The Art of Block Grafting

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VOLUME 2, NO. 2 MARCH 2010 The Journal of Implant & Advanced Clinical Dentistry The Art of Block Grafting VOLUME 1, NO. 1 MARCH 2009 VOLUME 1, NO. 2 APRIL 2009 VOLUME 1, NO. 4 JUNE 2009 VOLUME 1, NO. 7 OCTOBER 2009 VOLUME 1, NO. 8 NOVEMBER 2009 The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry The Journal of Implant & Advanced Clinical Dentistry The Agony and Ecstasy of CAD/CAM BOisspothRfeoteohlsnaepethJecarodownsaiste MAuaxgimlilvaerneytraSstiniaournsyHistologicandHistomorphometricAnalysis Buying Cone Beam Technology Overdenture Bar Fabrication Part 1: The Ecstasy | Dale A. Miles Premiere Issue CASE OF THE MONTH: Restoring the Severely Year AnnThe BioDerm Single Surgery A New Smile Utilizing an Atrophic Maxilla 1Technique Implant and Ten All Ceramic Septal Sinus Lift 2 Hours of CE Credit Comprehensive Gingival CE Credit Restorations | Ross W. Nash Implant Induced with Immediate Grafting Technique Sublingual Hematoma Implant Placement 2 Hours of

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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 19 Case of the Month Multidisciplinary Restoration of Anterior Maxillary Dentition Luis J. Pazos Cóppola 27 Minimally Invasive Sinus Augmentation using Ultrasonic Piezoelectric Vibration and Hydraulic Pressure Dong-Seok Sohn, Paul Maupin, Ramon Ponce Fayos, Kenneth Lee, Sungho Jun, Yoshiharu Hayashi 45 The Art of Block Grafting: A Review of the Surgical Protocol for Reconstruction of Alveolar Ridge De ciency Nicholas Toscano, Nicholas Shumaker, Dan Holtzclaw 71 Evaluating the E cacy of Bone Marrow Aspiration Added to Grafts in Oral defects: 2 Clinical Reports Sherman Lin, Dennis Smiler, Muna Soltan The Journal of Implant & Advanced Clinical Dentistry 5

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The Journal of Implant & Advanced Clinical Dentistry Table of Contents 83 Factors Driving Peri-implant Crestal Bone Loss - Literature Review and Discussion: Part 4 Mohammad Ketabi, Robert Pilliar, Douglas Deporter 93 Dental 3D Imaging Centers - Usage and Findings: Part IV – Anterior Extension of Inferior Alveolar Nerve From the Mental Foramen Alan A. Winter, Kouresh Yousefzadeh, Alan S. Pollack, Michael I. Stein, Frank J. Murphy, Christos Angelopoulos 101 Atypical Gingival Manifestations that Mimic Mucocutaneous Diseases in a Patient with Contact Stomatitis Caused by Toothpaste Hiroyasu Endo, Terry D. Rees, Fifita Sisilia, Kayo Kuyama, Mitsuhiro Ohta, Takanori Ito, Takao Kato, Yoshiharu Kono, Hirotsugu Yamamoto The Journal of Implant & Advanced Clinical Dentistry 7

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The Journal of Implant & Advanced Clinical Dentistry Publisher Copyright © 2010 by SpecOps Media, LLC. All rights SpecOps Media, LLC reserved under United States and International Copyright Conventions. No part of this journal may be reproduced Design or transmitted in any form or by any means, electronic or Jimmydog Design Group mechanical, including photocopying or any other information www.jimmydog.com retrieval system, without prior written permission from the publisher. Production Manager Stephanie Belcher Disclaimer: Reading an article in JIACD does not qualify 336-201-7475 the reader to incorporate new techniques or procedures discussed in JIACD into their scope of practice. JIACD Copy Editor readers should exercise judgment according to their JIACD staff educational training, clinical experience, and professional expertise when attempting new procedures. JIACD, its Digital Conversion staff, and parent company SpecOps Media, LLC (hereinafter NxtBook Media referred to as JIACD-SOM) assume no responsibility or liability for the actions of its readers. Internet Management InfoSwell Media Opinions expressed in JIACD articles and communications are those of the authors and not necessarily those of JIACD- Subscription Information: Annual rates as follows: SOM. JIACD-SOM disclaims any responsibility or liability Non-qualified individual: $99(USD) Institutional: $99(USD). for such material and does not guarantee, warrant, nor For more information regarding subscriptions, endorse any product, procedure, or technique discussed in contact [email protected] or 1-888-923-0002. JIACD, its affiliated websites, or affiliated communications. Additionally, JIACD-SOM does not guarantee any claims Advertising Policy: All advertisements appearing in the made by manufact-urers of products advertised in JIACD, its Journal of Implant and Advanced Clinical Dentistry (JIACD) affiliated websites, or affiliated communications. must be approved by the editorial staff which has the right to reject or request changes to submitted advertisements. Conflicts of Interest: Authors submitting articles to JIACD The publication of an advertisement in JIACD does not must declare, in writing, any potential conflicts of interest, constitute an endorsement by the publisher. Additionally, monetary or otherwise, that may exist with the article. the publisher does not guarantee or warrant any claims Failure to submit a conflict of interest declaration will result made by JIACD advertisers. in suspension of manuscript peer review. For advertising information, please contact: Erratum: Please notify JIACD of article discrepancies or [email protected] or 1-888-923-0002 errors by contacting [email protected] Manuscript Submission: JIACD publishing guidelines JIACD (ISSN 1947-5284) is published on a monthly basis can be found at http://www.jiacd.com/author-guidelines by SpecOps Media, LLC, Saint James, New York, USA. or by calling 1-888-923-0002. The Journal of Implant & Advanced Clinical Dentistry 9

