Fibrin network present within PRP provides BioOss with scaffold for osteoblastic migration and platelet GF enhance the regenerative potential.

Topic:sinus lift

Authors: Schmitt CM, Doering H,

Title:Histological results after maxillary sinus augmentation with Straumann® BoneCeramic, Bio-Oss®, Puros®, and autologous bone. A randomized controlled clinical trial.

Source:Clin Oral Implants Res. 2013 May;24(5):576-85. doi: 10.1111/j.1600-0501.2012.02431.

Type:randomized clinical trial

Rating: good

Keywords:biomaterials, bone regeneration, bone substitutes, clinical research, clinical trials, guided tissue regeneration, sinus floor elevation

Purpose:To compare the clinical and histological characteristics of the tissue after sinus floor augmentation with:

• biphasic calcium phosphate (BCP, Straumann BoneCeramic®)

• anorganic bovine bone (ABB, Geistlich Bio-Oss®)

• mineralized cancellous bone allograft (MCBA Zimmer Puros®)

• autologous bone (AB)

Methods: Thirty patients with a posterior edentulous maxilla and a vertical bone height of ≤4 mm participated (45 sinuses and 94 implants in posterior maxilla). A two-stage procedure was carried out. Mucoperiosteal incision was made and Schneiderian membrane was elevated through lateral bone window. After augmentation of the maxillary sinus with ABB, BCP, MCBA, or AB followed by a healing period of 5 months, biopsies were taken from the future implant sites. Drilling with the trephine bur was performed as apically as possible. Thus, oral mucosa, residual maxillary bone, augmented sinus, and Schneiderian membrane were included in the biopsies. The trephine sites were used for implant placement after definitive treatment of the implant site. All patients received postoperative nose drops for 10 days (Otriven® nose drops 1-1-1; Novartis®) The samples were analyzed microradiographically and histologically.

Results: Course was uneventful. Although patients undergoing retromandibular bone harvesting demonstrated more swelling. Exposition of alveolar nerve occurred in 2 cases of harvesting bone block from mandible. No membrane perforations. Placement of implants was uneventful as well. 53 bone biopsies were generated from the later implant site; 41 samples were lost during removal or implant was peripheral to the augmented sinus. In total there were: 15 ABB, 14 BCP, 12 MCBA, and 12 AB samples.

Microradiography and histomorphometric analysis were carried out. Parameters for the residual bone(ROI1) and augmented sinus (ROI2) for each group were measured. (table 1)

Conclusion:Autologous bone provides the highest rate of de novo bone formation and can be considered to remain the gold standard in sinus floor augmentation. All tested control materials showed comparable results and are suitable for maxillary sinus augmentation.

Topic:Sinus Lift

Author:Mardinger O, Chaushu G.

Title:Factors affecting changes in sinus graft height between and above the placed implants

Source:Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Jan;111(1):e6-11

Type:Longitudinal Study

Rating: Good

Keywords:Sinus lift; bone grafting; dental implants

Purpose: The aim of this study was to compare the radiographic dimensional changes of sinus graft height above and between placed implants, and to evaluate the factors effecting these changes with 2 different grafting materials and a combination of both.

Methods: The study group included 42 patients (27 F, 15M) who underwent 50 sinus augmentation procedures, with a total of 154 implants placed. Three different grafting materials were used: 1-intraoral autogenous bone alone; 2-anorganic bovine bone (Bio-oss) alone; 3-mixtures of both (20% autogenous, 80% Bio-oss). Lateral wall technique was used for all sinus lifts. Four panoramic radiographs were evaluated: Before surgery (T0); 1 year (T1); 1-5 years (T2); 5-10 years (T3) after implant placement. The following measurements were performed for analysis: 1-Vertical new bone height at the center b/t the 2 most distal implants

2-Vertical height of the grafted bone above implant

3-Residual alveolar ridge height at the center b/t the 2 most distal implants

4-Implant length

Results:The mean percentage of autogenous bone height reduction was 23% between implants and 13% above the implants. Bovine xenograft showed a mean of 6.5% graft height reduction between implants and 0% above implants. The only two parameters that correlated with reduction of graft height above and between the implants were time elapsed from surgery and the type of bone graft. Autogenous bone graft presented significantly more reduction, whereas anorganic bovine graft only had minor or no changes in height.

