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Maxillary sinus lift surgery (MSLS) is considered to be a useful treatment method for patients with atrophic alveolar bone. Choosing a suitable surgical procedure to simultaneously decrease graft absorption and obtain long-term survival of dental implants is still a challenge. In this study, 20 patients received MSLS with graft of bone morphogenetic protein 2 (BMP2)-loaded calcium phosphate. Dental implants were placed simultaneously in 10 patients receiving MSLS (1-stage group), and in 10 patients receiving dental implants with a 3 to 6 months delay (2-stage group). The effects were evaluated based on clinical and radiographic examination during a 4 to 5 years follow-up. The results showed that only 1 perforation of the maxillary sinus mucosa was observed in 1-stage group, and was patched with a collagen membrane. An average bone gain of 6.8 mm was observed, and all implants exhibited no looseness, peri-implantitis, or fracture, all of which were stable during the follow-up and exhibited nice dental function during a 4 to 5 years follow-up. The loss of peri-implant bone height was 1.12 ± 0.47 and 1.10 ± 0.39 mm, the probing depth of periodontal pocket was 1.79 ± 0.62 and 1.81 ± 0.71 mm, the sulcular bleeding index was 1.63 ± 0.47 and 1.72 ± 0.54 in 1-stage group and 2-stage group, respectively, and no significant differences existed between these 2 groups. These findings implied that BMP2-loaded calcium phosphate may be a suitable material for MSLS, especially for patients with minimal bone height. Clinicians can use the 1- or 2-stage technique based on clinical condition, patients' choice and clinicians' experience. In patients where implants cannot be stabilized for patients with minimal bone height, 2-stage surgery may be more suitable.

This retrospective study demonstrates, by clinical and histologic evaluation, the benefit of the replaceable bony window as a homologous bony barrier in lateral sinus augmentation.A total of 103 maxillary sinus augmentations were performed using a piezoelectric device and a Er,Cr:YSGG laser apparatus. The detached bony windows were repositioned over various bone grafts. Sixteen bone biopsy specimens were harvested at the time of uncovering or implant placement.Three sinuses developed postoperative infections (2.91%). After 6 to 8 months of healing, uncovering procedures were carried out. Radiographically, reconstruction of the lateral sinus wall was observed in all cone-beam computed tomogram. Clinically, complete bone healing between the replaceable bony window and the lateral sinus wall was observed in all cases, except for the 3 infected sinuses (100 sinuses, 97.09%). Histologically, favorable new bone formation was observed in all specimens without any fibrous connective tissue invagination. More mature bone was observed along the floor of the replaceable bony window than at the center of the graft site.This study demonstrates that the replaceable bony window acts as an osteoinductive homologous barrier membrane over various bone graft materials and accelerates new bone formation in lateral sinus augmentation.

This clinical report illustrates a modern method for oral rehabilitation of severe edentulous atrophic ridge. Shallow vestibule and small denture-bearing area of the maxilla provide insufficient retention, and only the symphyseal region of the mandible has obvious alveolar ridge. The surgery of deepening vestibule of the maxilla ridge was done by using tentative miniscrew combined with old denture and soft liner. The osseointegrated dental implants were installed over symphyseal region of the mandible to act as retentive devices for prostheses. In addition, functional reline with rebase material to build buccal-tongue contact over the retromolar area after denture delivery obtained high satisfaction from the patient. Many clinical conditions cannot be managed solely with implants or preprosthetic surgery alone, whereas a combination of the 2 can achieve successful outcome.

The aim of this work was to investigate, through histological evaluation, the in vivo behavior of fresh frozen bone (FFB) used as particulate bone substitute in intraoral regenerative procedures. A total of 10 patients (group 1) received particulate FFB graft for bone regeneration in postextractive sockets, and 10 (group 2) underwent maxillary sinus augmentation by using the same bone substitute as filling. Fresh frozen bone was supplied from the Tissue Bank of the Veneto Region, Treviso Section.Healing was uneventful for all the patients and was monitored by periodical radiographs. Patients were scheduled for implant insertion according to the radiographic aspect. However, the mean healing time for group 1 was 45 days, whereas for group 2 patients, it was 100 days. At the moment of implant insertion, bone specimens were collected at the site of implant placement, from both groups and processed for histological analysis.Histological analysis after hematoxylin-eosin staining obtained from group 1 patients showed the presence of newly formed bone tissue, still well distinguishable from the grafted bone substitute. In samples from group 2 patients, a better integration could be recognized associated with active bone remodeling phenomena.These results showed a good integration of the considered FFB graft within the host tissue both at 45 and 100 days after grafting, displaying this biomaterial as suitable for preimplant regenerative procedures.