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

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Editorial Commentary No Respect Ioften think that the late great stand-up comedian Rodney Dangerfield must have In fact, he sings a catchy song about it. Even secretly been a dentist. His infamous children’s movies take pleasure in poking fun at dentists. Remember Hermey from the Rankin and trademark quip “I get no respect!” can easily Bass® holiday classic Rudolph the Red Nosed be used by most of us in the dental profession. Reindeer? Yep, this elf had problems and was Even though dentists are consistently rated outcast as a “misfit” because he wanted to be a among the top five most trusted professions dentist. in annual polls, we are consistently denigrated The lack of respect for dentists does not stop and serve as the butt of one joke after another. on the movie screen; it persists in real life as well. Take the recent hit movie The Hangover When my oldest daughter was having her adenoids (Warner Brothers Studios®) as an example. In removed, my wife and I accompanied her into the this movie, one of the main characters (Stu Price) pre-op holding area. The ENT surgeon and the is a dentist and great care is taken to remind anesthesiologist stopped by with a group of medical the viewers that he is only a dentist. In one of students in tow. The ENT surgeon introduced me the many scenes depicting Stu as being a lowly to the medical students as Dr. Holtzclaw, to which dentist, Stu and his pals are checking into a Las the anesthesiologist quickly commented “He’s just Vegas hotel. Stu reserves the room under the a dentist.” Nice. Then there was the time I most name “Dr. Price” which leads to the following recently renewed my ACLS certification. When dialogue with his buddy Phil: my time came to run the mega-code, the instructor Phil: “Doctor Price? Stu, you’re a dentist. Hey, said “Ah, our token dentist!” While he gave every don’t try and get fancy.” other person very simple scenarios, mine was an Stu: “It’s not fancy if it’s true.” elderly gentleman with multiple heart conditions Phil: (to the hotel clerk) “He’s a dentist. Don’t who was struck by lightning on a golf course. I get too excited…and if, uh, someone has a heart ran through every code perfectly and my “patient” attack, you should still call 911.” still died. I knew I had run each code correctly and The Hangover is just one of many in a long line asked what was the problem? The instructor says, of movies that pick on dentists. Let’s see, we had “You did everything right. Great job! It was just the wonderful series of horror movies The Dentist your patient’s time to die.” Of course, none of the and The Dentist 2 in which a psychotic dentist “real doctors” had patients die. goes on a murderous rampage after discovering Hopefully, when I die, my grave will not say that his wife was having an affair. We had the “Here lies Dr. Holtzclaw. He was just a dentist… infidelity thing pop up again in The Secret Lives don’t get too excited.” of Dentists. Oh, I almost forgot, Stu’s fiancé in The Hangover was unfaithful as well. (What is it with Hollywood portraying dentists as having bad marriages and poor relationships)? In the classic film version of The Little Shop of Horrors, Steve Martin provides a great performance as a sadistic Dan Holtzclaw, DDS, MS Nick Toscano, DDS, MS dentist who enjoys causing his patients pain. Founder, Co-Editor-In-Chief Founder, Co-Editor-In-Chief The Journal of Implant & Advanced Clinical Dentistry 13



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







Case of the Month Cóppola et al Multidisciplinary Restoration of Anterior Maxillary Dentition Luis J. Pazos Cóppola DDS, MD1 Abstract A41 year old male patient with no con- osteotomy and bovine xenograft (NUOSS from tributory medical history presented with ACE SURGICAL SUPPLY) (figure 6). The a chief complaint of a broken central bone graft was covered with a collagen mem- incisor (figure 1). After careful oral and radio- brane (CONFORM from ACE surgical sup- graphic examination (figure 2) a periapical lesion ply) (figure 7) to avoid soft tissue invagination. in the left central incisor and several old com- To augment soft tissue aesthetics, a palatally posite restorations in all the other upper inci- obtained subepithelial connective tissue graft (fig- sors were noted. The treatment plan offered ure 8) was sutured to the facial flap (figure 9) and to the patient included endodontic treatment of was advanced to obtain primary closure (figure 10). the left central incisor, replacing the right central After finishing the surgery, the healing abut- incisor with an immediately loaded provisional ment was removed and an implant transfer cop- fixed screwed implant crown, and ultimately four ing was placed to take a fixture level silicon ceramic crowns on the four maxillary incisors. impression (figure 11). A metal-resin immediately Root canal therapy of the left central inci- loaded provisional screw retained crown (fig- sor was accomplished using K3 rotary files ure 12) was delivered 24 hours later (figure 13). (Sybron) with the Tri-auto device and filling the After 5 months of uneventful healing (fig- root canal with Real Seal applied with the Sys- ure 14), the three other upper incisors were tem B machine (Sybron) (figure3). Later, on prosthetically prepared and a mixed tooth- the day of surgery, a flap from cuspid to cus- implant silicon impression was taken (figure 15). pid without vertical incisions was reflected. The A gold-plastic UCLA abutment was cus- root of the central incisor was atraumatically tomized and ceramized (figure 16) so as extracted using piezosurgery and adjacent the to cement a LAVA ceramic crown over the root apex was cleaned and debrided (figure 4). implant abutment for the final restoration. A 4.75 x 13mm dental implant was placed The other incisors were restored with LAVA 2mm subcrestally in the extraction socket of the metal free crowns as well (figures 17,18). central incisor (figure5). Afterwards, the adja- The final restorations and the esthetic results cent periapical defect was grafted with a mixture (figures 19,20) were considered success- of autogenous bone obtained from the implant ful and the patient was completely satisfied. KEY WORDS: Dental implants, customized abutment , ceramic crowns 1. Private practice dedicated to implantology and restorative dentistry in Gijón (Spain) The Journal of Implant & Advanced Clinical Dentistry 19