Discussion: The most dominant factor influencing long-term vertical stability of the grafted bone after sinus augmentation is the grafting material. Sinus grafting with bovine xenograft yields the best results regarding long-term stability of the graft height and implant survival rates. The second factor those influences stability is the presence of a functional implant. Grafted bone height maintenance was superior above the implant compared with bone height between the implants.

Conclusion:The most important factor influencing reduction in vertical bone height on the time axis, following sinus augmentation is the grafting material, followed by the presence of a functional implant. Anorganic bovine bone was found superior in graft height maintenance in an up to 10 years of follow-up.

Topic:Sinus lifts

Authors: Cha H, et al.

Title:: Prospective study of consecutive two hundred seventeen sinus lift and four hundred sixty-two implants.

Source:Clin Implant Dent Relat Res. 2012 Nov 15

Type:

Rating: Good

Keywords:Dental implants, perforation, residual alveolar bone, Schneiderian membrane, sinus lifting, smoking, xenogenic bone

Purpose:To evaluate the survival and success rates of implants simultaneously placed into grafted sinus and evaluate whether there are any differences in survival and success rates regarding residual alveolar bone height, smoking status, and membrane perforation.

Method:217 lateral window sinus lifts and 462 implants were performed by the same oral surgeon. Medical and dental histories including smoking habits were reviewed for each patient. Tapered implants (10-12 mm long) with microthreads in the coronal part with sand blasting, large grit, and acid etched surface were used. Grafting was completed with xenogenic bone (Bio-Oss) soaked in gentamycin for 5 minutes. Implants were placed initially with automated handpiece and finalized with hand wrench. Perforated membranes were repaired with porcine membrane and fibrin glue. Implants were divided into 2 groups: Group 1- implants installed in posterior maxilla with <5 mm residual bone height and Group 2- ≥ 5 mm alveolar bone height. Survival rate of each group was evaluated, as well as smoking status and membrane perforation. Uncovery was at 6 months and implants were further evaluated every 6 months for the next three years. Success was defined as absence of pain (1), infection (2), mobility (3), PA radiolucency (4), and <1.5 mm of bone resorption in the first year as well as < 0.2 mm in years following (5). Survival was indicated by the first 4 parameters only.

Results:Cumulative survival rate was 98.91%, and survival was slightly higher in group 2, though not significantly different. Cumulative success rate was 96.54% and slightly (but not significantly) higher in group 1. There was no significant difference in implant survival in perforated membranes versus non perforated membranes. There was a significant difference in smokers versus not smokers in regard to implant failure.

Conclusion: Residual alveolar bone had no significant effect on survival and success rates of implants. Sinus lifting with simultaneous implant placement reduces treatment time and number of surgeries required. Selecting and implant with characteristics that enhance initial stability is crucial for success. Membrane perforation at the time of surgery did not have an impact on implant success/survival however smoking is a possible factor for implant failure.

Topic:Advanced Surgery 2                   survival rates for implants placed in the grafted maxillary sinus

Authors: Wallace SS, Froum SJ

Title:Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review

Source:Annals of Periodontology, December 2003, Vol. 8, No. 1, Pages 328-343

Type:Systematic Review

Rating: Poor

KeywordsN/A

Purpose:To determine the efficacy of the sinus augmentation procedure and compare the results achieved with various surgical techniques, grafting materials and implants.

Methods:MEDLINE, the Cochrane Oral Health Group Specialized Trials Register, and the Database of Abstracts and Reviews of Effectiveness were searched for articles published through April 2003. Hand searches were conducted on Clinical Oral Implants Research, International Journal of Oral and Maxillofacial Implants, and the International Journal of Periodontics and Restorative Dentistry and the bibliographies of all relevant papers and review articles. Also, researchers, journal editors and industry sources were contacted to see if pertinent unpublished data that had been accepted for publication were available. Inclusion Criteria were: Human studies with a minimum of 20 interventions, a minimum follow-up period of1-year loading, an outcome measurement of implant survival, and published in English, regardless of the evidence level, were considered.

