Maxillary Sinus Lift Material Comparison

VOLUME 2, NO. 5 JUNE 2010 The Journal of Implant & Advanced Clinical Dentistry Maxillary Sinus Lift Material Comparison Using Short and Extra-Short Implants in Daily Clinical Practice



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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 5 • JUNE 2010 Table of Contents 19 The Use of Short and Extra-Short BTI Implants In the Daily Clinical Practice Eduardo Anitua 33 Simplifying Implant Placement with Partially Edentulous Arch Surgical Stents Gregori M. Kurtzman, Douglas Dompkowski 47 A Comparative Clinical, Histological and Histomorphometric Study of Mineralized Allograft and Xenograft Materials in the Treatment of Atrophic Maxillary Sinuses Sammy S. Noumbissi, Alejandro J. Kleinman The Journal of Implant & Advanced Clinical Dentistry • 5

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The Journal of Implant & Advanced Clinical Dentistry VOLUME 2, NO. 5 • JUNE 2010 Table of Contents 63 Case of the Month Acellular Dermal Matrix Allograft Used for Root Coverage and Increased Connective Tissue in Restorative Cases Daniel Melker 73 Osseointegrated Implant in Myasthenia Gravis Patient: A Case Report Wiroj Suphasiriroj, Theerathavaj Srithavaj 81 Management of a Patient Who Developed Uncontrolled Diabetes After Implant Placements A Case Report John F. Carpenter 91 The E ect of Methotrexate on Bone Healing of a Simulated Fracture Defect in Rat Mandible Leonardo Toledo de Aguiar, Suzana Beatriz Veríssimo de Mello, João Gualberto de Cerqueira Luz The Journal of Implant & Advanced Clinical Dentistry • 7

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The Journal of Implant & Advanced Clinical Dentistry Founder, Co-Editor in Chief Founder, Co-Editor in Chief Dan Holtzclaw, DDS, MS Nicholas Toscano, DDS, MS Editorial Advisory Board Tara Aghaloo, DDS, MD Robert Horowitz, DDS Michele Ravenel, DMD, MS Faizan Alawi, DDS Michael Huber, DDS Terry Rees, DDS Michael Apa, DDS Richard Hughes, DDS Laurence Rifkin, DDS Alan M. Atlas, DMD Debby Hwang, DMD Georgios E. Romanos, DDS, PhD Charles Babbush, DMD, MS Mian Iqbal, DMD, MS Paul Rosen, DMD, MS Thomas Balshi, DDS Tassos Irinakis, DDS, MSc Joel Rosenlicht, DMD Barry Bartee, DDS, MD James Jacobs, DMD Larry Rosenthal, DDS Lorin Berland, DDS Ziad N. Jalbout, DDS Steven Roser, DMD, MD Peter Bertrand, DDS John Johnson, DDS, MS Salvatore Ruggiero, DMD, MD Michael Block, DMD Sascha Jovanovic, DDS, MS Henry Salama, DMD Chris Bonacci, DDS, MD John Kois, DMD, MSD Maurice Salama, DMD Hugo Bonilla, DDS, MS Jack T Krauser, DMD Anthony Sclar, DMD Gary F. Bouloux, MD, DDS Gregori Kurtzman, DDS Frank Setzer, DDS Ronald Brown, DDS, MS Burton Langer, DMD Maurizio Silvestri, DDS, MD Bobby Butler, DDS Aldo Leopardi, DDS, MS Dennis Smiler, DDS, MScD Donald Callan, DDS Edward Lowe, DMD Dong-Seok Sohn, DDS, PhD Nicholas Caplanis, DMD, MS Shannon Mackey Muna Soltan, DDS Daniele Cardaropoli, DDS Miles Madison, DDS Michael Sonick, DMD Giuseppe Cardaropoli DDS, PhD Carlo Maiorana, MD, DDS Ahmad Soolari, DMD John Cavallaro, DDS Jay Malmquist, DMD Neil L. Starr, DDS Stepehn Chu, DMD, MSD Louis Mandel, DDS Eric Stoopler, DMD David Clark, DDS Michael Martin, DDS, PhD Scott Synnott, DMD Charles Cobb, DDS, PhD Ziv Mazor, DMD Haim Tal, DMD, PhD Spyridon Condos, DDS Dale Miles, DDS, MS Gregory Tarantola, DDS Sally Cram, DDS Robert Miller, DDS Dennis Tarnow, DDS Tomell DeBose, DDS John Minichetti, DMD Geza Terezhalmy, DDS, MA Massimo Del Fabbro, PhD Uwe Mohr, MDT Tiziano Testori, MD, DDS Douglas Deporter, DDS, PhD Dwight Moss, DMD, MS Michael Tischler, DDS Alex Ehrlich, DDS, MS Peter K. Moy, DMD Michael Toffler, DDS Nicolas Elian, DDS Mel Mupparapu, DMD Tolga Tozum, DDS, PhD Paul Fugazzotto, DDS Ross Nash, DDS Leonardo Trombelli, DDS, PhD Scott Ganz, DMD Gregory Naylor, DDS Ilser Turkyilmaz, DDS, PhD David Garber, DMD Marcel Noujeim, DDS, MS Dean Vafiadis, DDS Arun K. Garg, DMD Sammy Noumbissi, DDS, MS Emil Verban, DDS Ronald Goldstein, DDS Arthur Novaes, DDS, MS Hom-Lay Wang, DDS, PhD David Guichet, DDS Charles Orth, DDS Benjamin O. Watkins, III, DDS Kenneth Hamlett, DDS Jacinthe Paquette, DDS Alan Winter, DDS Istvan Hargitai, DDS, MS Adriano Piattelli, MD, DDS Glenn Wolfinger, DDS Michael Herndon, DDS George Priest, DMD Richard K. Yoon, DDS Giulio Rasperini, DDS The Journal of Implant & Advanced Clinical Dentistry • 11

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Editorial Commentary To come to come Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry • 13

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Letters to the Editors JIACD has been a great addition for and a camaraderie building experience with your dentists to learn about the latest in peers. Additionally, you can receive feedback techniques and interdisciplinary care. from readers in over 80 countries in as quickly as The thing that has impressed me the most 3 to 6 months following submission. TRY IT! about this journal is that the information Dr. Tom Wilcko, Erie, Pennsylvania, USA is online, easy to access, and the quality of the photos and case presentations is JIACD brings to all aspects of dentistry some amazing. things that are lacking with other journals. Dr. Paul Rosen, Philadelphia, The articles are timely, relate to all aspects of Pennsylvania, USA dentistry, and are relevant to all readers. As a researcher and clinician, I appreciate the I really appreciate JIACD because it’s a timeliness of getting my articles published fundamental tool for both practitioner and AND reading the current research performed researcher in the field of Periodontology and by others in the field. This is what dentistry dental implant continuing education. What I has needed for a long time to help us all move prefer most is the reliability, the friendly use, and forward more quickly to deliver the best, latest, the extremely high quality of the images and the state-of-the-art care to our patients. interesting topics. Clinicians and scientists can Dr. Robert Horowitz, Scarsdale, New York, USA find clear clinical suggestions and solutions to new and old problems for daily practice. My complements on what you have Dr. Giulio Rasperini, Italy accomplished with this online publication. Content has been superb. What a service JIACD is a very informative and educational to implantology. online journal. Each issue educates with cutting Dr. Gary Henkel, Horsham, Pennsylvania, USA edge clinical technology. The best advantages of JIACD are unlimited openness to clinicians After reading several informative, well written all over the world. I highly recommend dental articles by highly respected educators and clinicians to become subscribers of JIACD. clinicians I was inspired to submit my own article Dr. Dong-Seok Sohn, Republic of Korea to JIACD. The editorial process was speedy and painless and the reviewers made some very The internet is now the medium of choice helpful suggestions actually improving my original for the timely distribution and collection of submission. I intend to continue writing for the knowledge. The editors and reviewers of journal as I am anxious to be a part of this superb JIACD understand the concept of “timely”. The online educational process. JIACD review process is thorough but streamlined Dr. Michael Toffler, New York, New York, USA The Journal of Implant & Advanced Clinical Dentistry • 15