Cóppola et al Figures 1-5 20 Vol. 2, No. 2 March 2010

Cóppola et al Figures 6-11 The Journal of Implant & Advanced Clinical Dentistry 21

Cóppola et al Figures 12-15 22 Vol. 2, No. 2 March 2010

Cóppola et al Correspondence: Figures 16-20 Luis J. Pazos Cóppola , MD , DDS c/Avenida de la Costa 52-1-J, 33201, Gijon, SPAIN Phone: +34 985330611 Disclosure The author reports no conflicts of interest with anything mentioned in this article. Acknowledgements The author wishes to express his gratitude to Drs. Ramón and Marisa Antin from San Sebastian for their continuous support and help. The author also wants to thank the dental technicians Emilio Menendez, Artemio Picaza, and Eduardo Setien for their wonderful technical work in the elaboration of this case. The Journal of Implant & Advanced Clinical Dentistry 23

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Minimally Invasive Sinus Augmentation using UltrasoSonhincet al Piezoelectric Vibration and Hydraulic Pressure Dong-Seok Sohn, DDS, PhD1 2 3 Kenneth Lee BDS4 5 6 Abstract Background: The atrophic posterior maxilla is a puted tomograms were taken before surgery to challenging site to place dental implants. Lateral evaluate bone quantity in posterior maxilla. The window or crestal approaches are common sur- sinus floor was broken with a specially designed gical techniques to overcome the vertical defi- ultrasonic insert with ultrasonic vibration, and ciencies of the atrophic posterior maxilla. Sinus hydraulic pressure was applied to elevate sinus augmentation using the lateral window procedure membrane evenly simultaneously. A surgical has been predictable for several decades. How- mallet was not used to break sinus floor in any ever, this procedure may result in patient mor- case. Bone graft was not an absolute prereq- bidity such as postoperative swelling, pain, and uisite in this report. Implants were placed simul- a long edentulous healing period. The crestal taneously or delayed depending on situations. approach using a surgical mallet and osteotome Postoperative radiographs were taken to evalu- is less invasive than the lateral approach, but it ate sinus augmentation results in all patients. has some limitations such as postoperative ver- tigo, membrane perforation from bone packing to Results: All cases in this report show sinus membrane, and limited vertical augmenta- successful vertical augmentation with tion due to difficult accessibility. This case series implant survival. Patients showed mini- report demonstrates sinus membrane elevation mal or no postoperative pain and swelling. using hydraulic pressure and piezoelectric ultra- sonic vibration. This technique results in mini- Conclusions: The crestal approach to maxil- mal patient morbidity and offers an alternative lary sinus augmentation using hydraulic pressure to lateral window maxillary sinus augmentation. and ultrasonic vibration is simple and safe pro- cedure with minimal patient morbidity and can Methods: Preoperative radiographs or com- be an alternative technique to lateral approach. KEY WORDS: Maxillary sinus, bone graft, dental implants, piezoelectric surgery 1. Professor and Chair, Department of Dentistry and Oral and Maxillofacial Surgery, Catholic University Medical Center of Daegu, Daegu, Republic of Korea 2. Private Practice, Regina, Saskatchewan, Canada 6. Private Practice, You-Building Dental Clinic, Tokyo, Japan The Journal of Implant & Advanced Clinical Dentistry 27

Sohn et al Figure 1: Piezoelectric device reduces membrane INTRODUCTION perforation due to micro-vibration and selective cutting. Missing dentition in the maxillary alveolar ridge Figure 2: Sinus oor penetrated with round carbide insert. brings challenges in implant placement due to This insert provides tactile control to the sinus membrane. rapid sinus pneumatization and ridge resorption. In order to place implants of adequate height, ridge augmentation is often necessary.1-2 The lat- eral window approach is usually the technique of choice for ridge augmentation in the maxil- lary posterior area, especially in cases of minimal residual bone. The lateral window approach has been recognized as a predictable method. How- ever, some patients may reject the lateral window approach due to surgical fear and postopera- tive pain, swelling, and a long edentulous heal- ing period. Furthermore, surgeons with limited surgical experience tend to avoid this method. To overcome the disadvantages of the lat- eral window approach in maxillary sinus aug- mentation, variable crestal approaches, such as osteotome technique4, piezoelectric inter- nal sinus elevation(PISE) , hydraulic sinus condensing(HSC) technique6, internal sinus manipulation(ISM) procedure method, and crestal window technique(CWT)8, have been introduced. Most of these techniques rely on bone compaction in order to elevate the sinus membrane. Too much pressure of bone compac- tion may lead to membrane perforation during or after surgery. ISM and CWT techniques use small instrument to manipulate the sinus mem- brane, but membrane perforation and delayed surgical time can occur due to limited visibility and accessibility. The aim of this report is to dem- onstrate an innovative surgical procedure to ele- vate the sinus membrane crestally with hydraulic pressure and piezoelectric ultrasonic vibration before bone condensation without manipu- lation of crestally approached instruments. 28 Vol. 2, No. 2 March 2010

