Ocluzia Dentara Ionita Petre

Nevins/Wang
CONTRIBUTORS
Edited by
Myron Nevins, dds
A. Ackermann F. Alfonsi L. Aranguren G. Avila-Ortiz L. Canullo D. Cardaropoli H. Chan C. Chen Y. Cho
Hom-Lay Wang, dds, mds, phd
Clinical Approaches and Evidence of Success, Second Edition

IMPLA NT THERAPY
J. Chow L. Cooper T. Cracknell M. de Araújo Nobre A. Decker M. Deflorian B. DeGroot M. Del Fabbro D. Ferreira
IMPL ANT
THERAPY
S. Froum J. Fu F. Galli J. Ganeles W. Giannobile C. Hämmerle P. Hawker P. Hengjeerajaras R. Herman
M. Iwata R. Jung D. Kim G. Liddelow C. Lin K. Liu M. Ludlow S. Maeda P. Maketone
P. Maló G. Mandelaris J. Martins da Rosa R. Marx T. Matsui C. Misch A. Monje S. Mühlemann K. Nakamura
Clinical Approaches and
Evidence of Success
M.L. Nevins M. Nevins F. Norkin Y. Ono S. Ono Rubin S. Parel A. Parenti W. Park S. Parma Benfenati SECOND EDITION
L. Pereira M. Roncati M. Ronda K. Saburi T. Sasaki R. Scaini D. Schneider C. Shapoff Y. Shi
M. Simion M. Stefanini T. Testori C. Tinti I. Urbán L. Velasco S. Wallace C. Wang H. Wang
ISBN 978-0-86715-798-7
H. Zadeh S. Zfaz G. Zucchelli 90000
9 780867 157987
Nevins/Wang cover spread.indd 1 3/19/19 9:24 AM

Implant Therapy: Clinical Approaches and Evidence of Success, Second Edition
Nevins/Wang_FM.indd 1 3/4/19 3:43 PM

I dedicate this effort to my wife, Marcy. She has remained the wind
beneath my wings, even when I was preoccupied with the editing
process. She is my best friend and soulmate and encourages my
commitment to education.
I dedicate this book to my lovely family, my research collaborators,

my friends, my former and current students, my chairs, and the
University of Michigan for their continued support of my career.
Without their sacrifices and support, this journey would be impossible.
viii

ral implant therapy is recognized as one of the posed by each area. The cases and illustrations wonder-
most significant innovations of dentistry in the fully depict the clinical scenarios and treatment protocols
20th century. The reconstruction of edentulous to emphasize the principles so well portrayed in the book.
or partially edentulous patients with osseointegrated dental There are valuable chapters on managing the maxillary
implants has been revolutionary to improve esthetics, sinus or when insufficient vertical and/or lateral alveolar
phonetics, and function for our patients. In this compre- bone is available. Treatment alternatives using sinus floor
hensive book, Drs Myron Nevins and Hom-Lay Wang— augmentation, vertical bone augmentation, or the use of
leaders in regenerative and reconstructive dentistry—have short dental implants play into these alternatives prepared
assembled a text that will be a tremendous benefit to by leaders in the field. The use of cutting edge therapies
students, clinical scholars, and practicing clinicians alike. for hard and soft tissue reconstruction using tissue engi-
Given the strong adoption of dental implant therapy into neering methodologies (growth factor biologics, novel
clinical practice, it has become increasingly important for scaffolding technologies, or bone graft substitutes) have
clinicians to have the proper guidance in both the identi- improved the repertoire of regenerative options for reha-
fication of suitable patients and the clinical scenarios for bilitation for the partially or fully edentulous patient.
the placement of dental implants for oral rehabilitation. Drs Nevins and Wang also bring together critical aspects
No longer is it sufficient for a dental implant simply to in interdisciplinary clinical care in highly complex clini-
survive: To be successful, implants must be placed optical situations, when tooth preservation is often coupled
mally to provide the proper esthetics and function that with implant therapy as well as with orthodontics and/or
last predictably over time. Thus, the appropriate training orthognathic surgery. Loading protocols for immediate- or
and treatment planning is critical to implant success to delayed-implant placement are presented to consider the
avoid biologic and/or technical complications that have most appropriate applications of these treatment guide-
increasingly plagued implant therapeutic outcomes over lines. How these reconstructions are planned, delivered,
the years. and maintained both provisionally and long-term are
In this text, Drs Nevins and Wang have brought presented in fine detail.
together chapters from leaders in implant dentistry. First, With the long-term maintenance of dental implants,
they work to improve the understanding about clinical a key biologic complication following therapy is the
decision making over the dilemma of tooth preservation initiation and progression of peri-implantitis. This
versus extraction. However, if extraction of a hopeless difficult-to-manage clinical situation is addressed using
tooth is required, how do we appropriately treatment plan? a variety of approaches, ranging from nonsurgical care
The plan must be designed for the good of the patient to to resection, regenerative therapy, or implant removal
facilitate the coordination of the team of surgeons, restor- and augmentation of the residual bony defect. Finally,
ative dentists, and auxiliaries needed to deliver functional specific protocols are presented for appropriate dental
implant reconstructions for the lifetime of the patient. The implant maintenance therapy in collaboration with restor-
first several chapters of the book focus significantly on ative dentists, surgeons, and dental hygienists to promote
treatment planning, including the use of 3D imaging and the long-term preservation, stability, and clinical success
patient and implant-site risk assessment to determine the of osseointegrated dental implants.
potential for implant installation and clinical success. If In summary, I anticipate that this text will be a valu-
there are insufficient soft and hard tissues present, how able asset to the student and clinician who have the high-
does a surgeon augment deficient alveolar bone ridges est standards of clinical care. Please enjoy the book and
for single or multi-implant placements? The book provides implement the principles presented here for the optimal
expert step-by-step guidance on local bone augmenta- rehabilitation of the dental implant patient.
tion situations by region (anterior, posterior, mandibular,
and maxillary areas) and the unique clinical challenges William V. Giannobile, dds, ms, dmedsc
ix

very text is a reflection of its era. We saw the need tion to help avoid or alter anatomical obstacles. Grafting of
in this era for an extraordinary textbook that would the floor of the maxillary sinus, bone augmentation, and
present to contemporary readers the long-term eventually, vertical growth of bone all provided correc-
patient benefits of implant therapy. It was immediately tions that were previously thought impossible. To quote
evident that it would cover the scope from diagnosis and Sir Anthony Eden, “Every succeeding scientific discov-
treatment planning through various treatment modalities ery makes greater nonsense of oldtime conceptions of
and conclude with the maintenance of the result, because sovereignty.”
we are very mindful of the many complications in implant All educational institutions include osseointegrated
treatment that require thoughtful management. It was implants in their curricula. This is because of the over-
necessary for us to seek contributions from leaders and whelming improvement in treatment demonstrated by the
role models for each phase and modality. The response leaders of surgical innovation, and the prosthetic commu-
from contributors was positive, and the excellence of their nity has participated in a similar fashion to produce excel-
chapters reveals their enthusiasm for the topic. lent results through implant treatment. Dentistry not only
For many years, osseointegrated implants have demon- offers a remarkable base of evidence that supports many
strated successful tooth replacement, much to the satis- well-established concepts but also continues to push for
faction of the dental profession. The initial research results intellectual advancements. We must continue our inves-
emerging from P-I Brånemark and associates captured tigation of new therapies to improve dentistry. An old
the attention of dentistry. It is worth noting that their Chinese proverb states, “Learning without thought is
research took place over a considerable period of time, deceptive; thought without learning is perilous.”
without marketing a product until many unknowns were Unfortunately, the challenge of peri-implantitis has
resolved. The dental community was intrigued with the threatened long-term implant survival. This has awak-
scientific studies that were brought to their attention, and ened the profession to the need for strict oversight with
research and innovation continued. well-constructed maintenance programs to provide early
The early emphasis was centered on the edentulous diagnosis and appropriate correction. Our patients are
patient, but implant treatment is routinely used today as not immune to biologic complications, with or without
an alternative to fixed restorative dentistry. The perio- implants. The main issue today is the fundamental clinical
dontist or surgeon was a prisoner of the size and form question: Can we or should we preserve the remaining
of the jaw, but changes in treatment planning were initi- natural dentition, or do implants offer a more predictable
ated in 1989 with the first reports of simultaneous deliv- prognosis?
ery of an implant into an extraction wound. Then came This text addresses the challenge of decision making
recovery of implant fenestrations or dehiscences with with specific solutions for each area of the dentition. It
regenerative protocols as well as the development of uses the evidence that is now available for both paths of
guided tissue regeneration, which expanded the popula- treatment and directs the well-informed clinician toward
tion of implant candidates with the regeneration of bone resolution. We expect to affect the thinking process of
surface deformities. Reports of implant treatment in the the discriminating dentist who is willing to invest time in
maxillary and mandibular posterior regions surfaced as a the decision-making process to arrive at the optimal result
result. Three-dimensional radiography provided informa- for the patient’s benefit.

Heading
bc d mc d dds p d
Private Practice Limited to Prosthodontics Associate Dean of Research and Head
Sandton, South Africa Department of Oral Biology
College of Dentistry
dds University of Illinois at Chicago
Private Practice
Private Practice
Genova and Domodossola, Italy
Chicago, Illinois
dds mds
be m ms c e
Private Practice Limited to Periodontics and Implant
Research Engineer
Dentistry
Southern Implants
Boca Raton, Florida
Irene, South Africa
dds p d ms
rdh ms e
Professor and Chair
Director
Department of Periodontics
Department of Research and Development
University of Iowa College of Dentistry
Department of Oral Hygiene
Iowa City, Iowa
Malo Clinic
Lisbon, Portugal
dds p d
Private Practice Limited to Surgery and Implant-
dmd
Supported Prosthetic Rehabilitation
Doctoral Student
Rome, Italy
Department of Periodontics and Oral Medicine
University of Michigan School of Dentistry
dds
Ann Arbor, Michigan
Scientific Director
Institute for Professional Education in Dentistry
dds
Private Practice Section of Implantology and Oral Rehabilitation
Turin, Italy Dental Clinic
Department of Biomedical, Surgical, and Dental
dds ms Sciences
Clinical Associate Professor Institute for Scientific Clinical Research and Treatment
Department of Periodontics and Oral Medicine (IRCCS)
University of Michigan School of Dentistry Galeazzi Orthopedic Institute
Ann Arbor, Michigan University of Milan
Milan, Italy
dmd
Research Fellow dds ms
Division of Periodontology Private Practice Limited to Periodontics and Dental
Harvard School of Dental Medicine Implant Surgery
Boston, Massachusetts Chicago, Illinois
dds p d ms p d
Osteology Foundation Scholar Department of Biomedical, Surgical, and Dental
Department of Periodontology Sciences
School of Dentistry Institute for Scientific Clinical Research and Treatment
Seoul National University (IRCCS)
Seoul, Korea Galeazzi Orthopedic Institute
University of Milan
mds mbbs Milan, Italy
Honorary Clinical Associate Professor
Oral and Maxillofacial Surgery bc d h md
Faculty of Dentistry Private Practice Limited to Prosthodontics
The University of Hong Kong Lyttelton, South Africa
Hong Kong, China
xi

dds bds ms
Adjunct Clinical Professor and Director of Clinical Private Practice Limited to Prosthodontics
Research Adelaide, South Australia
Department of Periodontology and Implant Dentistry
New York University College of Dentistry dds
Resident
Private Practice
Advance Program in Implant Dentistry
New York, New York
New York University College of Dentistry
BDS ms
New York, New York
Assistant Professor
dds
Department of Periodontics
Adjunct Clinical Professor
Faculty of Dentistry
Department of Postgraduate Endodontics
National University of Singapore
Nova Southeastern University
Singapore
Fort Lauderdale, Florida
md
dds p d
Head of Prosthodontics
Private Practice
Department of Implantology and Oral Rehabilitation
Okayama City, Japan
Institute for Scientific Clinical Research and Treatment
(IRCCS)
p d p d
Galeazzi Orthopedic Institute
Head and Vice Chair
University of Milan
Division of Implantology
Milan, Italy
Clinic for Fixed and Removable Prosthodontics and
Private Practice Material Science
Monza, Italy Center of Dental Medicine at the University of Zürich
Zürich, Switzerland
dmd
Adjunct Associate Professor dds dms
Department of Periodontology Associate Professor
Nova Southeastern University Department of Oral Medicine, Infection, and Immunity
Fort Lauderdale, Florida Director, Postgraduate Program in Periodontology and
Clinical Associate Professor Continuing Education
Goldman School of Dental Medicine Harvard School of Dental Medicine
Boston University Boston, Massachusetts
Boston, Massachusetts
bds ms d dc d
Private Practice Limited to Periodontics and Implant Clinical Associate Professor
Dentistry Department of Health and Medical Sciences
Boca Raton, Florida School of Dentistry
University of Western Australia
dds ms, dm s
Nedlands, Australia
Professor and Chair
Department of Periodontics and Oral Medicine dds dms
University of Michigan School of Dentistry Lecturer
Professor of Biomedical Engineering Division of Oral Medicine, Infection, and Immunity
Department of Biomedical Engineering Harvard School of Dental Medicine
College of Engineering Boston, Massachusetts
University of Michigan
Ann Arbor, Michigan dds
Doctoral Student
p d Department of Periodontology and Implant Dentistry
Chair New York University College of Dentistry
Clinic of Fixed and Removable Prosthodontics New York, New York
Center of Dental Medicine at the University of Zürich
xii

dmd ms dds ms
Assistant Professor and Division Director of Implant Director, Division of Periodontology
Prosthodontics Clínica CICOM
Department of Oral Rehabilitation Badajoz, Spain
College of Dental Medicine Associate Professor
Medical University of South Carolina Department of Periodontology
Charleston, South Carolina International University of Catalonia
Barcelona, Spain
dds p d
Private Practice d
Osaka, Japan Center of Dental Medicine
Clinic of Fixed and Removable Prosthodontics and
dds
Dental Material Science
Doctoral Student
University of Zürich
New York University College of Dentistry
New York, New York dds p d
Private Practice
dds p d
Osaka, Japan
Clinical Director
Malo Clinic dmd mms
Lisbon, Portugal Assistant Professor
Department of Oral Medicine, Infection, and Immunity
dds ms
Harvard School of Dental Medicine
Adjunct Clinical Assistant Professor
Department of Graduate Periodontics Private Practice
College of Dentistry Boston, Massachusetts
University of Illinois at Chicago
dds
Private Practice Limited to Periodontics and Dental Associate Professor
Implant Surgery Department of Oral Medicine, Infection, and Immunity
Chicago, Illinois Harvard School of Dental Medicine
Boston, Massachusetts
dds ms p d
Private Practice dmd
Caxias do Sul, Brazil Private Practice Limited to Periodontics and Implant
Dentistry
dds
Boca Raton, Florida
Professor of Surgery and Chief
Division of Oral and Maxillofacial Surgery dds
Miller School of Medicine Director
University of Miami The Japan Institute for Advanced Dental Studies
Miami, Florida Osaka, Japan
dds
dmd mds
Private Practice Clinical Assistant Faculty
Tokyo and Osaka, Japan Division of Periodontology
Department of Oral Health and Diagnostic Sciences
dds mds
University of Connecticut Health Center
Clinical Associate Professor
Department of Periodontics/Prosthodontics Private Practice
School of Dental Medicine West Hartford, Connecticut
University of Florida
Gainesville, Florida dds
Private Practice Limited to Prosthodontics and Implant
Private Practice Limited to Oral and Maxillofacial Dentistry
Surgery and Prosthodontics Dallas, Texas
Sarasota, Florida
xiii

dds dds
Lecturer Section of Implant Dentistry and Oral Rehabilitation
Department of Implantology and Oral Rehabilitation Dental Clinic
Institute for Scientific Clinical Research and Treatment Department of Biomedical, Surgical, and Dental
(IRCCS) Sciences
Galeazzi Orthopedic Institute Institute for Scientific Clinical Research and Treatment
University of Milan (IRCCS)
Milan, Italy Galazzi Orthopedic Institute
Private Practice University of Milan
Piacenza, Italy Milan, Italy
pd d d
dds ms
Private Practice Lecturer
Seoul, Republic of Korea Center for Dental, Oral, and Maxillofacial Surgery
University of Zürich
md dds ms Private Practice
Assistant Professor Zürich, Switzerland
Master Degree in Periodontology
School of Dental Medicine dds
Turin University Private Practice Limited to Periodontics and Dental
Turin, Italy Implant Surgery
Private Practice Limited to Periodontology and Fairfield, Connecticut
Implantology
dds
Ferrara, Italy
Doctoral Student
md ms p d
Professor New York University College of Dentistry
Department of Biochemistry and Tissue Biology of the New York, New York
Institute of Biology
md dds
University of Campinas
Professor and Chairman
Campinas (SP), Brazil
Department of Periodontology and Implant Restoration
rdh dds
School of Dental Medicine
Assistant Professor University of Milan
Alma Mater Studiorum Milan, Italy
Bologna University
dds p d
Bologna, Italy
Researcher
md dds
Department of Biomedical and Neuromotor Sciences
Private Practice Alma Mater Studiorum
Genova, Italy Bologna University
Bologna, Italy
dds, p d
Private Practice md dds
Osaka, Japan Head of Section of Implantology and Oral Rehabilitation
Department of Biomedical, Surgical, and Dental
dds Sciences
Private Practice Institute for Scientific Clinical Research and Treatment
Tokyo, Japan (IRCCS)
Galeazzi Orthopedic Institute
University of Milan
Milan, Italy
Private Practice Limited to Implantology and
Periodontology
Como, Italy
xiv

md dds dds dms
Assistant Professor Clinical Assistant Professor and Director of Predoctoral
Turin University Periodontics
Turin, Italy Department of Periodontics and Oral Medicine
Private Practice Limited to Periodontology and University of Michigan School of Dentistry
Implantology Ann Arbor, Michigan
Flero, Italy
dds msd p d
dmd md p d
Collegiate Professor of Periodontics
Assistant Professor Professor and Director of Graduate Periodontics
Department of Restorative Dentistry Department of Periodontics and Oral Medicine
School of Dentistry University of Michigan School of Dentistry
Loma Linda University Ann Arbor, Michigan
Loma Linda, California
dds p d
Private Practice Associate Professor
Budapest, Hungary Director, Postdoctoral Periodontology Program
Herman Ostrow School of Dentistry
dds ms p d University of Southern California
Chief of Oral and Maxillofacial Surgery Los Angeles, California
Clínica Eleve
Hospital da Face dds
São Paulo, Brazil Private Practice Limited to Periodontics and Implant
Dentistry
dds Aventura, Florida
Clinical Associate Professor
Department of Periodontics dds ms p d
Columbia University College of Dental Medicine Professor
New York, New York Department of Biomedical and Neuromotor Sciences
Private Practice Limited to Periodontics University of Bologna
Waterbury, Connecticut Bologna, Italy
xv

1 MYRON NEVINS • RICHARD HERMAN • YOSHI ONO
A Clinical Decision:
Save the Tooth or
Place an Implant?
Treatment Planning Considerations
Treating Periodontally Compromised Teeth
The Endodontic Treatment Option
Treating Patients with Sound Periodontium and
a Localized Problem
Periodontal Regeneration
Decision Making for Saving the Natural
Dentition
Esthetic Considerations
Nevins/Wang_Chap_01.indd 1 2/28/19 2:09 PM

1 | A Clinical Decision: Save the Tooth or Place an Implant?
T
he contemporary hallmark of a superior clinician is • What is the position of the roots of the tooth relative to each
the ability to select therapies that are predictable and other and to the neighboring teeth?
have long-lasting results. The question of whether • Is the tooth vital, and how intact is the tooth structure and
to save a tooth or replace it with a dental implant is the occlusal level of bone (Figs 1-1c and 1-1d)?
multifaceted, and the assessment requires a multidisciplinary • What type of lip line and dental display does the patient have,
approach to dental care. Giannobile and Lang have reported a and how will it affect the esthetics?
trend over the past two decades toward a reduced emphasis • Could the tooth be treated endodontically? (A 2009 report by
in clinical practice to save compromised teeth.1 They suggest Morris et al31 concluded that implants require more postop-
that clinicians should revisit the long and successful history of erative treatment than endodontically treated teeth, possibly
tooth maintenance, preserving the natural dentition without the a result of contemporary advancements. In addition, many
rush to extract teeth and replace them with implants. Dental endodontic complications, with the exception of fractured
practitioners do a disservice to their patients and themselves teeth, are resolvable.)
when they fail to carefully weigh the advantages and disad-
vantages of such options in providing optimal oral health care Implant patients fall into two general categories. The first
delivery to patients. includes individuals with teeth that are congenitally missing
or damaged by trauma or root resorption (Fig 1-2). The second
group has demonstrated susceptibility to inflammation that is
evidenced by radiographic bone loss (Fig 1-3). Those in the first
TREATMENT PLANNING category require only tooth structure correction or replacement,
CONSIDERATIONS whereas the second group presents the additional challenge of
preventing or minimizing recurrent inflammation. The primary
Decisions made in treatment planning often determine the value factor dictating decision making becomes the length of the
of the result for the patient. Contemporary dentistry has bene- clinical root, ie, that portion of the tooth that resides in the
fited from the predictability of osseointegration,2–10 periodontal alveolar process (see Figs 1-1c and 1-1d). With a susceptible
regeneration,11–29 successful endodontics,30 and prosthodontics, patient, it is advisable to eliminate the periodontal disease and
four compelling areas in which the clinician must be knowledge- provide a carefully constructed periodic maintenance program
able in order to make an informed decision regarding when to to reduce the risk of active inflammatory disease.32 The ther-
save the tooth or place an implant. apeutic result has to provide an environment that the patient
Nearly every patient asks the same questions during consul- and dental hygienist can maintain (see Fig 1-3).
tations. They are the following: It is of paramount importance to recognize at the outset
that it is possible, and in some instances preferable, to use the
• How much discomfort will I endure? time-honored therapeutic approaches of conventional restorative
• How many visits will be required? dentistry. Although there is a lack of controlled studies in the
• What will be the total treatment time? discipline of periodontal prostheses, there is a paucity of signif-
• How will this affect my appearance? icant randomized controlled human studies to support the clin-
• What is the financial commitment? ical application of many periodontal and prosthetic approaches.
• What is the expected longevity of the treatment outcome? There is, however, overwhelmingly positive clinical evidence
gathered through the observation of treated patients to be
There is minimal information available in evidence-based considered. Periodontally compromised patients with mobile,
dentistry to assist in making many clinical decisions because drifting, or missing teeth have been successfully rehabilitated
of the number of variables that challenge the recruitment of with or without implants (Figs 1-3 to 1-5). Such patients require
populations for randomized controlled trials. As a result, when a treatment plan that provides predictability over an extended
considering the prospect of replacing a maxillary first premolar time frame.
with two roots, for example, clinicians eventually resort to their In patients with few missing teeth or those with obvious peri-
own clinical experience or case report publications. Consider- odontal disease, total extraction of the dentition and replace-
ations that must be made include the following: ment with implants is frequently unnecessary (Figs 1-6 and 1-7).
There are many examples of positive long-term results with
• What is the distance from the apex of the tooth to an anatom- maintenance of the dentition, while at the same time there are
ical obstacle, and will it be necessary to augment the bone increasing complications with implants. It is unfortunate that the
in the floor of the sinus (Figs 1-1a and 1-1b)? dental profession frequently is unaware of the positive results
of traditional periodontal, endodontic, and prosthetic care.10,33,34

a b c d
Fig 1-1 (a and b) It is impossible to have just one protocol for a maxillary first premolar. There is ample bone on the left side to accept an osseointe-
grated implant; however, if the maxillary first premolar were extracted on the right side it probably would be necessary to augment bone to receive
an implant. (c and d) Cadaver material demonstrating the difference in bone levels between a patient with a healthy dentition and a patient who is
severely compromised periodontally. The prime dictating factor relates to the length of the clinical root rather than the length of the anatomical root.
a b c
d e f
Fig 1-2 (a to c) A young woman with root resorption on the distal surface of the right central incisor. An esthetic dental display is very important
to the patient. (d to f) The clinical and radiographic postoperative result after replacing the damaged tooth with an osseointegrated implant.
a 1995 b 1999 c 2009
Fig 1-3 (a) The patient presented for a periodontal regeneration procedure. The radiographic examination demonstrated intrabony defects that
were not contained, therefore eliminating the possibility of periodontal regeneration. The two premolars were removed, the alveolar process
underwent reconstruction, and two dental implants were placed. (b) A 3-year posttreatment radiograph illustrates significant recovery and no
evidence of bone loss. (c) The bone-implant contact remains steady after 14 years. This demonstrates that patients susceptible to disease can
accept osseointegrated implants successfully.

d e f
2015
g 25 years
Fig 1-4 (a) The patient presented with generalized advanced periodontitis. (b) A radiographic survey 1 year after the placement of many dental
implants. Red circles indicate post and core risk. (c and d) Radiographic and clinical observation after 7 years. The maxillary left canine suffered a
vertical root fracture and was replaced by a third 18-mm implant. The molar was removed and replaced with a cantilever. (e and f) Clinical presen-
tation after 17 years. (g) A radiographic survey after 25 years. Once again, this demonstrates that people susceptible to periodontal disease can
be treated successfully with osseointegrated implants.

Fig 1-5 (a and b) Before and after radiographic surveys of a patient clearly susceptible to inflammatory periodontal disease. (c) A 13-year radiographic
survey demonstrating the replacement of the maxillary first molars with fixed restorative dentistry. (d) The radiographic survey after 34 years. Red
circles indicate loss of supporting bone. (e) A 50-year posttreatment radiographic survey. Treatment has been provided in an incremental fashion
as additional areas required treatment.

1962 1974 1983 1999
a b c d
Fig 1-6 This patient first presented in the year 1962 (a). Finances prevented the extraction of the maxillary first premolars and the construction of
fixed partial dentures. These radiographs taken at 12 (b), 21 (c), and 37 (d) years show that the first premolars remained in the patient’s mouth for
37 years with no corrective therapy. The recall interval was 3 months, and the patient continued to be punctual until her death. This is an example
that must be looked at as an outlier.
a 1968
b 1978
c 1988
d 2016
Fig 1-7 (a) This patient presented with significant loss of the periodontium in 1968. Her chief complaint was that the teeth were too mobile to
masticate food. The initial therapy included nonsurgical treatment and splinting of the teeth. After this was successful, bone was harvested from
the edentulous maxilla to regain periodontium where possible. (b) The patient retained all 10 teeth for 10 years. (c) Radiographs at 20 years. Her
restorative dentist restored all of the teeth with fixed crowns in 1997. (d) The 2016 radiographic survey demonstrates 9 of the 10 teeth still func-
tioning. The original endodontic treatment for the left central incisor was questionable and became problematic (green arrow).

The Endodontic Treatment Option
a b c
Fig 1-8 (a) A preoperative apical pathosis accompanied by lateral periodontal breakdown. (b) After treatment with bioceramic sealer and a lateral
canal adjacent to the cervical periodontal bone loss. The red arrow designates loss of bone on the mesial surface of the molar. (c) Postoperative
radiograph showing healing periapically and periodontally. The green line indicates the lateral canal. The red arrow designates loss of bone on the
mesial surface of the molar. (c) Postoperative radiograph showing healing periapically and periodontally. The green line indicates the lateral canal.
The red arrow shows the regeneration of bone adjacent to the root.
TREATING PERIODONTALLY esthetics may be greatly affected, even in a posterior quadrant.