Results:43 studies, 3 randomized controlled clinical trials (RCTs), 5 controlled trials (CTs), 12 case series (CS), and 23 retrospective analyses (RA) were identified. 34 were lateral window interventions, 5 were osteotome interventions, 2 were localized management of the sinus floor, and 2 involved the crestal core technique.

Conclusion:

1. Survival rate of implants placed in sinuses augmented with lateral window technique averaged 91.8% (range 61.7% and 100%)

2. Implant survival rates compare favorably to survival rates of implants placed in non-grafted posterior maxilla.

3. Survival rate of rough-surfaced implants is higher than machined-surfaced implants when placed in grafter sinuses.

4. Higher survival rates of implants placed in particulate graft augmented sinuses than those placed in sinuses augmented with block grafts.

5. Higher survival rates when a membrane was placed over the lateral window.

6. 100% autogenous bone grafts or the inclusion of autogenous bone as a component of a composite grafe did not affect implant survival.

7. No statistical difference between the covariates of simultaneous versus delayed implant placement, type of rough-surfaced implants, length of follow-up, year of publication and the evidence level of the study.

8. Insufficient data were present to statistically evaluate the effects of smoking, residual crestal bone height, screw versus press-fit implant design or the effect of implant surface micromorphology other than machined versus rough surfaces.

9. Insufficient evidence exists to recommended the utilization of platelet-rich plasma in sinus graft surgery.

Topic:Grafted maxillary sinus

Authors: Del Fabro M, Testori T, Francetti L, Weinstein R.

Title:Systematic review of survival rates for implants placed in the grafted maxillary sinus.

Source:International Journal of Periodontics and Restorative Dentistry 2004; 24: 565-577.

Type:Systematic Review

Rating:Good

Keywords:maxillary sinus, sinus lift, sinus augmentation, sinus elevation, sinus graft, bone grafting, dental implants, endosseous implants

Purpose:To determine the survival rate of root-form dental implants placed in the grafted maxillary sinus. Determine effects of graft material, implant surface characteristics and simultaneous versus delayed placement on survival rate.

Materials and methods: Computer search of electronic databases from 1986 to 2002. The search was limited to human studies. Additionally a hand search was performed. Inclusion criteria: 1) at least 20 sinus elevations performed 2) mean follow up no less than 12 months of implant loading 3) fewer than 5% of patients lost to follow up 4) multiple interventions (likesimultaneous ridge augmentation) were not performed 5) access to the antrum occurred by lateral window procedure 6) grafting material and implant placement timing were clearly reported 7) type of implants used was indicated.

Results:The search yielded 252 articles. Of these, 39 met the criteria.

Within autogenous graft subgroup, the influence of using graft in a block or particulate form was examined. Survival rates of block grafts 82.9%, block plus particulate grafts 89.4%, particulate grafts alone 92.5%. This suggests that the addition of particulate grafts or use of them alone, would improve survival rates.

Conclusion:Sinus grafting is considered a safe and well-documented procedure to prepare an environment in which dental implants may have an excellent prognosis. The choice of the type of graft material and the implant micromorphology may significantly influence the outcome. The performance of rough surface implants is superior to that of smooth surface. Grafts using bone substitutes are as effective as autogenous bone.

Topic: Sinus grafting, long-term survival

Authors:Del Fabbro, Wallace, Testori

Title: Long-term implant survival in the grafted maxillary sinus: a Systematic Review

Source:Int J Perio Rest Dent. 2013 Nov-Dec;33(6):773-86

Type:systematic review

Rating:

Keywords:

Background:Maxillary sinus augmentation has been shown to be the most predictable of the preprosthetic surgical techniques used to enhance bone volume for the placement of dental implants in previously compromised sites.