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The Use of Short and Extra-Short BTI Anitua Implants In the Daily Clinical Practice Eduardo Anitua, DDS, MD1 Abstract Background: The aims of this study were Results: The overall survival rates of short to evaluate the long-term survival rates of implants were 100% both for the implant and short (7 mm to 8.5 mm) and extra-short BTI subject-based analysis respectively. The mean fol- implants (5.5 mm and 6.5 mm) installed low-up period for short implants was 80.5 ± 8.9 both in the maxilla and the mandible. months. In the extra-short BTI implant study, sur- vival rates were 97.9% and 97.1% for the implant Methods: Two different retrospective cohort and subject-based analysis respectively. In this studies are reported. In the short BTI implant second study, follow-up period was 23.4 ± 6.4 study, 340 implants installed in 201 consecu- months. Distal and mesial bone loss of extra- tive patients were evaluated whereas in the short implants at 24 months post-insertion ranged extra-short BTI implant study, 48 implants placed between 1.30 mm and 1.39 mm respectively. 35 were considered. All implant installations were performed by two experienced surgeons Conclusions: Results of the present retrospec- and rehabilitations were done by 3 prosth- tive study show that treatment with short and extra- odontists. Each implant failure was carefully short BTI implants can be considered safe and analyzed. Implant survival was analysed using predictable if used under strict clinical protocols. a life-table analysis (Wilcoxon [Gehan] test). KEY WORDS: Dental implants, short implants, extra-short implants, treatment planning 1. Private practice in implantology and oral rehabilitation in Vitoria, Spain The Journal of Implant & Advanced Clinical Dentistry • 19

Anitua INTRODUCTION short BTI implants (7 mm to 8.5 mm) and extra- short BTI implants (5.5 mm and 6.5 mm) installed In the past, surgeons aimed for placement of the both in the maxilla and the mandible follow- longest possible implant in any given site as long ing consistent and predictable protocols are as its placement did not hinder the final prosthetic evaluated. Briefly, in the first study a total of result in terms of aesthetics. This was especially 340 short BTI implants installed in 201 con- crucial when implants presented a machined secutive patients were followed whereas in surface and the most common way to increase the second study 48 extra-short BTI implants implant-to-bone contact was to increase the sur- installed in 35 patients were evaluated. In both face area available by placing a wider or longer implant studies an implant-based and a patient- implant. The progress both in the implant sur- based analysis of failures have been carried out. face engineering together with the development of novel strict protocols have opened the doors MATERIAL AND METHODS to new clinical options that are revolutionizing the axiomatic concepts of oral implantology. For The protocols of both retrospective longitudi- example, the posterior maxillae present a uniquely nal studies were approved following the national challenging site for implant placement due to and international (International Conference of several complicating factors including, difficult Harmonization rules) policies on clinical studies. and challenging access, limited visibility, reduced All implant installations were performed by two space, bone resorption and poor bone quality experienced surgeons and rehabilitations were and quantity among others. In these clinical situa- done by 3 prosthodontists. The inclusion crite- tions, several alternatives such as bone augmenta- ria included subjects demanding rehabilitation tion techniques or the use of short implants may of posterior areas by means of dental implants bring new therapeutic options for the surgeons. with residual ridges that impede the insertion of implants longer than 8.5 mm. Subject selection Biotechnology Institute (BTI) has developed was based on an absence of any local or systemic a family of short implants and more recently diseases that might contraindicate the treatment extra-short implants with some characteris- On the other hand, the exclusion criteria included tic and distinguishing properties including a subjects with systemic diseases and subjects tak- micro-rough acid-etched surface, and a bioac- ing drugs that alter the bone metabolism. All sub- tive implant surface.1,2 The latter is obtained jects gave their written consent to carry out the by humidifying the implant surface with plasma treatment according to the described protocol. rich in growth factors (PRGF®) leading to an overall improved and accelerated implant In the short BTI implant study, subjects with Osseointegration.3 PRGF® consists on a lim- short implants inserted in years 2001 to 2003 ited volume of plasma enriched in platelets and were included (follow-up period ranging from 5 growth factors rapidly obtained from the patient to 8 years from the date of insertion). Subjects and easily prepared and which may enhance were treated with short BTI implants with a length and accelerate implant osseointegration.4,5 raging from 7.0 to 8.5 mm. On the other hand, in the extra-short BTI implant study, subjects with In the present study, the survival rates of 20 • Vol. 2, No. 5 • June 2010

Anitua extra-short implants (5.5 and 6.5 mm in length) implant surface. Liquid PRGF® was prepared inserted between January 2007 and January 2009 from patient’s blood using the PRGF® system® were included. Only implants with at least 1 year (Vitoria, Spain). Briefly, peripheral blood from of follow-up from their insertion were included. each patient was taken by venipuncture before surgery and placed directly into 9 mL blood Amoxicillin 1 g was administered 30 min- collecting tubes (BTI blood collecting tubes®) utes before the surgery and the same antibi- which contain 3.8% (wt/vol) sodium citrate as otic (500 mg every 8h) was prescribed to all anticoagulant. Liquid PRGF® was prepared by patients for the next 6 days. Subjects received centrifugation at 580 g for 8 minutes at room acetaminophen 1 gr. 1 hour before the sur- temperature. The 1 mL plasma fraction located gery and for the next three days (1 gr. / 8 just above the red cell fraction was collected hours). Depending of the clinical situation, sub- and activated with calcium chloride (50 µL jects were prescribed with magnesium met- PRGF® activator per mL of preparation) in order amizol during two days after the surgery (1 gr. to initiate clotting and the continuous release / 8 hours). Saline solution rinses (during 48 of platelets’ growth factors and proteins. hours) and additional twice daily chlorhexidine (0.12% w/v) rinses were recommended until Short and extra-short BTI implants (BTI sutures were removed. The latter was mainly Implant system, Biotechnology Institute, Vitoria, used in patients with poor oral hygienic situ- Spain) are characterized by their self-tapping ation. Subjects were instructed how to main- apex with “drive” capacity. The same features tain proper oral hygiene around implants. allow a gentle approach in the posterior max- illa, because it allows the collection of bone The clinical histories of all patients were by the implant during its advance whereas it evaluated carefully, and the surgical proce- avoids the danger of compressing the most dures were chosen in function of the subjects´ apical bone against the mental nerve. In addi- characteristics, the anatomic peculiarities of tion, the special design of these short implants the insertion places and intrinsic properties of allow drilling 1 or 2 mm away from the men- the different short and extra-short implants. tal nerve and then introducing the implant practically to the limit, placing it with excel- A complete radiological evaluation (conven- lent depth control. After treatment patients tional orthopantomogram plus analysis of three- were called in for oral hygiene and clinical and dimensional reconstruction from CT scan using radiographic examinations at least once a year. the BTI Scan program (Biotechnology Institute, Vitoria, Spain) was carried out. In addition, the The marginal bone loss around extra-short surgery guides were elaborated and provisional implants was measured mesially and distally and final prostheses adapted to each patient in all available radiographs of each patient and were prepared. All implant reception sites were data was grouped into 4 groups according to prepared using a novel low-speed drilling pro- time elapsed since the date of insertion of the cedure (50 rpm) without irrigation. Before implants (from 0 to 6 months, 6 to 12 months, installation, implants were carefully embedded 12 to 24 months, and more than 24 months). in liquid PRGF® with the aim of bioactivating the The Journal of Implant & Advanced Clinical Dentistry • 21