If there is horizontal bone loss beyond 50%, the bone level of
COMPROMISED TEETH adjacent teeth will contribute to vertical bone reconstruction,
allowing implant placement to be favorable and providing a more
Favorable results can be accomplished when implants are placed acceptable result than resorting to pocket elimination surgery
in patients with a chronic history of periodontal disease. There (see Fig 1-3).
are many publications that have demonstrated long-term healthy
and functional implants in place after the loss of periodontally
compromised teeth.9,10,35–39 It has been recognized that two very
important factors are the elimination of periodontal disease THE ENDODONTIC TREATMENT
before implants are placed and the availability of oral hygiene OPTION
programs.32,40
Implants have provided an opportunity to greatly reduce the Recent literature demonstrates that endodontics and single-tooth
necessity for periodontal heroics by taking advantage of osse- implant therapy have similar success rates. Hannahan and
ointegration. However, there is overwhelming evidence that Eleazer found that 95% to 97% of teeth with treated root canals
periodontally compromised teeth can survive indefinitely.41–43 were retained after a period of 8 years compared with implant
Esthetics and masticatory function may become compromised retention rates of 85% to 90% over a similar time span.47 Postop-
over time for some patients, but this is not usually the case. erative intervention, an indication of treatment failure, was noted
Osseointegrated implants have been one of the most signifi- for 12.4% of implants compared with 1.3% of endodontically
cant improvements of the 20th century, and when appropri- treated teeth. A more recent report studied the 10-year success
ate, provide solutions heretofore unavailable. It is important rate of 1,175 endodontically treated teeth.48 The life-table analy-
that the dentist weigh the success of saving a tooth using the sis demonstrated that 93% of the teeth survived 10 years after
capabilities of contemporary periodontal regeneration and/or endodontic treatment. However, it is critical to determine the
endodontics against the success of an implant. This presents a criteria for success used when discussing implants.
significant conflict for the knowledgeable dentist, while practi- Endodontic procedures are best performed under the surgical
tioners with minimal knowledge of the success of periodontics operating microscope, as it enhances the clinician’s ability to
and endodontics generally find it easier to place an implant. The locate and navigate canals.49 It has been shown that with the
most important question for the dentist is, “What would I do microscope the ability to locate second mesiobuccal canals has
if this problem were in the mouth of a friend or loved one?” increased from 53% to 93%.50,51 The success rates of periapical
Before peri-implantitis was encountered, it was believed that surgery have also demonstrated significant improvement (Figs
implant success would exceed 90%.2–4,11 Several studies have 1-8 to 1-10). In such procedures, it is imperative to prepare the
demonstrated the error of thinking that implants always have a crypt and the canals as well as place the retroseal.52
better long-term prognosis than teeth with treatable problems.44 The introduction of nickel titanium instrumentation allows
Recent studies show that peri-implantitis and mucositis are the clinician to shape the canal, which increases the ability of
frequent complications that challenge the future health of an the irrigation protocol to clean the complex anatomy of the
implant.45,46 Therefore, the decision has to be carefully consid- root canal system. In addition, new advancements in material
ered before treatable teeth are removed. science related to obturation have developed. It is now possi-
Conversely, there are routine treatment plan objectives for ble to have a biocompatible sealer that bonds to dentin, as
which tooth replacement with implants offers a better progno- well as gutta-percha, which provides a fluid yet impermeable
sis. When teeth are mobile because of significant loss of bone, and tight seal.52

a b c
Fig 1-9 (a) Preoperative radiograph of a nonvital mandibular molar with periapical pathosis. (b) Following obturation with biocompatible bioceramics.
(c) Healed periapical pathosis at 6 months.
a b c
Fig 1-10 (a) Preoperative periapical lesion with a post present in the distal canal. (b) Following microsurgery using compatible bioceramics with
an ultrasonic retrograde preparation. (c) Complete resolution of periapical pathosis at 6-month recall.
a b c
d e f
Fig 1-11 (a and b) A fistula (yellow arrows) remains at the maxillary right central incisor root after apical surgery. (c) The tooth was extracted, and
the area was grafted to repair the osseous damage. (d) Six months later, a dental implant was placed. (e) The result satisfied the patient. (f) There
is scar evidence of the previous endodontic surgery.
However, this should not be perceived as a competition TREATING PATIENTS WITH

between endodontics and implant treatment; rather, they should
complement each other. On the basis of survival rates, it appears SOUND PERIODONTIUM AND A
more than 95% of single-tooth implants and teeth that have LOCALIZED PROBLEM
undergone endodontic treatment remain functional over time50
(see Figs 1-8 to 1-10). There are frequently situations in which a tooth in the esthetic
region can be saved, but the patient would benefit from its

Periodontal Regeneration
a b c
d e f
g h i j
Fig 1-12 (a) Presurgical evaluation demonstrates a probing depth of 9 mm with no bleeding and pink gingiva. (b) The intrabony defect is almost com-
pletely devoid of a buccal wall. (c) The radiograph demonstrates severe loss of osseous support, although the tooth is stable. (d) The graft material
and recombinant human platelet-derived growth factor are placed into the osseous defect. (e) The clinical appearance after 3 days demonstrates
initial healing. (f) The flap is reflected after 1 year and demonstrates regeneration of the osseous defect. (g) A 1-year radiograph demonstrates the
premolar in contact with the canine and significant bone response. (h) A 6-year postoperative radiograph. (i) A 10-year postoperative radiograph. (j)
The 10-year postoperative clinical appearance.
replacement with an implant. When both conventional and sur- in patients with either a localized problem or advanced general-
gical endodontics have failed, extraction and site reconstruction ized periodontal disease. Variables such as age, medical history,
allow the clinician to place an implant or a three-unit fixed partial esthetic expectations, and finances may influence the selection
denture. It is then possible to consider the length of the resto- of treatment, but it is appropriate for practitioners to consider
ration and predict the likelihood of interproximal black triangles. what they would do if this was their own mouth.
It is also an advantage to replace one tooth without altering Treatment may include barrier membranes, autografts,
adjacent teeth (Fig 1-11). allografts, xenografts, and alloplasts17–23 (Fig 1-12). The intro-
duction of recombinant human platelet-derived growth factor
BB (rhPDGF-BB) together with any of the previously mentioned
materials has significantly improved the ability to achieve a
PERIODONTAL REGENERATION successful outcome.23–29 Once again, it is necessary to consider
the stability of the tooth and the morphology of the defect. The
Not every tooth with reduced alveolar support is a candidate containment of the defect provided by remaining osseous struc-
for extraction, especially if it would result in loss of continuity ture provides the protection of the blood clot while it becomes
of the natural dental arch.53–56 These defects may be identified organized and provides space maintenance for regeneration to

TR
a b c
d e f g
Fig 1-13 (a) An 8-mm probing depth with pink, non-bleeding tissue. (b) The histologic block section after 8 months. (c) Note the new cemen-
tum (NC), new periodontal ligament (PDL), and the new bone (NB). Very little graft material remains. Clinical enlargement of the middle block is
observed. (d) The apical position of the junctional epithelium (JE) was prohibited by the connective tissue (CT) attachment. Note two small pink
pieces occlusal to the new bone. This is the only evidence of the biologic after healing. (e) This is the result of conventional periodontal regeneration
without rhPDGF. (f) This implant demonstrates osseointegration. (g) This regenerative result demonstrates new cementum and a strong periodontal
ligament. However, the bone-to-implant contact is limited. OB, old bone; TR, trunk.
occur. It is generally impossible to achieve periodontal regen- periodontal ligament connecting them, it is important to select
eration when the defect morphology is completely horizontal, the appropriate grafting materials (Figs 1-13 and 1-14), whose
but it is possible for vertical osseous defects. The stability of predictability should be supported by clinical studies.26,28,29 There
the tooth is critical to accomplishing regeneration; therefore, is abundant evidence to suggest long-term success with and
stabilization of the tooth may be required before regeneration. without surgical treatment.
It is necessary to consider the type of defect and identify the The bone morphology will frequently dictate decision making
source of the progenitor cells and vascularity. Since almost every in esthetic areas. Unfortunately, experience is required to make
defect is a combination of one, two, and three walls, contained the decision, and even then it may be a compromise. The avail-
versus noncontained seems to be more meaningful terminology. ability and efficacy of methods and materials available have
What is important is to recognize the possibility of regenerating expanded the possibilities of both successful implant placement
the lost periodontium rather than removing the tooth to place and periodontal regeneration, which can complicate decision
an implant when this is not necessary.22–28 making. Results are achievable today that were unlikely to be
Since the definition of periodontal regeneration is a histo- seen in the past.
logic demonstration of new cementum and bone as well as a
10

Decision Making for Saving the Natural Dentition
c d e
Fig 1-14 (a) There is a lingual Class II furcation involvement of the mandibular molar. (b)
This is grafted with a bone allograft combined with rhPDGF-BB. (c) An overall histologic
section of the molar following treatment of the Class II furcation. The green line demon-
strates the difference between the very thin eruption cementum and the regenerative
cellular cementum, which is broader. (d) A magnified view of the notch made at the level
of bone. Once again, it is obvious that there is new cementum (NC), new periodontal
ligament (PDL), and new bone (NB). The arrow demonstrates the thin, eruptive cementum
and the thick, new cellular cementum to show periodontal regeneration. TR, trunk. (e)
b
A magnified view focusing on the furcation regeneration.
DECISION MAKING FOR SAVING from the cementoenamel junction to the furcation is frequently
no more than 4 to 5 mm. It is not wise to open the furcation
THE NATURAL DENTITION by removing bone for crown lengthening, and extraction and
replacement with an implant is logical.61,62 Of course, the saving
In the posterior dentition in which there is damage to tooth grace is the rare instance when the roots are fused (Figs 1-17
structure, periodontal disease associated with significant loss and 1-18). Essentially, root resection converts furcated molars to
of alveolar structure, and/or the need for endodontic therapy, single-rooted teeth with a favorable environment for oral hygiene.
the most frequent clinical decisions are to treat and retain the Decisions for anterior single-rooted teeth are greatly influ-
natural dentition or place osseointegrated implants. Let us first enced by esthetics. Mandibular intrabony defects can be
consider the loss of bone support for multirooted teeth with successfully managed over a long period of time without
furcation involvement. A Class I furcation should be addressed encountering esthetic disappointment from the patient.63,64
with the mindset of stopping the progress before it becomes a There is significant evidence that teeth with reduced peri-
Class II furcation. This can be confidently achieved with reduc- odontium can provide successful mastication and patient
tion of the sulcus and perhaps minor osseous surgery. There is satisfaction for many decades. As previously mentioned, the
human histologic evidence to demonstrate periodontal regen- uninvited problem of peri-implantitis challenges earlier beliefs
eration in Class II furcations21–24 (see Fig 1-14). However, these that implant success was expected to be in the 95th percen-
were proof-of-principle studies and do not guarantee the goal tile.44,46,65–67 It is of utmost importance for the clinician to be
will be achieved 100% of the time. cognizant of all therapeutic opportunities to arrive at the best
There is no clear human histologic evidence that the regen- solution for the patient.
eration of Class III furcations can be expected using any current Similar decisions are involved in endodontic treatment of
treatment regimens. Therefore, the next consideration is single-rooted mandibular teeth or defects in tooth structure that
whether the tooth can be preserved with root resections over require crown lengthening. It is necessary to become knowl-
an extended period of time. The prognosis of root resection edgeable about contemporary endodontic therapy supported
has been clearly demonstrated in previous publications.57–60 by evidence-based dentistry in order to be successful when
The dictating factors for this decision are the length of the clin- compromised teeth are saved and remain part of the natural
ical root and the size of the edentulous span. When there is a dentition (Figs 1-19 and 1-20).
combination of a long root and a small edentulous distance, the Some of the technologic advancements that enable us to save
likelihood for success is high (Figs 1-15 and 1-16). Conversely, teeth include the surgical operating microscope, nickel-titanium
short roots and long edentulous spans will have a much worse instrumentation, apex locators, ultrasonics, mineral trioxide
prognosis. The stopgap decision is crown-lengthening surgery aggregate, hydrodynamic irrigation, bioceramics, and cone beam
to address the loss of tooth structure. However, the distance computed tomography.
11

a 1969 b 1994
Fig 1-15 (a) This mandibular molar had significant mesial caries and furcation involvement (arrow) in 1969. (b) The result after 25 years demonstrates
the success of root resection of a multirooted tooth. Note the bone level (arrow).
a b c
Fig 1-16 (a) Both mandibular molars have Class III furcation invasion. (b) The finished prosthetic restoration. The retention of the apical portion of
the mesial roots remains after 21 years. (c) Definitive restoration.
a b c
d 1976 e 1977 f 1980 g 2000
Fig 1-17 (a and b) This case predates osseointegration, and crown lengthening was necessary to construct a restoration with margins on healthy
tooth structure. (c) The sutured position of the flaps. (d to g) Radiographs from 1976, 1977, 1980, and 2000, respectively. The tooth has served the
patient’s masticatory needs for 24 years.
a b c
Fig 1-18 (a) Crown lengthening was performed with screws and composite. The gutta-percha cone (yellow arrow) demonstrates that the lingual
cusps of the tooth fractured. It was decided that no further therapy should be performed for this tooth, and it would be replaced by dental implants.
(b) The restored implants in 1992. (c) An updated radiograph in 2017, after 25 years.
12

Esthetic Considerations
a b c a b c
Fig 1-19 (a) Preoperative view showing previous endodontic treatment Fig 1-20 (a) Preoperative view of periapical pathosis. (b) Following
failure accompanied by a lateral periodontal lesion. (b) Following retreat- endodontic treatment with biocompatible bioceramics. (c) Postoperative
ment with biocompatible bioceramics. Notice the lateral canals. (c) Com- view of complete resolution of periapical pathosis.
plete resolution of the lesion.
a b c
d e
Fig 1-21 (a) The patient’s chief complaint centers on esthetics, but she is unaware of her advanced loss of periodontium. (b) It is evident that there has
been a significant loss of supporting bone for these teeth. (c) If implants are placed without significant successful regenerative therapy, the implant-
abutment junction will be too apical to allowing cleaning by the patient or the hygienist. The decision was made to remove the teeth and place a pro-
visional partial denture. (d) Radiographs showing the loss of bone. (e) If a patient is susceptible to inflammation, it is important to have structures in a
position where the hygienist and patient can decontaminate the components of the restoration, such as the implant abutment and prosthetic restoration.
ESTHETIC CONSIDERATIONS ration is a realistic goal when a tooth is lost to fracture from
trauma or endodontic failure. A fractured tooth may require a
Many contemporary patients identify esthetic improvement as crown-lengthening procedure to provide sound tooth structure
their motivating factor to seek dental care. Although the esthetic for the cervical margin of a new crown. This may be accom-
region includes the maxillary and mandibular anterior teeth, plished with soft tissue excision but usually requires some
most individuals’ display area focuses on the maxillary region. removal of bone. In these instances, esthetics may be opti-
It is important for the dentist to be cognizant of the patient’s mized by preserving the bone, extracting the damaged tooth,
wishes and whether or not they are realistic and to explain the and replacing it with an implant (see Fig 1-2).
difficulty of the procedure and the need to satisfy both esthetic All patients would prefer the restoration to re-create their
and biologic goals for long-term success, as this may be the natural, younger appearance, and all dentists would like to
discerning factor. Every effort should be made to provide clinical accommodate this request. Therefore, it can be helpful to ask
and radiographic documentation that will enhance the diagnosis the patient to provide a photograph from the past to help in
and planning of an optimal result. planning the restoration.
The esthetic restoration of a single tooth is identified by the The conflict between the desire for longevity and the desire
patient as one that matches the shade and size of the adjacent for esthetics can complicate treatment. Perhaps the most
teeth (see Figs 1-2 and 1-11). Patients are generally dissatisfied difficult treatment plan involves the patient with a large dental
with interproximal black triangles, which may be present with a display and a significant loss of supporting structure for the
single tooth- or implant-supported restoration. Esthetic resto- remaining teeth (Fig 1-21). However, esthetic goals can be real-
13

a b c
d e
f g
h i
Fig 1-22 When a patient has a high lip line and significant loss of periodontium, esthetic treatment is of prime importance. It is necessary to
construct a prosthesis that will allow oral hygiene access for the patient and the hygienist. (a to c) This patient always had spaces between her
teeth, so she met with the dental technician to create a solution. She has a high lip line with significant dental display. (d and e) Intraoral and
smile views 22 years later. (f) Radiograph from 1992. Note within the red circle the preservation of all of cervical bone because the patient has
adequate oral hygiene access. (g) Radiograph taken 24 years later. (h) The patient’s esthetic display due to her high lip line in 2018. (i) The patient
performing using dental floss in 2018.
ized even with a high lip line. It is important to create a prosthesis partial denture from canine to canine (Fig 1-23). This will preserve
that allows access for oral hygiene. A primary goal is to preserve the soft tissue papillae and prevent the need to place implants
the bone-implant contact, and this can be accomplished with at the level of bone, which would result in the implant-abutment
the use of pink ceramics to effectively emulate the papillae. junction being placed significantly subgingivally. A prosthesis
The evidence of success can be established radiographically with limited oral hygiene access would be a poor choice for
by comparing the bone-implant contact over a period of years the patient who has lost periodontium because of susceptibil-
(Fig 1-22). ity to inflammation. In addition, not every patient is an appro-
If periodontally compromised maxillary incisors are to be priate candidate for distraction osteogenesis or guided bone
removed, an alternative to implants may be constructing a fixed regeneration.
14

Summary
Fig 1-23 (a) The patient presented with es-

thetic and phonetic complaints. All four max-
illary incisors were replaced with pontics. (b)
The solution to the problem was prosthetic
reconstruction with no dental implants.
a 1969 b 1994
a b c
Fig 1-24 (a to d) This 45-year-old man presented with advanced periodontal disease and all of his teeth were mobile. However, he did not want
implant treatment. The maxillary molars were beyond treatment and the remaining teeth had very short clinical roots. The mandibular molars
had Class 3 furcation invasions. The lateral views demonstrates gingival recession on all of the teeth. On the left side, the teeth were splinted to
stabilize them during initial debridement treatments.
SUMMARY ity to deliver even the most challenging esthetic and functional
prostheses (Fig 1-24).
It is important for dental practitioners to expand their horizons The most alluring part of the dental profession is that treat-
if and when patients demand to preserve their remaining den- ment regimens continue to improve and benefit the patient.
tition. It is critical to provide an outcome that allows adequate There is no factor in treatment more important than developing
access for daily oral hygiene and a personalized maintenance the treatment plan. Dental practitioners have the opportunity
program based on the patient’s demonstrated susceptibility to for a rewarding career when they use their knowledge to create
inflammatory disease. It is equally important to have the abil- a satisfied patient.
15

Fig 1-24 (cont) (e and f) Clinical view and radiographic survey after treatment was concluded. The patient wanted to keep this status for 5 years.
(g and h) Clinical view and radiographic survey 26 years later demonstrating the possibility of long-term benefits for the patient.
16

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without the use of high magnification. J Endod 2012;38:1–10 evidence. Int J Periodontics Restorative Dent 2019;39:157–163.
50. Stetzer FC, Kim S. Comparison of long-term survival of implants 65. Norton MR. Efficacy of Er:YAG laser in the decontamination of
and endodontically treated teeth. J Dent Res 2014;93:19–26. peri-implant disease: A one-year prospective closed cohort study.
51. Stropko JJ. Canal morphology of maxillary molars. Clinical obser- Int J Periodontics Restorative Dent 2017;37:781–788.
vations of canal configurations. J Endod 1999;25:446–450. 66. Yamamoto A, Tanabe T. Treatment of peri-implantitis around
52. Zhang W, Li Z, Peng B. Assessment of a new root canal sealer’s TiUnite-surface implants using Er:YAG laser microexplosions. Int
apical sealing ability. Oral Surg Oral Med Oral Pathol Oral Radiol J Periodontics Restorative Dent 2013;33:21–30.
Endod 2009;107:e79–e82. 67. Berglundh T, Abrahamsson I, Lindhe J. Bone reactions to long-
53. Mayo CH. Focal infection of dental origin. Dent Cosmos standing functional load at implants: An experimental study in
1922;64:1206–1208. dogs. J Clin Periodontol 2005;32:925–932.
18

2
From Osseointegration to
Predictable Long-Term
Implant Stability:
Clinicians’ Perspectives
The Development and Predictability of
Osseointegrated Implants
MYRON NEVINS
Long-Term Results of Implants in Native

and Regenerated Bone
MASSIMO SIMION
Connective Tissue Attachment to a

Laser-Microtextured Surface
CARY A. SHAPOFF
Long-Term Implant Success: Part I

JEFFREY GANELES • FREDERIC J. NORKIN • LILIANA ARANGUREN • SAMUEL ZFAZ
Long-Term Implant Success: Part II

DAVID M. KIM • WONBAE PARK
Long-Term Implant Success: Part III

TAMSIN J. CRACKNELL • DEON FERREIRA • PETER HAWKER • ANDREW ACKERMANN
19

2 | From Osseointegration to Predictable Long-Term Implant Stability: Clinicians’ Perspectives
Fig 2-1 A mandibular subperiosteal implant placed in 1968. The patient died in 2010. This implant
restoration provided 42 years of masticatory function and improved personal confidence.
a b c
d e f
Fig 2-2 (a) This pseudo-Class III malocclusion with a loss of vertical height required occlusal support in the mandibular left posterior quadrant. (b)
Provisional restorations reestablished an acceptable occlusion. (c) The extension of the mandibular left quadrant would require a removable partial
denture or a dental implant in 1971. (d) The subperiosteal implant. (e) The definitive fixed prostheses. (f) The left lateral view demonstrating a full
gold crown on the implant. A screw was placed on the mesial surface into a small slot on the implant to prevent it from becoming loose. (g) The
full-mouth radiographic survey at the completion of treatment. (h) A full-mouth radiographic survey after 21 years.
20

THE DEVELOPMENT AND PREDICTABILITY OF OSSEOINTEGRATED IMPLANTS
b c
Fig 2-3 (a) Full-mouth radiographic survey in 1988. (b) It was necessary to replace both fixed prostheses in the mandible and maxilla. (c) Left lateral
view of implants replacing the maxillary left premolars.
The Development and Most clinicians placing implants had extensive surgical
credentials, resulting in extraordinarily high success rates.1–3
Predictability of 3. 2000 to 2018: Expansion of the industry with many new
Osseointegrated Implants companies emerging and implants being placed by clinicians

with varied levels of surgical training.
MYRON NEVINS The author’s experience with subperiosteal implants ended
A
in 1984. They were most predictable with advanced atrophy of
lthough dental implants were first introduced to the edentulous mandible. When successful, patients reported
the profession in the 1950s, they were not readily an enhanced lifestyle with comfort, a return of long-lost masti-
accepted by the profession because of a lack of cation, and improved personal confidence4 (Fig 2-1). Success
investigations and questionable predictability. This was later experienced in treating partial edentulism, but not at
author’s experience with dental implants has involved three a high level of predictability4 (Fig 2-2). They served to provide
distinct eras: support for fixed prosthetic restorations and greatly reduced
the use of removable partial dentures.
1. 1966 to 1984: Subperiosteal implants, blade implants, and Likewise, osseointegrated implant treatment was some-
a variety of intrabony implants. what limited to addressing complete edentulism at the time of
2. 1984 to 2000: A high percentage of implants with machined introduction, but it rapidly became useful and predictable for
surfaces. There were significant advances as a result of replacement of a single tooth or quadrant5–8 (Figs 2-3 and 2-4).
clinical investigations and biologic research. A transition From the year 2000 to the present, much research has been
occurred, with a change from edentulous reconstruction to focused on modifications to implant surfaces and abutments.
implants being used to treat the partially dentate patient. Another focus of research has been peri-implantitis, which has
21

2
d e f
Fig 2-3 (cont) (d) Note the metal residue from the previous apicoectomy. (e) The clinical picture demonstrating a good keratinized gingiva level after
28 years. (f) Radiograph taken in 2016. The position of the metal artifact documents the stability of the bone. The sectioned molar was replaced
with two additional implants.
a b
Fig 2-4 (a) An implant was placed at bone level in 1989. (b)
A clinical photograph demonstrating a high lip line. (c) The
25-year radiograph demonstrates no bone loss over this period
of time. (d) Clinical observation after 25 years. The interdental
papillae are in place (green arrows), so it was not necessary to
place the implant further apically to achieve an esthetic result.
been addressed in periodical publications, textbooks, and at the ment this goal. The radiographic measurement of success
podium of every dental meeting. is bone-implant contact with little or no change in bone level
over time (Figs 2-3 to 2-5). Clinical success includes continued
support not only of the implant but also of the restorations,
an issue that is of great concern for the patient. Esthetics are
SUCCESS AND SURVIVAL important to most patients, who generally are not satisfied if
interproximal black triangles or gingival recession occur. The
Criteria for success were recognized in 1986 and have not yet final evidence of success would be histologic, ie, evidence
been significantly updated by the dental community.9 There of bone-implant contact. This path begins with optimal pre-
is some conflict between these criteria for success and the clinical results that can be translated into clinical research for
demonstration of survival. It is truly believed that success can patient treatment, which will later be translated to exceptional
be accomplished, and every effort should be made to imple- patient benefits.
22

1991
a b
e f
Fig 2-5 (a) Intraoral view of a 32-year-old man with a history of periodontal disease and previous periodontal surgery. (b) A 1991 full-mouth
radiographic survey. The decision was made to replace the maxillary teeth with a fixed implant prostheses. Every effort was made to retain the
mandibular posterior teeth, and the mandibular incisors were replaced with a fixed partial denture. (c) A 2006 full-mouth radiographic survey
demonstrating an excellent level of implant support. The remaining mandibular posterior teeth were mobile and demonstrated continuing loss of
bone. (d) Full-mouth radiographs after 26 years. All four premolars and the left first molar were replaced with implant prostheses. The excellent
level of crestal bone continued. (e) The clinical prostheses in place. (f) The maximum tooth display in the patient’s smile.
23

a b c d
Fig 2-6 (a) Example of a tooth whose extraction would allow implant placement in an appropriate position. (b) Example of a tooth position that
would not allow successful implant placement. (c) Patient presents with maxillary and mandibular protrusion. (d) The mandibular left canine shown
in c appears to be buccal to the alveolar process.
a b c
Fig 2-7 (a) Imaging demonstrates extreme bone loss around

the mandibular anterior teeth. Lack of patient diligence in main-
taining the teeth led to a situation in which it was imperative
to remove the remaining anterior mandibular teeth and place
implants. A navigation system produced a stent that dictated
the position of the implants. (b) The extraction sockets after all
granulation tissue was removed. (c) Implant placement dictated
by the stent. (d) The implants in place prior to regenerative
procedures. (e) Radiographs taken 4 years after the implants
were placed.
d e
SURGICAL VARIABLES Once the implant has been selected, there are other factors
that greatly influence the result. One of these is the position of
The surgical variables in implant treatment include the following: the implant as it relates to the volume of bone, and cone beam
computed tomography (CBCT) has provided the opportunity to
• Selection of implants investigate the proposed implant position prior to placement10
• The level of the implant shoulder in relation to the bone (Fig 2-6). The introduction of digital dentistry allows this infor-
• Tooth position in the dental arch mation to be transferred to surgery via surgical stents. Such
• Appropriate preparation of osteotomy guided surgery may not be necessary for every implant, but
• Amount of compression at placement the digital planning process can help guide surgical decisions11,12
(Fig 2-7). This is especially important in cases of thin ridges in
In terms of implant selection, most implant companies have nonsurgical implant placement in which the diameter of the
manufactured their products carefully and upgraded consis- implant is barely contained by the volume of bone. Preclinical
tently. There is no effort on the part of this chapter’s authors to studies have suggested three possible locations of the implant’s
guide the reader to use any particular implant system. Rather, coronal surface in bone: at, above, or below the level of bone13
the goal is to show how clinical success has been achieved using (Fig 2-8). Clinical experience suggested that the collar of the
many different systems, and the choice of implant depends implant should be placed at the bone level (see Figs 2-3 and
on clinician preference and experience as well as the specific 2-4). Considering information from preclinical studies,13 one
needs of a given patient. might even place the polished collar of an implant above the
24