Purpose:The primary purpose of this systematic review was to investigate implant survival rates based on clinical studies with a follow-up of a minimum 3 years. A further aim was to assess whether implant survival was affected by several of- ten confounding variables. Specifically researched were: type of graft material, implant surface texture, simultaneous or staged implant insertion, residual crestal bone height, use of a biologic barrier membrane, timing of implant failure, duration of follow-up, publication date, and level of evidence (study design) of included studies

Materials and Methods:The inclusion criteria of this review extended the minimum postloading evaluation to 3 years to determine if the previously reported short-term survival rates are maintained. An electronic search of the literature was performed and retrieved articles were screened using specific inclusion criteria, paramount of which was a minimum of 3 years of follow-up. The search revealed 18 articles for the lateral window approach (6,500 implants in 2,149 patients) and 7 for the transalveolar approach (1,257 implants in 704 patients).In summary, 1 RCT (4%), 3 con- trolled trials (12%), 5 case series reports (20%), and 15 retrospective studies (64%) were included.

Results:Overall, implant survival after a minimum of 3 years loading was 93.7% and 97.2% for the lateral window and transalveolar approaches, respectively. Of importance is the fact that 80% of failures occurred within the first year and 93.1% of the failures occurred within 3 years. The risk of implant failure after 3 years can now be directly calculated as the overall risk of failure after 3 years (6.3%)×the incidence of late failures (6.9%), thus equaling 0.43%.The overall implant survival using 100% autogenous bone was significantly lower than that using 100% bone substitute (P< .001; OR, 4.42; 95% CI, 3.78 to 5.06)

Conclusions:This review discredits the theory that studies of a lower level of evidence report inflated results when compared with prospective randomized controlled clinical trials.

Critique: Distinguished authors (+); confounding variables make it hard to compare (-)

One of the major problems encountered in reviews of this type is the presence of confounding variables, ie, situations in which more than one variable may affect the outcome of a procedure. It is sometimes difficult to surmount this problem because of factors such as inadequate data reporting, changes in surgical techniques over time, lack of prospective trials with only one variable, or the reality that eliminating studies with only one variable would result in a very small database.

It is quite likely that failures occurring after 3 years are the result of factors unrelated to the placement of implants into grafted sinuses. Certainly one can speculate on the possibility of implant fracture in the heavy load-bearing area of the posterior maxilla and failures resulting from peri-implantitis.

Topic:Lateral maxillary sinus lift

Authors:Felice P, Pistilli R, Piattelli M, Soardi E, Pellegrino G, Corvino V, Esposito M

Title:1-stage versus 2-stage lateral maxillary sinus lift procedures: 4-month post-loading results of a multicenter randomised controlled trial.

Source:Eur J Oral Implantol. 2013 Summer;6(2):153-65.

Type:Prospective study

Rating: Good

Keywords:anorganic bovine bone, dental implant, sinus lift, surgical procedure

Purpose: To compare the efficacy of 1-stage versus 2-stage lateral maxillary sinus lift procedures.

Materials and methods:

• 60 partially edentulous patients requiring 1 to 3 implants and having 1 to 3mm of residual bone height and at least 5mm of bone width below the maxillary sinus, as measured on CT scans, were randomized into two equal groups to receive:

  • 1-stage lateral window sinus lift with simultaneous implant placement

  • 2-stage procedure with implant placement delayed by 4 months using a bone substitute in 3 different centers.

• Implants were submerged for 4 months and loaded with reinforced provisional prostheses, which were replaced, after 4 months, by definitive prostheses.

• Outcome measures were augmentation procedure failures, prosthesis failures, implant failures, complications and marginal peri-implant bone loss assessed by a blinded outcome assessor.

• Patients were followed up to 4 months after loading. Only data of implants placed in 1 to 3mm of bone height were reported.


Results: 2 patients dropped out from the 1-stage group and none from the 2-stage group.

	1 stage (n=30)	2 stage (n=30)	P value
Sinus lift procedure failures			NSSD (P = 1.00)
Prosthesis failure			NSSD (P = 0.51).
Implant failure			NSSD (P = 0.28).
Complications			NSSD (P = 0.61).
Peri-implant bone loss	0.56 mm (SD: 0.36; 95% CI: -0.70 to -0.42	0.61mm (SD: 0.34; 95% CI: -0.74 to -0.48	P< 0.001

There is NSSD in bone loss between groups at loading (0.05mm).