Anitua Table 1: Characteristics of the inserted short implants. Figure 1: Anatomic distribution of the 340 short BTI calculated for qualitative variables, and means ± implants. The y-axis shows the anatomical location of SD were calculated for quantitative variables. A implants whereas the x-axis illustrates both the frequency database was employed for the analysis. Implant of the inserted implants (lower side) and the jaw location loss was the principal variable under study and (upper side). included any implant lost because of biologi- cal (failure to achieve osseointegration or loss Statistical analyses of acquired osseointegration) or biomechanical Data collection and analysis was performed by causes. The other variables included demographic two independent examiners (other than restorative factors, clinical factors, surgery-depending factors dentists). Descriptive statistics were performed, and prosthetic variables. The full list of variables absolute and relative frequency distributions were under analysis included: age; gender; smoking habits; implant position (maxillary; mandibular); implant diameter, implant length, implant stag- ing (one-stage versus two-stage approach); spe- cial techniques including: vertical bone growth, ridge expansion and bone grafting. The overall survival rate of implants was estimated both by an implant-based and subject-based analysis. In the implant based analysis, each inserted implant was considered as the analysis unit whereas in the subject-based analysis each subject was fol- lowed up until the failure of his/her first implant. In both types of analysis, the implant survival as a function of the time was analyzed using a life- table analysis (Actuarial method), comparing 22 • Vol. 2, No. 5 • June 2010

Anitua Table 2: Months of follow up by patients and implants from implant insertion. the survival rates among the different variables lowed a two-stage surgery. A total of 24 implants with the Wilcoxon test (Gehan). Data analysis (7.1%) were placed following special techniques. was performed with statistical software pack- Regarding the prostheses employed, most of age (SPSS v15.0 Inc., Chicago, IL, USA). The the implants supported fixed partial dentures (a level of statistical significance was P < 0.05. total number of 279, 82.1%), 44 implants sup- ported hybrid overdentures (12.9%) and only 17 RESULTS implants had unitary prostheses (5%). In addition, most of the prostheses were cemented (85.9%). In the short BTI implant study, the mean (± S.D.) Nine short BTI implants were immediate loaded. age of the 201 subjects was 60.2 (±10.4) years (range 28-93) at the beginning of the study. A At the end of the study period, the sur- total of 147 were female (73.1%). Forty eight vival rate using the actuarial method was 100% subjects were smokers (23.9%). The frequency both for the implant and subject-based anal- of the lengths and diameters of the 340 short ysis. The mean follow-up period for all the BTI implants is shown in Table 1. Regarding implants was 80.5 ± 8.9 months (6.7 years). implant position, 145 were inserted in the maxilla Table 2 shows the length of observation by (42.6%), whereas 195 inserted in the mandible. subject and by implant. Figures 2 to 7 illus- The detailed anatomic distribution of the short trate one clinical case involved in the study. BTI implants is presented in Figure 1. The surgical approach used for implant insertion was carefully Regarding the study with extra-short BTI evaluated. In fact, a total of 230 implants (67.6%) implants, the mean (± S.D.) age of the 35 sub- were placed using one-stage surgery and 110 fol- jects was 55.5 (±8.3) years (range 39-73) at the beginning of the study. Most of the patients The Journal of Implant & Advanced Clinical Dentistry • 23

Anitua Figure 2: Example of one case involved in the study of Figure 3: Note the occlusal collapse and the lack of several short BTI implants. The case corresponds to a 65 year old posterior teeth. female. Pre-operative radiograph. Figure 4: The BTI Scan will facilitate correctly planning the case. 24 • Vol. 2, No. 5 • June 2010

Anitua Figure 5: Rehabilitation of the lower maxilla using facing were female (71.4%) and only 7 patients were porcelain veneers. smokers. Table 3 illustrates the frequency of the lengths and diameters of the 48 extra short Figure 6: Radiograph 3 years after treatment. Short BTI implants. Nineteen implants were installed implant has avoided the use of more aggressive in the upper maxilla and 29 in the lower max- treatments. illa (60.4%) according to Figure 8. Forty five out from forty eight implants were placed using two- Figure 7: Final situation of the patient. stage surgery. Fifteen implants followed special techniques and only 3 implants were immediately loaded. Regarding the prostheses employed, all implants supported fixed partial dentures and 31 out from 48 implants were cemented. The survival rate of the extra-short BTI implants was 97.9% for the implant-based analysis and 97.1% for the subject-based analysis. The mean follow-up period for all the implants was 23.4 ± 6.4 months. Only one implant was lost dur- ing the observation period. The mean (± S.D.) bone loss around implants was calculated. Table 4 shows the maximum, minimum and mean mar- ginal bone loss in function of the time elapse since the date of insertion of the extra-short BTI implants. Figures 9 to 11 illustrate one clini- cal case involved in the second clinical study. DISCUSSION Implant therapy based on the principle of implant osseointegration has been widely accepted and very well documented.6-9 However, the placement of long dental implants in some anatomical sites such as the posterior maxilla and mandible may be limited due to the residual ridge height. The pneumatization of the maxillary sinus and the atro- phic ridge resulting from tooth loss significantly reduce the available osseous tissue height in the posterior region, making implant placement more challenging. In fact, a study involving 431 partially edentulous patients revealed that the posterior The Journal of Implant & Advanced Clinical Dentistry • 25

Anitua Table 3: Characteristics of the Inserted Extra-Short BTI Implants. Figure 8: Anatomic distribution of the 48 extra-short BTI Figure 9: Example of one case involved in the study of implants. extra-short BTI implants. Pre-operative radiograph. existing available bone height was at least 6 mm in 100% have been reported for the atrophic man- only 38% of maxillae and 50% of the mandibles.10 dible15 whereas rehabilitation of partial edentu- lism and severely resorbed maxillae with short The use of short implants (< 8 mm) has implants leads to survival rates around 95%.16 historically been related with low success rates.11,12 However, current data suggest From a biomechanical point of view, the ratio- that the same level of clinical success may be nale for the use of short implants is well docu- reached for short implants compared with longer mented.17 It has been reported that when an implants.13,14 In fact, survival rates from 88% to implant is loaded the majority of the stress is distributed at the level of the first few threads to the crestal cortical bone; therefore once a mini- mum implant height is osseointegrated, implant width is more important than the additional 26 • Vol. 2, No. 5 • June 2010