Fig 2-8 A 1997 preclinical study13 compared implants placed at the bone level (a),
1 mm above
1 mm above the bone level (b), or 1 mm below the bone level (c). For all two-piece At crest 1 mm below
implants, whether nonsubmerged or submerged, the most coronal bone-implant
contact was located approximately 2 mm below the microgap. The result is that
the least amount of bone loss occurred when the implant was placed above the
bone level (b), and the most loss of bone occurred when it was placed below the
level of bone (c).
a b c
a b c
d e f
Fig 2-9 (a) The maxillary right lateral incisor is a candidate for extraction. (b) The lateral incisor was extracted, after which a provisional partial denture
was placed. Vertical and horizontal bone augmentations were performed. (c) The result of the regeneration procedure. The implant has an external
hex and a polished 1-mm collar that was placed above the bone level (circle). (d) Clinical image of the finished prostheses in 1994, showing the
patient’s limited display. (e) Intraoral view of the definitive restoration in 1994. (f) After 12 years, the papillae are in place, and there is no recession
on the lateral incisor. There is minor recession on the adjacent natural canine (arrow).
1991 1992 2016 2016
a b c d
Fig 2-10 (a) The patient was referred for an implant to replace the maxillary left
2016
lateral incisor in 1991. The author’s team considered replacing the central incisors
and using a cantilever to restore the left lateral incisor, but the patient was adamant
about retaining the central incisors. (b) An implant was placed with the polished collar
above the bone level. (c) Clinical radiograph in 2016. The crestal bone remained the
same after 25 years. (d) Extraoral view in 2016 showing maximum esthetic display.
(e) Intraoral view in 2016 showing adequate keratinized mucosa and the interdental
papillae remaining in place.
25

a b c
d e f
g h i
Fig 2-11 (a) A 19-year-old woman presented with a

maxillary left canine with a fistula. (b) The tooth and
buccal bone after flap reflection. (c) The interprox-
imal bone level is approximately 1 to 2 mm apical
to a line joining the cementoenamel junctions. (d)
The palatal bone level is approximately the same as
the interproximal bone level. (e) There is a deficiency
of buccal bone. (f) A healing abutment is placed,
and the buccal flap is coronally positioned. (g) The
lip line and the smile display. (h) Close-up view of
the result. (i) Intraoral view of the healed result. (j)
Radiograph taken in 1998, after crown delivery. (k)
Radiograph taken in 2007. (l) Radiograph taken in
2013. Note the crestal bone level.
j k l
cervical bone level (Figs 2-9 and 2-10). In clinical practice, it is a canine study. It is very interesting to see the difference in
very unusual to place an implant in completely level bone with- bone-implant contact in this model from day 0 to day 56 (Fig
out performing bone reduction, which may be done according 2-12).14 The author and his team also have been fortunate to have
to the lingual/palatal and interproximal levels of bone (Fig 2-11). the opportunity to compare bone-implant contact in localized
It is very important to place the implant following the direc- autogenous edentulous sites compared with extraction sockets.
tions of the manufacturer. Every effort should be taken not The comparison shows the bone-implant contact to be 74.5%
to overheat the bone during implant placement, although the (Fig 2-13) for the edentulous region and 66.2% for the extraction
value of compression on the bone is unclear.14 It was impos- socket15,16 (Fig 2-14). The author believes either choice allows for
sible to recruit enough human donors to study the effects of implant stability, but results will vary with the degree of bone
compression, so the author and his colleagues performed trabeculation in the implant placement site.
26

Fig 2-12 A preclinical canine study of the effects of bone compression on implant osseointegration. The radiographs show very little difference
from day 0 to day 56, but the histologic images show that the bone-implant contact develops from 17% at 0 hour to 74% at day 56.
Fig 2-13 Four autogenous human bone blocks 6 months after implant placement in edentulous ridges. The bone-implant contact is estimated to
be 74.5%. (Reprinted from Nevins et al15 with permission.)
Fig 2-14 Five examples of autogenous biopsies after implants were immediately placed in extraction sockets. Bone-implant contact is 66.2%.
(Reprinted from Nevins et al16 with permission.)
CONCLUSION ral dentition (Figs 2-5 and 2-15). It is optimistic to assume that
every patient will practice ideal oral hygiene habits, and there
The purpose of this chapter is to demonstrate the predictability are some geographic areas with no trained dental hygienists17–19
of osseointegrated implant treatment to restore function, esthet- (Fig 2-16). The combination of these limitations are potentiated
ics, and phonetics over the long term. It demonstrates results when implants are placed too far subgingivally or interproximal
over a significant period of time from a variety of clinicians using spaces are blocked out so that hygiene access is impossible.
different implant systems. There is overwhelming evidence Therefore, the responsibility of establishing success is greatly
that successful implant treatment can be achieved, not only for influenced by the treatment planning of the multidisciplinary
young, healthy patients, but also for patients with susceptibility team of clinicians involved in patient care.
to inflammation demonstrated by bone loss around their natu-
27

Fig 2-15 (a) Full-mouth radiographic survey demonstrating tooth loss and moderate periodontal disease in 1986, prior to implant treatment. (b) Ra-
diographic survey after 5 years. (c) Periapical radiographs after 20 years. There is some small evidence of countersinking, which was routine in 1986.
Fig 2-16 (a) An anterior view demonstrating a

patient’s capability of practicing proper oral care.
The patient does not have a high lip line and is
ecstatic that no teeth needed to be removed.
(b) Right lateral view showing significant loss of
support but a level of hygiene that demonstrates
that a patient can be a partner in long-term peri-
odontal success.
a b
28

LONG-TERM RESULTS OF IMPLANTS IN NATIVE AND REGENERATED BONE
TABLE 2-1 Overview of studies reporting on Brånemark turned dental implants placed in native bone
Implant survival rate Final MBL
Article (%) Implants (n) Patients (n) Follow-up (years) (mm; mean ± SD)
Lindquist et al (1996)26 98.9 273 47 15 1.2
Ekelund et al (2003)25 98.9 273* 47* 20 1.6 ± 0.90
Jemt and Johansson (2006)29 90.9 450 76 15 2.1 ± 0.58
Lekholm et al (2006) 7
91 69 27 20 1.0
Jemt (2008) 27
100 47 38 15 NA
Astrand et al (2008) 22
99.2 123 21 20 2.33
Jemt (2009) 21
100 41 35 10 0.26 ± 0.66
Dierens et al (2012)24 91.5 118 97 18.4 1.7 ± 0.88
Bergenblock et al (2012)23 96.8 53 40 18.4 0.9 ± 0.76
Simion et al (2015)28 93.2 59 29 12 0.78 ± 0.88
Simion et al (2018)3 97.7 382 105 20.7 1.9 ± 0.9

MBL, marginal bone loss; NA, not applicable.
*Same population as Lindquist et al (1996).26
Long-Term Results of Implants IMPLANTS PLACED IN NATIVE

in Native and Regenerated Bone BONE
The first study was presented by Adell et al at the NIH Implant

MASSIMO SIMION Consensus Conference in Toronto in 1978 and published in
P
1981.20 The authors demonstrated a survival rate of 81% in the
-I Brånemark was performing preclinical studies on maxilla and 95% in the mandible. It was at the beginning of
bone physiology when he was a professor of anat- the learning curve, and the follow-up period was from 5 to 10
omy at the University of Gothenburg in Sweden. In years. The implants placed later in the 1980s showed a sur-
order to create in vivo observational studies, he used vival rate of 95% in the maxilla and 99% in the mandible after
titanium optical chambers placed in rabbit tibiae to observe the 4 years of function. Following the data presented by Adell et
behavior of blood vessels under different conditions. The tita- al, 11 studies assessed the implant survival rate of more than
nium chambers were supposed to be removed at the end of 6,000 implants with a follow-up period ranging between 10 and
the study and implanted in different rabbits, but the impossibil- 20.7 years, demonstrating an implant survival rate from 91% to
ity of detaching the titanium chambers from the tibial bone led 100%.21,22 The mean marginal bone loss was reported as 0.26
him to investigate the micro-characteristics of the interface of mm after 10 years21 and 2.33 mm after 20 years of function,22
bone and titanium. It was by chance that the biologic principle clearly demonstrating long-term peri-implant hard tissue sta-
of osseointegration was thus discovered. bility. Table 2-1 summarizes the results of studies on implants
Data from preclinical and clinical studies were presented to with more than 10 years of follow-up.3,7,21–29
the scientific community during the Dental Implant Consensus Machined-surface implants, placed with either a single- or
Conference held in Toronto in 1978 organized by the National two-stage surgical protocol, demonstrated very little suscepti-
Institutes of Health (NIH) and Harvard University. This event bility to the modern plague of implant systems: peri-implantitis.
brought new recognition to the Brånemark osseointegrated In fact, a negligible percentage of implants with progressive
implant system and, eventually, changed the approach to dental bone loss has been reported in the literature and experienced
treatment planning. The system was based on the use of by clinicians worldwide. In a recent study, Simion et al analyzed
commercially pure titanium root-form implants with a machined patients who were treated with machined implants and avail-
surface and a very strict two-stage surgical protocol in which able for follow-up after a period of 13 to 32 years of observa-
the implant was submerged for 3 months in the mandible and 6 tion.3 All patients received implants between 1985 and 2001,
months in the maxilla before prosthetic functional loading. This with placement in partially or completely edentulous ridges. A
system was successfully used for the treatment of millions of total of 105 patients, 43 male and 62 female with a mean age
patients around the world for 20 years. of 45.2 years (range, 18 to 72 years), received 382 implants
in either the maxilla or mandible. The cumulative survival rate
29

a b c
d e f
g h i
j k
l m
Fig 2-17 (a and b) Frontal and lateral views of three-dimensional reconstruction of the CBCT scan, demonstrating advanced bone atrophy in both
jaws. (c) Intrasurgical occlusal view before implant placement, showing interpositional bone grafting after the healing period. (d) Occlusal view
following placement of eight machined-surface implants. (e) Presurgical aspect of the mandible. (f) Implant site preparations showing accurate bone
pre-tapping. (g) The parallel pins have been positioned in the implant sites. (h) Five machined Brånemark implants have been placed in the native
bone of the mandible. (i) Panoramic radiograph showing the implants placed in the maxilla and mandible. (j) Clinical aspect of the definitive hybrid
full-arch restorations after 3 months of submerged healing. (k) Panoramic radiograph of definitive hybrid full-arch restorations. (l) Clinical aspect
after a follow-up of 23 years. Mild inflammatory recession of the peri-implant soft tissues is visible. (m) Panoramic radiograph after a follow-up of
23 years showing absence of bone loss.
30

was 97.7% with a success rate of 92.7%. There was a mean A number of different techniques have been developed to
marginal bone loss of 1.9 ± 0.9 mm. Out of 382 implants, only reconstruct deficient alveolar ridges to allow dental implant
7 suffered significant peri-implantitis. The authors stated that placement in either a simultaneous or staged approach. The
machined implants in place from 13 to 32 years demonstrated first preclinical studies on guided bone regeneration (GBR) were
a small incidence of peri-implantitis and other complications. published in 1988 and 1989 using rat and rabbit models.35,36
It should be considered that the treatment protocol for many According to the principle, a secluded space was created around
years focused on a two-stage surgical approach. a bone defect to allow for proper blood clot formation, blood
vessel budding, and the slow-migrating progenitor cell to colo-
nize the defect without the competition of epithelial and connec-
Clinical case 1 tive tissue cells. Nonresorbable polytetrafluoroethylene (PTFE)
and bioabsorbable barrier collagen membranes were used to
In 1994, a 44-year-old totally edentulous, healthy, nonsmoking create space maintenance around the bone defect.
woman requested full-arch implant-supported fixed rehabilita- The GBR biologic concepts were applied to partially eden-
tions in both the maxilla and mandible. The oral examination tulous atrophic mandibles in 1994 to achieve vertical bone
and CBCT scan demonstrated advanced bone atrophy in both regeneration with the aid of titanium-reinforced nonresorbable
jaws, but the patient was strongly motivated toward implant membranes.37 By the late 1990s, small variations including
treatment (Figs 2-17a and 2-17b). autogenous and freeze-dried bone to fill the defect under the
She was treated with a maxillary Le Fort I osteotomy with membrane were developed to enhance vertical bone growth,
interpositional bone grafting from the iliac and subsequently allowing a vertical gain of 7 mm or more.38 Nevertheless, extra-
eight machined Brånemark implants (Figs 2-17c to 2-17e). She or intraoral harvesting of autogenous bone was associated with
also received five mandibular machined implants, 3.75 mm in a high degree of patient discomfort and morbidity. Hence,
diameter and 7 mm in length. Full-thickness flaps were elevated, efforts were applied to decrease the volume of autogenous
the implant sites were prepared, and implants were inserted bone harvested by applying different ratios of autogenous bone
(Figs 2-17f to 2-17j). Bone pre-tapping was performed only in and osteogenic biomaterials under the expanded PTFE (e-PTFE)
the mandible. The implants were submerged under the oral membranes for vertical bone regeneration.39
mucosa and left to heal for 6 months in the maxilla and 3 months The e-PTFE membrane was the most investigated barrier used
in the mandible. At the end of the respective healing periods, for vertical GBR and therefore was considered the gold standard
a hybrid full-arch restoration was delivered in each arch (Figs for this procedure. Recently a less porous form of PTFE (dense
2-17k and 2-17l). PTFE, d-PTFE) has been compared to e-PTFE in a randomized
The patient followed a maintenance program with oral controlled clinical trial,40 where the authors reported that the two
hygiene at 6-month intervals. After a follow-up of 23 years different membranes showed identical clinical results.
the patient demonstrates mild inflammation and recession Starting in 1996, the intent of clinicians and researchers
of the peri-implant mucosa, but virtually no bone loss (Figs was to verify the procedure in terms of efficacy and safety.
2-17m and 2-17n). The long-term implant stability and resorption patterns of bone
regenerated with this technique were reported in a retrospective
multicenter study41 of 1 to 5 years of prosthetic loading eval-
uating 123 implants inserted in atrophic alveolar ridges either
IMPLANTS PLACED IN at bone augmentation or after a healing period. Another study
REGENERATED BONE demonstrated a high clinical success rate (94.7%) of 81 implants
placed in vertically regenerated bone after a mean follow-up
A prerequisite for long-term successful implant outcomes is a time of 40.3 months.42
sufficient amount of bone at the implant site in both vertical and A recent retrospective study reported the clinical and radio-
horizontal dimensions. However, bone volume is frequently lack- graphic results obtained from 91 machined implants placed
ing as a result of trauma or infectious diseases such as advanced in vertically regenerated bone in 33 patients after a mean
periodontitis. After tooth extraction, the anterior maxilla exhibits follow-up time of 15 years.43 The study population was derived
significant alveolar bone remodeling with a mean alveolar bone from patients who received a vertical GBR procedure between
loss of 1.5 to 2 mm (vertical) and 40% to 50% (horizontal) in 3 1993 and 2000 and were available for a recall visit between April
to 6 months.30–33 In the absence of restorative complications, 2013 and December 2014. The authors founded a satisfactory
continued bone loss of up to 40% to 60% of the ridge volume cumulative implant survival rate (94%). The radiographic analy-
occurs during the following 3 years,34 and the loss of horizon- sis showed marginal bone loss between the first year of func-
tal and vertical bone height leads to great challenges in den- tion and the final visit (after 13 to 21 years) of 1.02 mm, which
tal implant placement. This lack of sufficient bone volume can suggests high dimensional stability of the vertically augmented
jeopardize the implant success and survival rate and, in some bone. Only 9.9% of the implants showed moderate and slow
cases, the final esthetic outcome. progressing bone resorption.
31

a b c
d e f
g h i
Fig 2-18 (a) Complete loss of the buccal bone plate in the maxilla. (b) Occlusal view. (c) Implant placement with buccal thread exposures. (d) Two
e-PTFE membranes have been positioned. The space under the membrane has been filled with autogenous bone chips. (e) Regenerated buccal
bone revealed at e-PTFE membrane removal after 6 months of healing. (f) Panoramic radiograph after 6 months of healing. (g) Clinical aspect of
the definitive fixed porcelain prosthesis. (h) Intraoral radiographs after a follow-up of 18 years showing minimal bone loss around the implants. (i)
Clinical intraoral view after a follow-up of 18 years.
Clinical case 2 dent. The first premolar was fractured horizontally at the apical
third of the root (Figs 2-19a and 2-19b). After flap elevation, a
In 1995, a 39-year-old woman presented with missing maxillary bone defect measuring 17 mm vertically and 20 mm mesiodis-
anterior teeth due to the failure of previous endodontic treat- tally was detectable (Fig 2-19c). Vertical ridge augmentation
ment. After full-thickness flap elevation, a complete loss of the with a staged surgical technique was performed by means of
buccal bone plate was evident (Figs 2-18a and 2-18b). Implant a titanium-reinforced e-PTFE membrane and autogenous bone
placement resulted in large dehiscences with thread exposure chips (Figs 2-19d to 2-19g).
on the buccal implant surfaces (Fig 2-18c). The peri-implant bone After 1 month of healing, the fractured premolar was
defects were treated with e-PTFE membranes associated with extracted (Fig 2-19h). At stage-two surgery, the membrane was
autogenous bone chips (Fig 2-18d). removed, and sufficient vertical bone regeneration was evident
Six months later, at membrane removal, abundant bone forma- (Fig 2-19i). Three machined-surface implants were placed at the
tion was evident with complete coverage of the implant surfaces right first premolar, canine, and central incisor sites (Fig 2-19j),
(Figs 2-18e and 2-18f). The patient was rehabilitated with a fixed and a connective tissue graft was placed to increase the thick-
porcelain prosthesis (Fig 2-18g). After 18 years of function, there ness of the soft tissues (Figs 2-19k and 2-19l). The lateral inci-
is minimal bone resorption at the implants, and the peri-implant sor was left as a pontic. After 6 months of submerged healing,
soft tissues appear healthy (Figs 2-18h and 2-18i). the implants were connected with the abutments, and a fixed
porcelain prosthesis was placed (Fig 2-19m). After 16 years of
function the peri-implant soft tissues appeared healthy, and
Clinical case 3 no bone resorption was seen apical to the first threads (Figs
2-19n and 2-19o).
In 1996, a 21-year-old woman lost her maxillary right central inci-
sor, lateral incisor, and canine as a result of an automobile acci-
32

a b c
d e f
g h i
j k l
m n o
Fig 2-19 (a) Clinical view of a 21-year-old woman missing her maxillary right central incisor, lateral incisor, and canine. (b) Intraoral radiograph
showing the deep vertical bone defect. The first premolar is fractured horizontally. (c) Bone defect measurement after full-thickness flap elevation.
A tenting screw has been placed according to the bone peak height; multiple cortical bone perforations have been made to stimulate bleeding
and expose the medullary spaces. (d) An e-PTFE membrane has been fixed on the palatal site, and bone chips have been packed in the defect.
(e) The e-PTFE membrane has been fixed to the buccal bone plate with titanium tacks. (f) Clinical aspect at the time of suture removal, 2 weeks
after surgery. (g) Intraoral radiograph of the regenerated site at suture removal. (h) The fractured first premolar was extracted 1 month after re-
generative surgery. (i) After 6 months the membrane was removed, and the newly formed bone is visible. (j) Three machined-surface implants
have been placed in the right first premolar, canine, and central incisor sites. (k) A connective tissue graft has been placed over the implants to
increase the thickness of the soft tissues. (l) Horizontal mattress and interrupted sutures have been placed. (m) Intraoral view of the final fixed
porcelain prosthesis. (n) Intraoral view of the patient after 16 years of follow-up. (o) Periapical radiographs after 16 years of follow-up showing no
bone loss apical to the first implant threads.
33

Connective Tissue Attachment to nontextured implants. In a landmark study, Nevins et al56 showed
perpendicular fibroblast attachment and impeded epithelial
a Laser-Microtextured Surface downgrowth on the implant collar in multiple histologic speci-
mens of a series of patients treated with Laser-Lok implants. In
CARY A. SHAPOFF an animal study published in 2010 using Laser-Lok microchannels
D
placed on a restorative abutment, Nevins et al57 reported similar
ental implant placement and restoration have histologic results with perpendicular fibroblast attachment and
become commonplace to treat compromised teeth blocked epithelial downgrowth on the abutment surface above
in partially edentulous patients and allow for fixed the implant-abutment interface. This attachment phenomenon
restorative options in fully edentulous patients. was also demonstrated with human histology as a reattachment
Goals of dental implant procedures have evolved from replace- after a laser-microtextured abutment was removed and replaced
ment of missing or damaged teeth to esthetic replicas of natu- by another laser-microtextured abutment.58–60
ral teeth with long-term stability. Stability of the dental implant The goal of this microengineered design was to provide
restoration is defined by long-term retention of the implant in the long-term crestal bone and soft tissue stability. The initial dental
alveolar bone as well as stability of the crestal bone supporting implant prototype designed with a laser-microtextured platform
the marginal gingiva and interproximal papillae. Previous papers collar surface had a 1-mm collar height (in 2000). However,
have reported on the average tissue heights and soft tissue the first commercially available dental implant (in 2001) had
dimensions associated with teeth, dental implants, and pontic a 2-mm collar height with a 0.5-mm machined surface at the
sites adjacent to teeth or dental implants.44,45 These dimensions implant-abutment interface and 1.5-mm laser-microtextured
are significant in that long-term stability of the bone–soft tissue surface on the remaining collar dimension. Further modifica-
complex is required to maintain esthetic results. tions to the collar design, following clinical experience and
research, initially reduced the machined metal margin to 0.3
mm and currently to 0.0025 mm. This is the masking dimension
required to prevent damage to the implant marginal interface
IMPLANT SURFACE in the excimer laser micromachining of the 8-µm microtextured
MODIFICATION Laser-Lok surface.
Implant companies have modified dental implant surfaces from

smooth metal to roughened surfaces to achieve a higher per-
centage of bone-implant contact and maintain crestal bone.46 CRESTAL BONE MAINTENANCE
Dimensional crestal bone loss changes regarded as “normal”
after 1 year of restoration have been reported in the early dental Crestal bone loss, especially in the esthetically demanding
implant literature to be 1.5 to 2 mm with less than 0.1 mm of anterior region, can result in loss of interdental bone, loss of
additional loss each subsequent year.9,47,48 Roughened textures papilla height, and open interproximal embrasures. Loss of mar-
on dental implants are random surfaces that increase surface ginal bone on facial surfaces can lead to gingival recession and
area for bone attachment but have little to no influence on soft possible exposure of crown margins. A variety of theories of
tissue. Previously published articles have described the soft crestal bone remodeling have been discussed in the literature.
tissue attachment (ie, connection) to dental implant surfaces The formation of a natural biologic width, the microgap con-
as epithelial hemidesmosomal or light attachment with parallel cept at the abutment-implant interface, and excessive stress
and circular arrangements of connective tissue fibers.49 and strain at the alveolar crest have been reported to explain
Another approach to the maintenance of crestal bone was the crestal bone loss commonly seen at dental implants after
laser-microtexturing of the implant collar. Organized roughened restorative loading.61 Figure 2-20 presents the 18-year radio-
surfaces of specific dimensions have been developed to selec- graphic appearance of the first prototype Laser-Lok implant
tively influence fibroblast and osteoblast activity and growth placed in clinical practice, illustrating maintenance of crestal
patterns through contact guidance.50 These 8- to 12-µm grooves bone around a 1-mm laser-microchannel collar on an external
(Laser-Lok microchannels; formerly BioLok Implant Systems hex BioLok implant.
[2000 to 2006], currently BioHorizons) were designed to provide Recommendations for placement of two or more adjacent
a functional attachment surface for both bone and connective dental implants in the anterior region have also been described.45
tissue. This nanotopography also directly affects the rate and A previous study62 noted vertical bone loss extending 1.4 mm
amount of osteogenesis.51,52 The ability of Laser-Lok microchan- laterally on adjacent implants, resulting in the loss of inter-
nels to limit crestal bone loss has been reported in numerous clin- proximal bone height if implants were positioned closer than
ical studies and case reports.53–55 Shapoff et al53 noted 0.44- and 3 mm apart. Others have recommended implant placement
0.46-mm crestal bone loss in a series of cases measured from distances relative to natural teeth63 because the dental implant
a private practice setting. Pecora and others54,55 also published could adversely influence bone height on the adjacent natu-
favorable clinical studies comparing laser-textured implants to ral tooth. The crestal bone height on the natural tooth has a
34

CONNECTIVE TISSUE ATTACHMENT TO A LASER-MICROTEXTURED SURFACE
Fig 2-20 First Laser-Lok implant prototype (1-mm collar on external hex BioLok implant)
placed in clinical practice. (a) Radiograph at initial crown placement. (b) Radiograph at 18
years after initial crown placement.
a b
a b c
Fig 2-21 Placement of two adjacent BioHorizons Laser-Lok implants. (a) Initial radiograph of
a woman (aged 52 years) whose teeth were deemed nonrestorable. (b) Radiograph 4 months
after placement of implants, at delivery of screw-retained provisional crowns shaped using
polycarbonate plastic provisional abutments. (c to e) Radiograph and clinical views 5 years
e
after implant placement.
a b c d
Fig 2-22 Placement of three adjacent BioLok Laser-Lok implants (2005). (a) Initial radiograph of a 71-year-old man with an edentulous maxillary left
posterior region with narrow buccopalatal ridge dimensions. (b) Radiograph following implant placement with healing abutments in place under a
provisional partial denture. (c) Radiograph immediately after definitive restoration. (d) Radiograph 12 years after implant placement and restoration.
direct effect on the height of the interproximal papilla, which 1 year of loading demonstrated maintenance of the interprox-
has significant implications in the esthetic zone. A preclinical imal bone level and preservation of the interproximal papillae
canine study placed implants either 2 or 4 mm apart. Histologic (Figs 2-21 and 2-22).
examination demonstrated no evidence of interimplant crestal This functional soft tissue attachment to the implant collar
bone loss at either distance. Moreover, new bone formation allows for a variety of platform placement positions at the time of
often occurred on the laser-ablated microgrooved collar adjacent surgery. Often the alveolar ridge height is different on mesiodis-
to the implant-abutment junction microgap.64 In a subsequent tal surfaces and buccopalatal surfaces. All BioHorizons dental
clinical study65 utilizing implants with laser-microchannel implant implants with the Laser-Lok collar design allow for slightly supra-
collars and abutment margins placed 2 mm apart, results after crestal to crestal positioning. Supracrestal placement of a portion
35

a b c d
Fig 2-23 Single anterior tooth replacement with a BioHorizons 3.0 Laser-Lok implant with immediate placement and provisional loading in a
41-year-old woman. (a) Initial radiograph showing a congenitally missing right lateral incisor with a resorbed root. (b) Radiograph of implant and
definitive crown. (c) Radiograph at 7 years. (d) Clinical view at 7 years.
a b c
Fig 2-24 Single posterior tooth replacement with a Laser-Lok implant in a 62-year-old man. (a) Extraction site of fractured maxillary left second
premolar. (b) Radiograph of implant restoration shortly after crown placement. (c) Radiograph of implant restoration 10 years after initial restoration.
Note that there has been no change in the crestal bone over the 10-year period.
a b c d
Fig 2-25 Single anterior tooth replacement in an extraction site with immediate placement of a BioHorizons Laser-Lok implant in a 53-year-old
woman. (a) Radiograph of a vertically fractured maxillary right lateral incisor with prior root canal treatment and apicoectomy. (b) Radiograph of
restored implant 5 months after placement. (c) Radiograph of restored implant at 4 years. Note stable crestal bone levels. (d) Clinical photograph
of implant-supported crown at 4 years.
of the collar allows for soft tissue functional attachment to the placement and provisional loading (Fig 2-23), posterior imme-
microchannels, thereby protecting the crestal bone in a similar diate extraction sites (Fig 2-24), the esthetically demanding
manner to the connective tissue attachment of a natural tooth. anterior regions (Fig 2-25), reconstructed severely damaged
extraction sockets (Fig 2-26), and periodontally compromised
sites. Figure 2-27 shows long-term stability of Laser-Lok micro-
channel technology in a patient with long-standing advanced
CLINICAL CASES periodontal breakdown. The patient was unable to tolerate a
maxillary provisional prosthesis; therefore, hopeless teeth were
The following case examples demonstrate the ability strategically used to support a resin composite fixed prosthesis,
of Laser-Lok technology to provide long-term bone and soft allowing large compromised extraction site defects to be recon-
tissue stability in regions of narrow bone with immediate structed prior to dental implant placement in a phased approach.
36

