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Treatment Options for the Posterior Edentulous

Jaw: Surgical Options for Implant Therapy in
the Posterior Maxilla of...

Article · June 2017


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3 authors, including:

Daniel Buser Alberto Monje

Universität Bern Universität Bern


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Treatment Options for the Prof. Dr. Daniel Buser

Posterior Edentulous Jaw: is Professor and Chair-

man of the Department

Surgical Options for Implant of Oral Surgery and Sto-

matology at the School

Therapy in the Posterior of Dental Medicine,

University of Bern. He

Maxilla of Partially Edentulous did research at Harvard,

USA from 1989 to 1991, with sabbaticals at the Baylor

Patients College of Dentistry, USA (1995), the University

of Melbourne, Australia (2007/2008) and Harvard
School of Dental Medicine, Boston, USA (2016). His
main scientific interests include tissue integration of
dental implants, guided bone regeneration including
autografts and bone substitutes. He has authored/
Daniel Buser, Alberto Monje, Waldemar Polido co-authored more than 350 publications. Daniel
Buser was ITI President from 2009 to 2013 and has
received several awards, among them the the André
Schroeder Research Prize (1995) and the Brånemark
Osseointegration Award (2013). With over 30 years
of surgical experience, he continues to treat more
than 150 implant patients per year.

Dr. Alberto Monje

started his research
career as a clinical post-
doc at The University
of Michigan in 2011.
He then obtained the
certificate and Masters
in Periodontology
from the University of Michigan, Department of
Periodontics and Oral Medicine in 2016. He has
also received awards and grants for his research and
clinical achievements from scientific societies such
as the American Academy of Periodontology, the
International Team for Implantology and the Osteol-
ogy Foundation. He is currently the ITI Scholar in
the Department of Oral Surgery at the University
of Bern, Switzerland, headed by Prof. Daniel Buser,
where his research focus is on the long-term
outcomes of surgical options for the rehabilitation
of the posterior atrophic ridges.

6 Forum Implantologicum

ABSTRACT A single tooth replacement with 6-mm

Dr. Waldemar D. Polido implants in molar sites is only used in ex-
is an oral and maxil- The rehabilitation of the posterior maxilla ceptional situations. In all other situations,
lofacial surgeon with with an implant-supported prosthesis SFE is required. Both surgical techniques
DDS, MS and PhD is often a demanding treatment for the are well documented, but the transalveo-
degrees from PUCRS implant surgeon. The local anatomy can lar osteotome technique is utilized
in Porto Alegre, Brazil, be difficult due to a reduced ridge height less frequently, since it requires a ridge
and a residency in OMFS in potential implant sites. The present height of 5–8 mm and a flat morphology
at the University of clinically oriented paper discusses the of the sinus floor. Whenever possible,
Texas, Southwestern Medical Center at Dallas, USA. three most often utilized surgical options: a simultaneous implant placement is per-
A Fellow and Speaker of the ITI, Dr. Polido was Chair (i) the utilization of short implants, (ii) formed to avoid a second surgery. For that,
of the ITI Section Brazil from 2007 to 2009 and is sinus floor elevation (SFE) with the lateral sufficient primary stability is important,
the current Education Delegate for the Section until window technique, and (iii) SFE with the which can be optimized with tissue level
2018. He is also a member of the ITI Education transalveolar osteotome technique. A implants. In addition, grafting with a com-
Committee. Dr. Polido lectures extensively in Brazil thorough clinical and radiographic examin- posite graft is preferred, which includes
and internationally on his main interests: advanced ation is required to choose the appropriate locally harvested autogenous bone chips
and complex implant surgery and orthognathic surgical approach, which should offer a mixed with a low-substitution bone filler.
surgery. In March 2017 he joined the Indiana successful outcome with high predict- The various treatment options are dis-
University School of Dentistry in Indianapolis, USA, ability and a low risk of complications. In cussed and documented with case reports.
as a Clinical Professor, Director of the Predoctoral addition, treatment should offer minimal
Program in Oral and Maxillofacial Surgery and invasiveness and morbidity, when possible. Keywords: Posterior maxilla, sinus floor
Co-Director of the Center for Implant, Esthetic Low morbidity is offered by short 6-mm elevation, short implants, transalveolar
and Innovative Dentistry. implants, which are utilized when multiple technique, lateral window technique,
implants are feasible with splinted implant composite graft