Conclusions: NSSD were observed between implants placed according to 1- or 2-stage sinus lift procedures. However, this study may suggest that in patients having a residual bone height between 1 and 3 mm below the maxillary sinus there might be a slightly higher risk for implant failures when performing a 1-stage lateral sinus lift procedure.

Topic: Maxillary sinus

Authors:Nooh N.

Tittle:Effect of Schneiderian Membrane Perforation on Posterior Maxillary Implant Survival.

Source:J Int Oral Health 2013; 5(3):28-34 

Type: Clinical study

Rating: Good

Keywords:Schneiderian membrane, implant, sinus floor, perforated membrane

Background: To assess the survival rate of implants placed in the posterior maxilla by intentionally perforating the Schneiderian membrane and protruding the implant up to 3mm beyond the sinus floor in cases of reduced crestal bone height (CBH).

Methods: 56 patients with reduced CBH received 63 implants in the posterior maxilla. All implants intentionally penetrated the Schneiderian membrane and engaged the sinus floor cortical bone. All patients were followed up and implant survival was assessed at the end of one year post implant restoration.

Results: Out of 63 implants, there was only one failure (98.4% Survival rate) after a follow up period of one year. 7 patients experienced mild epistaxis during the immediate post-operative period with no associated implant loss. One patient developed sinusitis secondary to the surgical procedure, which was treated by antibiotic therapy and the patient improved clinically with no associated implant loss.

Conclusion: An intentional perforation of the Schneiderian membrane using a 2mm twist drill at the time of implant placement and protrusion of the implant up to 3mm beyond the sinus floor does not alter the stability and outcome of dental implants, one year post-restoration. This could be associated with minor complications ranging from epistaxis to sinusitis, which are manageable.

Topic:Dental implants in maxillary sinus

Authors: Najm SA, Malis D, Hage ME, Rahban S, Carrel JP, Bernard JP

Title: Potential adverse events of endosseous dental implants penetrating the maxillary sinus: Long-term clinical evaluation.

Source: Laryngoscope. 2013 Dec;123(12):2958-61. doi: 10.1002/lary.24189

Type:Retrospective cohort study

Rating:

Keywords:Dental implant, sinus membrane perforation, maxillary sinusitis

Purpose:To evaluate the nature and incidence of long-term maxillary sinus adverse events related to endosseous implant placement with protrusion into the maxillary sinus

Method:Patients with dental implant penetrating into the maxillary sinus were included. Minimum 5 year follow-up after implant placement. Sinus assessment was both clinical and radiographic.

Results:70 patients with 83 sinus implants with sinus perforation. Mean age 65.96. 12 patients had multiple implants penetrating the sinus and another 7 had bilateral sinus perforation. Estimated penetration was under 3 mm in all cases. The average follow up was 9.98 years. During follow up there were no signs of sinusitis clinically or radiographically in any patients.

Conclusion:No sinus complications are observed when implants penetrate into the maxillary sinus. This can be attributed to maintenance of successful osseointegraiton. In the presence of an acute or chronic maxillary sinusitis the differential diagnosis must always consider other potential odontogenic and nonodontogenic etiologies.

Topic: Short Implants

Authors:Fugazzotto PA

Title:Shorter implants in clinical practice: rationale and treatment results

Source:Int J Oral Maxillofac Implants. 2008 May-Jun;23(3):487-96.

Type:Retrospective Study

Rating: Good

Keywords:osseointegrated implants, short implants, treatment planning

Purpose:The purpose of this retrospective study was to assess the survival of short implants in various clinical situations in function over time.

Method:A retrospective study was conducted of all patients treated between May 2000 and May 2007 who received endosseous implants that were less than 10 mm in length. Patient age, gender, location of implants, type of prosthesis, time in function, and stability of peri-implant crestal bone were assessed.

Results:The retrospective analysis identified 2,073 implants of 6 mm, 7 mm, 8 mm, or 9 mm in length placed in a variety of clinical situations in 1,774 patients. Cumulative implant survival rates for implants in function in various areas of the mouth supporting single crowns or short-span fixed prosthese

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.

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