CONNECTIVE TISSUE ATTACHMENT TO A LASER-MICROTEXTURED SURFACE
b c d
Fig 2-26 Single mandibular anterior tooth replacement with delayed placement of
a Laser-Lok implant. (a) Clinical photograph of a 63-year-old man with an acute peri-
odontal abscess on his mandibular left lateral incisor. (b) Radiograph of mandibular
left lateral incisor region. Note the severe periodontal bone loss. (c) Radiograph
of implant with provisional crown. (d) Radiograph 7 years after definitive crown
placement. (e) Clinical photo showing definitive crown in place.
e
Fig 2-27 Full-arch stability achieved with Laser-Lok implants in a 62-year-old woman with advanced periodontal breakdown and medical risk fac-
tors. (a) Initial radiograph showing advanced periodontitis, with all teeth regarded as hopeless. (b) Provisional resin composite implant-supported
fixed partial denture in place after phased sequence of extraction, grafting, and implant placement. The patient refused a provisional full denture;
therefore, four hopeless teeth were used to support an acrylic provisional denture to allow repair of large extraction site defects prior to implant
placement. (c) Definitive prosthesis at 5 years showing crestal bone stability with laser-microtextured implant-supported fixed partial dentures.
LONG-TERM RESULTS WITH ifications. Only the dimension of machined metal consistently
influenced the location of crestal bone, with no bone evident
LASER-LOK IMPLANTS on the smooth metal component.
Patients, referred by a variety of the periodontist’s restorative
A recent clinical study66 reviewed data from cases using laser- colleagues, were provided complete periodontal examinations
microtextured abutments of various styles placed on dental with a review of their pertinent medical and dental histories.
implants with laser-microtextured collars (Fig 2-28). Long-term Following the examination, dental implant procedures and alterna-
clinical and radiographic results from a single private practice tive restorative options were discussed with the patients. Patients
were evaluated and sorted by various parameters from a review presented with numerous dental implant scenarios, from edentu-
of patient records and radiographs. Results of that data from 5 lous sites, congenitally missing teeth, nonrestorable teeth due to
to 18 years following restoration were reported. The clinical dental caries or endodontic failures, root fractures, and teeth with
results represent pooled findings from all micromachining mod- unmanageable periodontitis. Most posterior sites requiring tooth
37

Fig 2-28 Single tooth replacement with a Laser-Lok im-

plant and immediate provisional restoration. (a) Five-year
posttreatment radiograph of the maxillary left central
incisor site following immediate flapless extraction,
implant placement, and provisional loading. (b) Clinical
photograph of the 5-year clinical result demonstrating
excellent tissue health and marginal stability.
a b
extraction were treated by a delayed approach using freeze-dried • Crestal bone on implant threads in functioning prosthesis
bone allograft (FDBA) material with and without biologic modifi- (5.6%)
ers. Anterior and premolar sites were often treated by extraction • Progressively ailing implants (0.4%) or failed implants after
and immediate dental implant placement with grafting unless restoration (1%)
extraction site anatomy precluded adequate implant stabilization
or the socket defect exhibited compromised facial bony walls. A total of 18 implants failed following restoration (1% of
Immediate loading of provisional restorations was considered in reviewed implants). One anterior implant failed because of an
intact anterior sites with good stability and protected occlusion in endodontic abscess on an adjacent tooth. The majority of failed
patients with minimal to no risk factors (eg, bruxism, tobacco use, implants were in grafted posterior sites, and half of the failures
compromising medical issues). In those cases, a screw-retained served as nonsplinted abutments under removable dentures.
provisional restoration was utilized to shape the gingival tissue and Others failed while splinted to adjacent implants in a two- or
allow for bone maturation prior to the definitive restorative phase. three-unit fixed partial denture. In those cases, the distal implant
Implant placement was evenly distributed in all four quad- failed.
rants. Sixty-one percent of the implants placed were in the The majority (93%) of Laser-Lok implants maintained crestal
maxillary arch. Most anterior and premolar implants were placed bone on the collar for a period of greater than 5 years (5 to
immediately after extraction based on adequate insertion torque 18 years). Crestal bone was not maintained on the machined
(> 40 Ncm) and a generally intact facial bone plate. Bone graft- metal coronal portion of the laser-microtextured collar with either
ing with FDBA (with and without platelet-derived growth factor manufacturer. The machined metal dimension was 0.5 mm on
[PDGF]) was utilized within the socket when indicated. All molar BioLok implants and 0.3 to 0.0025 mm on BioHorizons implants.
extraction sockets were bone grafted with FDBA (with and with-
out PDGF) and covered with a PTFE barrier and allowed to heal
3 to 4 months before implant placement. About 10% of ante-
rior implants placed had immediate loading of a screw-retained CONCLUSION
provisional restoration.
In this study, long-term Laser-Lok data was collected from The author’s long-term clinical experience with dental implants
1,499 patient records and radiographs available from a single peri- designed with Laser-Lok microchannels has demonstrated
odontal practice. Sixty-two percent of those patients (845) had exceptional bone stability. The restorative colleagues who pro-
greater than 5-year clinical follow-up with radiographs. The aver- vided the prosthetic support have remarked about the excel-
age follow-up period was 5.8 years for patients with Laser-Lok lent tissue health around the implants. The author’s periodic
collars on BioHorizons implants. The average follow-up period for reevaluation of clinical cases has demonstrated shallow sulcular
those with Laser-Lok collars on BioLok implants was 8.7 years. depth and excellent soft tissue health. The stability of crestal
Radiographs of 1,865 Laser-Lok dental implants were exam- bone has been noted in immediate extraction cases, grafted
ined. Long-term success was scored by dividing implants into sites, and single-tooth restorations, as well as multiple adjacent
four groups: implants. It is the author’s experience that the reality of bone
and soft tissue stability using laser-microtextured implants has
• Crestal bone maintained on Laser-Lok collar consistent with been achieved in a private practice setting with a wide variety
radiograph of initial restoration (70%) of clinical situations.
• Crestal bone on Laser-Lok collar but below initial placement
level and not on implant threads (23%)
38

LONG-TERM IMPLANT SUCCESS: PART I
Long-Term Implant Success: accounting for all of the implants placed. This study included
nonsubmerged, tissue-level implants that were all titanium and
Part I had the original TPS surface. It also included several hollow
endosseous designs that were subsequently discontinued.
JEFFREY GANELES, FREDERIC J. NORKIN, However, what was most significant about this study was the
LILIANA ARANGUREN, AND SAMUEL ZFAZ nonsubmerged implant design and surgical protocol, which was
I
novel at the time, and the large number of patients that were
mplant dentistry has become a significant method for meticulously tracked in the university setting.
providing “permanent” tooth replacement since the Of the 2,359 implants placed, 13 failed to integrate (0.55%)
concept of osseointegration was first published by and were considered early failures; 2,346 implants were subse-
Albrektsson, Brånemark, and colleagues in 1981.67 It is now quently accounted for until the close of the study. Nineteen
estimated that there are about 500 different implant manufac- implants failed during follow-up, 17 demonstrated peri-implant
turers producing 4,000 implant brands from which the clinician infections, and patients accounting for 127 implants dropped out
can choose.68 Straumann, headquartered in Basel, Switzerland, for various reasons and were lost to follow-up. The actual 5-year
is one of the largest implant manufacturers and has significant survival rate was calculated to be 98.2%, with a success rate
longevity data for their implant systems. of 97.3% for 488 implants. These rates were slightly better than
the 8-year cumulative survival and success rates (CSR), which
were calculated to be 96.7% and 93.3%, respectively. Statistical
analysis of various implant characteristics such as design, length,
IMPLANT DESIGN and anatomical location suggested that differences were appar-
CHARACTERISTICS ent. For example, screw-type implants (threaded) had a higher
CSR (> 95%) than nonthreaded designs (91.3%). Mandibular
Straumann’s implant designs fall into two general categories. implants had a higher CSR (approximately 95%) than maxillary
The first, available since the late 1980s, is designed as a solid implants (approximately 87%). Implants that were 12 mm or
screw with a roughened intraosseous portion and a machined longer had a CSR of 95.0%, and 8-mm implants had a CSR of
transmucosal portion.69 The second, available since 2008, is 91.4%, suggesting minor differences related to implant length.
strictly designed as an intraosseous (bone-level) implant that Another university-based prospective study by Romeo et
has a selection of transmucosal abutments. This implant incor- al76 looked at anatomical location as well as prosthetic design
porates platform-switched abutments that are smaller in diam- to compare success and survival data. They also included
eter than the implants with a machined beveled surface shown SLA-surface implants in addition to TPS-surface implants. They
to preserve marginal crestal bone levels.70 followed 759 implants in 250 consecutive patients and performed
Initially, Straumann implants were manufactured from life-table analysis of implants for up to 7 years. They found CSRs
work-hardened grade 4 titanium. Consequently, most of the of 95.6% for implants restored with single-tooth restorations;
longevity data on Straumann implants is generated from these 94.4% for implants supporting fixed cantilevered restorations;
implants. In the early 2010s, a titanium-zirconium alloy called 96.1% for implants supporting fixed partial dentures; 100%
Roxolid was introduced; therefore, some later and shorter-term for implants supporting fixed full-arch restorations; 90.6% for
longevity studies include implants made of this material.71,72 implants connected to natural teeth with fixed partial dentures;
The original surface of Straumann implants was titanium and 95.7% for implants supporting overdentures. Further, they
plasma spray (TPS). In the mid-1990s, this surface was replaced noted that neither anatomical location nor implant size had an
with a sand-blasted, large-grit, acid-etched (SLA) surface. This influence on implant survival.
modified the manufacturing process and also resulted in a reduc- Fugazzotto et al77 retrospectively reported on a combination
tion in healing times prior to loading.73,74 In the mid-2000s, a of 5,526 TPS and SLA implants placed in three private practices
new, chemically active version of the SLA surface was intro- and followed in function for up to 6 years. They noted a CSR of
duced, called SLActive.75 More recent longevity studies gener- 94.8% for the maxilla and 97.5% for the mandible. There was
ally include data from both SLA and SLActive surfaces. no correlation between implant location in the arch and bone
quality with respect to failure to achieve osseointegration.
Subsequently, other investigators looked at implant longevity
in specific circumstances. Ferrigno et al78 evaluated 323 consec-
RESULTS OF LONG-TERM utively enrolled patients who received 588 maxillary implants
STUDIES placed in conjunction with osteotome (crestal approach, closed)
sinus augmentation. Surfaces were SLA for 234 implants and
The first long-term paper published on Straumann implants TPS for 354 implants. Augmentation was most often accom-
reported on a university-based, multicenter study that included plished using autogenous bone chips, while occasionally depro-
2,359 implants placed by five surgeons in 1,003 patients fol- teinized bovine bone matrix (DBBM) (Bio-Oss, Geistlich) was
lowed for up to 8 years.1 A life-table analysis was completed, added for greater volume. One implant failed to integrate and
39

a b
Fig 2-29 Radiograph showing 14-year Fig 2-30 (a) Radiograph following placement of two Wide Neck tissue-level implants
follow-up of three Regular Neck tissue-level immediately placed in molar extraction sockets grafted using autogenous bone chips and
implants placed in a healed edentulous DBBM. (b) Radiograph taken 16 years postoperatively, showing excellent maintenance
ridge without need for augmentation with of marginal bone levels with the first bone contact at the junction of the rough and
maintenance of crestal bone levels at the machined implant surfaces despite a slight misfit of the crowns.
junction of the machined and roughened
implant surfaces.
was removed. Life-table analysis showed a cumulative survival CLINICAL CASES

rate of 94.8% at 12 years and cumulative success rate of 90.8%.
Though not statistically significant, there was a trend toward A healthy 76-year-old woman had three Regular Neck tissue-level
higher CSR for implants with a length of 10 mm or longer implants placed in a healed edentulous ridge without need for
compared with 8-mm-long implants. augmentation. Implants were allowed to heal conventionally
Many other long-term studies that looked at specific circum- before restoration with splinted cemented restorations. The
stances or uses are available in the literature. These different radiograph shows 14-year follow-up with radiographic mainte-
applications all had CSRs of 95% to 99%. Early loading at 6 nance of crestal bone levels at the junction of the machined and
weeks was not found to have an effect on CSR at 5 years by roughened implant surfaces as designed (Fig 2-29).
Bornstein et al.74 Immediate versus early loading protocols with A healthy 79-year-old man had two Wide Neck tissue-level
the SLActive-surface implants had no effect on CSR at 3 years implants placed without flaps at the time of extraction of nonre-
in a large multicenter study by Nicolau et al.79 High predictabil- storable molars (immediate placement; Fig 2-30a). Sockets were
ity of 6-mm implants was confirmed by Nedir et al,80 Arlin,81 grafted using a composite of autogenous bone chips and DBBM
and Rossi et al.82 (Bio-Oss). The implants were restored 3 months after placement.
More recent studies report on newer surfaces and implant The 16-year postoperative radiograph shows excellent mainte-
designs, enhancing the evidence base for Straumann implants. nance of marginal bone levels with the first bone contact at the
French et al83 reported on 4,591 implants placed over 10 years junction of the rough and machined implant surfaces despite a
in a private practice setting and found a CSR > 98% for up to slight misfit of the unsplinted cement-retained crowns (Fig 2-30b).
7 years. Some specific circumstances had lower predictability, The maxillary left first molar of a healthy 48-year-old woman
such as short implants in the posterior maxilla. He also noted was extracted due to chronic, unresolvable endodontic pathology.
more implant failures in patients who were smokers or had auto- A Wide Neck 4.8 × 8–mm implant was placed in conjunction with
immune diseases or penicillin allergies. These patient-related simultaneous osteotome sinus augmentation using a combination
factors are known to adversely effect all implants. High predict- of autogenous bone and DBBM (Fig 2-31a). The 18-year follow-up
ability in the esthetic zone was also reported by Sanz et al and shows excellent incorporation of graft material and stability of
Buser et al for bone-level implants for up to 9 years.84,85 the crestal bone levels with bone contact at the junction of the
While there are differences in long-term results for many machined collar and the roughened endosseous implant support-
authors and in different clinical situations, it is clear there is a ing an unsplinted restoration (Figs 2-31b and 2-31c).
substantial evidence base to create expectations for generally A healthy 45-year-old woman required extraction of her
high predictability of Straumann implants. Additionally, studies maxillary lateral incisors as a result of nonrestorable caries and
continue to be generated as implant design, surface charac- endodontic failure. Bone-level implants were placed in conjunc-
teristics, and composition change, allowing clinicians to make tion with hard and soft tissue grafting 10 weeks after extraction
well-informed decisions about appropriate methods, materials, and allowed to heal for 3 months prior to restoration (Figs 2-32a
and applications for patient care. and 2-32b). She was a participant in a prospective multicenter
study evaluating crestal bone levels and submerged versus
nonsubmerged healing. Details of her treatment were published
by Cordaro et al.86 Ten-year posttreatment radiographs show
maintenance of crestal bone levels coincident with the coronal
bevel of the platform-switched, bone-level implants as designed
(Figs 2-32c and 2-32d).
40

LONG-TERM IMPLANT SUCCESS: PART II
a b c
Fig 2-31 (a) Radiograph following placement of a Wide Neck implant in conjunction with simultaneous osteotome sinus augmentation in a maxillary
left first molar site. (b and c) The 18-year follow-up shows excellent incorporation of graft material and stability of crestal bone levels.
a b c d
Fig 2-32 (a and b) Radiographs following placement of bone-level implants in conjunction with hard and soft tissue grafting 10 weeks after extraction
of a 45-year-old patient’s maxillary lateral incisors. (c and d) Maintenance of crestal bone levels can be seen in the 10-year posttreatment radiographs.
Long-Term Implant Success: into 66 male and 55 female patients, and the average observa-
tion period was 7.2 years. Of the 370 implants, 13 failed, giving
Part II a 10-year cumulative survival rate of 94.83%. Smoking and max-
illary implants were the significant risk factors of implant failure.
DAVID KIM AND WONBAE PARK Another retrospective study performed to evaluate the effi-
D
cacy of the SLA implant surface (Implantium) reported main-
ental implants have been successfully incorporated tenance of the crestal bone level in a variety of clinical situa-
into contemporary dental practice for the treatment tions encountered in private practice.2 The study population was
of edentulous and partially dentate patients.24,87–93 patients requesting dental implant therapy to replace their miss-
Despite the overall survival and successful ing teeth in five private dental offices. All implants were placed
outcomes, clinicians seek the latest available evidence for and restored by early 2000, and the patients were encouraged
implant systems that have been recently introduced into the to continue their dental care at the same office. The records
market. were reviewed and analyzed by five clinicians who each have
practiced dentistry longer than 15 years. A total of 74 patients
with 242 implants were recalled up to 10 years (mean follow-up:
9.21 ± 1.7 years) after loading. Some patients had a history of
RESULTS OF LONG-TERM osteoporosis (14%), diabetes (18%), hypertension (42%), and
STUDIES smoking (32.4%). The study group included 39 male and 35
female patients (mean age, 50.6 ± 11.3 years) who received
A number of studies from university- and hospital-based cen- dental implant treatment. A total of 107 implants were placed
ters have been published on long-term implant survival.2,24,87–98 in the maxilla, and 135 implants were placed in the mandible. Of
As an example, a retrospective clinical study was performed in the 242 implants, 19 were placed in the anterior region (7.9%),
a hospital setting evaluating SLA dental implants (Implantium and the remaining 223 implants were placed in the posterior
dental implant system, Dentium) that had been placed in 121 region (92.1%). There were 139 implants placed in edentulous
patients.96 Three hundred seventy dental implants were placed sites; 33 were placed in previously bone-grafted sites, and 70
41

a b
Fig 2-33 (a) A 43-year-old man presented with a partially edentulous mandibular ridge, and his medical history was significant for hypertension
and smoking. Two dental implants (3.8 × 12 mm and 4.4 × 12 mm) were placed in the mandibular left second molar and second premolar sites,
and they were restored with a three-unit screw-retained partial denture. (b) The 8-year follow-up radiograph shows excellent maintenance of the
crestal bone around both implants.
a b
Fig 2-34 (a) A 25-year-old woman presented with a nonrestorable mandibular right first molar with a periapical lesion. Her medical history was
unremarkable. An implant (4.8-mm diameter and 14-mm length) was immediately placed, and the socket was grafted with a mixture of autograft,
allograft, and xenograft. The implant was restored with a screw-retained crown. (b) The 10-year follow-up radiograph demonstrating maintenance
of the crestal bone level around the implant.
a b c d
Fig 2-35 (a and b) A 66-year-old man presented with hopeless mandibular first molars bilaterally. He was a smoker and reported both hypertension
and hyperlipidemia. Following extraction, dental implants were placed immediately in both mandibular first molar sites, and the sockets were grafted
with an allograft. The adjacent second molar sites had been edentulous for a while and received two implants at the same time. All implants were
restored with screw-retained restorations. (c and d) The 10-year follow-up radiographs demonstrate minimal remodeling of the crestal bone level.
were placed in extraction sites. There were 93 implants that The data were generated from an unrestricted general popula-
were placed in grafted sites or received simultaneous graft- tion from five private practices, and the advantage of this study
ing at the time of the implant placement. The average length design was inclusion of a broad spectrum of patients who have
of the implant used was 11.5 mm, and the average diameter been treated and maintained by private practitioners. Dental
was 4.1 mm. There were five implant failures from this radio- implants with an SLA surface appeared to achieve successful
graphic observation period, resulting in a 97.9% dental implant osseointegration in this long-term observation period. However,
survival rate. The mean crestal bone level change on the mesial the downside of this study was the retrospective nature of the
aspect was –0.36 ± 1.05 mm, while the mean crestal bone level observation as well as the use of nonstandard radiographs.
change on the distal aspect was –0.18 ± 0.96 mm. Thus, the Nonetheless, the data that have been generated are very strong
overall mean bone loss was 0.28 ± 0.05 mm. Figures 2-33 to and supportive of the safety and efficacy of implant treatment
2-35 present case examples from the study. for missing teeth.
42

LONG-TERM IMPLANT SUCCESS: PART III
Long-Term Implant Success: change in bone level was –1.61 mm (SD: 1.35 mm, range: 0.00
to –8.25 mm) for all implants. Significantly more bone loss was
Part III observed around the enhanced-surface implants (mean: –1.73
mm, SD: 1.54 mm, range: 0.00 to –8.25 mm) compared with
TAMSIN J. CRACKNELL, DEON FERREIRA, turned implants (mean: –1.41 mm, SD: 0.92 mm, range 0.00
PETER HAWKER, AND ANDREW ACKERMANN to –4.00 mm) (P = .016). The cumulative implant survival rate
T
was 97% overall at 21 years. Incidence of peri-implantitis was
he first Southern Implants fixtures were placed in less than 5% in all patients evaluated.
1988 at the University of Pretoria, South Africa. The This case describes a mandibular full-arch implant-supported
patient was male, diabetic, and required two fixed removable denture, adapted 5 years later to a fixed solution,
full-arch prostheses. Eight implants were placed in that remains in function, supported by the same implants after
the mandible in a two-stage surgical protocol. The implants 24 years. This case was included in the original paper by Vande-
were external hexagon with a machined surface. The implants weghe et al105 at 21 years and was reevaluated 3 years later.
were fitted with standard abutments at stage-two surgery, and A woman, then aged 39 years, presented with complete
a bar to retain an overdenture was fitted to the abutments. The conventional dentures in both jaws. Her main complaint was
patient moved from South Africa to his homeland of Austria a loose, nonfunctional mandibular denture. Possible implant
and in 2013 consulted an implant dentist familiar with Southern treatment in the mandible was discussed with the patient. At
Implants regarding a maxillary complication. Even though the the time, the anterior mandible had favorable existing bone for
abutments were covered in calculus, the bone levels seem to implants, although keratinized soft tissue was insufficient. The
have remained stable over the 25-year period (Fig 2-36). conventional two-stage implant treatment protocol was followed.
An interim diagnostic denture was provided to establish a
suitable esthetic outcome. A free gingival graft was harvested
from the palate, grafted to the anterior mandible, and left to
LONG-TERM RANDOMIZED mature for at least 6 weeks. The denture was adapted after
CONTROLLED TRIALS each surgical procedure.
Five 3.75-mm-diameter, 13-mm-long external hex implants
The Southern Implants roughened surface was introduced in (IB13, Southern Implants) were placed in the interforaminal
1992 and has remained unchanged for 16 years at the time of this region. The implants were made of grade 3 titanium, which was
publication. This has allowed for prospective clinical follow-ups the strongest grade commercially available at that time, but
in excess of 10 years. In a 2014 Cochrane systematic review later implant designs were changed to grade 4 titanium due to
comparing clinical outcomes for different commercially avail- its superior strength.106 The implants in this case were some of
able dental implants,99 implant surface was one of the variables the earliest to feature the Southern Implants moderately rough
assessed, and five articles on randomized controlled trials using surface, which had been introduced in 1992.
Southern Implants were selected for inclusion, including one Cover screws were installed at stage-one surgery, and
article with 10 years of follow-up.100–104 The review concluded the implants were submerged (Fig 2-37a). After 3 months,
that overall there was insufficient evidence to suggest that one the implants were exposed, and standard abutments were
implant surface had a lower failure rate or led to reduced mar- connected. The soft tissue was allowed to heal before the
ginal bone changes compared with another. impression was taken. A cobalt-chrome alloy mesostructure
was retained on standard abutments, with a removable overlay
acrylic denture (Fig 2-37b) providing good esthetics and func-
tion. Five years later, the restoration design was altered to a
RETROSPECTIVE STUDIES fixed hybrid denture on standard abutments because the patient
requested a fixed solution (Fig 2-37c). In 2017, the patient exhib-
Retrospective studies have been published with follow-up times ited excellent bone level stability, and the prosthesis was again
of up to 21 years. adapted to passively connect directly to the implant interface.
In so doing, she could receive state-of-the-art prosthetics on
the original implants more than 20 years later. No prosthetic or
Clinical case 1 surgical complications were observed in this case.
Standard protocols as described previously are still in use at
A 2015 study (published in 2016) recalled patients treated this practice today. However, immediate implant placement and
by one clinician with 76 turned surface implants and loading, more modern protocols and materials, and improved/
121 surface-enhanced implants placed in full-arch edentulous additional components assist to provide patients with a more
cases.105 After a mean follow-up time of 172 months (standard comprehensive and effective implant treatment.107
deviation [SD]: 42 months, range: 120–252 months), the mean
43

Fig 2-36 Radiograph taken 25 years after treatment in the first patient to receive Southern
Implants fixtures.
a b c
Fig 2-37 (a) Submerged implants left to heal for 3 months. (b) Original definitive prosthesis, a cobalt-chrome alloy mesostructure, placed in 1994.
(c) Original implants after 21 years in function. The fixed prosthesis was removed before radiography, and the abutments were left in situ so as
not to disturb the tissues before bone level measurement.
Clinical case 2 Dunedin abutments, except for the implant in the mandibu-
lar right third molar site, which was connected directly to the
In another 2015 study, Vandeweghe et al reviewed 211 prosthesis (Fig 2-38a).
rough-surfaced implants (Southern Implants) for a mean follow-up Peri-implant bone level at the 10-year follow-up was measured
period of 7.5 years (90 months, SD: 45 months, range: 17 to from new radiographs, using the implant-abutment platform as
143 months).108 The mean change in bone level was –1.17 mm reference. The patient experienced mean bone loss of 1.25 mm
(SD: 0.49 mm, range: –0.36 to –4.88 mm). One implant expe- over all four implants (range: 0.63 to 1.62 mm) (Fig 2-38b). Inter-
rienced peri-implantitis, resulting in a success rate of 99.5%. estingly, the site where the prosthesis was connected directly
A woman aged 63 years had been treated previously with bilat- to the implant experienced marginally more bone loss mesially
eral posterior tooth-supported partial dentures in the maxilla, and and distally (1.54 and 1.60 mm, respectively) compared with the
in the mandible only her natural central incisors, lateral incisors, abutment-level implants (mean values of 1.18 mm mesially and
and canines were still in situ. She underwent total extraction and 1.11 mm distally over the other three implants).
after a healing period was treated with a fixed implant-supported The prosthesis was removed for clinical examination, and
mandibular denture spanning from left to right first molar. At this there were no signs of inflammation, calculus around the abut-
time she also received a fixed full-arch prosthesis in the maxilla. ments, or suppuration. Very little calculus was found on the
She returned for clinical evaluation 10 years later. underside of the prosthesis (Fig 2-38c). Probing depths ranged
Four implants were placed in the mandible, all of which from 1 to 3 mm, with bleeding observed only on the mesial and
featured a tapered body, external hex connection, 0.8-mm lingual sides of the right distal implant. Periotest (Medizintech-
machined-surface collar, and moderately rough body surface. nik Gulden) values ranged from –6 to –5, indicating excellent
The two distal implants, placed in the premolar sites, had a diam- axial stability (the Periotest scale ranges from –8 to +50, repre-
eter of 5 mm and length of 15 mm (BAT, Southern Implants), and senting lowest and highest mobility, respectively) (Fig 2-38d).
the anterior implants in the lateral sites were 4 mm in diame- No unplanned maintenance, mechanical, or biologic compli-
ter and 15 mm in length (IBT, Southern Implants). The implants cations occurred over the 10 years in function. In responding
were loaded within 24 hours of surgery with a metal-reinforced, to the Oral Health Impact Profile-14 oral health–related quality
screw-retained provisional partial denture. At 3 months, the of life questionnaire, the patient rated her experience as excel-
definitive prosthesis was delivered, consisting of a titanium lent for hygiene, comfort, fit, speech, appearance, chewing, and
framework with resin teeth screw-retained to compatible tasting. She rated her phonetics as good.
44