INTRODUCTION an extraoral donor site, was often recom- This concept, documented with four inter-
mended (Tolman 1995). connected circles, can also be applied to the
Loss of teeth in the posterior maxilla is a treatment of the posterior maxilla (Fig. 1).
frequent scenario encountered in dentistry. The primary objectives of implant therapy The first and most important circle reflects
Brugger et al. (2015), analyzing a 3-year continue to be successful treatment out- the implant surgeon, or rather his/her clin-
patient pool in a surgical specialty clinic, comes with high predictability concerning ical team, since the treatment quality by the
reported that the posterior maxilla accounted long-term function and esthetics and low surgical and restorative dentist –sometimes
for 36 % of the total number of sites treated risk of complications (Buser and Chen 2008). provided by the same person – is probably
with dental implants (Brugger et al. 2015). The ultimate goal is long-term success of the most crucial factor. Additional members
This area has always been considered a 30+ years, which means that an inserted and of the clinical team are also the dental
challenging region with its unique anatomy restored implant should have the best pre- technician and – if available – the dental
of teeth and alveolar bone as well as its requisites for successful long-term stability. hygienist for the supporting maintenance
proximity and relationship to the maxillary The secondary objectives of therapy include care program. The talent and expertise
sinus. Early findings in implant dentistry minimal invasiveness and low morbidity, of the implant surgeon are decisive for the
demonstrated significantly lower survival including the least number of surgical pro- treatment outcome, as he/she examines
rates in the posterior maxilla, which were cedures and shorter healing periods. In the the patient to establish his/her risk profile,
correlated with different causes such as past 15 to 20 years of fine tuning in implant decides on the most appropriate treat-
poor bone density, complex anatomy and dentistry, aspects related to the second- ment option, selects the necessary bio-
loading protocols with shorter healing ary objectives have substantially improved materials, and finally performs the surgical
periods (Adell et al. 1981, Jaffin & Berman to make implant therapy more attractive treatment. The crucial importance of this
1991). We must not forget that those were for patients and more patient friendly but first circle is also documented by the fact
the days where titanium implants with without jeopardizing the primary objectives that it is larger than the three other circles.
a machined surface were most often used. of therapy (Buser et al. 2017).
In addition, longer implants (≥ 15 mm) The second circle represents the patient
with bicortical stabilization were recom- Successful outcomes in implant therapy are with his/her risk factors, indicators and
mended (Bahat 1993). Hence, the use of influenced by four factors as first outlined determinants, which include medical, dental
large autogenous bone grafts, mostly from by Buser and Chen (Buser and Chen 2008). and anatomical risk factors together with

Volume 13 / Issue 1 / 2017 7


smoking. All these factors must be consid- Dental risk Anatomic risk
factors factors
ered in the selection of the most appropri-
ate treatment option. In the posterior Medical risk Smoking
maxilla, the local anatomy is probably the Education Short implants
most relevant factor for the selection of the
Skills Transalveolar
treatment approach. technique

Implant Surgical Lateral window

The third circle represents the biomater- technique
ials, which include the selected implant
Surgeon Approach
Grafting vs.
and its material, surface, shape, diameter non-grafting
and length, and the implant abutment. In Bio- Simultaneous vs. staged
Experience approach
addition, bone grafts, bone substitutes, and materials
barrier membranes are important elements Implant type Xenografts
for sinus floor elevation (SFE) procedures. Allografts
Lastly, the fourth circle to consider is the Membrane Autografts
treatment approach itself for a given clinical
situation. In the posterior maxilla with a Fig. 1: The four factors influencing outcomes for the rehabilitation of the posterior maxilla. The circle with the
reduced ridge height and pneumatized sinus implant surgeon is larger, documenting the crucial importance of the experience and treatment quality provided
by the implant surgeon
cavity, various treatment options are avail-
able to achieve the anticipated treatment

In accordance with the scope of the Forum the posterior maxilla in partially edentulous recommendations for when to use which
Implantologicum, the purpose of this patients. It reflects the authors’ personal treatment option to have the best chance
clinical paper is to discuss the surgical long and thoroughly documented experience of a successful treatment outcome in this
options available for implant therapy in in the field. In addition, it provides clinical challenging clinical scenario.