Since 1977, osseointegrated implants have played a strong role in oral rehabilitation. Despite the large success of this technique for the edentulous maxilla and mandible with sufficient bone height, patients with atrophic jaws continue to be the challenging cases for an adequate reconstruction of aesthetics and functionality. Orthognathic surgical procedures have been developed to reposition the jaws and have been traditionally used in the dentate patient to correct a skeletal malocclusion; these procedures can be used on the edentulous patient to correct the discrepancies between the jaws followed by the placement of implants to rehabilitate the oral cavity. Recently, surgeons can use a computer-assisted software package that enables them to insert implants after a digital analysis of the residual alveolar and basal bone that makes for greater implant osseointegration. We describe a one-step oral rehabilitation with Le Fort I osteotomy and computer-guided implant placement to correct a posttraumatic deformity.The first step of the definitive treatment, the implant placement, was planned with the aid of a computer-assisted surgery software package (NobelGuide; Nobel Biocare AB, Goteborg, Sweden). Ten computer-planned implants (Nobel Biocare AB) were inserted (6 on the maxillary arch and 2 on each posterior area of the mandible). Simultaneously, the patient underwent a Le Fort I osteotomy to correct the maxillary deficiency without any bone grafts.The use of Le Fort I osteotomy as a preprosthetic procedure for the atrophic edentulous maxilla has been well accepted. This is a technically demanding procedure, and there are some described complications such as unfavorable fractures of the maxilla, oroantral fistulas, bone exposure, and low implant survival rates. However, in selected cases, this reconstructive method has the advantages over the other commonly used preprosthetic techniques of simultaneously allowing the placement of osseointegrated implants while correcting an unfavorable intermaxillary relationship and improving facial aesthetics. Computer-assisted surgery offers to the surgeons the possibility to visualize anatomic structures, evaluate implant position and inclination, insert accurately implants, prefabricate prosthesis, and avoid the morbidity of bone grafting procedures.One-step oral rehabilitation by Le Fort I and computer-guided implant placement can be used in selected patients. Despite the difficulty of this procedure, this approach enabled the authors to solve simultaneously a double problem: the malocclusion and the partially atrophic and edentulous jaws. According to the literature, this is the first case of a simultaneous Le Fort I osteotomy and computer-guided implant placement. The patient introduced had a posttraumatic deformity, but we think that this procedure could be extended in the future to manage other situations.

Reconstructive treatments for jaw defects are complex procedures that can combine multiple techniques including fibula free flap (FFF) grafting. The purpose of this retrospective study was to document and share our experience on mandibular and maxillar reconstruction with FFF followed by secondary dental rehabilitation using implant insertion.We reviewed 198 patients treated by FFF grafting for mandibular and/or maxillary defects in our department during the past 11 years (1996-2007). A selection of 30 patients (18 males and 12 females, mean age of 46 y) with adequate criteria (hygiene, motivation, and prognosis) received secondary placement of osseointegrated implants. The implant success was clinically and radiographically evaluated.A total of 105 osseointegrated implants were placed in the grafted fibulas 5 months to 3 years after the reconstruction surgery. Only 4 implants were lost because of peri-implantitis (3 patients) and fibular fracture (1 patient); this corresponds to a 96.2% implant success rate.During the mean follow-up of 76 months, patient's satisfaction and functional and aesthetic results were evaluated. Radiologic findings indicated a low crest resorption around the implants despite an unfavorable crown-to-root ratio.The main difficulties in the reconstructions were lack of FFF height, absence of a vestibular groove, limitation of mouth opening, skin paddle thickness, and the reconstruction of surrounding tissues including the lip. Our management strategy is discussed.Prosthetic choice is fundamental to achieving patient-specific solutions. The prostheses used included sealed or screwed bridge, resin-bonded bridge, tooled bar, implant-borne denture, or implant-stabilized dentures. Dental implants may be used even in situations involving an unfavorable crown-to-root ratio and implant position by using milled bar and overdenture. The FFF provides a consistent bone graft that allows a reliable and predictable restoration with dental implants, leading to a satisfactory functional and aesthetic restoration.