LONG-TERM IMPLANT SUCCESS: PART III
a b
c d
Fig 2-38 (a) Occlusal view of the definitive prosthesis. (b) Ten-year follow-up of mandibular fixed screw-retained prosthesis. (c) Prosthesis underside
at 10 years showing minimal calculus. (d) Periotest to measure axial stability after prosthesis removal at 10 years.
Clinical case 3 bony crest and away from the buccal wall (Fig 2-39b). No graft
material was placed in any of the socket voids. Healing was
Immediate placement of a conventional dental implant into uneventful, and the patient had no need to use any analgesic
a molar extraction socket presents a number of surgical diffi- or anti-inflammatory medications.
culties, primarily related to the dimensions and configuration After a healing period of 3 months, bone integration was clini-
of the typical multirooted socket.109,110 The ultra-wide-bodied, cally verified, and the implant was restored with a screw-retained
heavily tapered MAX implant (Southern Implants) has improved crown (Figs 2-39c to 2-39e). The restoration was fabricated
the potential for immediate implant placement with favorable by means of a custom-milled zirconia substrate, veneered in
primary stability in multirooted sockets where bone-implant ceramic, and fitted to the implant using a pre-machined titanium
surface contact is often limited. This approach shortens treat- interface component, referred to as a passive abutment. The
ment time and can negate the grafting procedures that are fre- passive abutment is assembled to the finished crown using a
quently used where the maxillary sinus is involved.111 In a report resin luting agent, which is held in compression by the retaining
of 580 MAX cases over a 10-year period, a clinical survival rate screw (Fig 2-39f). The gold alloy retaining screw was torqued
of 95.17% was found, of which 3.62% were early failures and to 35 Ncm.
1.20% were late failures.110 Initial healing showed complete fill of the socket voids by
The 52-year-old woman presented with a failing endodonti- bone ingrowth, and the subsequent crestal bone heights, soft
cally treated maxillary left first molar. It was decided to remove tissue margins, and contours remained remarkably stable (Figs
the tooth by sectioning the individual roots to preserve the 2-39g to 2-39j). The 7-mm restorative interface provided a stable
interradicular bone. The implant site was prepared without a flap connection and facilitated an emergence profile that closely
by drilling into the interradicular bone using tapered burs and mimicked that of a natural molar tooth, largely obviating open
finalized with a dedicated tapered bone tap. The MAX implant gingival embrasures.110,111,113 No restorative maintenance has
of 9-mm diameter and 7-mm length (Fig 2-39a) was placed with been required, and the patient has continued to enjoy normal
insertion torque in excess of 80 Ncm and fitted with a tempo- comfort and function with the implant restoration.
rary healing abutment, platform switched to a 7-mm diame- The surgical technique for immediate placement of the MAX
ter. A randomized controlled trial evaluating platform switching implant has subsequently benefited from further innovation and
on a similar implant showed reduction in bone loss of 30%.112 now allows for predictable implant placement in the majority of
The implant was placed at a depth of 2 mm below the buccal molar extraction sockets.110
45

a b c
d e
Prosthetic
retaining screw
Plastic waxing
sleeve g h
Luting screw
(only used during
luting procedure)
Titanium
interfacial ring
f i j
Fig 2-39 (a) Ultra-wide-body, heavily tapered Southern Implants MAX implant (9-mm diameter, 7-mm length). (b) Immediate placement of MAX
implant in maxillary first molar extraction socket, positioned away from the buccal wall. (c) Healed site prior to restoration at 3 months after implant
placement. (d and e) Radiographic and clinical views of screw-retained restoration at 3 months after implant placement. Bone fill of the socket
can be seen in the radiograph. (f) Passive abutment showing pre-machined titanium interfacial ring with burnout sleeve, luting screw for crown
fabrication, and prosthetic retention screw. (g) Radiograph at 5.5 years of follow-up. (h) CBCT image of MAX implant at 9.5 years showing mainte-
nance of buccal and palatal bone walls. (i and j) Clinical and radiographic views at 10-year follow-up. The clinical view shows healthy soft tissues.
SURFACE PARAMETERS OF and falls in the “moderately rough” category as defined by

Albrektsson and Wennerberg.114 Their paper showed that sur-
SOUTHERN IMPLANT FIXTURES faces with Sa values between 1.0 and 2.0 µm show stronger
bone responses than smoother or rougher surfaces. Surface
The modern Southern Implants surface has an Sa value (area topography is obtained via gritblasting with alumina particles,
surface arithmetical mean height) of approximately 1.5 µm residues of which are removed with inert chemical solvents.
46

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in humans. Clin Adv Periodontics 2011;1:29–33. Implant System. Int J Oral Maxillofac Implants 2004;19:247–259.
59. Nevins M, Camelo M, Nevins ML, Schupbach P, Kim DM. Reattach- 77. Fugazzotto PA, Vlassis J, Butler B. ITI implant use in private prac-
ment of connective tissue fibers to a laser-microgrooved abutment tice: Clinical results with 5526 implants followed up to 72+ months
surface. Int J Periodontics Restorative Dent 2012;32:e131–e134. in function. Int J Oral Maxillofac Implants 2004;19:408–412.
48

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49

3 HOM-LAY WANG • JIA-HUI FU
Introduction to
Implant Surgery:
Optimal Positioning of
the Dental Implant
Spatial Implant Position
Timing of Implant Placement
Soft Tissue Grafting
51
Nevins/Wang_Chap_03.indd 51 2/28/19 11:56 AM

3 | Introduction to Implant Surgery: Optimal Positioning of the Dental Implant
Apicocoronal dimension
Anterior: Anterior:
3–4 mm apical to CEJ 1.5 mm between
tooth and implant
Maintenance of 2 mm Posterior: Posterior:
of buccal bone thickness 1–3 mm apical to CEJ 3–4 mm between
preferred, especially in tooth and implant
anterior region
3–4 mm between implants
Buccolingual dimension Mesiodistal dimension
Timing of implant Soft tissue

placement thickness
Late/early/ Preferable to have

immediate 2 mm of soft tissue
Anterior:
thickness for long-
Directed to cingulum
term stability
Posterior:
Aligned to the central groove
of adjacent teeth
Angulation of implant
Fig 3-1 The six critical dimensions of implant spatial positioning under healthy conditions. CEJ, cementoenamel junction.
R
ehabilitation of an edentulous span with dental peri-implant tissues and esthetic outcomes. In addition to 3D
implants involves keen recognition of hard and soft spatial implant positioning, this chapter discusses crucial influ-
tissue contours and meticulous planning of implant encing factors such as the angulation of the implant body, timing
positions so that a harmonious relationship between of implant placement, and thickness of peri-implant soft tissues
an implant restoration and surrounding tissues can be created. (Fig 3-1). Clinical scenarios are used to illustrate important consid-
This is important for several reasons: (1) a well-contoured prosthe- erations prior to implant placement.
sis facilitates effective plaque control and thus prevents biologic
complications such as peri-implantitis; (2) esthetics can be
achieved when a prosthesis has the correct emergence profile, as
indicated by a 15-degree emergence angle for maxillary anterior SPATIAL IMPLANT POSITION
teeth1; and (3) the occlusal forces will be directed along the long
axis of the implant, thus minimizing mechanical complications Numerous studies have reported on the ideal 3D implant posi-
such as abutment screw loosening and peri-implant marginal tion that would result in the fabrication of an esthetic and func-
bone loss.2,3 However, the ability to construct such a prosthe- tional prosthesis.3–6 Traditionally, the position of an implant at
sis is heavily dependent on the three-dimensional (3D) position an edentulous site was described based on the location of its
of the implant fixture.4 As such, in order to achieve an ideal platform with reference to the neighboring anatomical struc-
implant position, changes in clinical workflow are necessary. For tures. However, it is important to bear in mind that the position
example, cone beam computed tomography scans can be used of the implant within a 3D space also involves the angulation of
in combination with computer-aided design/computer-assisted its long axis in relation to the adjacent structures.
manufacture technology to fabricate 3D printed surgical stents Apicocoronally, it is generally proposed that the implant plat-
for complete guidance of the implant osteotomy preparation form be placed as shallow as possible but as deep as neces-
and implant placement in a prosthetically driven position with a sary. This simple maxim bears great meaning as it guides clini-
biologic foundation; the development of surgical protocols and cians to consider both the biologic health of peri-implant tissues
biomaterials that improve the predictability of bone augmentation and the esthetics of the implant prosthesis. Periopathogens
procedures enable placement of implants in the correct restor- tend to reside in anaerobic environments such as deep pock-
ative position; and the addition of connective tissue grafts or their ets (5 mm or deeper), stimulating the release of proinflamma-
substitutes around implants thicken and modify the peri-implant tory cytokines, eg, interleukin 1, by activated resident cells,
soft tissue contours for enhanced long-term maintenance of eg, macrophages. This upregulation of inflammatory cytokines
52

a b c
Fig 3-2 A healthy 32-year-old man presented with a single screw-retained implant crown replacing the
maxillary right lateral incisor. The implant was placed too deep, resulting in the current clinical presentation.
(a) A discharging buccal sinus tract with midfacial mucosal recession was observed. (b) Collapse of hard
and soft tissues was observed from the apicocoronal view. (c) An 8-mm probing depth was detected at the
mesiofacial site. (d) Periapical radiograph of the implant prosthesis with slight bone loss on the mesial surface.
will increase susceptibility to peri-implant tissue breakdown. In Mesiodistally, it would be favorable to maintain a safe distance
addition, if the implant platform is placed too deep, unnecessary of at least 1.5 mm between the implant and adjacent roots (Figs
circumferential horizontal and vertical peri-implant crestal bone 3-6a and 3-6b) and 3 to 4 mm between implants6 (Figs 3-6c to
remodeling/loss and mucosal recession may occur7 (Fig 3-2). 3-6i). However, in the posterior location, a minimum of 3 mm
Therefore it is key to place the implant platform at a depth that from the CEJ of the adjacent tooth is often needed to ensure
is as shallow as possible (ie, 1.5 to 3 mm below the cemento the proper restorative emergence profile and hygiene access.
enamel junction [CEJ] of the adjacent teeth) to facilitate plaque Respecting these dimensions not only prevents damage to the
control and maintain health and stability of the peri-implant adjacent root structure but also aids in the preservation of inter-
tissues. On the other hand, the platform should be as deep as proximal peri-implant bone and soft tissue volume. By preserving
necessary to provide adequate vertical depth for the develop- the bone volume that provides blood supply to the area, the bone
ment of an esthetic and cleansable emergence profile for the resorption and soft tissue collapse that often occur in thin inter-
implant restoration. As such, it is suggested that the implant proximal bone areas could be prevented.13 Also, in a single-tooth
platform be placed at least 3 to 4 mm apical to the CEJ of the space, the long axis of the implant fixture should be aligned with
adjacent teeth in highly esthetic areas (Fig 3-3). In addition, it the midline of the future prosthesis or centered between the
would thus be possible to position the interproximal contact adjacent roots (see Figs 3-6a and 3-6b). When placing multiple
point at a maximum of 3 mm away from the alveolar bone crest consecutive implants, the long axis of these implants ideally
to facilitate the creation of complete interproximal papilla fill.8 It should be parallel, aligned with the opposing arch, and adequately
is important to recognize that physiologic bone remodeling will spaced (7 to 9 mm between the center of the implants) to main-
occur at the implant platform; therefore, bone level implants tain sufficient interimplant bone and soft tissue dimensions for
should be placed 1 mm subcrestally to avoid exposure of the peri-implant health and stability (Table 3-2; see Figs 3-6d to 3-6i).
implant surface9,10 (Fig 3-4). Likewise, when placing consecutive In the maxillary anterior esthetic area, it is recommended to
implants at one site, it is important to create a flat bone surface place the implant in the cingulum position to prevent biologic
so that the implants are at the same apicocoronal level without bone remodeling, which results in midfacial mucosal recession
sacrificing too much supporting bone. Otherwise, bone remod- and potential esthetic compromise. As reported, in the maxillary
eling will end at the most apical level, leading to exposure of anterior region, the long axis of the implant can be directed at
the implant surfaces and the initiation of peri-implantitis11,12 (Fig the marginal edge, cingulum, or palatal to the cingulum of the
3-5). Table 3-1 presents a summary of the key considerations future implant prosthesis. Its angulation has direct influence on
when determining the apicocoronal position of the implant. the emergence angle and cervical contour of the implant pros-
53

a b c
d e f
g h i
j k l
Fig 3-3 This healthy 50-year-old female patient had undergone extraction of her maxillary left central incisor as a result of periodontitis. (a and b)
She presented with a deep overbite, a widened mesiodistal space that was 1.5 times wider than the width of the contralateral central incisor, and
a narrow residual ridge width of 4 mm. (c) The implant platform was placed 3 to 4 mm apical to the CEJ of the adjacent teeth. (d) The long axis of
the implant was directed toward the marginal edge of the future implant prosthesis because of the deep overbite. (e) The implant was placed with
no fenestration or dehiscence of the facial bone plate. (f) Soft tissue profile at the time of implant uncovering. (g to j) A connective tissue graft was
harvested and secured under a pouch created on the facial surface of the implant at the implant uncovering stage. (k) A provisional crown was
subsequently delivered to contour the peri-implant soft tissue. (l) The definitive crown after 1 year of functional loading. (Prosthetic work done by
Dr Joanne Uy, National University of Singapore.)
a b c d
Fig 3-4 Comparison between the depths of implant placement for bone-level implants. (a) Implant replacing a missing maxillary left central incisor,
placed approximately 1 mm subcrestally. (b) After 6 months of functional loading, the peri-implant bone levels have remodeled to the implant
platform. (c) Implant replacing a missing maxillary left central incisor, placed at the level of the crestal bone. (d) After 6 months of functional load-
ing, the peri-implant bone levels have remodeled approximately 1 mm apical to the implant platform, resulting in exposure of the implant surface.
54

Fig 3-5 A 56-year-old healthy woman presented

with multiple implants. (a) In the mandibular left
posterior region, the distal implant was placed
slightly coronally compared with the other im-
plants. (b) After 5 years of function, it was ob-
served that the bone level at the distal implant
was close to the bone level at the mesial im-
plants, indicating that bone had remodeled to
the most apical level at that site.
a b
TABLE 3-1 Key considerations when determining the apicocoronal position of an implant
Bone level (CEJ)

Recommended apicocoronal
Implant type ≤ 3 mm (pristine) > 3 mm (reduced) Recommended sites position
Tissue-level implant Crestal level Rough-smooth junction at bone Posterior sites Non-esthetic region: 1.5 to 3 mm
crest Sites with reduced residual bone height apical to adjacent CEJ
Highly esthetic region: 3 to 4 mm
Bone-level implant 1 mm subcrestal Crestal level (not preferred) Esthetic zone (ie, maxillary anterior region)
apical to adjacent CEJ
a b c
d e f
g h i
Fig 3-6 Mesiodistal dimension. (a) Digital planning of an implant replacing the maxillary right central incisor. The implant was placed 1.9 mm away
from the adjacent roots and 3.6 mm apical to the future implant crown margin. (b) Observe that the implant platform was centered between
the two adjacent roots. (c) A surgical guide should be used to guide the implant placement. (d to g) Multiple implants should be placed at least
3 mm apart (or 7 to 9 mm between the midlines of the adjacent implants in the posterior region), aligned to the central groove of the opposing
teeth, and parallel to one another. (h and i) Restored multiple implants in the posterior region exhibiting stable peri-implant tissues after 2 years
of functional loading.
55

TABLE 3-2 Key considerations when determining the mesiodistal position of an implant
Number of Recommended mesiodistal width Recommended mesiodistal

implants Implant position required for implant placement position from adjacent tooth
Single implant Center 3-mm-diameter implant: 6 mm Anterior: 1.5–2 mm (for preventing

4-mm-diameter implant: 7–12 mm bone remodeling that causes future
5-mm-diameter implant: 11–13 mm bone loss)
6-mm-diameter implant: 12–14 mm Posterior: 3–4 mm (for prosthetic
emergence profile and hygiene access)
Multiple implants First implant should be 5 to 5.5 mm from the adjacent root ≥ 15 mm (for at least two implants)
Distance between midlines of consecutive implants in the
posterior region: 8, 8, and 9 mm
15 degrees 30 degrees 45 degrees

Incisal Cingulum Palatal
Marginal edge of Cingulum of Palatal to the cingulum
future restoration future restoration of future restoration
Natural tooth Slight buccal ridge lap Severe buccal ridge lap
emergence profile
a b c
Fig 3-7 Emergence angles of 15, 30, and 45 degrees obtained when the long axis of the implant is directed
at (a) the marginal edge, (b) the cingulum, and (c) palatal to the cingulum of the future implant prosthesis,
resulting in a natural emergence profile, slight buccal ridge lap, and severe buccal ridge lap of the prosthesis,
respectively. (Reprinted from Testori et al13 with permission.)
thesis1,13,14 (Fig 3-7). The emergence angle is the angle between contours of a maxillary anterior tooth. However, with a slightly
the long axis of the tooth or implant and the crown surface at more facial position, a screw-retained prosthesis will be unes-
the gingival or mucosal margin. It is typically 15 degrees for a thetic, making a cement-retained prosthesis a more appropri-
maxillary anterior natural tooth.13 If the implant platform is placed ate choice. Additional bone augmentation procedures are thus
palatal to the cingulum position, the emergence angle will be commonly required to augment the facial bone thickness to
about three times greater than what is considered natural for approximately 4 mm,6 which will eventually undergo postsurgical
a maxillary anterior tooth.13 It inevitably leads to a severe facial remodeling, leaving behind a minimum of 1.5 to 2.0 mm around
ridge lap at the cervical contour that will impede proper plaque the implant.6,16 This facial bone thickness is critical because it
control on the buccal surface of the implant prosthesis. Angulat- provides support to the crestal bone and soft tissues to resist
ing the implant toward the cingulum of the future implant pros- bone and mucosal recession over time (Fig 3-8).17 If the long axis
thesis reduces the emergence angle from 45 to 30 degrees, thus of the implant is directed too facially, resorption of the facial plate
giving rise to a slighter facial ridge lap that will still hinder plaque will follow, resulting in midfacial mucosal recession (Fig 3-9).
control measures. Therefore, it is suggested that screw-retained In the posterior region, the center of the implant platform
prostheses be delivered for these implants because it is almost should be in line with the midline of adjacent teeth. Thus, the
impossible to completely remove the excess cement film (a implant would be centered in an edentulous ridge that had
contributing factor for peri-implantitis) in these ridge lap areas.15 minimal horizontal bone resorption. Likewise, it is important to
It is only when the long axis of the implant is directed at maintain at least 1.5 mm of peri-implant bone thickness around
the marginal edge of the future prosthesis that the emer- the implant for stability of the peri-implant tissues (Table 3-3;
gence angle and the facial cervical contour mirror the natural see Figs 3-8h to 3-8l).
56

a b c
d e f
g h i
j k l
Fig 3-8 This 55-year-old healthy man had single implant crowns placed to restore his missing maxillary left canine and mandibular left first molar.
For the maxillary left canine: (a and b) The edentulous residual ridge appeared to have a slight buccal concavity with adequate ridge height and
keratinized mucosa. (c to e) The implant was directed at the marginal edge, and additional horizontal bone augmentation using guided bone re-
generation was performed to increase facial bone thickness to 3 to 4 mm. (f) At implant uncovering, the facial bone thickness was approximately
1.5 to 2 mm. (g) The implant crown had a satisfactory soft tissue profile at 1 year after functional loading. For the mandibular left first molar: (h)
The edentulous residual ridge appeared to have adequate ridge width and height with a sufficient band of keratinized mucosa. (i) The implant
was placed in the center of the ridge, leaving behind a thick buccal plate. (j) At implant uncovering, the buccal bone thickness was approximately
1.5 to 2 mm. (k and l) The implant crown had a satisfactory soft tissue profile at 1 year after functional loading. (Prosthetic work done by Dr Loke
Weiqiang, National University of Singapore.)
Fig 3-9 This patient presented with midfacial mucosal recession because the implant
was placed beyond the incisal plane, resulting in resorption of the facial plate and
subsequent collapse of the facial soft tissue.
57

TABLE 3-3 Key considerations when determining the buccolingual position of the implant
Parameter Anterior region Posterior region
Timing of implant placement Immediate Late Immediate Late

Anatomical landmark Cingulum Cingulum Central groove Central groove
Type of prosthesis Cemented Screw-retained
Flat or concave abutment contour Slightly convex abutment contour
Soft tissue augmentation is often necessary Soft tissue augmentation is often unnecessary
Clinical recommendations At least 2 mm of buccal bone thickness
At least 2 mm of soft tissue thickness (with at least 1 mm of keratinized mucosa)
Screw-retained prosthesis
a b c
d e f
g h i j
k l m
Fig 3-10 A 45-year-old female with a high smile line presented with a hopeless maxillary left central incisor. (a and b) Preoperative photo and periapical
radiograph of the maxillary left central incisor. (c) Assessment of the hard and soft tissue height and thickness with a periodontal probe revealed
that the soft tissue biotype was thick and the facial plate was intact, with the crest 4 mm apical to the mucosal margin. (d and e) The implant was
placed using a guided surgical protocol with its long axis directed at the marginal edge of the future restoration. (f and g) Bone substitutes were
used to augment the implant site, which was subsequently sealed with a xenogenic collagen matrix. (h) Periapical radiograph showing that the
implant was positioned approximately 1 mm subcrestally. (i to k) At implant uncovering, the edentulous ridge appeared to have adequate ridge
width and height, with the soft tissue profile at a harmonious level compared with the adjacent teeth. A palatal roll flap was performed to roll the
crestal and palatal connective tissue buccal to the implant. (l) The definitive implant crown on the day of delivery. (m) The definitive implant crown
after 6 months of functional loading. (Prosthetic work was done by Dr Frank Lee, National University of Singapore.)
58

Soft Tissue Grafting
TABLE 3-4 Summary of the advantages and disadvantages of the timing protocols of implant placement and
clinical recommendations23–25
Timing
Category Definition (weeks) Advantages Disadvantages Clinical recommendations
Type 1 Implant placed 0 Reduced treatment time Technically challenging Careful case selection
into a fresh Reduced number of surgical procedures Increased risk of a suboptimal 3D Low esthetic demand
extraction site Reduced patient morbidity implant position and subsequent Thick soft issues
Enhanced regenerative potential since midfacial mucosal recession Thick and intact facial bone (> 1 mm)
there is containment of the grafting Increased risk of incomplete bone fill No acute infection at the extraction site
material and presence of osteoprogenitor due to lack of soft tissue coverage Adequate bone volume for proper
cells primary implant stability
Ability to provide an immediate fixed Flapless surgical approach
provisional restoration to enhance Deliver provisional restoration for
esthetic outcomes and patient acceptance improved support of peri-implant
tissues and esthetic outcomes
Type 2 Implant placed 4–8 Adequate soft tissue volume for Technically challenging Suitable for most anterior sites if
into a site with tension-free primary wound closure to Increased risk of a suboptimal 3D primary implant stability and ideal 3D
complete soft ensure predictable bone and soft tissue implant position and subsequent implant positioning are achieved
tissue coverage augmentation midfacial mucosal recession
Local pathology, if present, may have Increased treatment time
resolved. Increased number of surgical
Enhanced regenerative potential26,27 procedures
Reduced postextraction osteoclast
activity28
Improved implant stability29
Type 3 Implant placed 12–16 Adequate soft tissue volume for Increased treatment time Can be used for most sites
into a site with tension-free primary wound closure Increased number of surgical May consider alveolar ridge
significant bone Local pathology, if present, may have procedures preservation procedures to reduce
fill resolved May require additional hard and soft the need for advanced augmentation
Significant bone fill that facilitates primary tissue augmentation procedures as procedures
Type 4 Implant placement > 16
implant stability and its 3D positioning ridge resorption may have occurred
into a healed site
TIMING OF IMPLANT significantly deeper probing depths, increased tendency for

radiographic bone loss, and five times greater wound fail-
PLACEMENT ure compared with delayed implant placement, and almost
half of the cases had inadequate pink esthetic scores.23 As a
The timing of implant placement can be broadly categorized summary, Table 3-4 features the advantages, disadvantages,
into immediate implant placement (type 1), early implant place- and clinical recommendations of the different categories of
ment with complete soft tissue coverage (type 2) and partial implant placement.23–29
bone healing (type 3), and late implant placement in a healed
site (type 4).18 Briefly, immediate implant placement, although
technically challenging, appears to yield high implant survival
and success rates with good patient satisfaction because of SOFT TISSUE GRAFTING
the reduced surgical procedures and treatment time.19 Ideally
flapless immediate implant placement with immediate pro- In a natural tooth, the cervical contour is often divergent. How-
visionalization should be performed so that there is minimal ever, for an implant prosthesis, modification to the abutment
disturbance to the vascularization of the soft tissue and the morphology to create a convergent cervical contour is pre-
slightly concave provisional prosthesis or customized healing ferred.30 This is because the additional space available at the
abutment will not only provide support for the soft tissue archi- soft tissue cuff will allow for thicker soft tissue infill and thus
tecture but also seal the underlying graft material and implant, increased stability of the peri-implant tissues.31 It has, there-
thus enhancing esthetic outcomes20–22 (Fig 3-10). In situations fore, been suggested to have at least 2 mm of soft tissue thick-
when flap closure is mandatory, for example, implant place- ness, of which at least 1 mm is keratinized to ensure long-term
ment with simultaneous bone augmentation, early implant implant stability.32 As such, numerous techniques and biomateri-
placement is preferred so that there is adequate soft tissue als were used to increase the peri-implant soft tissue thickness
available to close the surgical site. A recent randomized con- and keratinization.33 Recent randomized controlled clinical trials
trolled clinical trial evaluated the treatment outcomes of imme- found that addition of a connective tissue graft was beneficial
diate and delayed implant placement at the 1-year review.23 in reducing midfacial mucosal recession at immediate implant
The authors reported that immediately placed implants had sites34 and in increasing peri-implant soft tissue thickness at
59

a b c
d e f
Fig 3-11 (a and b) The long axes of the implants were directed to the incisal edges of the future
crowns. (c to f) In order to improve the soft tissue contours of the prostheses, connective tis-
sue grafts were secured over the facial bone augmentation sites. (g) Provisional crowns were
subsequently installed to provide support and condition the soft tissues prior to delivery of the
definitive prostheses.
implant uncovering.35 This is especially advantageous in sites REFERENCES

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6. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant
optimal position. A digital workflow that involves combining the relationship on esthetics. Int J Periodontics Restorative Dent
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8. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow
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Belser UC. Stability of contour augmentation and esthetic implant placement and restoration in the anterior maxilla: Tissue
outcomes of implant-supported single crowns in the esthetic zone: dimensional changes after 2–5 year follow up. Clin Implant Dent
3-year results of a prospective study with early implant placement Relat Res 2017;19:694–702.
postextraction. J Periodontol 2011;82:342–349. 23. Tonetti MS, Cortellini P, Graziani F, et al. Immediate versus delayed
10. Caneva M, Botticelli D, Rossi F, Cardoso LC, Pantani F, Lang NP. implant placement after anterior single tooth extraction: The timing
Influence of implants with different sizes and configurations randomized controlled clinical trial. J Clin Periodontol 2017;44:
installed immediately into extraction sockets on peri-implant hard 215–224.
and soft tissues: An experimental study in dogs. Clin Oral Implants 24. Fu JH, Lee A, Wang HL. Influence of tissue biotype on implant
Res 2012;23:396–401. esthetics. Int J Oral Maxillofac Implants 2011;26:499–508.
11. Bashutski JD, Wang HL. Common implant esthetic complications. 25. Bishti S, Strub JR, Att W. Effect of the implant-abutment interface
Implant Dent 2007;16:340–348. on peri-implant tissues: A systematic review. Acta Odontol Scand
12. Aljateeli M, Fu JH, Wang HL. Managing peri-implant bone loss: 2014;72:13–25.
Current understanding. Clin Implant Dent Relat Res 2012;14(suppl 26. Thoma DS, Mühlemann S, Jung RE. Critical soft-tissue dimensions
1):e109–e118. with dental implants and treatment concepts. Periodontol 2000
13. Testori T, Weinstein T, Scutella F, Wang HL, Zucchelli G. Implant 2014;66:106–118.
placement in the esthetic area: Criteria for positioning single and 27. Fu JH, Su CY, Wang HL. Esthetic soft tissue management for
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14. Wheeler R. Complete crown form and the periodontium. J Pros- suppl):129–142.
thet Dent 1961;11:722–734. 28. Zuiderveld EG, Meijer HJA, den Hartog L, Vissink A, Raghoebar
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16. Grunder U. Stability of the mucosal topography around single-tooth 29. Cairo F, Barbato L, Tonelli P, Batalocco G, Pagavino G, Nieri M.
implants and adjacent teeth: 1-year results. Int J Periodontics Xenogeneic collagen matrix versus connective tissue graft for
Restorative Dent 2000;20:11–17. buccal soft tissue augmentation at implant site. A randomized,
17. Spray JR, Black CG, Morris HF, Ochi S. The influence of bone controlled clinical trial. J Clin Periodontol 2017;44:769–776.
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through stage 2 uncovering. Ann Periodontol 2000;5:119–128. extraction in esthetic single tooth sites: When immediate, when
18. Chen ST, Buser D. Clinical and esthetic outcomes of implants early, when late? Periodontol 2000 2017;73:84–102.
placed in postextraction sites. Int J Oral Maxillofac Implants 31. Fu PS, Wu YM, Tsai CF, Huang TK, Chen WC, Hung CC. Imme-
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19. Lang NP, Pun L, Lau KY, Li KY, Wong MC. A systematic review zone: A case report. Kaohsiung J Med Sci 2011;27:80–84.
on survival and success rates of implants placed immediately into 32. Chappuis V, Gamer L, Cox K, Lowery JW, Bosshardt DD, Rosen
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20. Tarnow DP, Chu SJ, Salama MA, et al. Flapless postextraction 33. Caballé-Serrano J, Bosshardt DD, Buser D, Gruber R. Proteomic
socket implant placement in the esthetic zone: Part 1. The effect analysis of porcine bone-conditioned medium. Int J Oral Maxillofac
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21. Chu SJ, Salama MA, Salama H, et al. The dual-zone therapeutic 2005;32:212–218.
concept of managing immediate implant placement and provisional 35. Chappuis V, Engel O, Reyes M, Shahim K, Nolte LP, Buser D.
restoration in anterior extraction sockets. Compend Contin Educ Ridge alterations post-extraction in the esthetic zone: A 3D anal-
Dent 2012;33:524–532,534. ysis with CBCT. J Dent Res 2013;92(12 suppl):195S–201S.
61