Fig. 2a: Buccal view of the first quadrant with an Fig. 2b: The panoramic view of the CBCT shows Fig. 2c: The occlusal CBCT view shows the sinus
extended edentulous space. Tooth #14 is hopeless a reduced ridge height in area 15 and 16. pneumatization, a sufficient crest width in all potential
and needs to be removed. The patient is asking The Schneiderian membrane is slightly thickened. implant sites, and a radiolucent interradicular lesion
for a fixed dental prosthesis There is no bone septum visible at tooth #17

Fig. 2d: The oro-facial CBCT at tooth #14 shows Fig. 2e: The oro-facial CBCT in area #15 shows Fig. 2f: The oro-facial CBCT in area #16 shows suf-
sufficient crest width of >6 mm for a future implant sufficient crest width, but a ridge height of less than ficient crest width, but a ridge height of only 2.5 mm,
placement 4 mm requiring a staged SFE procedure

8 Forum Implantologicum

ANATOMIC RISK FACTORS • the neighboring teeth that are still implant type, bone grafts and bone substi-
IN THE POSTERIOR MAXILLA present in the quadrant, tutes, barrier membranes and the healing
• the width and height of the alveolar periods.
For surgical treatment planning in the ridge at potential implant sites,
posterior maxilla, a detailed pre-surgical • the bone density, 1. The utilization of short dental implants
examination of the remaining teeth, the • the extension of the maxillary sinus, The use of short implants has been regarded
alveolar ridge dimensions and the maxillary • the status of the Schneiderian as an effective alternative to approach
sinus play an important role in the decision- membrane, the posterior atrophic maxilla with minimal
making process to find the most suitable • the presence, location and height of invasiveness (Monje et al. 2013). A recent
treatment approach. For this, the utiliza- bone septa prospective 1-year study on patient-reported
tion of a 3-dimensional (3D) radiographic • the presence of foreign bodies in the outcomes has highlighted the high satisfac-
analysis utilizing a cone beam computer- maxillary sinus, and tion obtained with the use of short im-
ized tomography (CBCT) is recommended • the presence of sinus pathology like plants compared to SFE, as it decreases
nowadays (Jensen & Katsuyama 2011; mucous retention cysts or acute/ morbidity, treatment time and cost (Thoma
Bornstein et al. 2015). The detailed clinical chronic sinusitis (Baciut et al. 2013, et al. 2015). The utilization of short (6 mm)
and radiographic examination must include Bornstein et al. 2015) Straumann implants with the TPS surface
several aspects, which are listed in Table 1. goes back to the late 1980s, and favorable
A typical case report is shown in Fig 2. Table 1: The clinical and radiographic examination clinical results were first reported in the
should include these aspects late 1990s (ten Bruggenkate et al. 1998).
In the posterior maxilla, the main anatomi- In the past 10 years, short (6 mm) implants
cal challenge is the ridge height due to have attracted a lot of interest (Srinivasan
the proximity of the maxillary sinus cavity. Once this clinical and radiological examina- et al. 2014). It is noteworthy, however,
Nunes et al. reported in a CBCT study tion has been carried out, the most reason- that it must be differentiated between single
that the crest width is most often sufficient able surgical option can be selected, which standing implants and multiple adjacent
for the placement of a standard diameter offers the best chance for a successful implants, which can be splinted. In the case
implant (4 mm) (Nunes et al. 2013). outcome with high predictability and low of multiple implants, short (6 mm) implants
The main problem was the lack of sufficient risk of complications. have been routinely utilized in the posterior
subantral bone height. The ridge height maxilla with good clinical outcomes, but
significantly decreased towards the first they are routinely splinted (Figs 3a–b).
and second molar sites. In first molar sites, SURGICAL OPTIONS IN SITES For single standing implants, routine appli-
88.2% showed a ridge height of <8 mm WITH REDUCED RIDGE HEIGHT cation of such implants is not recommended
and 55% of <5 mm. IN THE POSTERIOR MAXILLA in molar sites. This conservative approach
is supported by two recent prospective
In addition, the anatomy of the sinus floor The clinician has three options from 5-year studies with short, 6-mm implants
must be analyzed before choosing the a surgical point of view: (Table 2). One study with single standing
surgical approach. If the sinus floor has a 1. Utilization of short dental implants for implants in the posterior mandible
flat configuration in the mesio-distal and a standard implant placement without (Rossi et al. 2016) showed a failure rate of
oro-facial direction, a transalveolar SFE pro- bone grafting 13.3% at 5 years, which is unacceptable
cedure with the use of osteotomes can be 2. The lateral window technique for SFE from our point of view. Another study with
considered, which is a less invasive surgical (simultaneous and staged approach) splinted implants showed slightly better
technique. However, if the sinus floor has 3. The transalveolar osteotome technique outcomes, but still with a 6.3% failure
an oblique configuration in at least one of for SFE (simultaneous approach) rate at 5 years (Felice et al. 2014). In rare
the two directions, the use of the transalveo- cases, such as for elderly patients with
lar osteotome technique increases the risk In the following, all three treatment options a clearly reduced bite force, excep-
of tearing the lining mucosa during surgery. will be discussed, including the selection tions are made for short single standing
As such, the lateral window technique of appropriate biomaterials such as the implants (Fig. 4).
is the treatment of choice under these
anatomical conditions.

