Indications for implant-supported rehabilitation of the posterior atrophic maxilla: A multidisciplinary consensus among experts in the field utilising the modified Delphi method.

PURPOSE: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. MATERIALS AND METHODS: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. RESULTS: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. CONCLUSION: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable.

Guided bone regeneration (GBR) using cortical bone pins in combination with leukocyte- and platelet-rich fibrin (L-PRF).

Two of the fundamental requisites for guided bone regeneration (GBR) are space maintenance and primary soft-tissue closure. Allogeneic cortical bone pins measuring 2 mm in diameter in customized lengths can protect surrounding graft materials, support bioresorbable membrane barriers, and resist wound compression from the overlying soft tissues. In addition, a second-generation platelet concentrate, leukocyte- and platelet-rich fibrin (L-PRF), may be incorporated into the augmentation procedure to provide multiple growth factors, accelerate wound healing, and aid in the maintenance of primary closure over the grafted materials. Highlighting two case reports, this article features a GBR technique that uses bone pins in combination with L-PRF membranes to provide both horizontal and vertical ridge augmentation at severely compromised implant sites.

Osteotome-mediated sinus floor elevation using only platelet-rich fibrin: an early report on 110 patients.

PURPOSE: This article describes a technique and reports on the early healing for localized sinus augmentation using a crestal approach in combination with an autologous leukocyte- and platelet-rich fibrin (PRF) concentrate. MATERIALS: From November 2008 to January 2010, 138 implants were placed in 110 patients using osteotome-mediated sinus floor elevation (OMSFE) with PRF. RESULTS: The mean residual subantral bone height of the alveolar ridge was 6.6 mm (range, 4-8 mm). The mean increase in the height of implant sites by OMSFE/PRF was 3.4 mm (range, 2.5-5 mm). A variety of 8- to 11.5-mm long (mean length, 10.1 mm) and 3.5- to 6-mm wide (mean width, 4.4 mm) screw-type implants were used. Of the 138 implants that had been placed, 97 have been restored and in function for an average loading time of 5.2 months (range, 1-11 months). The mean healing time for the loaded implants was 4 months until abutment insertion (range, 3-5 months). Three implants failed before loading for an early survival rate of both loaded and unloaded implants of 97.8%. CONCLUSIONS: Early review of the OMSFE/PRF technique presented for localized sinus floor elevation and implant placement demonstrates a high degree of safety and success at sites with 5- to 8-mm residual subantral bone height.

Horizontal ridge augmentation utilizing a composite graft of demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically degradable thermoplastic carrier combined with a resorbable membrane: a retrospective evaluation of 73 consecutively treated cases from private practices.

Ridge deficiency is an unfortunate obstacle in the field of implant dentistry. Many techniques are available to rebuild the deficient ridge. Some of these techniques are associated with significant morbidity and often require a second surgical site. With the advent of guided bone regeneration (GBR), one may now graft the deficient ridge with decreased morbidity and without a second surgical site. The purpose of this retrospective consecutive case series from 5 private practices is to report on the outcomes of a composite material of demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically degradable thermoplastic carrier (Regenaform RT) when combined with a resorbable membrane for GBR of lateral ridge defects in human patients. The specific aim was to quantify clinical results through direct measurement. Data were obtained from 73 consecutively treated lateral ridge augmentations performed on 67 partial and/or completely edentate patients. Clinical data (presurgical ridge width, ridge width at implant placement, and bone density at implant placement) were obtained retrospectively from 5 private practices via an exhaustive retrospective chart review, which was pooled and averaged for analysis. The average gain in horizontal ridge width was 3.5 mm (range, 3-6 mm). The density of the bone was noted to be type 2 to 3, with type 3 being the predominant finding. This retrospective case series from 5 clinical private practices suggests that the use of a composite material of demineralized freeze-dried allograft, mineralized cortical cancellous chips, and a biologically degradable thermoplastic carrier, when covered by a resorbable collagen membrane for GBR, is an effective means of horizontal ridge augmentation.

Treating the atrophic posterior maxilla by combining short implants with minimally invasive osteotome procedures.

Edentulous sites in the posterior maxilla are often compromised by reduced bone volume, prohibiting the placement of 10-mm implants without sinus augmentation. The use of shorter implants minimizes the need for more extensive sinus floor elevation, thus reducing treatment duration and morbidity. Two implant designs are presented in combination with localized internal sinus floor elevation to restore the posterior maxilla. This simplified treatment modality can make implant rehabilitation of the atrophic posterior maxilla more accessible and more palatable to even the most reluctant patients and referring doctors.

Minimally invasive sinus floor elevation procedures for simultaneous and staged implant placement.

Osteotome techniques are used as a less invasive alternative to the lateral window osteotomy to increase the volume of bone in the posterior maxilla. Implants may be placed simultaneously for four to six months after performing osteotome-mediated sinus floor elevation, depending upon the residual crestal bone remaining beneath the sinus floor. This article describes the clinical indications and techniques for localized internal sinus elevation using osteotomes. The incorporation of this minimally invasive crestal approach to sinus augmentation into the clinical practice results in increased case acceptance with reduced treatment duration, trauma and cost.

Osteotome-mediated sinus floor elevation: a clinical report.

PURPOSE: It was the aim of the present study to clinically evaluate the success of osteotome-mediated sinus floor elevation (OMSFE) using autogenous and xenogenic bone and a variety of screw-type implants. MATERIALS AND METHODS: From August 1995 to February 2003, 276 OMSFE procedures with simultaneous implant placement were completed in 167 patients. RESULTS: The mean residual bone height (RBH) of the alveolar ridge was 7.1 mm (range 3 to 10 mm). The mean increase in height of the implant sites using osteotome techniques was 3.8 mm (range 2 to 7 mm). Of the 276 implants placed, 240 had been loaded for an average of 27.9 months (range 1 to 84 months). There were a total of 18 failures: Ten implants failed to integrate, 3 implants were lost within the first 18 months of loading, 1 implant fractured after 3 years in function, and 4 implants demonstrated excessive bone loss. The overall survival rate was 93.5%. When only sites with an RBH of 4 mm or less were considered, the survival rate dropped to 73.3%. Small tears in the schneiderian membrane were clinically assessed at 13 sites, for a detectable perforation rate of 4.7%. DISCUSSION: The primary determinant in implant survival with OMSFE procedures was the height of the residual alveolar ridge. Implant design, graft material, and the method of sinus floor infracture (direct or bone-cushioned) exerted minimal influence on survival outcome; however, factors such as edentulism, osteoporosis, and an overdenture prosthesis were shown to negatively influence postloading survival of implants placed in areas of limited RBH. CONCLUSION: OMSFE procedures can be used predictably for implant placement at sites with moderate vertical deficiencies in the posterior maxilla.

Staged sinus augmentation using a crestal core elevation procedure and modified osteotomes to minimize membrane perforation.

Staged sinus floor elevation allows predictable implant placement in the severely deficient posterior maxilla. An alternative to the most commonly used lateral window approach involves the apical displacement of crestal core(s) using osteotomes and a composite graft. Crestal core elevation (CCE) incorporates specially designed osteotomes to minimize the incidence of membrane perforation and placement of a barrier membrane over the core osteotomy. This article presents the technique and instrumentation, as well as documentation of 43 patients demonstrating the efficacy of this modality.