Sohn et al SURGICAL TECHNIQUE Figure 3: HPISE insert simultaneously cuts bone using micrometric vibration and also elevates the sinus The hydrodynamic piezoelectric internal sinus ele- membrane using hydraulic pressure vation (HPISE) technique is a crestal approach using ultrasonic micro-vibration and hydrau- Figure 4: Membrane elevation using hydraulic pressure. lic pressure. The HPISE tip uses a specially Water pressure gently elevates the sinus membrane. designed tip that attaches to a piezoelectric ultra- Physical pressure from a hand instrument is not necessary. sonic unit (Surgybone®, Silfradent srl, Sofia, Italy or compatible device) and allows water to pass through the tip to elevate the membrane (Fig- ure 1). After local anesthesia using lidocaine (1;100,000 epinephrine) in the surgical site, a full thickness flap is reflected to expose the alveolar ridge. Flapless surgery may also be performed depending on the width of the alveolar ridge. As a first step, a 2.2mm wide carbide round insert (S022®, BukBu Dental Co, Daegu, Korea) with external irrigation is used to break sinus floor (Figure 2). After breaking the sinus floor with the round tip, a 2.8mm wide cylindrical carbide insert (HPISE insert®, BukBu Dental Co, Daegu, Korea) is used to enlarge the osteotomy site and elevate the sinus membrane using hydrau- has 4mm working tip height, and depth indicat- ing lines are marked by 2mm intervals. Hydrau- lic pressure to the sinus membrane from internally irrigated sterile saline causes membrane detach- ment from the sinus floor and membrane perfo- ration is very rare. After breaking the sinus floor cortex using ultrasonic vibration, hydraulic pres- sure is applied for 10-20 seconds to detach sinus membrane from sinus floor. After this stage, sur- geons can observe up and down movement of sinus membrane whenever patients take a breath. Bone graft is dependent on surgeon’s per- sonal preference. If the required sinus elevation be placed without bone graft. If additional verti- The Journal of Implant & Advanced Clinical Dentistry 29

Sohn et al Figure 5: Bone compaction is not a prerequisite in the Figure 6: Ultrasonic vibration assisted bone compaction HPISE technique because the sinus membrane is elevated with the HPISE insert reduces the physical pressure needed before bone compaction. pack the bone graft material under the sinus membrane. Figure 7: Implant placement. The HPISE insert is the nal bone (Bio-Cera TM, Oscotec Co, Chunan, Korea) osteotomy drill for the placement of regular sized implants or mineral allograft (Allotis®, Bio-Tis Co, Seoul, (approx. 4mm in diameter). Korea). The mixture of bone graft is carried with an amalgam carrier and is delivered beneath the cal augmentation is required, bone graft material elevated sinus membrane through the osteotomy should be used. Collagen sponge or fibrin rich block with concentrated growth factors (CGF®, used alone, direct injection of the gel conditioned Medifuge, Silfradent srl, S.Sofia, Italy) was used bone into new compartment is recommended. as an alternative to bone graft in this report. The Bone compaction can be attained by using the authors’ preferred bone graft is gel-conditioned ultrasonic vibration of the piezoelectric device allograft (Orthoblast II®, Isotis Orhtobiologics (Figure 6). This procedure controls pressure to Inc, Irvine, USA) or the mixture of gel-conditioned the bone graft when bone packing is performed, allograft with Ca-P nonocoated anorganic bovine thereby reducing the possibility of membrane per- foration during bone compaction. The implant may be placed simultaneously or delayed (Fig- ure 7). When an implant less than 4mm wide is placed, the HPISE insert is the last instrument to make the osteotomy prior to implant placement. Undersizing the osteotomy ensures better initial stability of the implant. When a wider implant is placed, intermittent drilling is often required to accommodate the wide body implant. For this particular procedure, it is recommended that 30 Vol. 2, No. 2 March 2010

Sohn et al Figure 8: A radiograph showing insu cient bone height Figure 9: Application of hydraulic pressure to elevate the and high septum at #4 and #5. sinus membrane after breaking the sinus oor with the HPISE insert. the osteotomy be undersized by one drill size to ensure adequate primary stability of the implant. in the new compartment under the elevated sinus membrane at #4 using an amalgam carrier, but CASE REPORTS - Case 1 - implant, Thommen Medical Co, Waldenburg, Swit- zerland) were placed simultaneously, and guided ported fixed prosthesis visited our department. bone regeneration using bone substitute and col- The patient’s medical history was not significant. lagen membrane (Tutoplast Pericardium®, Tutogen Pre-operative plain radiographs showed residual medical GmBH, Germany) was performed to aug- ment the narrow ridge (Figure 11). The postoper- sinus septum was seen in the radiograph (Figure ative computed tomogram showed approximately 8). Local anesthesia was administrated and a full 10mm vertical elevation using hydraulic pressure thickness flap was retracted to expose the alveolar bone. A 2.7mm wide twist drill was used to make achieved at the #4 site using bone graft material. Unlike conventional osteotome mediated sinus sinus floor. The sinus floor was broken with the elevations, the sinus membrane was elevated HPISE insert, and hydraulic pressure was applied evenly at both the medial and lateral aspects as seen in conventional laterally approached aug- - mentations (Figure 12). A more radiopaque ure 9). When applying saline through the oste- image was seen at site #4 (where bone graft otomy socket of #4, the saline came out through was used. Implant uncovering was delayed to membrane was elevated over the septum. The wait for orthodontic treatment completion. The mixture of Orthoblast II and Bio-Cera was grafted The Journal of Implant & Advanced Clinical Dentistry 31