In some cases, the posterior maxilla can

Authors (year) Follow-up Implant Splinted Patients Implants Survival
have a combined vertical and horizontal (months) length (mm) implants (n) (n) rate
deficiency with an increased inter-arch
Rossi et al. (2016) 60 6 No 30 30 86.7 %
space, which might require the need for
Felice et al. (2014) 60 6.6 Yes 30 60 93.7 %
a more complex 3D bone reconstruction
(Chiapasco et al. 2009). Table 2: Long-term studies on the effectiveness of short dental implants in posterior sites

Volume 13 / Issue 1 / 2017 9


Fig. 3a: Distal extension situation in the right maxilla treated with two short 6-mm Fig. 3b: In the left maxilla, a short 6-mm implant is splinted to a
implants in a patient with no parafunctional habits. The short implants helped longer implant to bypass a SFE procedure. Both TL implants have
to avoid a SFE procedure. All three TL implants have been in function for 4 years been in function for 4 years and have stable bone crest levels
and show excellent bone crest levels

Fig. 4a: Panoramic CBCT view of a single posterior Fig. 4b: Considering the age and reduced masticatory Fig. 4c: Successful treatment outcome with an implant-
tooth gap in area 16 in an 87-year-old patient. function of the elderly patient, a short 6-mm was supported single crown, 2 years post-loading
The adjacent hollow-cylinder implant has been in place utilized, slightly tilted to avoid a perforation of the
for more than 20 years. The ridge height is borderline sinus floor
with more bone volume in the mesial area

More recently, Straumann released ultra- for 6-mm short implants, a ridge height Buser 1999). This initiated a change from
short 4-mm implants. There are no long- of roughly 7 mm should be present at the machined to micro-rough implant surfaces,
term results for these implants so far and future implant site for standard implant which significantly improved the survival
thus they are rarely used, and only under placement without SFE, for 4-mm ultra-short rates of dental implants placed simul-
exceptional circumstances when a SFE pro- implants, an alveolar ridge height of 5 mm taneously with SFE in the posterior maxilla
cedure must be avoided (Fig. 5). Such ultra- is necessary. (Pjetursson et al. 2008; Del Fabbro et
short implants must always be splinted to al. 2008).
longer implants. In such short implants, the 2. The lateral window technique
crown-to-implant (C/I) ratio is often greater The lateral window technique goes back Simultaneous vs. staged approach
than 2. However, evidence has shown that to the 1980s (Boyne & James 1980; Tatum The lateral window technique can be used
implant restorations with C/I ratios between 1986), and has been the standard technique with a simultaneous or a staged approach.
2 and 3 can be successfully used in posterior for SFE since then. The principles of this From the patient’s perspective, a simul-
implant sites (Blanes et al. 2007, Garaicoa- surgical technique have not changed sig- taneous approach is preferable, since this
Pazmino et al. 2014). Nonetheless, caution nificantly, but modifications were made approach requires only one open flap pro-
must be exercised in patients with para- for the preparation of the window by using cedure. The most important parameter for
functional habits, like bruxers, where the piezoelectric instruments in an attempt the surgeon’s decision is the primary implant
crestal stress could trigger implant failure to reduce intra-operative complications, stability, which depends on the ridge height
(Chrcanovic et al. 2016). such as the perforation of the Schneiderian and bone density at the potential implant
membrane (Wallace et al. 2007). In addition, site, the shape and the diameter of the
In summary, case selection and the optimal a paradigm shift took place with the surface inserted implant, and the precise prepar-
treatment approach are crucial for the technology of dental implants in the late ation of an implant bed. In ITI Treatment
long-term success of short implants. While 1990s (Albrektsson & Wennerberg 2004; Guide Volume 5, Katsuyama & Jensen (2011)