Anitua Table 4: The maximum, minimum and mean marginal bone loss in function of the time elapse since the date of insertion of the extra-short BTI implants. length.17,18 In addition, eliminating or minimiz- placement and the reduced surgical risks of ing the lateral force on the prosthesis and force sinus perforation or mandibular paresthesia.19 distribution from splinting multiple implants play a significant role in reducing stress on implants In the first clinical study focused on eval- and especially on short implants. Other potential uating the long-term predictability of short advantages of using short implants in the pos- BTI implants an overall survival of 100% was terior regions instead of longer ones include the observed. Results are even superior to those reduction of the need for bone augmentation reported recently in a retrospective study procedures prior or in conjunction with implant in which the survival rates of 532 short BTI implants installed in the posterior regions of the The Journal of Implant & Advanced Clinical Dentistry • 27

Anitua Figure 10: It is possible to observe an extreme reabsorption with a ridge of 4 mm height. The unique predictable alternative to extra-short implants is the use of block grafts. Figure 11: Radiograph 2 years after treatment. It is BTI implants, results showed that survival rate possible to distinguish the perfect bone stability around of implants was 97.9% for the implant-based implants. analysis and 97.1% for the subject-based analy- sis with only one implant failure. One important jaws and under different surgical approaches issue when using these extra-short implants is were 99.2% and 98.7% for the implant the drilling sequence according to bone den- and subject-based analysis, respectively.1 sity. In fact, we will find two different bone den- sities in most of the cases when inserting the Regarding the second study with extra-short implants in the posterior regions of the man- dible. One very dense cortical between 1000 and 1600 HU in the first 2-3 mm and a spongy bone between 400 and 100 HU along the rest. Additionally, these implants will be placed in two surgical steps independently to the torque achieved during insertion. Our recommendation is not to overcome 65 Ncm and obtain at least 28 • Vol. 2, No. 5 • June 2010

Anitua 30 Ncm. Placing these implants in one single Disclosure surgery may provoke that the patient moves the Dr. Anitua is the scientific director of BTI Biotechnology Institute. implant during the period of bone remodeling. References As a general rule, extra-short implants 1. Anitua E, Orive G, Aguirre JJ, Andía I. 5 year clinical evaluation of short dental constitute an excellent option to avoid can- tilevers and in some cases sinus lift surger- implants placed in posterior areas: a retrospective study. J Periodontol 2008; ies, especially when dealing with elder or high 79: 42-48. risk patients. Implants will always be splinted and the recommendation is to place the wider 2. Anitua E, Orive G, Aguirre JJ, Ardanza B, Andía I. 5-year clinical experience possible diameter (5 mm is the best option in with BTI dental implants: risk factors for implant failure. J Clin Periodontology the mandible and 5.5 mm or 6 mm in the max- 2008; 35: 724-732. illa). The switching platform concept enables obtaining a 4 mm emergency profile and 3. Anitua E. Enhancement of osseointegration by generating a dynamic implant minimizing soft tissue reception during time. surface. J Oral Implant 2006; 32: 72-76. The fact of placing the implant in the distal root will make the emergence profile design 4. Anitua E, Orive G, Plá R, Román P, Serrano V, Andía I. The effects of PRGF® on much easier. To improve biomechanics we bone regeneration and on titanium osseointegration in goats: a histologic and will always try to place one implant splinted histomorphometric study. J Biomed Mater Res A 2009; 91: 158-165. to another two or at least just to another one. 5. Anitua E, Sánchez M, Orive G, Andía I. The potential impact of the preparation In summary, the present study reports on rich in growth factors (PRGF®) in different medical fields. Biomaterials 2007; the clinical daily use of short and extra-short 28: 4551-4560. BTI implants. In our daily practice, the possibil- ity to use these implants in a predictable way 6. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of enables reducing the indications for especial partially edentulous patients: A preliminary study on 876 consecutively placed procedures like sinus lift and bone grafting pro- fixtures. Int J Oral Maxillofac Implants 1989; 4: 211-217. cedures. The data report in this study might help clinicians to improve their decision-making 7. Brånemark PI, Svensson B, van Steenberghe D. Ten year survival of fixed with the aim of enhancing implant success. protheses on four or six implants ad modum Brånemark in full edentulism. Clin Oral Implants Res 1995; 6: 227-231. Correspondence: Dr. Eduardo Anitua 8. Anitua E. Plasma rich in growth factors: preliminary results of the use in the Instituto Eduardo Anitua; preparation of future sites for implants. Int J Oral Maxillofac Implants 1999; c/ Jose Maria Cajigal 19 14: 529-535. 10005 Vitoria (Spain) Phone: +34 945160652 9. Buser D, Ingimarsson S, Dula K, Lussi A, Hirt HP, Belser UC. Long-term stability Fax: +34 945155095 of osseointegrated implants in augmented bone: a 5-year prospective study in E-mail: [email protected] partially edentulous patients. Int J Periodont Rest Dent 2002; 22: 109-117. 10. Oikarinen K, Raustia AM, Hartikainen M. General and local contradictions for endosteal implants, an epidemiological panoramic radiographic study in 65- year old subjects. Com Dent Oral Epidemiol 1995; 23: 114-118. 11. Bahat O. Treatment planning and placement of dental implants in the posterior maxillae: report on 732 consecutive Nobelpharma implants. Int J Oral Maxillofac Implants 1993; 8: 151-161. 12. Pierrisnard L, Renouard F, Renault P, Barquinis M, Influence of implant length and cortical anchorage on implant stress distribution. Clin Implant Dent Relat Res 2003; 5: 254-26213. Fugazzotto PA, Beagle JR, Ganeles J, Jaffin R, Vlassis J, Kumar A. Success and failure rates of 9 mm or shorter implants in the replacement of missing maxillary molars when restored with individual crowns: preliminary results 0 to 84 months in function. A retrospective study. J Periodontol 2004; 75: 327-332. 14. Goené R, et al. Performance of short implants in partial restorations: 3-year follow-up of Osseotite implants. Implant Dent 2005; 14: 274-280. 15. Stellingsma C, Vissink A, Meijer HJ, Kuiper C, Raghoebar GM. Implantology in the severely resorbed edentulous mandible. Crit Rev Oral Biol Med 2004; 15: 240-248. 16. Renouard F, Nisand D. Short implants in the severely resorbed maxilla: a 2-year retrospective clinical study. Clin Implant Dent Relat Res 2005; 7(Suppl 1): S104-110. 17. Griffin TJ, Cheung WS. The use of short implants in posterior areas with reduced bone height: a retrospective investigation. J Prosthetic Dent 2004; 92: 139-144. 18. Anitua E, Tapia R, Luzuriaga F, Orive G. Influence of implant length, diameter and geometry on stress distribution using finite element analysis. Int J Periodont Rest Dent 2010; 30: 89-95. 19. Misch CE, Steigenga J, Barboza E, Misch-Dietsh F, Cianciola LJ, Kazor C. Short dental implants in posterior partial edentulism: a multicenter retrospective 6-year case series study. J Periodontol 2006; 77: 1340-1347. The Journal of Implant & Advanced Clinical Dentistry • 29