4 HSUN-LIANG CHAN • HOM-LAY WANG • MYRON NEVINS
Implant Placement for

the Mandibular Posterior
Quadrant
Anatomical Considerations
Soft Tissue Characteristics
Implant Positioning Considerations
Biomechanical and Restorative Considerations
Case Demonstrations
63

4 | Implant Placement for the Mandibular Posterior Quadrant
R
ehabilitation with dental implants in the posterior extensive flap reflection6,7 (Fig 4-4). Extra care should be taken
mandible is predictable, given prudent treatment in the area immediately anterior to the mental foramen as there
planning, precise surgical execution, and proper may be an anterior loop.5 It is formed when the inferior alveolar
restoration. The anatomical structures that limit avail- nerve travels anteriorly for a short distance, passing the mental
able ridge height are the inferior alveolar nerve, mental nerve, foramen before curving posteriorly and exiting at the mental
and lingual concavity. The ridge width suffers from the same foramen, giving off the terminal branch, ie, the mental nerve.
amount of resorption as the rest of the locations after exodon- Therefore, in the presence of an anterior loop, the osteotomy
tia. The resorption is more extensive in the mandibular premolar should not go deeper than the mental foramen, or the loop
area than in the molar area due to a thin buccal plate. Therefore, may be injured. The loop length on average is 5 mm but varies
ridge augmentation is commonly required before or at the time greatly among studies, and exceptions can exist. Therefore,
of implant surgery. Please refer to chapters 17 and 18 for details when in doubt, a cone beam computed tomography (CBCT)
regarding horizontal and vertical bone augmentation procedures. scan should be ordered, and the anatomy should be studied
This chapter provides updates with the most current knowledge carefully. The safest approach is to place implants coronally to
about important anatomical structures in this region. The quality the mental foramen.
and quantity of soft tissue are as important as that of hard tissue
for successful ridge augmentation procedures and implant ther-
apy. Therefore, a comprehensive method for evaluating soft tissue The lingual nerve
features is provided. Since this is a high occlusal force-bearing
area, considerations to prevent potential biomechanical compli- The lingual nerve provides general sensation to the tongue.
cations are reviewed. Finally, cases of implant rehabilitation in It enters the oral cavity immediately lingual to the mandibular
the posterior mandible with long-term follow-up are presented. second and third molars6 (Fig 4-5). It is located approximately
3 mm apical to the osseous crest and 2 mm horizontally from
the lingual cortical plate in the third molar area.8 It may be sit-
uated at or above the crest of bone in 15% to 20% of cases.9
ANATOMICAL CONSIDERATIONS Additionally, the lingual nerve may contact the lingual cortical
plate in 22% of cases.8 The authors’ study of 18 cadaver heads
The inferior alveolar nerve and showed that 75% of lingual nerves turned medially toward the
mental nerve tongue at the first and second molar region.10 The vertical loca-
tion of the nerve, measured from the cementoenamel junction
The inferior alveolar nerve, which is a branch of the mandibu- (CEJ), was 9.6, 13, and 14.8 mm at the second molar, first molar,
lar nerve (V3), enters the mandible through the mental fora- and second premolar, respectively.
men. It is a sensory nerve, innervating the posterior teeth. Although lingual nerve damage is uncommon, the impor-
Its branches include the incisive nerve, which provides sen- tance of its anatomical location cannot be overstated because
sation to the incisors, and the mental nerve, which provides of the increasing number of implants placed and the popular-
sensation to the premolars and facial mucosa. Accompanying ity of the lingual releasing flap for ridge augmentation in this
the inferior alveolar nerve are the inferior alveolar artery and region. A 0.6% to 2% incidence of lingual nerve injury has been
vein. In a microscopic cross-sectional view, the artery and vein reported following third molar extraction.11–15 To reduce the inci-
are most likely in a more coronal position in the canal.1 There- dence of injuring this nerve, certain rules should be followed.
fore, when the osteotomy is very close to the canal, profuse For example, incisions in the retromolar area should be made
bleeding is usually the first sign. Additionally, since the canal toward the buccal aspect of the ridge and always on the bone.
is surrounded by denser bone, resistance encountered by the A full-thickness releasing flap is always performed in this area.
implant drill might indicate proximity of the canal. An intraop- A vertical incision should be avoided lingual to the second and
erative periapical radiograph will confirm the relative positions third molar region; however, it can be performed anteriorly. It is
of the canal and the drill tip to avoid violation of the inferior safe to place a vertical incision in keratinized mucosa or a couple
alveolar nerve. Evidence suggests that an 8-mm implant will millimeters beyond the mucogingival junction. When reflecting
survive as well as a longer implant.2–4 A 2-mm safety margin is lingual flaps, care should be exercised to not damage the flap
suggested between the crestal bone and the superior border because the nerve may be contained in it. Last but not least,
of the canal. The mental nerve is most commonly located apical the lingual flap should be retracted gently using a retractor to
to the premolars5 and gives off branches into the oral mucosa; avoid damaging the lingual nerve with sharp instruments.
therefore, sharp dissection is prohibited in this area. Examples
of avoiding this important structure are illustrated in Figs 4-1
to 4-3. Options may include: (1) short implants, (2) lingualized Lingual concavity
placement, or (3) bypassing the foramen. Novel imaging modal-
ities, eg, ultrasonography, can identify the foramen in real time The presence of a lingual concavity in the posterior mandible
at chairside and hence could be useful during surgery without may complicate implant surgery. In a previous study by the
64

Anatomical Considerations
a b c d
Fig 4-1 Planning implant positioning to avoid the mental

foramen. (a to d) A long implant with bicorticalization was
placed at the mandibular left second premolar location, fol-
lowed by two short implants at the adjacent first and second
molar locations. The first molar implant was placed lingually
to prevent nerve injury. (e) The three implants were splinted
to distribute occlusal force. (f) A follow-up period of 26 years
showed a satisfactory outcome.
e f
a b c
Fig 4-2 Implant positioning to bypass the mental foramen. (a to c) The

mandibular left second premolar had a vertical root fracture and was
extracted, followed by ridge augmentation. (d and e) Two implants were
placed using an approach that did not jeopardize the mental foramen.
d e
a b c
Fig 4-3 (a) During implant surgery, the mental foramen was identified in situ, and available ridge height was measured. (b and c) Three implants
were placed without complications.
65

Fig 4-4 The mental foramen can be accurately located (asterisk)

on ultrasound imaging (a), when compared to direct open bone
evaluation (b), and CBCT (c). It shows as a discontinuity of a white
line (mandibular bone surface). The three horizontal dotted lines
denote, from coronal to apical, the CEJ of the second premolar,
the crestal bone level, and the superior border of the mental fo-
ramen. (Scale bar in a = 5 mm.) (Reprinted from Chan et al6 with
permission.)
a c
Fig 4-5 Illustration of lingual nerve with ultrasonography

(a), as compared to direct dissection (b). The nerve (red
arrow) can be easily identified with this novel diagnostic
imaging modality, which therefore can be used to avoid
surgical complications. ( Reprinted from Chan et al6 with
permission.)
a b
Fig 4-6 (a to d) Distribution of various morphologies of

Lingual concavity distribution (%) the mandibular posterior ridge. The undercut type is the
80 most common, accounting for 66% of the cases, fol-
71.4 lowed by the parallel type. (Reprinted from Chan et al16
70 66 with permission.)
63.2
60
50
40
30
23.5 20.4
20 14.3 13.2 13.6 14.3
10
0
Convex (C) Parallel (P) Undercut (U)
Male Female Total
a
b c d
66

Soft Tissue Characteristics
Sublingual gland
Mylohyoid muscle
a b
Fig 4-7 A free gingival graft was added to augment the amount of KM around implants in the mandib-
ular right first and second molar sites. (a) Before the augmentation, the peri-implant soft tissue was
inflamed with a shallow vestibule. (b) After augmentation, there is evidence of a band of healthy KM.
Mandibular bone
Fig 4-8 Ultrasonographic image of the

lingual mucosa and the underlying struc-
tures in the posterior mandible. Sublingual
glands have a multilobular appearance,
residing underneath a very thin layer of lin-
ing oral mucosa. The mylohyoid muscle is
attached to the mandible. Its thickness is
measured to be around 5 mm in this case.
authors, cross-sectional ridge morphology was studied on 103 ment loss, and mucosal recession, especially in rough-surfaced
CBCT scans.16 The mandibular morphology 2 mm above the implants.21 Therefore, if KM width is found to be inadequate, a
inferior alveolar canal was classified into as convex, parallel, or free gingival graft may be indicated for optimal long-term implant
undercut, based on the presence of a lingual concavity and the outcomes (Fig 4-7).
shape of the alveolar ridge. The undercut type was the most It has been suggested that a thicker flap could provide
prevalent, accounting for 66% of the study population (Fig 4-6). higher mechanical strength,8 enhanced revascularization,22 and
The mean undercut depth was 2.4 mm. The estimated incidence increased bone regeneration.23 A thicker flap (1 mm or greater)
of perforating the lingual bone is 1%, and the undercut ridge has significantly lower incidence of incision exposure compared
morphology undoubtedly is associated with the highest risk with a thin flap,8 and a thick tissue biotype is associated with
for implant perforation.16 The immediate risk of perforating the less implant marginal bone loss.24–27 Therefore, having a thick
lingual plate in this region is injuring the lingual nerve and sali- flap (≥ 1-mm thickness) is beneficial to achieving and maintain-
vary glands. Chronic inflammation or infection may occur at the ing primary wound closure and marginal bone level stability.
site where the implant is extruded, and if left unattended, the The degree to which a flap can be mobilized is related to the
infection might spread to the parapharyngeal and retropharyn- flexibility (interior tension) of the flap. The number of elastic
geal space, leading to more severe complications.17 Therefore, fibers, thickness of the periosteum, the components of the
implants should be placed within bony housing. extracellular matrix in the flap, and muscle attachments may
account for the differences in flap tension among individuals. A
highly flexible (lower tension) flap is desirable for primary wound
closure. A shallow vestibule poses anatomical limitations when
SOFT TISSUE CHARACTERISTICS advancing the flap because of the decrease in flap flexibility.
Additionally, a shallow vestibule inhibits effective home hygiene
Soft tissue features have important clinical implications, espe- practices. Soft tissues in the posterior mandible are commonly
cially for achieving primary closure after ridge augmentation associated with (1) a limited zone of keratinized mucosa, (2) thin
and long-term implant success.18 The four key soft tissue fea- biotype, (3) a high degree of mobility, and (4) limited vestibular
tures are: (1) width of keratinized mucosa (KM), (2) flap thick- depth. Muscles that may be encountered are mylohyoid and
ness, (3) flap flexibility (tension), and (4) vestibular depth.19 A buccinator. The location of the attachment of the buccinator and
study showed that inadequate KM width is associated with mylohyoid muscles influences the mobility of buccal and lingual
a higher incidence of wound opening.20 Furthermore, it was flaps, respectively (Fig 4-8). Implant treatment planning should
found that implants with an adequate band of KM were more be tailored to these specific soft tissue conditions in order to
resistant to plaque accumulation, mucosal inflammation, attach- achieve a desirable outcome.
67

a b c
d e f
g h
Fig 4-9 (a) Three implants were planned at the mandibular right second premolar, first molar, and second molar locations. (b and c) A surgical
guide was made, based on the prosthetic-driven concept, with metal sleeves to indicate osteotomy sites. (d and e) Three implants were placed
with the guide. (f) Guided bone regeneration was performed to correct the minor ridge deficiency. (g and h) Final clinical and radiographic views
indicate successful rehabilitation of the right posterior mandible.
IMPLANT POSITIONING BIOMECHANICAL AND

CONSIDERATIONS RESTORATIVE CONSIDERATIONS
Ideal implant positioning is key to successful long-term function There is conflicting and limited information on crown-implant
(Fig 4-9). For buccopalatal positioning, the implant platform cor- (C/I) ratio. Although suffering from small sample size and high
responds to the functional cusps of opposing teeth. Having at heterogeneity between included manuscripts, a systematic
least 1 mm of buccal and 0.5 mm of lingual bone thickness is review showed that the C/I ratio of implant-supported resto-
acceptable in the posterior region. Mesiodistally, a posterior single rations has an effect on peri-implant marginal bone level.29 Sur-
implant should have at least a 1.5-mm distance from the adjacent prisingly, within the range of 0.6:1.0 to 2.36:1.0, the higher the
tooth root as a safety margin, although ≥ 3 mm is often required C/I ratio, the less the peri-implant marginal bone loss. This study
because of restorative emergence profile requirements.28 For indicated that crown length that is approximately two times
multiple implants, the distance between the implants should be longer than implant length does not pose a significant biome-
at least 3 mm. The implants should be located in the center of the chanical risk.
future crown. As a general rule, for consecutive implant place- Restoration contour had been shown to be a risk indicator for
ment, the distances between the distal canine root surface to peri-implantitis. A retrospective study investigating 168 implants
the center of the first premolar implant, and between the centers on 83 patients measured the restoration emergence and angles
of the following implants are 5 to 6, 7 to 8, 7.5 to 8.5, and 9 mm, as well as restoration profiles on radiographs and correlated
respectively.28 Apicocoronally, the implant smooth-rough surface these parameters to peri-implant conditions.30 It was found that
interface should be at the level of the crestal bone, which is under an emergence angle of > 30 degrees is a significant risk indica-
normal condition 2 to 3 mm apical to the adjacent CEJ. For fur- tor for peri-implantitis in a bone-level (rough-surfaced) implant. A
ther details regarding ideal implant positioning, see chapter 3. convex profile creates an additional risk for bone-level implants
68

Case Demonstrations
a b c
Fig 4-10 Restoration of the

mandibular posterior region
with four implants. The implant
surgery was performed with
a surgical guide (a to c). One-
(d and e) and 10-year (f and g)
follow-ups show successful clin-
ical outcomes.
d e
f g
but not for tissue-level implants. Therefore, implant size selec- performed with a surgical guide to ensure implants were placed
tion, placement depth, and restoration design should be care- with ideal three-dimensional positioning and an adequate zone of
fully evaluated to reduce the risk of peri-implantitis. keratinized mucosa. Bone augmentation was performed where
Loss of interproximal contact between an implant and an necessary. Areas were then restored with splinted prosthesis.
adjacent tooth is common, resulting in food impaction, soft Great care was given to the development of the occlusion in
tissue inflammation, and patient dissatisfaction.31 Its relation- this case. One- and 10-year follow-ups showed successful clin-
ship to marginal bone loss is unknown. It is estimated that ical outcomes.
approximately 50% of cases lose interproximal contact.32,33 Figure 4-11 illustrates a biomechanical complication resulting
The most plausible reason is continuous mesial shift of teeth from occlusal overload due to crown overcontouring. Because
with aging and occlusion. In light of this common complication, of the location of the mental foramen, the surgeon opted not
screw-retained implant prostheses may offer advantages when to place a short implant, and the area was constructed using
repair or replacement is required. Restoration of an adjacent an extended crown supported by the two posterior implants.
tooth to close the gap is an alternative option. After 7 years in function, the anterior implant (in the mandibu-
lar left first molar site) lost its integration and was loose due to
excessive occlusal load. No inflammation was noted. In order
to overcome this problem, the failed implant was removed and
CASE DEMONSTRATIONS replaced with two additional implants. To avoid the mental fora-
men, a short (7-mm) implant was used and splinted to the rest
Figure 4-10 shows a mandibular posterior region reconstructed of the implants. After 25 years, the implants were still in func-
with four ideally positioned implants. The implant surgery was tion with minimal bone level changes.
69

a b c
d e
Fig 4-11 (a) A biomechanical complication occurred as a result of occlusal overload and crown overcontouring. (b and c) The failed mandibular left
first molar implant was removed and replaced with two additional implants. To avoid the mental foramen, a short implant was placed and splinted
to the other implants. (d and e) After 25 years, good function and minimal bone level changes are seen.
CONCLUSION 2. Monje A, Chan HL, Fu JH, Suarez F, Galindo-Moreno P, Wang

HL. Are short dental implants (<10 mm) effective? A meta-
analysis on prospective clinical trials. J Periodontol 2013;84:
Careful evaluation of anatomy, soft tissue features, location of
895–904.
implants, and biomechanics is the key to the long-term suc- 3. Monje A, Fu JH, Chan HL, et al. Do implant length and width
cess of implant therapy in the posterior mandible. Important matter for short dental implants (<10 mm)? A meta-analysis of
anatomical structures in this region include the inferior alveo- prospective studies. J Periodontol 2013;84:1783–1791.
4. Monje A, Suarez F, Galindo-Moreno P, García-Nogales A, Fu JH,
lar canal, mental foramen, lingual concavity, and lingual nerve.
Wang HL. A systematic review on marginal bone loss around
These structures should not be violated because catastrophic short dental implants (<10 mm) for implant-supported fixed pros-
complications may result. Soft tissues in this region are usually theses. Clin Oral Implants Res 2014;25:1119–1124.
thin, nonkeratinized, highly mobile, and in proximity to muscle 5. Neiva RF, Gapski R, Wang HL. Morphometric analysis of implant-
related anatomy in Caucasian skulls. J Periodontol 2004;75:
attachments. These features should be taken into consider-
1061–1067.
ation. Ideal three-dimensional implant positioning should be 6. Chan HL, Wang HL, Fowlkes JB, Giannobile WV, Kripfgans OD.
planned and modified if necessary to reduce biomechanical Non-ionizing real-time ultrasonography in implant and oral sur-
complications. Restorative considerations, eg, occlusal load, gery: A feasibility study. Clin Oral Implants Res 2017;28:
341–347.
number of implants, C/I ratio, abutment and crown contour,
7. Bhaskar V, Chan HL, MacEachern M, Kripfgans OD. Updates on
and interproximal contact are also essential considerations in ultrasound research in implant dentistry: A systematic review of
implant treatment. potential clinical indications [epub ahead of print 6 June 2018].
Dentomaxillofac Radiol doi: 10.1259/dmfr.20180076.
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lingual nerve in the third molar region. J Oral Maxillofac Surg
2000;58:649–651.
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15. Valmaseda-Castellon E, Berini-Aytes L, Gay-Escoda C. Lingual 83–91.
nerve damage after third lower molar surgical extraction. Oral 27. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of
Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:567–573. soft tissue thickness on crestal bone changes around implants: A
16. Chan HL, Brooks SL, Fu JH, Yeh CY, Rudek I, Wang HL. Cross- 1-year prospective controlled clinical trial. Int J Oral Maxillofac
sectional analysis of the mandibular lingual concavity using cone Implants 2009;24:712–719.
beam computed tomography. Clin Oral Implants Res 2011;22: 28. Su CY, Fu JH, Wang HL. The role of implant position on long‐
201–206. term success. Clin Adv Periodontics 2014;4:187–193.
17. Greenstein G, Cavallaro J, Tarnow D. Practical application of 29. Garaicoa-Pazmino C, Suárez-López del Amo F, Monje A, et al.
anatomy for the dental implant surgeon. J Periodontol 2008;79: Influence of crown/implant ratio on marginal bone loss: A sys-
1833–4186. tematic review. J Periodontol 2014;85:1214–1221.
18. Lee A, Fu J, Wang H-L. Soft tissue biotype affects implant suc- 30. Katafuchi M, Weinstein BF, Leroux BG, Chen YW, Daubert DM.
cess. Implant Dent 2011:20:e38–e47. Restoration contour is a risk indicator for peri-implantitis: A
19. Chao YC, Chang PC, Fu JH, Wang HL, Chan HL. Surgical site cross-sectional radiographic analysis. J Clin Periodontol 2018;45:
assessment for soft tissue management in ridge augmentation 225–232.
procedures. Int J Periodontics Restorative Dent 2015;35: 31. Jeong JS, Chang M. Food impaction and periodontal/peri-implant
e75–e83. tissue conditions in relation to the embrasure dimensions be-
20. Leong DJ, Oh TJ, Benavides E, Al-Hezaimi K, Misch CE, Wang tween implant-supported fixed dental prostheses and adjacent
HL. Comparison between sandwich bone augmentation and allo- teeth: A cross-sectional study. J Periodontol 2015;86:
genic block graft for vertical ridge augmentation in the posterior 1314–1320.
mandible. Implant Dent 2015;24:4–12. 32. Koori H, Morimoto K, Tsukiyama Y, Koyano K. Statistical analysis
21. Lin GH, Chan HL, Wang HL. The significance of keratinized mu- of the diachronic loss of interproximal contact between fixed im-
cosa on implant health: A systematic review. J Periodontol plant prostheses and adjacent teeth. Int J Prosthodont 2010;23:
2013;84:1755–1767. 535–540.
22. Wang HL, Boyapati L. “PASS” principles for predictable bone 33. Wei H, Tomotake Y, Nagao K, Ichikawa T. Implant prostheses
regeneration. Implant Dent 2006;15:8–17. and adjacent tooth migration: Preliminary retrospective survey
using 3-dimensional occlusal analysis. Int J Prosthodont 2008;
21:302–304.
71

5 CRAIG M. MISCH
An Introduction to the
Success of Short Dental
Implants
Short Implant Outcomes
Crown-Implant Ratio
Splinting Dental Implants
Vertical Augmentation Versus Short Implants
Consequences of Marginal Bone Loss
Complete Edentulism
73

5 | An Introduction to the Success of Short Dental Implants
T
he alveolar process undergoes a remodeling process Fig 5-1 Axial view from
following tooth loss. The greatest amount of bone a CBCT scan with virtual
planning of a short implant
loss occurs in the horizontal dimension and mainly in the posterior mandible.
on the facial aspect of the ridge.1,2 There is also
loss of vertical bone height, which is most pronounced on the
buccal aspect as well. In addition to bone remodeling following
extraction, previous bone loss due to periodontal disease, infec-
tion, or trauma may further compromise the residual ridge bone
volume. Additional bone resorption can occur over time with
use of a soft tissue–borne removable prosthesis.3 The loss of
the alveolar process can limit the ability to place dental implants
for prosthetic support. This may especially be the case in the
posterior region because of the location of the mandibular canal
and maxillary sinus. To overcome limited available bone, onlay
bone augmentation or maxillary sinus grafting may be performed
to reestablish the height of bone volume and allow placement
of dental implants. However, these augmentation techniques implant dentistry. This approach attempts to avoid more compli-
are associated with increased postoperative morbidity, higher cated procedures involving bone augmentation, especially in a
costs, greater treatment length, and higher risks of complica- vertical dimension, for implant placement. In both the posterior
tions. The alternative is to use short implants within the native maxilla and mandible, the use of short implants can reduce the
bone. This may be a simpler approach with fewer complications, need for vertical bone grafting. Patients often prefer this approach
lower costs, and shorter treatment time. Thus, when manag- over more complex procedures that may cause complications
ing the atrophic ridge, a clinician must decide between using with increased morbidity, treatment length, and cost.11
vertical bone augmentation techniques to insert standard-length
implants (> 8.0 mm) or placing short dental implants.
Many surgeons previously favored the option of longer
implants during the early development of implant dentistry. SHORT IMPLANT OUTCOMES
Treatment of the atrophic ridge would require bone augmenta-
tion for placement of longer implants. During the early devel- As previously discussed, the use of shorter machined implants was
opment of osseointegrated implants, machined surfaces were associated with a lower survival rate. More recent evidence-based
primarily used. Several studies have found that shorter machined reviews on short implants with textured surfaces reveal similar
implants (< 10.0 mm) have lower survival rates, especially in survival rates compared with standard-length implants. One
poorer quality bone.4,5 There were also biomechanical concerns systematic review evaluated 3,573 short implants (< 8.5 mm),
that using shorter implants for prosthetic support could cause with the vast majority having a textured surface (> 95%).12 The
higher stress and implant overload, resulting in greater marginal average follow-up period was 3.9 years (range, 1 to 7 years). The
bone loss and failure.6 Manufacturers often limited the choice short implant survival rate was 98% (67 failures), and the major-
of shorter implant sizes available for clinical use. ity (71%) of failures occurred before loading. When short (< 8.5
Several advancements have led to the greater use of and mm) and longer (> 8.5 mm) implants were compared from an
successful outcomes with shorter implants. Microtextured aggregate data set, similar 5-year cumulative survival rates were
implant surfaces enhance earlier bone formation and a higher found (98.3% and 97.7%, respectively). The survival rate of the
percentage of bone-implant contact.7 Design improvements in surveyed implants was not related to length. Another systematic
the connection between the implant and abutment have resulted review evaluated 2,631 implants (1,650 standard and 981 short)
in greater stability and better fit than the external hex implant placed in 1,269 patients.13 The survival rate was similar between
system.8 Stronger grades of titanium, including titanium alloys, standard and short implants (97.3% versus 96.1%). There was
improve the implant strength and decrease the risk of fracture. no statistically significant difference found between standard
The use of cone beam computed tomography (CBCT) allows implants and short implants placed in the posterior regions.
clinicians to better evaluate constrained bone volumes for short Furthermore, there were no significant differences between
implant placement9 (Fig 5-1). short and longer implants in the maxilla or mandible. The overall
For many years after the introduction of osseointegrated analysis of studies that evaluated marginal bone loss showed
implants, a 10.0-mm length was considered short. Over the no significant difference between short implants and standard
last 5 to 10 years the definition of a short implant has evolved.10 implants. These findings support the view that an 8.0-mm length
Most publications define a short implant as < 8.0 mm in length. may well be included in the standard implant category. How-
Implants that are < 6.0 mm are referred to as extra-short, and the ever, when evaluating implants with length < 8 mm, there were
shortest implant, at 4.0 mm, is ultra-short. There has also been a lower survival rates than standard implants. Therefore, shorter
trend over time toward minimally invasive treatment options in implants with a length < 8 mm should be used with some cau-
74