10 Forum Implantologicum

Fig. 5a: In this 76-year-old female patient with multiple medical risk factors, Fig. 5b: The 2-year follow-up radiograph shows stable bone crest levels
a SFE was contra-indicated. An ultra-short, 4-mm implant has been used to bypass at both implants. As usual, the two crowns are splinted
a SFE procedure. The post-operative radiograph shows a 4-mm TL implant placed
with an 8-mm TL implant

defined a ridge height of 5 mm to be the the surrounding area (Caballe-Serrano et anatomy – the primary stability of the
minimum threshold level for a simultaneous al. 2014). For the bone filler, deproteinized inserted implant, which is an important
approach with the lateral window technique. bovine bone mineral (DBBM, Bio-Oss®, prerequisite for the achievement of os-
Our group used the same threshold for Geistlich, Wolhusen, Switzerland), and Bone seointegration, as demonstrated in the early
many years, but a few years ago we reduced Ceramic® (Straumann, Basel, Switzerland) days of modern implant research (Schroeder
the minimum height for the simultaneous have both demonstrated a low substitution et al. 1981; Albrektsson et al. 1981). Primary
approach to 4 mm, as did others as well rate in various pre-clinical and clinical stability can be optimized with a tapered
(Pjetursson et al. 2008). studies (Cordaro et al. 2008; Jensen et al. or conical implant shape, which can be pres-
2012; Jensen et al. 2013; Schmitt et al. 2013; ent in the entire length of the implant, or
Selection of appropriate bone grafts and Schmitt et al. 2015; Danesh-Sani et al. 2016). solely in the crestal area. A similar effect can
bone substitutes The utilization of autograft chips offers a be obtained with large diameter implants,
In the 1990s, the dental implant community reduction in the healing period, in particular since they offer a larger surface area in
started to examine bone grafts and bone when it is combined with a hydrophilic, the existing bone. Recent studies reported
substitutes not only for GTR and GBR pro- micro-rough implant surface. on better primary stability with the tapered
cedures, but also for SFE (Jensen et al. 1998; effect implant design, especially in situa-
Lundgren et al. 1996). Ideally, a grafting Other bone fillers have also proven their tions of grafted sites (Romanos et al. 2014;
material for SFE should not only accelerate efficacy for SFE procedures, as long as Schiegnitz et al. 2016).
new bone formation in the defect area, a sufficient healing period is respected
but it should also provide good volume (Chiapasco et al. 2009; Monje et al. 2017). In posterior sites, our group has a clear
stability over time. Currently, there is still The use of a resorbable collagen membrane preference for Straumann tissue level (TL)
no bone filler available that fulfills both is preferred by our group to protect the implants, since this hybrid implant design
characteristics. Thus, composite grafts are applied composite graft against the in- showed excellent long-term results in
mainly preferred by our group for SFE using growth of soft tissue cells of the buccal flap several long-term studies (Buser et al. 1997;
autologous bone chips combined with a during initial healing. A systematic review Buser et al. 2012; Fischer & Stenberg, 2012;
bone substitute with a low substitution rate. showed better implant survival in patients, Fischer & Stenberg 2013; Chappuis et al.
Autograft chips as osteogenic bone filler when the lateral window had been covered 2013; Roccuzzo et al. 2014; Chappuis et al.
can accelerate new bone formation in the by a membrane (Pjetursson et al. 2008). 2017). The recent 9-year study by Derks
defect area, whereas a low-substitution filler et al. confirmed the excellent long-term
is used for good volume stability (Jensen Selection of an appropriate implant performance of TL implants (Derks et al.
et al. 1996; Buser et al. 1998a; Schlegel When the clinician selects an implant for 2015), and their superiority when compared
et al. 2003; Jensen et al. 2006). Today, the posterior maxilla with insufficient to bone level implants of other implant
autologous bone chips are locally harvested bone height and a planned SFE procedure, brands. The superiority of TL in posterior
to minimize morbidity for the patient, he/she must carefully consider the following sites was also shown in a recent study by
resulting in small cortical bone chips of issues: (i) implant shape (tapered/conical Chiapasco et al. (Chiapasco et al. 2014).
1.5 to 2.0 mm in size (Miron et al. 2013). vs. parallel walled), (ii) implant diameter, The tapered (TE) design of the Straumann
Recent in-vitro studies showed the release and (iii) the implant surface. The first two implant system is slightly conical in the
of growth factors and other proteins into aspects influence – besides the local crestal area, which helps to improve primary