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Simplifying Implant Placement with PartiallyKurtzman et al Edentulous Arch Surgical Stents Gregori M. Kurtzman, DDS1 • Douglas Dompkowski, DDS2 Abstract Background: Dental implants are a pros- Results: The custom made stents described thetically driven treatment with a surgical com- in this article are easy to fabricate and help the ponent. It is important to guide the surgical restoring dentist ensure accurate communica- placement so that prosthetics are uncompli- tion about implant to the surgeon. Additionally, cated and predictable. Surgical stents pro- these stents have the ability to avoid complica- vide communication between the surgeon and tions such as image distortion from metal sleeves restoring dentist so that implant placement is during computed tomography evaluations. at the ideal prosthetic position and angulation. Conclusions: Implant dentistry is a prostheti- Methods: A 3/32 inch twist drill is placed into a cally driven treatment modality and commu- slow speed hand piece and a pilot hole is cre- nication between the restoring dentist and ated through the denture tooth spacing it at the surgeon is critical to treatment success. The center of the tooth in both the buccal/lingual and surgical stent is utilized to communicate the mesial/distal dimensions. Angulation should fol- desired position and angulation of the implant low the long axis of the adjacent teeth so that the so that the restorative phase of treatment does implant parallels the roots of those teeth and is not encounter problems that can compromise not directed into the natural teeth. A pin is placed the esthetic outcome and also complicate oral into the hole within the cast and the Guide Right hygiene for the patient. The Guide Right sur- sleeve is placed upon the pin and a light-curable gical stent system is an easy to use method for resin is used to fixate the sleeve in position and in-office fabrication of implant stents for the par- create an index to the remaining teeth. The guide tially edentulous arch. This technique allows the can then be carried intraorally to radiographi- desired/planned implant position and angula- cally verify fixture angulation prior to initiation tion to be easily communicated to the surgeon. of surgery and provides a stable guide during use of the osteotomy drills at fixture placement. KEY WORDS: Dental implants, surgical stent, CBCT, dental labratory 1Private practice, Silver Springs, Maryland, USA 2 Private practice, Bethesda, Maryland, USA. Clinical associate professor at the University of Maryland/ Dental School, Baltimore, Maryland, USA The Journal of Implant & Advanced Clinical Dentistry • 33

Kurtzman et al INTRODUCTION A restrictive stent guides the surgeon as to the exact position and angulation of the implant place- Proper implant placement has become less of a ment. The benefit of these type stents is that the prosthetic dilemma with the use of surgical stents.1-3 restoring dentist receives back implants placed in Surgical stents also provide communication the exact planned position they planned when the between the surgeon and restoring dentist, so that surgeon uses the guide for placement. Whereas, the implant is placed at the ideal prosthetic position a non-restrictive stent allows more latitude to the and angulations. We will be addressing simple tech- surgeon and the result may be an implant placed niques in this article for fabrication of surgical stents. at an angulation or a position that complicates the restoration process. As such, the authors, advo- Surgical Stents cates preplanning and the use of restrictive type Implant surgical stents for the partially edentulous surgical stents. With this in mind, the Guide Right arch can range from the simple to the complex with stent system permits easy fabrication of restrictive varying costs and technical expertise involved in implant surgical stents for various clinical situa- their fabrication. Simple stents vary from use of tions that may be encountered. We will address denture teeth to metal tubes in an acrylic or vac- the following types of clinical situations that are uform template. These require minimal technical commonly encountered; standard placement, expertise and are relatively inexpensive to fabricate. placement in restricted vertical cases and place- Whereas, complex stents may require a CT or cone ment in conjunction with CT and cone beam scans. beam scan and may be fabricated through a cad/ cam process. These raise the total treatment fee Use of metal tubes to guide the osteotomy drills higher as the scan has a fee and the stent involves is not a new concept and has been addressed in a costly laboratory fee and may place the treat- simple to complex stent designs. These have pros ment beyond the financial abilities of the patient. and cons to the basic concept. The metal tubes do not allow the osteotomy drill to diverge from the Stents utilized in partially edentulous arches trajectory of the tube and, due to their hardness, have the benefit of gaining stability from the the drill can not create shaving debris during its remaining teeth in the arch. When standard use as can be observed with pilot holes through radiographs and clinical evaluation determine denture teeth. The drawback to use of metal tubes that there is adequate bone height and width, in the past has been in order to retain the tube a simple surgical stent can provide the guid- in the stent, the entire tube had to be encased in ance required to position the fixtures properly. resin or acrylic. This prevented the tube from dis- lodging from the stent but resulted in a bulky stent Treatment of the partially edentulous arch which can obscure the surgical aspect of the crest. with dental implants is less of a challenge then treatment of the fully edentulous arch.4-6 An ideal stent using metal guidance tubes Fabrication of surgical stents for these par- would therefore require only enough resin/acrylic tially edentulous cases can be easily accom- to stabilize the stent on the remaining teeth and plished in the office at minimal time and cost. to retain the metal tube. A majority of the stent bulk would be absent so that the surgeon had Surgical stents can be broadly divided into two basic types; restrictive and non-restrictive. 34 • Vol. 2, No. 5 • June 2010

Kurtzman et al Figure 1: Denture tooth placed in the edentulous space on Figure 2: A 3/32” twist drill used to create a pilot hole the cast. through the denture tooth on the cast. clear visualization of the crest where the oste- Several different guide sleeves are available otomy drill was making contact. This would fulfill from Guide Right, which provide for various clini- the accepted criteria of an implant surgical stent cal situations. All sleeves contain a retentive without hampering the visibility during surgery. element to retain the sleeve within the surgical stent. Stainless steel sleeves are available as The Guide Right™ (DePlaque, Victor, NY) both straight and angled versions with each hav- system provides a metal or ceramic tube to be ing a bracket attached to the lingual side of the incorporated into a stent quickly and inexpen- sleeve. The straight sleeves are provided in 3.0, sively. This is composed of guide posts and vari- 4.5 and, 5.3mm diameters. Guide sleeve inserts ous guide sleeves for planning and fabrication of are available to permit use of the Guide Right implant surgical stents. The posts are available surgical stent with each osteotomy drill to be as a straight, an angled and an offset pin. Straight used, ensuring that the drills following the initial posts have a 2.0mm portion that corresponds to pilot do not diverge from the intended angula- a 3/32 inch drill used to create the pilot hole on tion. The angled guide sleeve is ideal for poste- the cast. Angled posts are available with both a rior applications when vertical dimensions may 3 and 6 degree angulation for use in the ante- not allow insertion of the drill into the straight rior where angled abutments will be utilized. The guide sleeve. To accommodate restricted verti- offset posts allow the practitioner to move the cal dimensions an open sleeve was developed. sleeve from 0.5 to 2.0mm from the guide hole As with the stainless steel sleeves, a retentive placed into the cast correcting positioning prior button is present to lock it into the resin used to to stent fabrication. Additionally, a magnetic fabricate the stent. The buccal portion of these post is provided for use with the open sleeves in sleeves is fully open allowing guidance of the both a straight and offset version. A set of guide osteotomy drill but not hampering its insertion posts is also provided for use with the ceramic into the guide. The open sleeves require use of a sleeves that mimic the other posts discussed. The Journal of Implant & Advanced Clinical Dentistry • 35