To date, most clinicians and researchers have been using platelet concentrate within the range of 4x to 8x baseline. In this case report a new procedure involving strategic pooling and triple spin was developed and used to concentrate platelets to 23x baseline. The concentrate alone was infused into morselized resorbable collagen sponge, activated with calcium chloride and autologous thrombin, then placed as an autologous graft into the left sinus floor of a healthy 80-year-old woman. The floor of the sinus had approximately 2 mm of bony height. A computed tomography scan taken after 5 months showed that new bone was formed and it was as dense as native bone around the surgical site. From the computed tomography scan bone density analysis using Hounsfield Units revealed that the bone formed was D3 bone (518.3 +/- 224.9 Hounsfield Units) and it was as dense as native bone on the axial, coronal and sagittal slices. Histomorphometric analysis of 2 bone core biopsies taken after 6 months showed that 1 core had 34% bone of which 98% was vital new bone and the other core had 39% bone of which 100% was vital new bone. The height of the bone formed in the sinus floor was 12 mm. It was also characterized by good trabecular pattern and connectivity. The quality of the bone generated was such that 2 endosseous implants were placed and torqued to 30 N cm after the cores were removed.

Bone grafting has become an essential part of implant dentistry. Thanks to the advancement of grafting technology, areas that could only be managed with removable dentures or teeth-supported fixed prostheses can now be successfully treated with implant-supported prosthesis. Nonetheless, the complications associated with bone grafting procedures have slowly emerged to be one of the main challenges to many clinicians. A Medline literature search of articles published from 1984 to 2006 related to advanced bone grafting complications were selected and analyzed. To make it easier to understand, implant-associated bone grafting complications were classified into: socket augmentation related, guided bone regeneration related, onlay grafting (autogenous or allogenic) related, sinus lift related, and others. Etiologies associated with the above complications were categorized into: material related, technique related, anatomical related, patient related, and others. In summary, management of grafting complications requires proper diagnosis of all contributing etiologies and then providing necessary treatments that include nonsurgical pharmacological as well as surgical interventions based upon their clinical implications. Nonetheless, prevention of complication is of the utmost importance.

Purpose This case report documents the histological, histomorphometric, and radiographic effects of a new radiated-preserved bone allograft for sinus elevation procedures. Materials and methods This unique bone substitute differs from other forms of bone allograft processed through the standard cryopreservation method. Histology from bone biopsy core samples revealed newly formed bone with a well-organized lamellar bone structure in general and remaining particles were observed in contact with surrounding newly-formed bone. Results Histomorphometric results demonstrated an average new bone formation of 31.8%. Radiographic linear data demonstrated an 8.49% +/- 6.77% graft resorption from baseline to 6 months. Conclusion The outcome of this report suggests that this bone allograft could be successfully used in sinus lifting procedures. It encourages further research of this radiated-preserved bone allograft material in oral and maxillofacial reconstruction.

A simplified technique for preparation of the window and elevation of the sinus membrane using conventional instruments is described for the practitioner to prepare the Schneiderian membrane without perforations in an easy and time efficient method. The clinician uses a combination of a mallet and a mirror holder to break the buccal aspect of the maxillary sinus border after a small osteotomy has been made. This is a complication-free procedure.

The placement of implants requires adequate basic conditions. Insufficient bone height and width in the area of the maxilla, because of expansion of the maxillary sinus and atrophic resorption of the alveolar ridge, represent a common anatomical complication, which can be solved by augmentation of the floor of the maxillary sinus. It is commonly shared that autologous bone graft is the gold standard method in the augmentation of the Higmoro antrum. The reconstruction of atrophies with adequate bone volume and density has become a viable treatment option with high predictability and success rates. The purpose of this study was to present the results obtained with a surgical procedure aimed at reconstructing (rehabilitating) advanced maxillary atrophies. This method includes the use of intramembranous, corticocancellous bone grafts harvested from the iliac crest. These are then fixed to the residual bone by endosseous implants.

Sinus augmentation, either osteotome or lateral window approach, is a predictable procedure to augment vertical height that allows for proper implant placement in areas with previous limited restorative options. Like any surgical procedures, there is always a risk of encountering either intrasurgical or postsurgical complications. A Medline literature search of articles published from 1984 to 2006 related to complications following sinus augmentation were selected and analyzed. To make it easier for understanding, sinus augmentation complications were classified into following categories: systemic disease and mediations related; anatomy and surgical procedure related; sinus pathology related; infection related; and prosthetic related. Depending on the source or cause of complication, treatment may include palliative approach to surgical intervention. This article will review a newly proposed complication classification, discuss treatment modalities for each encountered complication and propose methods to avoid these complications.