Sohn et al Figure 10: Mixture of Orthoblast II and Bio-Cera was Figure 11: GBR was performed after the placement of two grafted at site #4, but bone graft was not performed at #5. 4.5 x 11mm implants. Figure 12: Cross sectional view of CT showing ~10mm Figure 13: Site # 4 and 5 after 7 months in function. Note vertical elevation using hydraulic pressure alone at #5. favorable sinus augmentation with or without bone graft Note the even sinus elevation in the lateral and medial wall material. of sinus. implants were exposed after 8 months healing. A (approximately 7 mm) for a conventional den- radiograph of the final prosthesis showed favor- tal implant. A minimally invasive sinus lift tech- able bone augmentation at both sites, regardless nique using HPISE was chosen to augment the sinus. Local anesthesia was administered and a Case 2 conventional flapless osteotomy was made with - floor (Figure 14). The HPISE insert was then used to advance the osteotomy to and through placement but there was insufficient height the sinus floor. Hydraulic pressure was applied 32 Vol. 2, No. 2 March 2010

Sohn et al Figure 14: Twist drill was used to make an osteotomy Figure 15: After HPISE technique was performed, about 3 mm from sinus oor. collagen foam alone was packed under the elevated sinus membrane, and a 12mm length implant was placed. Figure 16: After 4 months healing, nal prosthesis was cemented. Note bony growth over the implant. a few seconds to gently lift the membrane. Col- lagen Foam (Ace Surgical, Brockton, MA, USA) was packed through the osteotomy into the sinus, 12mm implant (Cowell Medi Implant Co, Busan, Korea) was then placed and torqued to approxi- was placed and the patient was allowed to heal for 4 months before impressions were taken for a por- celain-to-noble crown (Figure 16). The patient reported no pain during or after the procedure. Case 3 A 60 year old woman with no significant medical history was referred to our department for sinus augmentation. Cone beam computed tomog- The Journal of Implant & Advanced Clinical Dentistry 33

Sohn et al Figure 17: CBCT showing presurgical residual bone height Figure 18: Perforation of sinus oor using the carbide of 1-5mm. insert. Figure 19: The application of hydraulic pressure and Figure 20: Sinus membrane integrity veri es with Valsalva widening of implant site using the HPISE insert. maneuver. raphy (CBCT) showed residual bone height of sinus membrane to accelerate bone formation, a mixture of Orthoblast II and Bio-Cera was 17). The round insert was used to penetrate the grafted through the osteotomy, and bone graft insert was pushed up to the sinus floor to elevate the sinus membrane using hydraulic pressure (Figures 18, 19). After application of hydrau- lic pressure, up and down movement of sinus membrane was observed during patient respira- tion. Fibrin block with concentrated growth fac- tors (CGF) was inserted under the elevated 34 Vol. 2, No. 2 March 2010

Sohn et al Figure 21: Insertion of CGF to accelerate bone formation in Figure 22: Application of HPISE insert with microvibration the sinus. for bone packing. Figure 23: Note approximately 15mm of sinus Figure 24: Radiograph showing placement of 12mm length augmentation at both sites. implants after 3 months healing. was packed with the HPISE insert using micro- Case 4 vibration (Figures 21, 22). The postoperative - cross-sectional view of CBCT images revealed - - cal history was revealed. The bone heights at tium Implant Co, Seoul, Korea) were placed by a was broken with the HPISE insert and hydraulic stability of implants was favorable (Figure 24). pressure was applied for a few seconds to elevate The Journal of Implant & Advanced Clinical Dentistry 35

Sohn et al Figure 25: Radiograph showing residual bone height of Figure 26: Radiograph showing more than 13mm high 4mm at site #3. vertical augmentation after implant placement at site #3. Figure 27: Note favorable sinus augmentation. of the #4 implant (Figure 26). Implants were uncovered after 6 months of healing and a porce- collagen sponge (Euroklee S.L., Cerdanyola del lain fused to metal crown was cemented after 4 - weeks use of a provisional prosthesis (Figure 27). stitute (Ostim, Heraeus Kulzer, Hanau, Germany) Case 5 (Frontier, Global Medical Implants SL. Barce- A 69 year old female patient visited at our depart- ment. Her chief complaint was masticatory dif- - ficulty due to an ill fitting denture. She wanted cal sinus augmentation was achieved, and sinus implant supported fixed prosthesis, but she was augmentation was continued to the apical area very apprehensive of sinus augmentations using a lateral approach. The cross section view of the CBCT image revealed residual bone height of - comfort, a crestal approach using the HPISE tech- nique was chosen. The HPISE insert was pushed up to break sinus floor and to elevate the sinus membrane. Orthoblast II was injected in the new compartment under the elevated sinus membrane - CGF alone was inserted under the elevated sinus 36 Vol. 2, No. 2 March 2010