Kurtzman et al Figure 3: A guide pin is placed into the pilot hole on the Figure 4: A stainless steel Guide-Right sleeve is placed on cast to verify position and angulation. the guide pin with the retentive bracket toward the lingual. Figure 5: Triad gel applied to the lingual of the adjacent Figure 6: Completed Guide Right surgical stent fabricated teeth and the retentive bracket of the Guide Right sleeve. with Triad gel carried over the incisal edge to create stability of the stent to the adjacent stent. magnetic post when fabricating the stent so that the sleeve remains where positioned as the stent Standard Implant Placement Stents is fabricated. With the growing use of CT and cone At the planning appointment, impressions for study beam scans, metallic sleeves pose issues due to modelsaremadeandcastsfabricated. Dentureteeth scatter in the images. Ceramic guide sleeves are placed into the edentulous space and affixed to were fabricated to circumvent this issue allowing the cast with wax to stabilize the tooth. The tooth clear visualization of the sleeve in the scan but is placed in the ideal position esthetically following eliminating all scatter that may hamper planning. the adjacent teeth (Fig. 1). If immediate implant placement at the time of extraction is planned, then 36 • Vol. 2, No. 5 • June 2010

Kurtzman et al Figure 7: Guide Right surgical stent shown intraorally. Figure 9: Radiograph with the Guide Right protractor Figure 8: Radiograph of the Guide Right surgical stent placed over an X-ray to determine the angle if correction is intraorally showing projection of the long axis of the needed. implant to be placed using the stent. the intact tooth is left on the cast or the missing portions of the tooth are built up using composite. A 3/32 inch twist drill is placed into a slow speed handpiece and a pilot hole is created through the denture tooth spacing it at the center of the tooth in both the buccal/lingual and mesial/ distal dimensions (Fig. 2). Angulation should follow the long axis of the adjacent teeth so that the implant parallels the roots of those teeth and is not directed into the natural teeth. Should a screw retained restoration be desired instead of a cement retained crown, then the screw access The Journal of Implant & Advanced Clinical Dentistry • 37

Kurtzman et al Figure 10: A 2mm osteotomy drill being used through the Guide Right surgical stent intraorally. Figure 12: Radiographs of the implant placed using the Figure 11: A radiograph of a guide pin in the initial Guide Right surgical stent demonstrating nal positioning osteotomy made using the Guide Right surgical stent taken relative to the stents sleeve. to verify position and parallelism relative to the adjacent teeth. can be designed at this stage to emerge lingual to the tooth’s incisal edge. The denture tooth is slipped over the guide post and the bracket posi- next removed from the cast and a guide pin is tioned on the lingual of the cast (Fig. 4). Triad inserted into the pilot hole in the cast (Fig. 3). gel (or other appropriate material) is applied to This is performed to verify the position and angu- the bracket and lingual of the adjacent teeth, car- lation and if necessary correction may be per- rying it over the incisal edges (or occlusal sur- formed at this time before the stent is fabricated. faces) of the adjacent teeth to provide stability from lateral displacement of the stent intraorally The cast is lightly lubricated with a water sol- and is light-cured (Fig. 5). The guide post is uble lubricant to prevent adhesion of the stent removed and the stent removed from the cast to to the cast. A stainless steel guide sleeve is finish and polish the peripheral edges (Fig. 6). 38 • Vol. 2, No. 5 • June 2010

Kurtzman et al Figure 13: A radiograph showing an open Guide Right Figure 14: Osteotomy drill being used in an open sleeve sleeve for placement of a lower rst molar. Guide Right surgical stent for placement of a lower rst molar. Figure 15: Final implant placement achieved using the Figure 16: CT scan tangential view showing three stainless open sleeve Guide Right surgical stent. steel sleeves of the same patient showing in Figure 17, demonstrating scatter and di culty identifying the sleeves. The Journal of Implant & Advanced Clinical Dentistry • 39

Kurtzman et al Figure 17: CT scan tangential view showing three ceramic Figure 18: Cross sectional view with minimal scatter also sleeves in the edentulous space demonstrating clear indicating some alteration in the angle of the sleeve is visibility of the sleeves with minimal scatter. needed. The completed stent is disinfected in cold ster- angle with the Guide Right Bending Tool. Follow- ilizing solution and is ready to try in intraorally to ing local anesthetic placement the initial osteotomy verify fit and stability (Fig. 7). It is important that is created with a 2mm pilot drill for the implant sys- the stent is stable and have no rocking. Should tem being used (Fig. 10). This may be done either the stent not be stable adjustment of the resin flapless or with a traditional flap depending on the interproximally may be necessary as this may be practitioners preference. The stent is removed and preventing full seating of the stent. A radiograph a sterile guide post is inserted into the osteotomy is taken with the stent in place to verify trajectory intraorally and a radiograph taken to verify implant compared to the adjacent natural tooth roots (Fig. 8). If the angle of the guide sleeve is not aligned correctly, the Guide Right Protractor is used to determine the angle of correction. The protrac- tor is placed over the x-ray and the correct angle determined (Fig. 9) Pre-bent angled guide posts are available in intervals of 2 degrees up to 14. Offset guide posts can also be bent to the desired 40 • Vol. 2, No. 5 • June 2010

Kurtzman et al Figure 19: Ceramic Guide Right sleeves in sizes (l-r) 3, 4 Figure 20: Ceramic Guide Right sleeve placed on the post and 5mm, showing the retentive element of the sleeve. on the model with the retention portion of the sleeve positioned on the palatal. Figure 21: A Guide Right surgical stent with a ceramic Figure 22: Radiograph of the nal implant placement and sleeve shown intraorally for placement of an upper ceramic sleeve used to achieve guided placement. premolar. position (Fig. 11). Should redirection be neces- Posterior Implant Placement with Restricted sary, additional correction can be made at this time. Vertical Dimension The Guide Right open sleeves are ideally designed Normal implant surgical protocol is followed for clinical situations when vertical heights will and the osteotomy is enlarged to the desired not permit the osteotomy drill from being inserted diameter and the implant is placed. A radio- into the sleeve within the stent. The open buccal graph may be taken at this time with the stent aspect of the sleeve allows an additional 3mm of intraorally to document alignment of the stents clearance for the drill to be inserted (from the buc- sleeve and long axis of the implant (Fig. 12). The Journal of Implant & Advanced Clinical Dentistry • 41