Primary bone grafts in congenital cleft alveolus do not always provide sufficient bulk or height of bone for ideal placement of endosseous implants. Thus, maxillary sinus or nasal floor elevation and inlay bone grafts in previously grafted areas are not exceptions in the daily routine. This case report stresses the need of a detailed treatment plan and careful surgical management of nasal floor elevation with particulate autogenous bone graft to successfully provide the patient with osseointegrated prostheses.

Purpose: To evaluate the histologic and histomorphometric data 10 years after grafting of maxillary sinus in a case using anorganic bovine bone matrix (ABBM) and plasma rich in growth factors (PRGF). Materials and Methods: Histomorphometric measures were performed for newly formed bone, ABBM particles remnants, marrow spaces, and the presence of osteoblastic and osteoclastic activity. Results: Histologic analysis showed ABBM particles surrounded by new compact and mature vital bone. Osteocytes were noted within lacunae. Some osteoblastic and osteoclastic activity could be identified. The histomorphometric results were 21.7% of newly formed bone, 33.9% of ABBM, and 44% was composed of marrow spaces. Conclusions: After 10 years postoperatively, the histologic evaluation of this case report demonstrated slow replacement of the ABBM particles by newly formed bone, even with the addition of PRGF. The residual ABBM particles were found in close contact to the newly formed bone.

The sinus cavity often limits the amount of available bone for the placement of implants in the posterior maxilla. The sinus lift operation and graft is a technique that can add grafted bone in excess of 10 to 16 mm through a lateral wall quadrilateral osteotomy. However, when moderate alveolar atrophy is present, an osteotome technique can provide an average bone height in crease of 3.5 mm. This article presents the trephine bone core sinus elevation graft, which is intended to increase bone height 4 to 8 mm. This procedure is especially indicated when adjacent teeth are present and there is only moderate atrophy of the alveolus.

One of the surgical procedures preceding implantation is elevation of the base of the maxillary sinus. Numerous bone substituting materials (grafts) may be used for this purpose, including autogenous bone, heterografts, xenogenous bone, and synthetic materials alone or in combination or mixed with growth factors and bone morphogenetic protein (BMP) preparations. A study of the frequencies of the failures (graft material resorption or implant loss) after sinus elevations with various graft materials or their combinations was conducted. In the 5-year period from 1996 through 2001, a follow-up investigation of 810 maxillary sinus augmentations was performed, in which the sinus elevations involved the use of autogenous bone, a calcium carbonate-coated polymer, hydroxylapatite of algal origin, calcium carbonate gel produced from coral or beta-tricalcium phosphate alone, autogenous bone mixed with these bone substitutes, or a combination of beta-tricalcium phosphate and platelet-rich plasma. The incidences of graft resorption and implant loss after the augmentations with various bone substitutes were recorded. Total resorption (disappearance) of the bone substitute material was observed in 2.7% of the cases. An essential difference was not experienced between the various bone substitutes from this aspect, with the exception of the gel-state calcium carbonate, where 40% of the grafts were resorbed. In total, 5.46% of the implants were lost; the differences between the various materials were not significant.

A maxillary sinus augmentation graft floor can increase vertical bone height for implant placement in patients with a pneumatized sinus. A simple technique can make this routine procedure even more predictable. After the sinus membrane has been adequately reflected, a cottonoid soaked with 1 carpule of 2% Lidocaine with 1:100,000 epinephrine and left in place for 5 to 15 minutes in each maxillary sinus can help create vasoconstriction and hemostasis. By arresting the oozing type of bleeding from the sinus membrane and the floor of the maxillary sinus, the cottonoid technique enhances direct visualization of the sinus and sinus membrane, further reflects the sinus membrane bluntly and gently with minimal risk of a membrane perforation, and serves as a volume indicator to assess the graft volume required.