Sohn et al Figure 28: CT cross sectional view showing presurgical Figure 29: CT cross sectional view showing presurgical bone height of 5mm at site #2 and #3. bone height at site #14. Figure 30: HPISE insert in use. Figure 31: Orthoblast II insertion into right maxillary sinus. Zimmer Co, CA, USA) were placed. Postopera- Figure 32: GCF insertion into left maxillary sinus. tive cross sectional view of CBCT images showed approximately 10mm of vertical sinus augmen- tation in the right posterior maxilla using bone graft and in the left posterior maxilla without bone very minimal. Cross sectional view of CT after 4 month healing revealed bone formation around all healing, all implants were uncovered. The final The Journal of Implant & Advanced Clinical Dentistry 37

Sohn et al Figure 33a: Postoperative CT cross sectional view Figure 33b: Postoperative CT cross sectional view showing showing approximately 10mm vertical sinus augmentation approximately 10mm vertical sinus augmentation with GCF regardless of bone grafting or non-bone grafting. alone. Figure 34a: CT cross sectional view after 4 months of Figure 34b: CT cross sectional view after 4 months of healing showing new bone formation around implants in healing showing new bone formation around implants in the sinus at sites #2 and #3. the sinus at sites #14 and #15. porcelain fused to metal prosthesis was cemented approach, the crestal approach has the advan- tage of being minimally invasive, which contrib- DISCUSSION utes to less postoperative discomfort. Multiple crestal techniques have been reported to over- The lateral window approach is a predictable come the disadvantages of the lateral window surgical method for augmentation of atrophic approach. Most of the crestal approaches use posterior maxillae, but complications associated a surgical mallet and osteotome to break the with the lateral window technique have been sinus floor. Several clinicians have reported reported.9,10 Compared to the lateral window postoperative positional vertigo related with 38 Vol. 2, No. 2 March 2010

Sohn et al osteotome mediated sinus floor elevations own venous blood, absorbable gelatin sponges (OMSFE) due to trauma to the inter ear from and CGF in a fibrin-rich block as alternatives to striking the surgical mallet.11-14 In addition, bone grafts for sinus augmentation have been OMSFE is a blind technique, so sinus augmen- reported in clinical studies. 24-26 Some studies tation is limited. The OMSFE technique has reported fibrin rich block with CGF acceler- lower success rates when residual bone height ated new bone formation.26,27 New bone forma- is 4mm or less (when compared to cases with tion in the sinus with collagen sponge and CGF as alternatives to bone grafts with the HPISE The PISE technique was evident in the present report. and HSC technique are innovative crestal meth- ods where a surgical mallet is not required to CONCLUSION break the sinus floor. These techniques are free from postoperative vertigo, but elevation The HPISE technique is a predictable sinus of the sinus membrane depends on bone com- augmentation method that does not involve paction because hydraulic pressure from exter- striking a mallet to break the sinus floor. This nal irrigation is not enough to elevate the sinus technique reduces the possibility of benign membrane. The crestal window technique positional vertigo, membrane perforation, and overcomes the blind nature of conventional postoperative patient discomfort. This tech- OMSFE,8 but the application is limited because nique does not rely on instrumentation or bone this technique is indicated when wide diameter compaction to elevate the sinus membrane. HPISE is an alternative surgical method to - the lateral sinus augmentation technique and tion, many instrumentations are necessary to can be used with or without bone graft mate- get a sufficient amount of sinus augmentation. this report and 9 total cases in this series. The HPISE technique uses ultrasonic piezo- electric microvibration and hydraulic pres- Correspondence: sure from internal irrigation. The piezoelectric Dr. Dong-Seok Sohn device using ultrasonic vibration only cuts hard Catholic University Medical Center of Daegu, tissue which allows it to come in contact with Department of Oral and Maxillofacial Surgery, the membrane without tearing it.16,17 Even and gentle elevation of the sinus membrane is Nam-Gu, Daegu, Republic of Korea possible due to hydraulic pressure from inter- email : [email protected] nal irrigation before bone packing. Therefore, bone compaction is not a prerequisite for sinus elevation in the HPISE technique unlike con- ventional crestal approaches. Some studies have recently reported successful sinus aug- mentation from lateral window approaches and crestal approaches with only membrane eleva- tion. New bone formation with patients’ The Journal of Implant & Advanced Clinical Dentistry 39