Kurtzman et al cal) without interference from the opposing arch. the images7,8 (Fig. 16). Ceramic sleeves in stents The stent is fabricated in a similar manner to provide minimal scatter but clear visibility on the scans and radiographs. They may be used in a the standard Guide Right surgical stent except scan taken prior to the surgical phase of treat- a magnetic post is used in place of the standard ment to verify the angle of the guide sleeve or guide post. Either a denture tooth is placed into allow correction of the angle prior to implant the edentulous space or one of the Guide Right placement (Fig. 17,18). The ceramic sleeves are setup disks is utilized. Should the setup disk be available in a 3.0, 4.0 and 5.0mm inside diameter used, a disk corresponding to the diameter of the with a retentive bracket with undercuts to attach tooth to be placed is placed onto the cast. The the ceramic sleeve to the body of the template. hole in the setup disk positions the center of the The bracket is fused to the body of the sleeve at implant in the center of the space so that the final a high temperature (Fig. 19) and is positioned crown has equal flare mesially and distally. A 3/32 on the lingual/palatal on the guide post in the inch twist drill is introduced through the center of cast (Fig. 20) and then the stent is completed the denture tooth or setup disk to create the hole with Triad gel or other appropriate material. in the cast. A magnetic guide post is placed into the hole in the cast and an open sleeve is placed Fabrication of the Guide Right stent with on the guide post with the retention portion of the ceramic guide sleeves is similar to the stan- sleeve positioned to the lingual. It is suggested dard Guide Right stent with metal sleeves. Care that the open portion of the sleeve may be directed should be taken not to torque the osteotomy drill toward the mesial buccal (position the retentive laterally while in the thin walled sleeve as this element to the distal lingual) as this will aid inser- may cause fracture of the sleeve or its retentive tion of the osteotomy drill. The stent is completed bracket. Metal sleeve inserts are available for by application of Triad gel or other appropriate use in the larger ceramic sleeves to allow guid- acrylic to complete the stent as previously outlined. ance of each drill to be used during the osteot- omy preparation. As with the other Guide Right The stent can then be inserted and a radiograph stents, the stent is tried in prior to surgical use taken to verify positioning of the guide sleeve (Fig. (Fig. 21). A cone beam scan can be taken to 13). During surgical use of the stent, the osteotomy verify the proposed trajectory in a buccal-lingual drill is guided along the closed portion of the sleeve and mesial-distal direction. The ceramic sleeve is to allow it to be guided by the stent (Fig. 14). Follow- clearly visible on the subsequent x-ray (Fig. 22). ing development of the osteotomy with the Guide Right open sleeve stent the implant is placed based CONCLUSION on the implant manufacturers instructions (Fig. 15). Implant dentistry is a prosthetically driven treat- Surgical Stents in Conjunction with CT ment modality and communication between the and Cone Beam Scans restoring dentist and surgeon is critical to treat- As CT and cone beam scans are becoming more ment success. As part of this use of surgical popular in implant treatment metal containing stents communicate the desired position and stents may result in scatter and poor visibility on angulation of the implant so that the restorative 42 • Vol. 2, No. 5 • June 2010

Kurtzman et al phase of treatment does not encounter prob- The Journal of Implant & Advanced Clinical Dentistry lems that can compromise the esthetic out- come and also complicate oral hygiene for the ATTENTION patient. The Guide Right surgical stent system PROSPECTIVE is an easy to use method for in-office fabrica- tion of implant stents for the partially edentu- AUTHORS lous arch. This technique allows the desired/ planned implant position and angulation to JIACD wants be easily communicated to the surgeon. to publish your article! Correspondence: Gregori M. Kurtzman, DDS For complete details 3801 International Drive, Suite 102 regarding publication in Silver Spring, MD 20906 301-598-3500 JIACD, please refer 301-598-9046 (Fax) to our author guidelines at [email protected] the following link: Acknowledgment: http://www.jiacd.com/ The authors would like to thank Dr. Sean Meitner for reviewing the article and his assistance with images. authorinfo/ author-guidelines.pdf Disclosure The author reports no conflicts of interest with anything mentioned in this article. or email us at: [email protected] References 1. Binon PP. Treatment planning complications and surgical miscues. J Oral Maxillofac Surg. 2007 Jul;65(7 Suppl 1):73-92. Erratum in: J Oral Maxillofac Surg. 2008;66(10):2195-2196. 2. Rosenlicht JL. Simplified implant dentistry for the restorative dentist: integrating the team approach. Int J Dent Symp. 1995;3(1):56-59. 3. John V, Gossweiler M. Implant treatment planning and rehabilitation of the anterior maxilla: Part 1. J Indiana Dent Assoc 2001; 80(2):20-24. 4. Small BW. Surgical templates for function and esthetics in dental implants. Gen Dent. 2001;49(1):30-32, 34. 5. Wat PY, Chow TW, Luk HW, Comfort MB. Precision surgical template for implant placement: a new systematic approach. Clin Implant Dent Relat Res 2002;4(2):88-92. 6. Mason WE, Rugani FC.: Prosthetically determined implant placement for the partially edentulous ridge: a reality today. J Mich Dent Assoc 1999;81(9):28, 30, 32, 34-37. 7. Cehreli MC, Sahin S. Fabrication of a dual-purpose surgical template for correct labiopalatal positioning of dental implants. Int J Oral Maxillofac Implants 2000 ; 15(2):278-282. 8. Kopp KC, Koslow AH, Abdo OS. Predictable implant placement with a diagnostic/surgical template and advanced radiographic imaging. J Prosthet Dent 2003; 89(6):611-615. The Journal of Implant & Advanced Clinical Dentistry • 43





A Comparative Clinical, Histological and Noumbissi et al Histomorphometric Study of Mineralized Allograft and Xenograft Materials in the Treatment of Atrophic Maxillary Sinuses Sammy S. Noumbissi, DDS MS1 • Alejandro J. Kleinman, DDS MS2 Abstract Background: Maxillary sinus augmentation with MSDBA 100% cancellous (n = 13), MSDBAM deproteinized mineralized bovine bone xenografts 1:1 Cortico-cancellous (n = 6) and DFDBA/ (DMBBX) alone or in combination with deminer- DMBBX 1:1 (n = 4). Biopsy cores were har- alized freeze-dried bone allografts (DFDBA) has vested in time frames ranging from 6 months to been well documented. Recently, articles have 12 months. Dental implants were placed into the been published evaluating histologically, histo- grafted bone immediately after core collection. morphometrically, and clinically the efficacy of using human mineralized cortical, cancellous, Results: All bone grafts resulted in new bone for- or a combination of both for atrophic maxillary mation and all implants osseointegrated. MSDBA sinuses. This study clinically, histologically and and MSDBAM graft turnover was faster than histomorphometrically compares three graft com- the DMBBX/DFDBA grafts. No complications binations currently used by practitioners in the with any of the grafts or implants were noted. augmentation of atrophic human maxillary sinuses. Conclusions: Graft resorption and replace- Methods: Study participants (n = 18) were par- ment by new bone occurred at a faster rate tially or completely edentulous patients who with MSDBA and MSDBAM compared to presented with bilateral or unilateral atrophic the bovine component (DMBBX) of the xeno- posterior maxillary sinuses. A total of twenty grafts; however, no differences in graft sta- two sinuses were grafted; they consisted of bility or osseointegration were noted. KEY WORDS: Bone graft, autograft, allograft, xenograft, sinus augmentation, cortical, cancellous, mineralized bone allograft, histology, histomorphometry 1. Private Practice Limited to Implant Dentistry, Silver Spring, Maryland, USA 2. Associate Professor, Graduate Program in Implant Dentistry, Loma Linda University, Loma Linda, California, USA The Journal of Implant & Advanced Clinical Dentistry • 47