It has been shown that women have a lower pain threshold and lower tolerance to some forms of experimental pain then men. However, the evidence that clinical pain is perceived differently by the two sexes is not yet as strong. The placement of intraoral implants is a highly controlled surgical procedure that we have used to investigate this possibility. Forty-eight edentulous (without teeth) subjects (27 females), aged from 35 to 63 years, received two titanium implants in the anterior mandible under local anesthesia. After the surgery, subjects completed a pain diary three times each day, rating pain intensity and unpleasantness on 100 mm visual analog scales (VAS). Once a day, they chose verbal descriptors from the McGill Pain Questionnaire (MPQ). Age of subjects, duration of surgery, the amount of local anesthetic used and the amount of pain medication taken were not statistically different for the two groups (P>/=0.32). Results showed that the senior surgeon produced significantly less pain than a 4th year resident (P=0.04). Although there were no significant differences between sexes for mean daily ratings of intensity or unpleasantness over time (P>/=0.10), most women experienced the highest intensity of pain during the day, while most men had higher pain in the evening (P=0.025). Also, the relative unpleasantness (unpleasantness/intensity ratio) increased significantly with time for males, but not for females (P=0.016). Males and females did not differ in the total number of words chosen from the MPQ (P=0.61), or in the averaged Pain Rating Index (PRI) (P=0.53). However, women used significantly more evaluative words than men (P=0.04), suggesting that woman found the overall intensity greater. These results indicate that women find post-surgical pain more intense than males, but that men are more disturbed than women by low levels of pain that last several days.

The posterior edentulous mandible presents unique challenges for implant reconstruction because of deficiencies in bone quality and quantity. Autogenous mandibular block grafts can be used in a predictable manner to enhance bone volume and density, allowing for placement of maximum diameter implants to facilitate stress distribution for long-term implant survival. This article will feature the importance of staging and recipient site preparation using mandibular block autografts for posterior mandibular edentulous reconstruction.

Maxillary sinus membrane perforation is the most common complication that occurs with the sinus elevation augmentation procedure. Repair of relatively small (5-10 mm) tears is commonly done using fast resorbing collagen membranes and/or by allowing the sinus membrane to overlap on itself. A technique using a cross-linked type I collagen membrane for predictable repair of large perforations (> 10 mm) as well as for circumstances in which no membrane is found is described. This technique has several advantages because of its inherent biologic properties.

The height of the available bone between the alveolar ridge and the sinus is often insufficient for placing endosseous implants in the posterior maxilla. Subantral augmentation after sinus elevation can be performed using bone-grafting materials such as autogenous bone, allografts, and alloplasts. The properties and performance of a recently developed resorbable bioactive glass (BioGran) were investigated with regard to bioactivity and bone-forming capability. The bioactive glass was grafted into the sinus cavities of 25 patients and biopsies were taken after 7 months. The samples were examined by conventional histologic techniques, elemental composition and distribution assayed by an electron probe microanalyzer, and comparative biomechanical data for BioGran and bone tissue gathered. Histologic and biomechanical examination indicated bone formation in all cases, with biomechanical properties of the regenerated bone close to those of bone tissue. The results of this study suggest that BioGran exhibits osteoconductive properties and efficacy as an alloplastic bone-grafting material.

Sinus lift and augmentation procedures with simultaneous insertion of cylindrical root form implants can be used to treat the atrophic posterior maxilla. The long-term use of a second stage provisional prosthesis is emphasized. The recommended metal-reinforced acrylic resin provisional restoration allows treatment and/or removal of a failing implant and progressive loading before fabrication of the definitive prosthesis. Modifications in prosthesis fabrication after sinus lift surgery and augmentation procedures are discussed.

Brånemark osseointegrated implants were used in combination with a cranial bone graft that was harvested from the outer table of the skull in a patient with a discontinuity defect of the anterior aspect of the mandible. First, a staged procedure allowed reconstruction of the defect. The second stage was placement of the Brånemark osseointegrated implant fixtures, followed by contouring the interior genial area by adding more bone grafts. The initial stabilization was done with an adoption plate that was used to stabilize the mandibular fragments during the healing phase. This plate was subsequently removed when the osseointegrated implants were placed. The patient had a full course of oral rehabilitation and a satisfactory final outcome.

A one-stage antral and nasal inlay composite bone grafting procedure is described. Preliminary statistical data (1 to 6 years experience with the procedure) is presented for 30 recipient sites in 20 patients. A complete bone-supported fixed prosthesis was used and has provided continuous function in all patients to date. Implant survival has approached that of implants placed in uncompromised maxillary or mandibular bone.

Summary The severly atrophied mandible presents multiple problems in reduction and fixation when bilateral mandibular body fractures occur. These problems sometimes result in malunited fractures. The two most common malpositions in these situations include a clockwise rotation (viewed from the patient's right) of the distal fragment and/or the counter-clockwise rotation of a proximal fragment. Body sagittal osteotomy as originally discribed by Sada (1966) offers some advantages in the secondary reconstruction of these mandibular deformities. Five patients with mandibular body malunions have been treated successfully with two cases used in this article to demonstrate the application of body sagittal osteotomy. Permanent damage to the inferior alveolar nerve appears minimal and no other significant problems were encountered.