Sohn et al Disclosure 9. Jensen TO et al. The sinus bone graft. 1st ed. 21. Lundgren S, Andersson S, Gualini F, The authors report no conflicts of interest with Chicago. Quntesence Publishing Co, Inc. Sennerby L. Bone reformation with sinus anything mentioned in this article. 1999:201-208. membrane elevation: a new surgical technique References for maxillary sinus floor augmentation. Clin 1. Boyne PJ. Restoration of osseous defects 10. Hunter WL 4th, Bradrick JP, Houser SM, Patel JB, Sawady J Maxillary sinusitis resulting from 22. Sohn DS, Lee JS, Ahn MR, Shin HI. New in maxillofacial casualties. J Am Dent Assoc. ostium plugging by dislodged bone graft: bone formation in the maxillary sinus without 1969: 78:767-776. case report. J Oral Maxillofac Surg 2009 2. Smiler DG. The sinus lift graft: basic technique Moncler S, Bernard JP. Osteotome sinus floor and variations. Pract Periodontics Aesthet 11. Peñarrocha M, Pérez H, García A, et al. elevation without grafting material: a 1-year Benign paroxysmal positional vertigo as a prospective pilot study with ITI implants. Clin augmentation techniques are the most complication of osteotome expansion of the Oral Implants Res 2006;17:679-686. successful in furnishing bony support maxillary alveolar ridge. J Oral Maxillofac Surg 24. Hatano N, Sennerby L, Lundgren S. Maxillary for implant placement? Int J Oral sinus augmentation using sinus membrane Maxillofac Implants. 2007;22:49-70. 12. Saker M, Oqle O. Benign paroxysmal elevation and peripheral venous blood for 4. Summers RB. The osteotome technique: positional vertigo subsequent to sinus lift implant-supported rehabilitation of the via closed technique. J Oral Maxillofac Surg atrophic posterior maxilla: case series. Clin sinus floor. Compendium of Contin Dent Educ et al. Paroxysmal positional vertigo as a formation in the maxillary sinus with elevation applications of piezoelectric bone surgery. complication of osteotome sinus floor of sinus membrane and graft of absorbable 8th congress of international congress of oral gelatin sponge: case series reports. implantologists. Singapore. 2004;Aug.28th. 14. Peñarrocha M, García A. Benign paroxysmal 6. Chen L, Cha J. An 8-year retrospective study: positional vertigo as a complication of 26. Choukroun J Antoine Diss A Simonpieri A, interventions with osteotome and mallet. J Girard MO, Schoeffler, Cet al. Platelet-rich using the minimally invasive hydraulic fibrin (PRF): A second-generation platelet sinus condensing technique. J Periodontol Rosen PS, Summers R, Mellado JR, Salkin LM, Shanaman RH, Marks MH, Fugazzotto PRF effects on bone allograft maturation in 7. Yamada JM, Park HJ. Internal sinus manipulation PA. The bone-added osteotome sinus floor sinus lift. Oral Surg Oral Med Oral Pathol Oral (ISM) procedure: a technical report. Clin elevation technique: multicenter retrospective report of consecutively treated patients Int J 27. Sohn DS, Moon JW, Moon YS, Park JS, Jung 8. Samuel Lee, Grace Kang, Kwang-Bum park, HS. The use of concentrated growth(CGF) Thomas Han. Crestal sinus lift: A minimally 16. Sohn DS, Ahn MR, Lee WH, et al. for sinus augmentation. J Oral Implant invasive and systematic approach to sinus Piezoelectric osteotomy for intraoral harvesting of bone blocks. Int J Perio Rest 88. 17. Lee HJ, Ahn MR, Sohn DS. Piezoelectric distraction osteogenesis in the atrophic maxillary anterior area: A case report. Implant piezoelectric bony window osteotomy and sinus membrane elevation: introduction of a new technique for simplification of the sinus augmentation procedure. Int J Periodontics 19. Sohn DS, Moon JW, Lee HW,Choi BJ,Shin HI. Comparison of two piezoelectric cutting inserts for lateral bony window osteotomy: A retrospective study of 127 consecutive cases. In Press. Int J Oral Maxillofac Implants. 20. Sohn DS, Lee JS, An KM, Choi BJ. Piezoelectric Internal Sinus Elevation (PISE) Technique: A New Method for Internal Sinus 40 Vol. 2, No. 2 March 2010

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The Art of Block Grafting Toscano et al A Review of the Surgical Protocol for Reconstruction of Alveolar Ridge De ciency Nicholas Toscano, DDS MS1 Nicholas Shumaker, DDS MS2 Dan Holtzclaw, DDS MS3 Abstract Alveolar ridge resorption after tooth loss tion. The purpose of this article is to review the is a common phenomenon. After a tooth modern art of block grafting using the mandibu- is extracted the alveolar ridge decreases lar symphysis and ramus buccal shelf donor in width and height very rapidly, with as much as sites for alveolar ridge reconstruction in prepara- 50% loss in width during the first year, two-thirds tion for dental implants. The clinical indications, of which occurs in the initial 3 months. Often in advantages and disadvantages of each site, and clinical practice, the loss of a tooth does not coin- the surgical techniques necessary for optimal cide with replacement by a dental implant and outcomes will be discussed. While earlier tech- there is frequently a lag of months to years before niques were rather rudimentary, this article will an edentulous site presents for therapy. There- show how current techniques which integrate the fore it is often required that we perform hard tis- principles of guided bone regeneration ensure sue ridge augmentation to increase bone volume minimal resorption during integration and a pre- prior to dental implant placement and restora- dictable, time-efficient, and cost effective outcome. KEY WORDS: Bone augmentation, ramus, symphysis, dental implants 1. Private Practice, New York, NY 2. Dental Department Head, Periodontics Department Head, Naval Health Clinic Quantico, VA 3. Private Practice, Austin, TX The Journal of Implant & Advanced Clinical Dentistry 45