Volume 13 / Issue 1 / 2017 11


stability. A similar effect can be achieved Authors (year) Follow-up Placement Bone filler Patients Implants Survival
(months) Approach (n) (n) rate
with the parallel-walled standard SL implant,
when it is inserted deeper into the implant Bornstein et al. 60 Staged AB+DBBM 56 100 98.0 %
bed, locating the border of the micro-rough
SLA surface 1.5 to 2.0 mm below the crest. Lutz et al. 60 Staged AB/DBBM 47 168 95.8%
This insertion technique improves primary
stability, since the tulip-shape of the implant Beretta et al. 3 up to Staged AB+DBBM 218 589 98.8%
(2015) 186
neck increases the friction fit in the crestal
area of the ridge. Zinser et al. Up to 168 Simultane- AB, Alloge- 224 1045 93.3%
(2013) ous/staged neic, DBBM

The third aspect – the implant surface – is Table 3: Long-term studies on implants with SFE using the lateral window technique
important for the dynamics and quantity
of new bone apposition to the implant during
initial wound healing. That aspect is clini-
cally relevant not only for the quality of the (Chiapasco et al. 2009). Micro-rough implant (Buser et al. 2004; Schwarz et al. 2007a;
implant anchorage, but also for the duration surfaces were introduced to the market in Schwarz et al. 2007b). This SLActive®
of the required healing period prior to load- the late 1990s based on preclinical studies titanium surface (Straumann, Basel, Switzer-
ing. Today, micro-rough implant surfaces demonstrating significantly faster bone inte- land) is preferred in the posterior maxilla
are clearly preferred in SFE sites, since they gration (Buser et al. 1991; Buser et al. 1998b; to profit from even shorter healing periods.
show much better survival rates than the Cochran et al. 1998; Wennerberg et al.
original Brånemark type implants with the 1998). In the mid-2000s, a new hydrophilic, In regard to the implant outcomes in SFE,
machined surface as was determined at micro-rough implant surface showed advancements in surface treatment have
the 4th ITI Consensus Meeting in Stuttgart even better results in pre-clinical studies significantly improved the survival rate

Fig. 6a: Extended edentulous space in the right maxilla. Fig. 6b: Due to the oblique sinus floor, a lateral window Fig. 6c: Following application of the first portion
The peri-apical radiograph shows insufficient ridge technique was preferred to gain additional bone of a composite graft, two TL implants were inserted.
height. In the pre-molar area, a simultaneous SFE is height. Following window preparation, the Schneide- As usual, the border to the SLA surface was located
feasible, but in area 16, a staged approach is necessary rian membrane was carefully elevated 1–2 mm below the crest

Fig. 6d: The remaining space was filled with the Fig. 6e: The window was then covered with a Fig. 6f: The SFE surgery was completed with a primary
composite graft as a mixture of locally harvested resorbable collagen membrane (Bio-Gide®) to avoid wound closure to protect the inserted implants against
autologous bone chips and a low-substitution ingrowth of soft tissue cells into the defect area loading forces during healing
bone filler (Bone Ceramic®) during initial wound healing

12 Forum Implantologicum

reaching comparable results to implants

placed in pristine bone as shown in review
papers (Del Fabbro et al. 2008; Del Fabbro
et al. 2013; Chiapasco et al. 2009; Pjetursson
et al. 2008). Data obtained from long-term
studies (≥5 years of follow-up) showed
survival rates between 93–98% (Table 3).