Noumbissi et al Figure 1: MSDBA: High-power (x10) New bone formation Figure 2: DMBBX/DFDBA: New trabeculae (NB) (NB) on the surfaces of MSDBA (P). bridges DMBBX (B) particles, while DFDBA particles (D) are incorporated and turning over into new bone INTRODUCTION (Magni cation x10). Implant placement in the posterior maxillary new bone through the processes of osteogen- jaw is often complicated by a lack of available esis, osteoinduction and osteoconduction, and bone. After tooth extraction, rapid resorption is thus widely viewed as the graft material of of the residual maxillary ridge typically occurs choice for these procedures.9 Several skeletal in the buccolingual and occlusoapical direc- locations have been used as donor sites for har- tions, and often results in a “knife-edge” ridge vesting autogenous bone, including the ilium,10 deformity.1-2 Use of a removable prosthe- calvarium,11 tibia,12 fibula,13 scapula,14 man- sis, the presence of periodontal disease and dibular symphysis15 and mandibular ramus.16 physical trauma can exacerbate this resorp- Variations in the dimensions, quality and quan- tion process.1-2 Pneumatization and enlarge- tity of obtainable bone, increased operating ment of the sinus can further diminish or time and cost for bone harvesting, and donor eliminate alveolar bone height, which can com- site morbidity are some of the inherent limita- plicate the ability to place dental implants.1-2 tions associated with the use of autografts.2, 4 Onlay ridge grafting3-4 and subantral aug- Deproteinized mineralized bovine bone mentation via a crestal1,4 or lateral window xenograft (DMBBX) has been widely used as (modified Caldwell-Luc technique)7-8 approach a substitute for autogenous bone. To prevent are commonly used to increase the volume of antigenicity, the bovine bone tissue is chemi- available bone for implant placement in the pos- cally treated to remove its organic components terior maxilla. Autogenous bone is currently the (calcium-deficient carbonate apatite).17 When only available graft material capable of growing processed under low heat (300° C), the basic trabecular architecture, porosity and apatite 48 • Vol. 2, No. 5 • June 2010

Noumbissi et al Figure 3: DMBBX/DFDBA: High-power (x10) magni cation Figure 4: MSDBA: Thick, dense trabeculae (NB) surrounded shows new bone formation (NB) on the surface and inside a some MSDBA particles (P) or incorporated them so former Haversian canal (box) of a large DMBBX (B) particle. well that the graft particles were di cult to distinguish (magni cation x10). crystalline content of the natural bone are main- tained.17 The resulting DMBBX is a mineralized variables can negatively affect the osteoinduc- xenograft that undergoes physiologic remod- tive capacity of the BMP in DFDBA, however, eling and incorporation into the host tissue at including donor age20 and factors in tissue pro- a very slow rate over time.17-18 In one canine cessing (e.g. retrieval time and temperature,21 study,1 for example, DMBBX and -tricalcium sterilization method22); consequently, clini- phosphate were placed into surgically created cal results with DFDBA have sometimes been defects. By 24 months, all -tricalcium phos- unpredictable. The influence of mineraliza- phate graft particles had resorbed, whereas tion (calcium) on the clinical performance of DMBBX particles still occupied a remark- allogenic bone grafts still remains unclear.17 able area fraction without discernable resorp- tion after 6 months.18 For this reason, some This article reports on the results of a pro- clinicians advocate only using DMBBX as a spective study where the clinical, histologic composite graft with autogenous or deminer- and histomorphometric results of mineralized alized freeze-dried bone allograft (DFDBA).17 cancellous allografts, mineralized cortico-can- cellous allografts and mineralized bovine com- Demineralizing allogenic bone exposes the posite grafts placed in human pneumatized bone morphogenetic protein (BMP) present in maxillary sinuses are evaluated and compared. the tissue, which is capable of inducing host mesenchymal stem cells to differentiate into MATERIALS AND METHODS osteoblasts and cause osteogenesis throughout the implanted area (osteoinduction).19 Several Patient Selection Candidates for this study were consecutive healthy patients from two private practices who The Journal of Implant & Advanced Clinical Dentistry • 49

Noumbissi et al Figure 5: DMBBX/DFDBA: A good trabecular pattern (NB) Figure 6: DMBBX/DFDBA: Thick trabeculae (NB) formed on surrounded multiple large DMBBX particles (magni cation the surfaces and bridged large residual DMBBX (B) particles x10). (magni cation x10). desired dental implants, but who presented ics (amoxicillin or erythromycin, 2 g: 1 tab- with less than 5 mm of residual bone inferior let 4 times daily). Immediately before surgery, to the maxillary sinus floor. Patients with seri- patients received ibuprofen (800 mg) and were ous health issues (e.g. uncontrolled diabetes, asked to rinse with 0.12% chlorhexidine diglu- destructive parafunctional habits, pregnancy, conate for 2 minutes. Anesthesia was admin- mental or psychological impairment), a history of istered by local infiltration using mepivacaine poor oral hygiene and smokers were excluded hydrochloride 2% (Polocaine, AstraZenica Phar- from the study. Medical and dental histories maceuticals LP, Wilmington, DE) with 1:20,000 were reviewed, complete oral and radiographic epinephrine (Astra USA Inc., Westborough, evaluations were performed and mounted study MA). An open sinus grafting procedure uti- casts were fabricated for each patient. A surgi- lizing a lateral window approach7-8 was used. cal template to guide placement of the implants relative to the planned restoration was cre- MSDBA and MSDBAM (Puros Bone Partic- ated from a prosthetic wax-up or by means of ulate, Zimmer Dental Inc., Carlsbad, CA) grafts 3D imaging technology. The treatment plan, consisted respectively of a 100% solvent-dehy- study requirements and alternative options were drated mineralized large particle cancellous reviewed, and each patient signed an informed bone allograft and a 1:1 large particle solvent- consent form prior to be admitted into surgery. dehydrated mineralized cortical and cancellous bone allograft mixture, which was prepared from Treatment Phase I cancellous and cortical donor bone treated for The day before surgery, patients commenced biological safety through a 5-step proprietary a 10-day regimen of prophylactic antibiot- process (Tutoplast Process, Tutogen Medi- cal GmbH, Neunkirchen am Brand, Germany): 50 • Vol. 2, No. 5 • June 2010

Noumbissi et al Figure 7: MSDBA Graft: Two MSDBA particles (P) were Figure 8: MSDBA Graft: Under high-power (x10) encapsulated and connected by newly formed bone (NB) magni cation, di erentiation can be made between new that they were di cult to distinguish even under high- bone formation (NB) and small incorporated MSDBA graft power magni cation (x10). particles (P). Figure 10: Bovine core formed mostly of large DMBBX particles surrounded by islets of new bone. Figure 9: MSDBA Graft: MSDBA particles (P) were di cult to distinguish in newly formed bone (NB), and the lamellar pattern of mature bone (L) could be seen around the MSDBA particles. The Journal of Implant & Advanced Clinical Dentistry • 51