Toscano et al INTRODUCTION AND only up to 4.5mm increase documented BACKGROUND with particulate GBR techniques.5,16 2. Rapid integration allows early reentry for Alveolar ridge resorption after tooth loss is a implant placement, often in 3-4 months common phenomenon. After a tooth is extracted compared to the 6-9 months required for the alveolar ridge decreases in width and height particulate GBR techniques.5, 12, 16, 17 very rapidly, with as much as 50% loss in width 3. Optimal bone density for implant stabil- during the first year, two-thirds of which occurs in ity due to the cortical nature of the graft. the initial 3 months.1 Restorations supported by 4. Reliable space maintenance during heal- dental implants are currently a widely accepted ing ensures the shape and stability of the and successful treatment modality for the treat- bone block is retained without collapse.17 ment of partial and complete edentulism2. 5. Locally available donor sites avoid the need for extraoral autogenous bone sources.26 Often in clinical practice the loss of a tooth The purpose of this article is to review the does not coincide with its replacement by a den- modern art of block grafting using the man- tal implant. Unfortunately there is frequently a dibular symphysis and ramus buccal shelf lag of months to years before an edentulous site donor sites for alveolar ridge reconstruction presents for dental implant therapy. Therefore in preparation for dental implants. The clini- it is often required that we perform hard tissue cal indications, advantages and disadvan- ridge augmentation to increase bone volume tages of each site, and the surgical techniques prior to dental implant placement and restoration. necessary for optimal outcomes will be dis- cussed. While earlier techniques were rather Several treatment modalities have been rudimentary, this article will show how current described for osseous augmentation of edentu- techniques which integrate the principles of lous ridges prior to implant placement. These guided bone regeneration ensure minimal to include guided bone regeneration3) with or no resorption during integration, and a predict- without particulate bone grafting,4,5 ridge able, time-efficient, and cost effective outcome. splitting,6,7 distraction osteogenesis,8 orth- odontic tooth movement through a deficient OVERVIEW ridge.9 and grafting of bone blocks harvested intraorally, extraorally, or from cadaveric (alloge- The mandibular symphysis and ramus buccal neic) sources.10-15, 26 Each treatment modality shelf are excellent intraoral sources to obtain a has its own indications and contraindications, cortico-cancellous or pure cortical bone block, as well as advantages and disadvantages. respectively, for alveolar ridge augmentation. Edentulous ridge augmentation using The symphysis has been reported to pro- intraorally harvested bone blocks from the man- vide sufficient bone to augment a deficient ridge dibular symphysis and the ramus buccal shelf by 4-6mm in the horizontal dimension, and up are attractive techniques for several reasons. to 4mm in the vertical dimension, covering a The advantages include: length of up to a 3-tooth defect.12,18 Bone block 1. Horizontal alveolar bone volume increase documented at up to 7.5mm, compared to 46 Vol. 2, No. 2 March 2010

Toscano et al size available from this location has been found Specific individual success rates of to be an average of 10 mm (height) x 15 mm bone block grafts from the mandibular sym- (width) x 6 mm (thickness), with an average physis and ramus buccal shelf are not well bone volume of approximately 860 mm.3,19 The reported in the literature, as most articles symphysis offers over 50% larger graft volume group ramus and symphysis grafts together than what can be obtained from the mandibu- in success data reporting. However, within lar ramus, with much easier surgical access.20 these data success rates are reported at The average symphysis graft has been found 87-100%, with success usually defined as suf- to be composed of 65% cortical bone and ficient bone for implant placement.11,18,20,26 36% cancellous bone, as opposed to the man- dibular ramus, which is nearly 100% cortical in ADVANTAGES AND nature.19 The cortico-cancellous nature of bone DISADVANTAGES harvested from this site facilitates faster vascu- lar in-growth once the block has been placed, While the mandibular symphysis has many advan- resulting in more rapid integration and less tages, there are some disadvantages which prac- potential resorption during healing.21 Moreover, titioners must be aware of when selecting this bone blocks harvested from sites formed by harvest site. Post-operative morbidity is reported intramembranous mechanisms (intraoral) have after symphysis grafting and is perhaps the largest been shown to revascularize faster than those concern with this site. Misch found that 10.7% from an endochondrally (extraorally) derived of patients experienced incision dehiscence at formation pathway.22 The mandibular ramus the donor site, 9.6% had temporary paresthe- buccal shelf block graft can provide adequate sia for up to 6 months, and 29% had altered bone for augmentations involving a span of lower incisor sensation.20 Chin ptosis (estheti- 2-3 teeth. Horizontal as well as vertical aug- cally unpleasing chin droop) is often a concern mentation of 3 to 4 mm can be achieved with surrounding symphysis harvest, however occur- this donor site, the former being more predict- rence of post-operative esthetic changes has able.17, 23-25 Ramus cortical bone blocks have a not been found in most published articles.20,27-29 maximum thickness of 4 mm, providing a rect- One long term follow-up report found that up to angular graft with a length which may approach 13% of patients have lasting loss of sensation 35 mm and a height of up to 10mm, depending of the local chin area, however when questioned on patient specific anatomy. The limits of bone all patients stated that they did not find it bother- block size obtained from the ramus area are some.28 Also another long-term study found that generally dictated by clinical access, in addi- a small residual radiographic bony defect in the tion to the coronoid process, inferior alveolar symphysis does persist after healing, however no canal, molar teeth, and width of the posterior esthetic changes were associated with this find- mandible.17,23-25 Therefore the selection of this ing.29 While long-term morbidity after symphysis location requires careful pre-operative planning harvest is minimal, reports show that it is slightly to ensure adequate block size can be obtained. higher than mandibular ramus grafts and therefore this must be taken into consideration when select- The Journal of Implant & Advanced Clinical Dentistry 47