Crown-Implant Ratio
tion. A prospective 5-year study on ultra-short implants (4.0 mm)

has shown a slightly lower survival (92%) but stable marginal
bone levels.14 This reduced survival rate may be an acceptable
compromise for some patients considering the alternative of
vertical bone augmentation.
In a meta-analysis of prospective clinical trials on short dental
implants (< 10.0 mm), the peak failure rate of short dental
implants was found to occur between 4 and 6 years of function.
This occurred at an earlier time point compared with standard
dental implants, where the peak failure rate occurred between
6 and 8 years of function.15
Some clinicians have advised that if a short implant is used,
it may be beneficial to select a wider diameter to compen-
sate for the bone-implant surface area lost in length. From a Fig 5-2 Wide-diameter (4.8 mm) implant to replace a mandibular molar.
biomechanical perspective, a wider-diameter implant would
reduce stress in the supporting bone given a similar load.16
Increasing the implant diameter can also better engage the CROWN-IMPLANT RATIO
buccal and lingual/palatal cortical plates for primary stability.
However, several studies using short implants with a wide diam- Crown-implant (C/I) ratio is derived from a term used in prostho-
eter found this did not significantly improve implant survival.17–19 dontics to evaluate a natural tooth abutment. Crown-root ratio is
A meta-analysis of prospective clinical trials on short implants defined as “the physical relationship between the portion of the
also found that the survival of short implants was not improved tooth within the alveolar bone compared with the portion above
by increasing their width.20 On the contrary, failure rates of the alveolar bone level.”26 This ratio is an important variable in
short implants increased with increasing diameters. This finding the evaluation of a tooth for use as an abutment to support a
was in agreement with a systematic review that demonstrated fixed or removable partial denture. The greater the root length
less favorable results for 5-mm-wide implants compared with the more favorable the crown-root ratio. A 1:1 ratio has been
narrower implants of lengths < 8 mm.21 This finding may be considered the minimum for a prospective fixed partial denture
attributed to less bone support around the neck of the implant abutment.27 Although teeth and dental implants have different
from placing a wider diameter in a reduced bone volume that support systems within the bone, the concept of crown-root
encroaches on the resorbed buccal cortex. Thus it may not be ratio has been applied to implant mechanics, implying that
necessary to routinely select the widest implant possible when increasing the length of an implant would improve the C/I ratio.
using short implants. However, there may be situations where a Biomechanical studies have found that the maximum
wider-diameter implant would be advantageous. For the replace- stresses on a dental implant are at the alveolar crest, and the
ment of a single molar, an implant diameter wider than 4.0 mm stress levels apical to the superior 5.0 mm are minimal.28 Regard-
may be preferred. A larger molar crown on a smaller-diameter less of implant length, stress distribution is less to the apical
implant would be subject to greater off-axis loading.22 In some third than to the crestal third.29 Finite element analyses (FEAs)
implant systems this could result in screw loosening, screw show that the maximum bone stress is virtually constant, inde-
breakage, and even implant neck fracture. A wider-diameter pendent of implant length.30,31 The implant length is less influen-
implant in this case would have biomechanical advantages for tial on stress distribution than the diameter.32 A greater implant
crown support as well as greater strength (Fig 5-2). length may provide better initial stability, but once integrated,
One consistent finding is that when short implants do fail, it the length becomes less relevant under loading conditions. From
typically occurs early on during the healing period.13 This may be these biomechanical studies it may be concluded that placing a
due to reduced bone-implant contact and difficulty in obtaining longer implant would not improve the C/I ratio (Fig 5-3). There-
primary stability in a constrained bone volume with compro- fore, the term crown-implant ratio is a misnomer and should not
mised bone quality.23,24 The posterior maxilla usually has a thin be used in the discussion of short implant mechanics. The focus
cortex with porous medullary bone, resulting in a type 3 to 4 of this discussion should be on the crown-abutment height.
bone quality. The posterior mandible often has a thicker layer of The clinical crown height is the distance from the occlu-
cortical bone at the crest, but the interior cancellous bone can sal aspect of the restoration to the most coronal bone-implant
be much less dense. Although implants can obtain bicortical contact.33 The position of the fulcrum is at the bone crest. If
stability in the maxilla, this may not be possible in the posterior marginal bone loss occurs, the clinical crown height increases
mandible. Using short implants without a tapered body and/or and represents a more detrimental biomechanical scenario. This
with a less aggressive thread design may also make it difficult does not exclude the fact that prosthetic failure may actually
to achieve optimal anchorage. There is evidence that smoking occur at the abutment-implant junction. Although the clinical C/I
patients may be at higher risk for failure when short implants ratio seems to describe a more realistic biomechanical scenario,
are used.25 the anatomical C/I ratio is most commonly found in the literature.
75

M=F×d
Vertical force
Lateral Lateral Vertical force
force force
=
d
Fig 5-3 Because the stresses are primarily con- Fig 5-4 Vertical load directly over the implant Fig 5-5 The off-axis load on the wider implant
centrated around the implant neck, a longer crowns. Because the load is directly over the crown (right side) is outside the supporting
implant would not improve the C/I ratio. supporting implant, the taller crown does not implant. As a result, there is greater stress
result in higher stresses around the implant. around the implant.
M=F×d M=F×d
100 N
F
Lateral Lateral
2.0 cm d d
force d force
d
200 ncm
d
Torque
Fig 5-6 The magnitude of the moment of a Fig 5-7 A wider short implant would decrease Fig 5-8 When a lateral load is applied, a
force (M) is defined as the product of the force the distance between the applied force and greater implant crown height increases the
(F) and the moment arm (d). The moment arm the supporting implant. moment as the distance between the load
or lever arm is the perpendicular distance be- and the implant is greater. This creates greater
tween the line of action of the force (crown) stress around the implant.
and the center of moments (implant).
The implant crown height, including the implant abutment, technical complications such as screw loosening and compo-
is much more influential on biomechanics than the implant nent fracture.36 One strategy to reduce the moment of force
length.34 If a vertical load on a crown is applied axially and directly would be to use a wider-diameter implant (Fig 5-7). A wider short
over the area of the supporting implant, the implant crown implant would decrease the distance between the applied force
height is of no mechanical consequence (Fig 5-4). However, if and the supporting implant. As the stress applied to a mate-
the vertical load on a crown is applied off-axis, outside the area rial is equal to the force per unit area applied to the material
of the supporting implant, then greater stresses are generated (Stress = Force/Area), a wider implant would also reduce the
around the implant35 (Fig 5-5). Off-axis loading of the crown acts stress in the surrounding bone. Depending on the design of the
as a lever or moment of force. The magnitude of the moment implant-abutment connection, a wider implant may also have
of a force (M) is defined as the product of the force (F ) and the greater strength to resist fracture. For these reasons, when
moment arm (d ) (M = F × d ). The moment arm or lever arm is replacing a single molar, it may be preferable to select a wider
the perpendicular distance between the line of action of the implant without compromising the volume of supporting bone at
force (crown) and the center of moments (implant) (Fig 5-6). the crest. Another strategy to reduce the moment of force would
For example, a vertical force applied to a cusp tip or marginal be to eliminate eccentric contacts and limit occlusal contacts
ridge of a molar implant crown would result in a moment or over the central area of the implant crown. Lateral contact in
torque on the implant (see Fig 5-5). This moment is magnified mandibular excursions should be minimized in posterior areas.
with a greater implant crown height. Nonaxial loading of the The occlusal width of the implant crown can be reduced, and
crown can strain the implant-abutment connection and cause cusp inclination can be flattened. When a lateral load is applied,
76

Crown-Implant Ratio
Implant crown + abutment height
< 10 mm 10–15 mm > 15 mm
no splint splint
Modifying factors for splinting implants:

Fig 5-9 Tall single im-
parafunction, extra/ultra-short implants, molar implant diameter < 4.0 mm, d > 5.0 mm,
plant crown that has implant angulation, lack of anterior guidance, external hex connection, grade 1 Ti implants
had chronic abutment
screw loosening. Fig 5-10 Guidelines for splinting implant crowns based on crown-abutment height. Ti, titanium.
a greater implant crown height increases the moment as the evaluated the effect of increased crown height on implants.47
distance between the load and the implant is greater (Fig 5-8). Occlusal force application at 30 degrees showed a significant
There is a need for longer crowns to compensate for bone increase in both buccal and palatal microstrain values as the C/I
loss, ie, a short implant must be restored with a longer crown ratio increased from 1:1 to 1:1.5. Force application at 30 degrees
to obtain occlusal contact. The concern is that an off-axis force in cases with C/I ratio of 1:1.75 and 1:2 resulted in fracture of the
on a longer crown will generate increased stresses within the abutment screw followed by dislodgment of the crowns. Failures
peri-implant crestal bone. This could result in bone overload, were noted at a crown height of > 15 mm. An FEA demonstrated
causing marginal bone loss. The loss of supporting bone would an increase in the crown height on a single implant caused an
increase the clinical crown height, resulting in more unfavor- increase in the maximum compressive and tensile stresses in
able biomechanical conditions and lead to implant failure.37 The the peri-implant bone.48 Additionally, the stress decreased at
greater crown height on a short implant could also challenge the the abutment screw and increased at the abutment connection.
implant-abutment connection and cause technical complications This may contribute to screw loosening and fatigue fracture
such as screw loosening, screw breakage, or implant fracture. by skewing the stress distribution to the transverse section of
There have been numerous studies on the effect of increased the implant. Other finite element studies found the increase in
crown height when using short dental implants. Three system- crown height led to greater stress distribution on the screw,
atic reviews revealed that marginal bone loss and the survival mainly in oblique loading.49,50 However, there are limitations in
rate of implants did not seem to be influenced by the C/I ratio these stress analysis studies because they model bone as a
of the implant prosthesis.38–40 Moreover, a systematic review by static supporting structure instead of a dynamic organ capable
Garaicoa-Pazmiño et al40 found a significant negative association of remodeling in response to forces placed upon it.
between the C/I ratio and marginal bone loss. Within the range The increase in implant crown height can impact the incidence
of 0.6:1 to 2.36:1, the higher the C/I ratio, the less the marginal of technical problems. Several studies have found that an unfa-
bone loss. There was no effect on implant survival. It appears vorable C/I ratio could be considered a potential risk factor for
that a high C/I ratio could actually provide a protective effect abutment loosening (C/I ratio ≥ 1.46) and abutment fractures (C/I
on implant marginal bone levels. This finding is consistent with ratio ≥ 2.01) in cases of single crowns in posterior areas.39,51–53
an evaluation of peri-implant bone density supporting implants The majority of reported technical complications were minor
of different lengths.41 Bone around short implants after 3 years issues, including screw loosening, 51,54–56 food impaction in
had higher mineralization on radiographs then bone around long interdental spaces,57 crown decementation, or porcelain frac-
implants. Bone remodels in response to forces placed upon it, ture54,55,57 (Fig 5-9). The heterogeneity of the findings on a correla-
and under overload conditions bone turnover increases, result- tion of C/I ratio with biologic or technical complications may
ing in bone gain.42 Although the majority of evidence suggests be due to confounding variables such as implant type, implant
that higher C/I ratios are not associated with greater biologic location, implant dimension, parafunctional habits, smoking,
problems, there are studies that have shown a correlation with periodontitis, opposing dentition, and prosthetic design (eg,
greater marginal bone loss.43–46 However, the increase in bone single crown, splinted crowns, or fixed partial denture).
loss in these studies was nominal and did not lead to progres- In general, short implants can be successfully used to support
sive bone loss and/or implant failure. crowns and fixed partial dentures with minimal risk of significant
In vitro biomechanical studies have shown that increasing complications. There are several guidelines that can be useful
crown height can have potential negative effects on implant in managing cases with greater crown height58 (Fig 5-10). The
components and the supporting bone. A photoelastic model dentition should have favorable anterior guidance so the poste-
77

Fig 5-11 Short implant restored with a single Fig 5-12 Peri-implantitis around short implants
crown. The occlusal table is reduced, and the oc- restored with splinted crowns. Excess cement
clusal contact is centered over the implant. removal and oral hygiene was complicated by the
splinted design.
rior teeth disclude in protrusive and lateral jaw movements. This as previously discussed, these static models do not mimic the
will minimize nonaxial loading of posterior implant crowns. In adaptive properties of living supporting bone. A study that com-
patients with an anterior open bite or a severely worn dentition pared strains for splinted and nonsplinted implant crowns using
this may require full-mouth rehabilitation. The occlusal width of an anatomical model found splinted prostheses generated more
the implant crown(s) can be reduced, cuspal inclines can be flat- uniform strain distributions.63 However, the strain distribution
tened, and centric contacts can be centered over the supporting was not statistically different from that seen for the nonsplinted
implant (Fig 5-11). A wider-diameter implant (> 4.0 mm) should prostheses, suggesting that splinting may not be significant for
be considered for a single molar replacement. When multiple internally connected implants when the C/I ratio is low.
posterior teeth are replaced, the implant crowns can be splinted. Splinting adjacent implant crowns could potentially reduce
In some instances, an additional short implant may be placed the risk of overloading the supporting bone and loss of implant
for added load distribution and prosthetic stability, even if it has integration. However, several clinical studies have failed
no opposing contact. In restoring patients with parafunctional to show any significant difference in marginal bone loss or
habits, the clinician should incorporate a more robust design to implant survival when comparing splinted and nonsplinted short
the prosthesis. This may include wider implant diameters, addi- implants.24,54,56,64–66 One retrospective review concluded that
tional implant abutments, and/or splinting the implant crowns. nonsplinted posterior short implants had a somewhat lower
The use of a nocturnal bite splint can also reduce stresses on success rate than splinted short implants.67 Other studies
the prosthesis. have found greater marginal bone loss around splinted short
implants.68–70 This may be due to more difficulty with oral hygiene
and the development of peri-implantitis (Fig 5-12). It could also
be related to the rough surface treatment of implants.68
SPLINTING DENTAL IMPLANTS There is compelling evidence to suggest that splinted resto-
rations generally have fewer technical complications such as
When restoring adjacent implants in the partially edentulous decementation, screw loosening, and component fracture.56,66,70
patient, the decision of whether or not to splint them is a Clelland et al compared splinted and individual crowns supported
common clinical question. Although this situation has been by either extra-short (6.0 mm) or standard-length implants using
researched by several biomechanical models and clinical studies, a split-mouth design.56 The implant system used had an internal
there is often no consensus on a preferred prosthetic design. conical connection. At least two implants were placed on each
There remains much controversy, and many times the decision side in the posterior mandible in 15 patients. They were randomly
is made based on dogma and/or clinician preference.59 restored with splinted prostheses on the left or right side with
nonsplinted crowns for the contralateral side. Screw loosening
was the most common complication and was limited to the
Rationale for splinting nonsplinted crowns. It occurred in five patients, and in all but
one case the crowns were supported by extra-short implants.
The influence of splinting versus nonsplinting of dental implants The use of shorter implants with greater crown height likely
has been evaluated by several biomechanical models. In gen- caused the screws to loosen under function. Of the 15 patients,
eral, photoelastic and FEA models show that splinting crowns 7 preferred the nonsplinted crowns, reporting that hygiene was
leads to a better distribution of stresses in the implants and easier. Four patients preferred the splinted restorations because
bone in comparison with nonsplinted restorations, especially they experienced screw loosening on the nonsplinted side, and
when the load is applied off-center to implants.60–62 However, the four other patients had no preference. A photoelastic study
78

Splinting Dental Implants
a b c
Fig 5-13 (a) Two short implants in the posterior mandible positioned lingually in the atrophic ridge. (b) The implants were restored with splinted
crowns and a reduced occlusal table. (c) Periapical radiograph of the restored and splinted short implants.
Fig 5-14 (a) Two narrow-diameter short im-

plants placed in the posterior mandible follow-
ing a ridge split. (b) The implants restored with
splinted crowns.
a b
evaluated the effect of splinting implants with different crown angulation significantly deviates from the direction of the occlu-
heights, using gauges to measure the strain.47 Under applied sal load. Although an angled abutment can correct the path of
nonaxial loads they found a significant increase in microstrain prosthetic retention or screw access, it does not change the
around the implants when the crown height increased from 10 increase in stress at the connection. When a horizontal ridge
to 15 mm. Crown heights of 17.5 and 20 mm had fracture of deficiency is present, a narrower-diameter implant may be used.
the abutments screws followed by dislodgement of the crowns. This smaller diameter could challenge the biomechanical support
Splinting did not prevent prosthetic failure in this in vitro study of the implant crown since the abutment connection is reduced
when the crown height was 15 mm or greater. When ultra-short and less robust. When using a smaller-diameter implant (< 4.0
dental implants (4.0 mm) are used, it is recommended to place mm) to replace a molar, splinting to an adjacent implant should
multiple implants (three to four) and restore them with splinted be considered (Fig 5-14). To compensate for medial positioning
crowns.14 External hex dental implants may be more prone to and/or narrow implant diameter, the clinician may also design
component loosening when crown heights are greater. As such, the crowns with reduced cusp heights and a narrower occlu-
splinted crowns would be the preferred design with this type of sal table. Another option to manage ridge discrepancy is to
prosthetic connection.71 With most internal connection implant perform horizontal bone augmentation to allow placement of a
systems, the abutment screw receives minimal loading as forces wider-diameter implant in a more ideal location. One particular
are distributed with the interface.72 Bruxism may be associated advantage of splinting multiple adjacent implants is that if an
with an increase in implant failure as well as greater technical implant failure occurs the existing prosthesis may still function
and mechanical complications.73,74 When using short implants to after its removal. However, in the case of short implants, the
replace posterior teeth in patients with parafunctional habits, it loss of a terminal abutment would result in a cantilevered pontic,
is recommended to splint the restoration. Bruxism patients are possibly negating this benefit.
also more susceptible to porcelain fracture with implant pros- When multiple implant crowns are splinted it may be more
theses, so the use of a nocturnal occlusal guard is advised.75 difficult to achieve a passive fit of the prosthesis, especially
The implant position can also influence the decision to splint. when a screw-retained prosthesis is used. Misfit of the pros-
Following tooth loss and subsequent bone remodeling the thesis can generate forces that may result in loosening of
buccal plate resorbs medially. As a result, a dental implant may abutment screws or fracture of implant components, super-
be placed more palatal or lingual than ideal. This medial posi- structure, veneering porcelain, or the implant. Theoretically this
tion of the implant can create greater off-axis occlusal loading additional stress in the system could also cause marginal bone
on the implant crown, with higher risk of mechanical complica- loss and loss of integration.76 However, a systematic review of
tions. If adjacent posterior implants are located medial to the the literature provides insufficient evidence as to the effect of
center of the crowns, then splinting is suggested to counteract misfit at the prosthesis-implant interface on clinical outcomes
nonaxial forces (Fig 5-13). Splinting may also apply if the implant of screw-retained implant-supported fixed dentures.77 Marginal
79

BOX 5-1 Rationale for splinting implants
Indications Advantages Disadvantages
• Extra-short/ultra-short implants • Improved stress distribution • Passive fit more difficult

• Parafunctional habits • Decreased screw loosening • Hygiene more difficult
• Excessive crown height (> 10 mm) • Improved cement retention • Increased risk of porcelain fracture
• External hex connection • Increased likelihood of continued
• Grade 1 titanium implants prosthetic function in case of
• d > 5.0 mm (M = F × d) implant failure
• Narrow molar implants (< 4.0 mm) • Closure of interproximal spaces
• Angled implants • Fewer interproximal contacts
• Medially positioned implants
• Lack of anterior guidance
a b c
Fig 5-15 (a) Placement of two wide-diameter short implants to replace the mandibular molars. (b) The implants restored with individual molar
crowns. (c) Periapical radiograph following implant placement and restoration.
gaps and static strains due to screw tightening were not found compared with a direct connection.81 If cement-retained splinted
to negatively impact marginal bone loss or implant integration. crowns are planned, custom abutments should be used to
The reality is that a passive fit, though desirable, is not clini- improve the emergence profile of the restoration and optimize
cally obtainable. A clinically acceptable degree of misfit or least the margin position.
amount of misfit possible is therefore the goal in delivering The indications, advantages, and disadvantages associated
the prosthesis. While prosthetic misfit may not cause unfavor- with splinting implants are summarized in Box 5-1.
able bone reactions under static strain, it may be magnified
under dynamic parafunctional occlusal loads. A misfit may also
affect the long-term performance of prosthetic retaining screws. Rationale for nonsplinted implants
Cement-retained splinted crowns may provide a more favorable
passive fit as a cement space is typically provided by use of The use of multiple crowns for the replacement of posterior
a die spacer.78,79 However, the use of cement can complicate teeth has been shown clinically to be successful.65,82,83 If the
retrieval of the prosthesis, and subgingival cement excess can crown height is not excessive (< 10.0 mm), then it may not
contribute to the development of peri-implantitis.80 be necessary to splint the implant crowns (Fig 5-15). One of the
If multiple implants are planned for splinting with a primary reasons for not splinting adjacent implants is to provide
screw-retained prosthesis, it is prudent to consider using abut- for easier oral hygiene. The patient can use dental floss to clean
ments as opposed to fabricating the splinted crowns directly the implant crowns in a similar manner as their natural teeth. This
to the implants. Any microgap between the prosthesis and the avoids the need for additional oral hygiene devices such as a floss
implant would allow ingrowth of microflora, resulting in inflam- threader or interdental brush. Some clinical studies have shown
mation and bone loss. Using an abutment moves any prosthetic greater marginal bone loss around splinted short implants that
misfit away from the bone level. It also allows the clinician to could be attributed to compromised oral hygiene.68–70 The collec-
better visualize the fit of the crown margins. If the crowns are tion of food debris around implant restorations is a common
removed, this does not disrupt the soft tissue attachment on complaint. Although it may be easier to reduce the spaces with
the implant abutment. The use of abutments has been shown a splinted restoration, this approach can hamper the removal of
to better maintain marginal bone levels around splinted implants trapped food particles. Another advantage of single crowns is
80

Fig 5-16 Taller individual implant crowns are designed with longer contacts
to reduce the cervical spaces.
BOX 5-2 Rationale for not splinting implants
Advantages Disadvantages
• Oral hygiene facilitated • Need to adjust interproximal contacts

• Reduced risk of porcelain fracture • Inability to place another short implant in same site in case
• Easier crown replacement of implant failure
• Passive fit easier to obtain • Chronic screw loosening
that if porcelain fracture occurs on a crown, it only impacts one VERTICAL AUGMENTATION
unit instead of an entire splinted restoration.82 The incidence
of porcelain fracture with implant restorations is higher than VERSUS SHORT IMPLANTS
in natural teeth, and the presence of a screw access opening
further increases the risk of this complication.75,84 Treatment options for managing posterior partial edentulism with
Although it may be more difficult to obtain a passive fit of jaw atrophy include vertical bone augmentation to allow insertion
the prosthesis with splinted implants, it can be challenging to of standard-length implants or the placement of short implants.
manage multiple interproximal contacts when restoring adja- In the posterior maxilla the sinus floor can often limit the avail-
cent implants with individual crowns. With tall crowns the inter- able bone for implant placement. The management of maxillary
proximal contacts should be longer and extended cervically to atrophy and sinus pneumatization for dental implant placement
minimize spaces (Fig 5-16). Dental implants rigidly integrated has evolved over the years. When sinus bone grafting was intro-
in bone require meticulous adjustment of the interproximal duced clinicians favored the use of longer dental implants. This
contacts. Guichet et al used a photoelastic model to evalu- was thought necessary for optimal biomechanical loading of the
ate three implants restored with splinted crowns or individual implant and prosthetic support as shorter machined-surface
crowns with varying degrees of interproximal contact under implants (< 10 mm) showed lower survival rates in the poste-
loading conditions.85 Individual crowns with heavier interproximal rior maxilla.86 Under these constraints it was often necessary to
contacts led to a nonpassive situation associated with increased perform sinus bone grafting through a lateral window approach
tensile stresses between implants. Splinted restorations shared to allow placement of longer implants. Improvements in implant
the occlusal loads and distributed the stresses more evenly materials, design, and surface properties has led to the use of
between the implants when force was applied. The load-sharing shorter dental implants. Many studies have even shown that
effect was most evident on the center implant but also was seen the survival of short implants is the same as longer implants
on the terminal abutments of the splinted crowns. placed into grafted sinuses.87,88 Even ultra-short implants have
There are other potential disadvantages of independent had favorable short-term results compared with sinus floor bone
crowns. If a patient is found to be susceptible to chronic screw augmentation.89 Sinus bone grafting has a higher incidence of
loosening, the only way to definitively manage the problem is to complications and greater costs and requires additional surgical
remake the prosthesis into a splinted restoration. If an implant and healing time. However, short implants do have a higher risk
failure occurs with individual crowns, it may not be possible to of failure during the early healing period due to their reduced
place another short implant in the same site. In this situation an stability in softer bone.12
implant-supported partial denture may be necessary. The clinical trend is to favor shorter implant lengths in the
The advantages and disadvantages associated with not splint- posterior maxilla. Using shorter implants reduces the volume of
ing implants are summarized in Box 5-2. bone graft material that is needed for sinus floor augmentation
81

Region Vertical bone height Treatment option
Fig 5-17 Decision tree for implant placement in the posterior maxilla based on vertical bone height below the sinus.
and may even avoid the need for grafting. It may also allow the ridge for superior movement. All of these vertical bone augmen-
surgeon to consider an internal sinus floor elevation for shorter tation procedures are technically difficult and require advanced
implant placement rather than a lateral window technique90 (Fig surgical skills. Even when performed by experienced surgeons,
5-17). For example, a vertical bone height of 6.0 mm below the complications are not uncommon, and failure can occur.96 These
sinus floor would allow placement of a 6.0- to 8.0-mm implant via procedures also increase cost and risk morbidity for the patient.
a transcrestal approach (Figs 5-18 and 5-19). If a lateral window Most clinicians stage the augmentation procedure and place
approach is used for sinus grafting with simultaneous implant implants secondarily, increasing the overall length of treatment.
placement, it may also be advantageous to consider using a Studies on treating the atrophic posterior mandible with short
shorter length implant (Fig 5-20). The bone graft surrounding implants versus various bone augmentation procedures for
the portion of the implant within the sinus cavity provides no longer implants have concluded that the short implant option
additional primary stability. Less sinus mucosa manipulation was preferred.97–100 Implant and prosthetic survival is similar in
and bone graft material is needed to place a shorter implant. A comparison studies, but there are more complications in the
smaller volume of graft material also requires less healing time augmented group. Another option to consider for managing the
for bone formation.91,92 Although there is no definitive bone partially edentulous patient with bilateral posterior atrophy is to
dimension needed before considering sinus bone grafting, there extract the remaining anterior teeth for implant placement in
also is a lack of substantive long-term data on shorter implants the anterior mandible. In this situation an immediately loaded
(< 8.0 mm) in the posterior maxilla. The decision to place short provisional prosthesis can be placed on the implants as well. This
implants versus sinus grafting for longer implants should be alternative may be preferred if the periodontal prognosis of the
based on long-term studies, implant design, sinus pathology, remaining teeth is guarded or the caries risk is high (Fig 5-22).
surgical experience, and patient preferences.87 When placing dental implants in the posterior mandible, it
Increasing bone height in the posterior mandible is more is critical to maintain a safe distance of a few millimeters from
complex and less predictable than vertical bone augmentation the mandibular canal. This allows for potential inaccuracies in
in the maxilla via sinus bone grafting. In the posterior mandible radiographic measurements, drilling depth, and implant inser-
vertical bone growth can be achieved by guided bone regeneration. With the effectiveness of shorter implant sizes, placing a
tion, block bone grafting, titanium mesh grafting, interpositional long implant and risking nerve injury is unnecessary. The minimal
grafting, or distraction osteogenesis. There is no consensus on height needed for placing a 6.0-mm-length implant in the atro-
the best method for vertical bone augmentation.93 Onlay bone phic posterior mandible would be least 8.0 mm of available bone.
augmentation in this area usually requires harvest of autoge- Therefore, vertical bone augmentation may not be required for
nous bone or use of a growth factor, such as recombinant placement of extra-short implants unless there is less than 8.0
human bone morphogenetic protein 2 or recombinant human mm of bone height superior to the canal (Fig 5-23). Ultra-short
platelet-derived growth factor BB94,95 (Fig 5- 21). Vertical graft- implants (4.0 mm) could be used when there is even greater
ing also necessitates flap release and advancement to obtain atrophy, but they are not available in every country.89 When there
passive primary closure. Interpositional grafting and distraction is minimal but adequate bone height in the posterior mandible
osteogenesis require the use of saws to perform osteotomies with horizontal resorption, it may be possible to perform buccal
over the mandibular canal that free a segment of bone from the augmentation for the placement of short implants (Fig 5-24).
82

a b c
Fig 5-18 (a) An osseodensification bur is used in a counterclockwise rotation to prepare the osteotomy below the sinus floor. (b) The implant
osteotomy is prepared to the sinus floor. Note the thin bone at the apex of the osteotomy with no sinus perforation. (c) A short tapered implant
is placed into the prepared site.
a b c
Fig 5-19 (a) An osteotome is used to elevate the sinus floor. (b) An extra-short implant (6.0 mm) is placed into the prepared site. (c) Radiograph
of the extra-short implant restored with a screw-retained crown. Note the internal lift of the sinus floor.
a b
Fig 5-20 (a) An 8.0-mm implant is placed following a lateral window approach to elevate the sinus mucosa. (b) Periapical radiograph of the short
implant following placement and grafting.
a b c
Fig 5-21 (a) Vertical augmentation in the atrophic posterior mandible with autogenous bone in a titanium mesh. (b) Placement of four dental implants
in the augmented posterior mandible after 4 months of graft healing. (c) Radiograph of the implants restored with splinted crowns.
83

a b c
Fig 5-22 (a) Severe bilateral atrophy of the posterior mandible. (b) Bone
reduction following extraction of the anterior teeth. (c) Four implants were
placed into the mandible: two posterior tilted implants and two anterior
vertical implants. (d) The implants were restored with an immediately loaded
fixed prosthesis.
Region Vertical bone height Treatment option

canal - ridge crest
Fig 5-23 Decision tree for implant placement in the posterior mandible based on vertical bone height above the canal.
a b c
Fig 5-24 (a) A cortical bone graft was used for horizontal augmentation of the atrophic ridge. (b) Placement of an extra-short implant in the grafted
posterior mandible. (c) Axial view of the horizontal bone graft.
84