Two typical case reports with SFE using

the lateral window technique are shown
in Figs 6 and 7. Fig. 6g: The post-surgical radiograph shows the two Fig. 6h: Clinical status at the 6-year follow-up. No ad-
inserted implants in position 14 and 15. Note the ditional implant was inserted. The two implant crowns
deep insertion technique of the TL implants providing were splinted and a distal cantilever unit added. The
3. The transalveolar osteotome technique additional primary implant stability due to the tulip peri-implant soft tissues are healthy
The transalveolar osteotome technique implant shape in the crestal area
was first described by Summers (1994).
The main goal was to simplify the surgical
technique and to reduce morbidity for
the patient. In the past 20 years, it has been
established as a well documented surgical
technique, if the anatomic conditions are
present (Pjetursson & Lang 2014). Our group
utilizes the osteotome technique only
in combination with simultaneous implant
placement (simultaneous approach).
Two clinical conditions must be present:
(i) The sinus floor at the potential site(s) Fig. 6i: The 6-year follow-up radiograph shows Fig. 6j: The 12-year follow-up radiograph confirms
should be flat in the mesio-distal and oro- excellent bone crest levels at both TL implants. excellent stability in the crestal area at both implants
The peri-implant bone structure has remodeled
facial directions, and (ii) the available ridge nicely over the years
height and bone density should provide
sufficient primary stability for the inserted
implant. The osteotome technique has a
major advantage, since it offers reduced
post-operative morbidity when compared to
the lateral window technique. However,
the potential gain in bone height is limited
to 3–5 mm. Therefore, we normally use this
technique with a ridge height of 5–8 mm.
A typical case report is shown in Fig. 8.

However, despite appearing to be less Fig. 7a: Severe atrophic posterior maxilla with Fig. 7b: Radiographic status at the 20-year follow-up.
difficult than the lateral window technique, a minimal bone height of less than 2 mm in area 26. The bone crest levels are excellent around the two
This required a staged SFE procedure with TL implants. In the mid-1990s, crowns were routinely
it should only be performed by experienced the window technique using a composite graft splinted following a SFE procedure. Today,
implant surgeons who master the lateral such splinting is only done with short implants
window approach. If an intra-surgical
complication like a perforation of the sinus
membrane or dislocation of graft material
occurs during the osteotome technique,
the solution is most likely to be found by
changing to the lateral window technique
(Katsuyama & Jensen 2011).

Long-term findings show that the transal-

veolar osteotome technique is an effective
Fig. 7c: The clinical status at the 20-year follow-up. Fig. 7d: The CBCT shows excellent peri-implant
surgical procedure in terms of implant The peri-implant soft tissues are healthy bone volume in the area of the former bone atrophy,
survival rates if performed under the afore- and an intact buccal bone wall

Volume 13 / Issue 1 / 2017 13


Fig. 8a: Single tooth gap in area 26 with a slight buccal Fig. 8b: The 6 months periapical radiograph showed Fig. 8c: Following flap elevation, an initial implant bed
flattening 6 months post-extraction a flat anatomy of the maxillary sinus and a bone preparation is done with the #1 spiral drill to a sink
height of 5–6 mm depth of 5 mm. A depth gauge was used to confirm the
proximity to the sinus floor

Fig. 8d: The periapical radiograph confirmed Fig. 8e: Then, implant bed preparation was Fig. 8f: As a composite graft, a mixture of locally
the correct depth of the preparation completeted and the floor of the sinus fractured harvested autologous bone chips and DBBM particles
with the osteotome instrument were used to push up the Schneiderian membrane
with this transalveolar technique

Fig. 8g: Status following insertion of a Wide Neck Fig. 8h: Status following adaptation of the wound Fig. 8i: The post-surgical radiograph shows the inserted
implant, fitting well into this first molar site margins allowing for non-submerged healing Wide Neck implants. The grafting material is clearly
visible in the periapical area

Fig. 8j: Clinical status at the 10-year follow-up. Fig. 8k: The periapical radiograph at the 10-year
The implant crown is integrating well, and shows follow-up examination shows excellent peri-implant
healthy peri-implant soft tissues bone crest levels and a good periapical bone volume
in the area of the former defect

14 Forum Implantologicum

mentioned conditions. A recent systematic Authors (year) Follow-up Placement Bone filler Patients Implants Survival
(months) Approach (n) (n) crate
review estimated a 3-year survival rate
of 92.8% (Pjetursson & Lang 2014). Several Soardi et al. 60 Simultaneous DBBM/ 538 376 94.9 %
(2013) DFDBA
studies with a 5-year follow up showed
survival rates between 90.0–94.9% (Table 4). Nedir et al. 60 Simultaneous DBBM/- 12 20 90.0 %

Grafting vs. non-grafting in SFE procedures Ferrigno et al. 12–144 Simultaneous AB+DBBM 323 588 94.8%
(2006) (mean 60)
In recent years, a few groups have proposed
performing SFE procedures without the Table 4: Long-term studies on implants with SFE using the transalveolar technique
use of bone grafting material. The technique
includes merely elevating the Schneiderian
membrane at the time of implant insertion Authors (year) Follow-up SFE Placement Patients Implants Survival
(Lundgren et al. 2017). This tenting effect (months) approach Approach (n) (n) rate

creates a void space in which blood clot Riben & Thor 12–84m Lateral Simultaneous 36 87 94.3%
formation occurs, followed by a partial fill (2016) (mean 55) window

with newly formed bone. In Table 5, recently Cricchio et al. 12–72 Lateral Simultaneous 84 239 98.7 %
published studies are listed with survival (2011) window

rates between 90.6 and 100%. Stefanski et al. 40 Lateral Simultaneous 19 28 100.0 %
(2016) window

Our group does not favor this surgical ap- Zill et al. 60 Osteotome Simultaneous 113 233 92.7 %
proach. The technique does not really
offer a clinical advantage, since pain and Si et al. 48 to 102 Osteotome Simultaneous 80 96 90.6%
(2016) (mean 66)
morbidity are not reduced for the patient.
In addition, the lack of autogenous bone Nedir et al. 60 Osteotome Simultaneous 9 17 94.1%
chips during initial healing does not allow
for the short healing periods that we can Nedir et al. 120 Osteotome Simultaneous 17 25 100.0 %
often offer our patients nowadays.
Table 5: Clinical studies on implants placed with simultaneous SFE without grafting material
Current healing periods for implants placed
with simultaneous SFE
Concerning the healing periods for implants
placed simultaneously with SFE, significant the hydrophilic SLActive® surface, since
progress has been made in the past 5 years. both accelerate new bone formation during
A recent case series study by Kuchler et al. initial healing. The 17% of implants with
(2017) examined in more than 100 consecu- ISQ values <70 were left to heal for 12 or
tive implants how often an 8-week healing even 16 weeks. The study confirmed that
period is possible in patients with implant RFA is a reliable method to objectively
placement and simultaneous SFE using a examine implant stability to help the clin-
lateral window technique. Grafting was done ician make a good decision for the suitable
with a composite graft with locally har- time point of loading.
vested autograft chips and DBBM particles
(50:50%). Implant stability was measured at SFE combined with horizontal or even
implant placement (day 0) and 8 weeks later vertical ridge augmentation
using Resonance Frequency Analysis (RFA) In patients with significant horizontal and/or
providing an ISQ (implant Stability Quotient) vertical ridge atrophy, the SFE procedure
value (Kuchler et al. 2017). Standard TL can be combined with horizontal and/or ver-
implants with a chemically modified SLA tical ridge augmentation. The main surgical
surface (SLActive®; Straumann, Basel, procedure applied is the GBR technique. In
Switzerland) were used. In this study, 83% such situations, not frequently encountered,
of the implants reached the threshold a staged approach is most often needed
level of ISQ ≥ 70 after 8 weeks of healing, requiring multiple surgeries and extended
and hence, allowed for an early loading healing periods. The complexity of these
protocol. The early failure rate was at 0.9%. surgical procedures is also increasing, requir-
These favorable results can be attributed to ing a specialist who can master such delicate
the utilization of autograft chips and surgical procedures.

Volume 13 / Issue 1 / 2017 15



• The posterior maxilla is a challenging • Both surgical techniques are done Adell, R., Lekholm, U., Rockler, B. & Branemark, P. I.
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to perform a simultaneous approach

16 Forum Implantologicum

Bornstein, M. M., Chappuis, V., von Arx, T. & Buser, Buser, D., Mericske-Stern, R., Bernard, J. P., Behneke, Chrcanovic, B. R., Kisch, J., Albrektsson, T. &
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Volume 13 / Issue 1 / 2017 19

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