Consequences of Marginal Bone Loss
d e f
Fig 5-24 (cont) (d) Axial view after placement of the extra-short implant. (e) Three implants were
placed into the augmented posterior mandible. (f) The three implants were restored with splinted
crowns. (g) A periapical radiograph of the restored short implants.
Fig 5-25 (a) Short and standard-

length implants in the posterior
mandible, restored with splinted
crowns. (b) Marginal bone loss
resulting in peri-implantitis and
implant failure.
a b
CONSEQUENCES OF MARGINAL using a longer implant. However, in this scenario both implants
would have compromised health and a questionable prognosis
BONE LOSS (Fig 5-25). Peri-implantitis around rough-surfaced implants can
be difficult to resolve. Although favorable short-term outcomes
A common concern with the use of short implants is the con- have been reported, a lack of disease resolution following treat-
sequence of bone loss, but short implants are not more sus- ment as well as progression or recurrence of the disease with
ceptible to marginal bone loss than longer implants.101 How- implant loss has also been found.102 When significant bone loss
ever, if peri-implant disease does occur, it could have a more has occurred, early removal of an ailing short implant could pro-
significant impact around short implants. For example, a loss vide a better prognosis for retreatment, as there may be more
of 3.0 mm of marginal bone around a 6.0-mm implant would remaining bone and it would be easier to remove a short implant.
be 50% of the total length. A loss of 3.0 mm of bone around Severe bone loss around a short implant would result in failure,
a standard 12.0-mm implant would be only 25% of the total which may not cause as much devastation as progressive bone
length. It would appear that this could be a distinct advantage of loss around a longer implant.
85

a b c
d e
Fig 5-26 (a) Preoperative view of the severely atrophic edentulous mandible. (b) Placement of
extra-short implants. (c) Following placement of four short implants. (d) Panoramic radiograph
following implant placement. (e) A bar fabricated using computer-aided design/computer-assisted
manufacture connecting the short implants. (f) The mandibular implant bar overdenture.
COMPLETE EDENTULISM This implant system has the advantage of not requiring bone
grafting. However, it necessitates a special implant armamen-
The severely atrophic edentulous mandible has been traditionally tarium, general anesthesia, and an extraoral skin incision.
managed by autogenous bone grafting to allow placement of Short implants offer another solution for the severely atrophic
dental implants. This requires general anesthesia for iliac bone mandible, and they can be performed in an office setting under
harvest and a possible hospital stay for recovery. The patient local anesthesia. No special equipment is required because
cannot wear a complete mandibular denture during healing of conventional implant systems can be used. The implants are
the bone graft to avoid trauma. Following a 4-month healing placed in the anterior mandible between the mental foramina.
period, standard-length implants are placed in the reconstructed Typically, four short implants are placed submerged, so patients
anterior mandible. Upon osseointegration of the implants, they are able to wear their relined denture during healing. Following
are uncovered for restoration with a fixed prosthesis or overden- implant exposure, abutments are inserted for fabrication of an
ture. Although this approach provides predictable outcomes, it implant-connecting bar and overdenture (Fig 5-26). The surgeon
is associated with high costs, general anesthesia, pain and mor- must be careful to avoid mandibular fracture when placing short
bidity from the iliac bone harvest, and limited use of the denture dental implants in the severely atrophic jaw because the implant
during graft healing. The treatment length is also extended to osteotomy weakens the thin mandible.103 Tapping the dense
allow healing of the bone graft. bone is often necessary to reduce stress during implant inser-
Another option for treating severe mandibular atrophy is the tion. Stellingsma et al104 evaluated 60 patients with extreme
use of transosteal or transmandibular implants. They are usually mandibular atrophy treated using iliac bone augmentation with
placed under general anesthesia. Access to the atrophic mandi- implants, a transmandibular implant, or placement of four short
ble is made inferiorly via a submental incision. The implant oste- implants. During the 10-year observation period, significantly
otomies are made through the anterior mandible for placement more implants were lost in the transmandibular (23.7%) and
of the implant posts, and a metal base plate fits against the infe- the augmentation groups (12%) compared with the patients
rior border. The transosteal posts are splinted intraorally with a provided with short implants (1.2%). They concluded that the use
connecting bar that has attachments that retain an overdenture. of short implants in combination with an overdenture is the first
86

Conclusion
a b c
Fig 5-27 (a) Advanced atrophy

in an edentulous maxilla. (b)
Placement of a short implant
in conjunction with nasal floor
elevation. (c) Placement of six
short implants. (d) Panoramic
radiograph after implant place-
ment. (e) Fixed prosthesis sup-
ported by the short implants.
d e
choice of treatment in patients with extremely resorbed mandi- failed because of infection, and short implants were placed. One
bles. Seemann et al105 reported on 17 patients with severely atro- implant failed in the augmented group, and two short implants
phic mandibles treated with four extra-short (5.0 mm) implants failed in two patients; the failures occurred before loading. All
to support a fixed, full-arch, fiber-reinforced resin partial denture. postoperative complications occurred in the augmented patient
The cumulative implant survival rates were 98.5%. After 5 years group. There was no significant difference in marginal bone
the mean marginal bone loss at the mesial implants was 1.5 ± 1.0 levels around the implants in both groups. The authors concluded
mm and at the distal implants was 2.2 ± 1.7 mm. They concluded that short implants may be a suitable, less expensive, and more
that the use of four short implants was a cost-effective, safe, expedient alternative to longer implants placed in bone grafts for
and stable alternative for prosthetic restoration of the severely rehabilitating edentulous atrophic maxillae. Another prospective
atrophic mandible. The use of two short implants for overden- study on 18 patients with severe maxillary atrophy evaluated the
ture support has also been suggested as a possible option for use of four short implants (4.0 × 5.0 mm or 3.0 × 8.0 mm) for
elderly, dependent patients with severe mandibular atrophy.106 support of a fiber-reinforced resin fixed prosthesis. The cumula-
Historically the atrophic edentulous maxilla has also tive 1-year patient-based implant survival rate was 88.8%, and
been managed with bone augmentation for placement of the cumulative 1-year implant-based survival rate was 97.2%.
standard-length implants.107 Bilateral sinus bone grafts are The marginal bone loss was minimal (< 1.0 mm) after 1 year.
performed in conjunction with onlay bone augmentation of the No prosthetic failures occurred within the first year of load-
anterior maxilla if needed. Multiple implants are then placed after ing.109 However, these preliminary results on short implants for
graft healing. The use of bilateral zygoma implants can avoid the severe maxillary atrophy need to be confirmed by larger trials
need for sinus bone grafting in these cases. Standard-length with longer follow-up.
or short implants can then be placed in the anterior maxilla to
provide full-arch prosthetic support. When there is a lack of
adequate available bone for implant placement in the anterior
maxilla, the use of two zygoma implants on each side of the CONCLUSION
maxilla (quad zygoma) can be used as abutments for a fixed
prosthesis. The placement of multiple short implants may offer The use of short dental implants for prosthetic support offers
another option for the atrophic maxilla when there needs to be several advantages over longer implants associated with ver-
enough residual bone (Fig 5-27). A recent randomized controlled tical bone augmentation. The concerns regarding increased
trial compared short implants versus bone augmentation for the biologic complications with short implants, such as bone loss
placement of longer implants in atrophic maxillae.108 Twenty-eight and implant failure, appear to have been overstated. There are
patients with 5 to 9 mm of residual bone height and adequate potential mechanical problems related to greater crown heights
ridge width were randomized into two groups to receive either that may require modifications in the design of the prosthe-
four to eight short (5.0 to 8.5 mm) implants (15 patients) or an sis. Although present research has shown that short implants
iliac bone graft to allow the placement of at least 11.5-mm-long provide favorable outcomes, long-term studies are needed to
implants (13 patients). One bilateral sinus elevation procedure confirm their use as a preferred option in atrophic conditions.
87

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90

6 GEORGE A. MANDELARIS • BRADLEY S. DEGROOT
The Evolution of
Imaging and Associated
Applications for Implant
Surgery
Accuracy, Precision, and Predictable Implant
Success
Defining the Digital Evolution in Periodontal and
Implant Therapy
Dynamic Navigation
Haptic Simulation and Robotically Assisted
Dental Surgery
The Importance of Planning for Predictable
Therapy: Applying a Global IDT Approach
Balancing Technology and Clinical Skillset
Future Directions
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6 | The Evolution of Imaging and Associated Applications for Implant Surgery
T
he evolution of dental implantology is progressively intraoperative technologic guidance was nonexistent or, at best,
shifting from an analog base to one of complete rather crude and rudimentary. From the late 1980s to the early
digital application for diagnostic planning and execu- 2000s, medical-grade spiral (helical) CT had been the dominant
tion. The widespread acceptance of osseointe- diagnostic modality for cross-sectional imaging in oral implan-
grated implants in the mid- to late 1980s (attributed to the tology, and surgery was a freehand, mentally guided/navigated
clinical success benchmarks established by the Brånemark event. Practical and specific dental applications of CT imaging
system1–4) initially relied on two-dimensional (2D) imaging beyond anatomical inquiry had yet to be developed.
limited to traditional radiographs, such as panoramic films. From a comparative perspective of currently available tech-
Prosthetic and patient outcomes depended mainly on the over- nologies, this early scenario served the treatment goals of
all expertise and skillset of the individual implant surgeon and neither the patient nor the clinician. Without advanced imag-
prosthodontist. At that time, final tooth or prosthesis position ing, clinicians’ capabilities relied much more on a comfort level
was not considered in the planning phase or execution of the driven by skillset and expertise in surgery, while discussions
surgery. Implant fixtures were placed in the best available of patients’ prosthetic expectations offered a narrower range
bone, generally with little to no consideration for the future of options compared to the patient-centric model of today.
prosthetic outcome. Interestingly, analysis of potential causes of late-stage implant
Ongoing advances in three-dimensional (3D) imaging diagnos- failures and diseases are now spotlighting fixture position
tics are assuming progressively pivotal roles in implant planning variables that can be traced back to preventable errors in
and execution. The increasingly widespread acceptance of cone the surgical setting.26 Some errors are suggested to be the
beam computed tomography (CBCT) as the standard of care for primary contributing factors in the development of peri-implant
implant surgery is driving continued advancements in the dental diseases, an emerging problem with an estimated prevalence
profession. Its use in conjunction with implant-planning software approaching 47%.27
including dynamic navigation systems for implant placement
and those incorporating haptic simulations5–7 and robotic assis-
tance,8–12 offers the potential for improved surgical outcomes
but also raises important questions. DEFINING THE DIGITAL
Four pivotal breakthroughs are responsible for the evolution
EVOLUTION IN PERIODONTAL
of the standard of care for present-day implant dentistry: (1) the
discovery and high success of osseointegration by Brånemark AND IMPLANT THERAPY
and colleagues1–3,13–16; (2) the progressive adoption of CT imag-
ing technologies (beginning with medical-grade CT) to facilitate The evolution of imaging related to implant therapy over the
planning, leading to surgical outcomes in parallel with optimal, past three decades and as it exists today as a key component
prosthetically directed prosthetic positioning12,17–20; (3) the use in the interdisciplinary dentofacial therapy (IDT) model can be
of computer-generated stereolithographic surgical guides5–8,20–23; categorized into four main periods, as described in the follow-
and (4) the adoption of CBCT imaging, which uses reduced radi- ing sections.
ation exposure and facilitates expanded access to 3D imaging
technology in private dental practices.9,10,24,25
A critical variable in this equation is how technology is impact- Analog diagnostics and freehand surgery
ing the costs of implant diagnostics, surgery, and prostheses (1982–1994)
for the patient relative to sustainable outcome predictability, as
well as its impact on overall cost to the individual private prac- Prior to the use of CT imaging, “surgical tourism” was largely
tice business model. Indirectly, the costs involved in embracing the method of anatomical discovery. Beginning in 1988, the
“digital dentistry” are, in part, driving a trend toward a group introduction of dental CT (pioneered by the work of Rothman
practice model with network-based digital implant-planning and Schwarz28–31) offered high-resolution thin-section CT as a
technology and increased interdisciplinary collaboration. more precise and accurate treatment-planning modality for the
preoperative evaluation of regional anatomy in the mandible and
maxilla prior to dental implant surgery. Importantly, this afforded
not only the surgeon, but also the restorative dentist, better visu-
ACCURACY, PRECISION, AND alization and awareness of bone volume, bone quality, and the
PREDICTABLE IMPLANT SUCCESS identification of key anatomical structures (such as the inferior
alveolar canal and associated foramina as well as the maxillary
Historically, accuracy (the quality or state of being correct or and nasal sinuses) in the planning phase.28
precise) and precision (the degree to which the result of a mea- The transition from traditional plain film 2D radiography to
surement, calculation, or specification conforms to the correct the incorporation of medical-grade CT, offering a previously
value or to a standard) relied almost exclusively on the exper- unavailable window into patient anatomy, proved to be a major
tise of the individual surgeon. Other than basic radiography, step forward in surgical safety and planning. However, the
92

Defining the Digital evolution in Periodontal and Implant Therapy
Fig 6-1 The DentaScan. CT-based evaluation of the mandible from an early medical-grade CT scan.
There is no tooth position reference considered, only evaluation of bone and regional anatomy.
(Reprinted from Mandelaris et al33 with permission.)
a b
Fig 6-2 (a and b) First-generation SimPlant planning software. Axial, cross-sectional, and panoramic planes were viewable and evaluated in 1-mm
increments. 3D imaging was not available. (Reprinted from Mandelaris et al33 with permission.)
analytical and interpretation methods were crude, and imag- 3D digital diagnostics and freehand surgery
ing was viewed via plain film. Multiple (usually 30 per minute)
(1994–2000)
axial slides were taken for the maxilla or mandible, each gener-
ally 1-mm in thickness, and were reformatted in the sagittal From the mid-1990s to 2000, singular interactive computer
and coronal planes. This became known as the DentaScan (GE software–based planning emerged in the marketplace to man-
Healthcare)32,33 (Fig 6-1). While incredibly cumbersome and labor age and apply Digital Imaging and Communications in Medicine
intensive to read through entirely, it was a beginning phase in (DICOM) data obtained from medical-grade CT. In the early
which the dental surgeon was forced, by default of the tech- 1990s, SimPlant (Materialise, now Dentsply Sirona), software
nology used, to recognize and apply spatial concepts in order that facilitated surgical-prosthetic collaboration, was introduced
to understand the surgical anatomy. 3D modeling from skeletal to the marketplace and offered individualized, digital presur-
imaging was not available, and it was up to the individual clini- gical planning (Fig 6-2). Axial, cross-sectional, and panoramic
cian to interpret the data and apply it for more careful surgical images were available for viewing and planning. No interactive
intervention. Before this era, the use of medical-grade CT was 3D modeling was available. The criticism at the time was that
limited to craniofacial surgery, head and neck infection, and while the clinician may be better prepared for surgery, more
other medical surgery or situations that were not considered precise in individualized treatment planning, and better able
elective dental therapies. The dental implant patient in this era to provide informed consent, there was no transfer applica-
was primarily the patient with complete edentulism and such tion of the computer-based surgical plan directly to the patient
highly resorbed jaws that they were unable to wear a functional during the procedure. An “indiscriminate use of radiation” and
denture. Restoring the ability to chew was the primary goal for “lack of surgical expertise and training” were often attributed
quality of life improvement for these patients, with esthetics to those who were early adopters of advanced imaging for sur-
being an afterthought of treatment. gical therapy. Since the ability to transfer planning simulations
Of importance, the expanded use of CT in implant plan- to the patient did not exist, conventional surgical guides made
ning—by default—forced outside-the-box thinking because the from vacuum-formed wafers based on a duplicate model of
cross-sectional, axial, and sagittal images gave the clinician the diagnostic wax-up were considered an elite level of pros-
more raw patient data that required a commensurate increase thetically based surgery for partially edentulous patients, while
in information management capabilities. This was a true para- anatomical landmarks identified during surgery were used for
digm shift for the profession. those who were completely edentulous.
93

a b
Fig 6-3 Conventional scanning and sur- Fig 6-4 (a and b) Examples of masks of the maxilla, scanning appliance at the lateral incisor sites, and
gical template. A 0.040 vacuum-formed the canines and central incisors for detailed treatment planning to replace congenitally missing maxillary
wafer is used to create the conven- lateral incisors. (Reprinted from Mandelaris et al33 with permission.)
tional template. The prosthetically
proposed tooth positions are coated
with barium to create a silhouette of
the optimal final prosthetic tooth posi-
tion. (Reprinted from Mandelaris et al33
with permission.)
a b
Fig 6-5 (a and b) Medical model of the mandible with sequential, stereolithographic static surgical guides (partially guided surgery) for progressive
osteotomy site preparation in the anterior mandible at the 2- and 3-mm level. (Reprinted from Mandelaris et al33 with permission.)
a b
c d
Fig 6-6 (a to e) Mucosa-supported sequential stereolithographic static surgical guides (partially guided surgery) for progressive osteotomy site
preparation in the edentulous maxilla at the 2-mm, 3-mm, and 4-mm levels. Implant placement is performed without guidance (ie, freehand).
(Reprinted from Mandelaris et al33 with permission.)
94

The prosthetically directed approach: A barometer 3D interactive, integrated, computer

of outcome assessment software planning and static guided surgery
With this information, the concepts of top-down planning and (2000–2016)
prosthetically directed treatment planning were established.
Mecall and Rosenfeld built upon the principle of planning in The aforementioned technology gap spurred the develop-
reverse with the introduction of medical-grade CT scans used ment of medical modeling and CT-guided surgery using the
in conjunction with diagnostic wax-ups and subsequent radi- first bone-supported surgical drilling guide (SurgiGuide, Mate-
opaque scanning appliances, which were initially barium sulfate– rialise), which was progressively documented with published
coated templates (fabricated from vacuum-formed wafers using research on its use through 2014 and beyond.21–23,36–40
a duplicate stone cast of diagnostic wax-ups), to proactively The application of stereolithographic principles and techniques
visualize and optimize prosthetic tooth position in space rela- to dental implant treatment involved the fabrication of medi-
tive to regional anatomy19,34 (Fig 6-3). These templates could cal models and subsequent bone-supported sequential stere-
also be used in surgery to ensure that implant positioning was olithographically and computer-generated surgical guides (ie,
commensurate with the planned optimal prosthetic position. static guides) for osteotomy site preparation alone. This was
This led to the published concepts of a prosthetically directed a paradigm shift in how implant surgery was performed as it
approach and optimal final prosthetic tooth position associated demanded presurgical CT-based implant planning to occur prior
with the use of CT assessment of residual ridge resorption to surgical intervention. In addition, it required “blind trust” on
patterns relative to implant placement and proper anatomical the part of the surgeon with regards to the accuracy and preci-
and physiologic orientation of the restored implant.17–19 Such sion of such technology since there was no representation of
concepts also allowed the implant team to use presurgical tooth position to regional anatomy using these static guides (Fig
prosthetic outcome information to make collaborative patient 6-5). At their inception, stereolithographic surgical guides were
care decisions about desired tooth positions relative to existing bone-supported, sequential drilling templates that allowed oste-
regional anatomy. Improvements in computer software eventu- otomy sites to be enlarged and controlled only in buccolingual
ally allowed 3D reconstruction and modeling from axial, sagittal, and mesiodistal orientations.14,41 These applications have been
and coronal DICOM data. In addition, individualization of struc- referred to as a partially guided approach to implant surgery.
tures with differing Hounsfield unit densities in 3D became Implant placement remained freehand as the implant itself could
possible through the use of masks that allowed even more not be delivered through the surgical template. Soon, opportuni-
interaction through software planning for improved planning ties for tooth-, tooth/mucosa–, and mucosa-borne static guides
and case scrutiny (Fig 6-4). From a diagnostic standpoint, case allowed more minimally invasive, and in some cases completely
type patterns were established based on the presenting anat- flapless, surgical options (Fig 6-6).
omy of the patient and the desired prosthetic outcome. These Static guided surgery for implant placement quickly became
case type patterns served to guide the restorative practitioner more mainstream in the surgical disciplines of dentistry with
or prosthodontist in creating a diagnostic wax-up or trial tooth specific implant applications. They have continued to be used
setup that would lead to a diagnostically meaningful scanning for all modalities of partially or totally guided surgery and are
appliance design for optimal, prosthetically directed imaging referred to as static guides because once they are constructed,
diagnostics and planning.35 there is no opportunity to change the treatment plan and still
The introduction of computer software–based treatment plan- use the guides. Stereolithographic guide use can be hampered
ning modalities, such as Simplant, allowed medical-grade spiral by inaccurate planning and guide fit, movement of the guide
CT to integrate with computer software and provided a more during surgery, and bone density difficulties that require angu-
practical application of DICOM data interpretation for anatomy lation changes during placement.8,20 The critical disadvantage of
review and planning. With this breakthrough, a prosthetically static guided surgery is that inaccuracies in the guides cannot
directed approach to implant planning had begun, although it be identified until the time of surgery, or worse, after implant
still required the clinician to use mental guidance/navigation in placement (Fig 6-7).
order to execute surgery. During this period, patient selection for The effect of stereolithographic surgical guides was immediate,
dental implant surgery expanded from only those with complete reducing entry point deviations and angle discrepancies by nearly
edentulism to patients with partially edentulous situations, most 50% when compared with conventional freehand surgery.15,42
of whom had tooth extractions without socket preservation. In 2003, Sarment et al published a two-case series demon-
Esthetic outcomes of treatment also began to emerge as an strating advanced applications of stereolithographic templates
expected and additional benefit of dental implant therapy as to implement CT-generated data in complex implant cases,41
survival rates and predictability of treatment improved through confirming the accuracy demonstrated in an in vitro study of
implant surface technology, planning applications, and refined such guided surgery.42 In 2014, Vercruyssen et al reported on a
surgical/prosthetic techniques. randomized, prospective study comparing the accuracy obtained
using static pilot-drilling templates from several providers with
that obtained from freehand (mental navigation) surgery in 72
95

a b c
Fig 6-7 (a) Medical model of partially edentulous maxilla with sequential stereolithographic bone-supported static surgical guide for partially guid-
ed surgery at the 2-mm level. (b) Intraoperative view of surgery demonstrating the use of the static, partially guided approach to surgery during
osteotomy site preparation. (c) Intraoperative view of guide pins in osteotomy sites at the stage of final osteotomy site preparation (3-mm level).
When compared to the tooth position verification template, accurate osteotomy site preparation has not been achieved by the static guide. At this
level, no further changes can be made to move osteotomy site positions without compromising primary stability of the fixtures. The conventional,
tooth-supported surgical template demonstrates the prosthetically planned tooth position, and each osteotomy site is in the embrasure spaces,
highlighting the inaccurate positioning of the bone-supported stereolithographic surgical template.
a b c
Fig 6-8 (a) Medical model of completely edentulous mandible with colorized vital structures (inferior alveolar nerve) and preplanned osteotomy
sites with implant analogs positioned (4.1-mm external hexagon configuration). (b) Mucosa-based, SAFE SurgiGuide for totally guided implant
surgery. (c) Intraoperative view of SAFE SurgiGuide system with 4.1-mm implant mounts used to deliver the implants at preplanned positions in
a flapless manner. (Reprinted from Mandelaris et al33 with permission.)
fully edentulous jaws. Their results confirmed other research that site preparation alone to one surgical guide for osteotomy site
guided implant placement is superior to freehand surgery.13,43 preparation and implant placement was introduced with the
No statistically significant differences between the accuracies SAFE system (Materialise). The introduction of the SAFE (acro-
obtained with different static guided systems were observed. It nym for secure, accurate, flexible, and ergonomic) system36
has become clear that osteotomies performed via static guides offered clinicians the first stereolithographic guide to provide
are more accurate than freehand osteotomies, with system- an innovative foundation for the mainstream use of computer/
atic reviews reporting less than 1 mm of deviation from entry CT–guided implant placement.36 The SAFE SurgiGuide system
point and angular discrepancy of less than 5 degrees, on aver- was limited to 4.1-mm external hexagonal implants, which was
age.44,45 Unfortunately, the potential for significant error still the most widely used implant system worldwide at the time
remains a concern because of the exponential impact of errors (Fig 6-8). With the ability to have a single surgical guide for oste-
and corresponding complexities left for correction in the pros- otomy site preparation and implant placement in addition to
thetic phase. While overall error averages may be significant medical models, surgical dress rehearsals could be performed
improvements compared with freehand surgery averages, the prior to intervention, which simplified complex surgery and the
standard deviations of published errors for static guided surgery immediate restoration. Implant manufacturers soon realized
are considerable and even lead clinicians to question the use of the value in system cross-compatibility and began to produce
such technology.44–46 Further, because there is no reference to implant mounts that enabled delivery of manufacturer-specific
tooth position using static guides, entry-point and angle discrep- implants through the SAFE SurgiGuide.
ancies are usually not realized until after the fact (see Fig 6-7). With the increasing popularity and adoption of CT-guided
Understanding such errors also requires the use of registration implantology in the profession, the transition to company-specific
software that is typically not available in private practice and CT guided systems emerged. However, more individualized
requires additional imaging after implant placement. applications of CT-guided technology often necessitated that
The eventual upgrade from sequential stereolithographi- individual clinicians align themselves with an implant manu-
cally or computer-generated surgical guides for osteotomy facturer and their specific armamentarium. In addition to the
96

a b c
d e
Fig 6-9 (a to c) 3D planning for a maxillary dentition in which full-arch extraction and im-
mediate implant placement and loading is planned using the Navigator (Zimmer Biomet)
fully guided implant system. Definitive prosthetic position is demonstrated in a transparent
trial tooth setup (purple denture) that is used during planning. (d) Cross-sectional planning
with a virtual implant, abutment, and crown in a case where tissue engineering for im-
plant site development has previously been performed. (e) 3D modeling of implant site
after tissue engineering, with masks created to enhance planning (maxilla; neighboring
teeth; mesh for space maintenance; virtual implant, abutment, and crown; and immedi-
ate provisionalization efforts). (f) Internal hex of virtual implant visualized in 3D software,
allowing for timing of the rotation of the implant during placement. Fully guided static
surgical therapy will reproduce the mesiodistal, buccolingual, apicocoronal, and rotation g
orientation of the planned implant dimensions. (g) Rotational timing demonstrated using
the Navigator fully guided surgery system, whereby the flat side of the hex is oriented
as planned preoperatively. (Reprinted from Mandelaris and Rosenfeld48 with permission.)
advantages offered by the SAFE SurgiGuide system in buccolin- fore, osteoplasty is often required to create a more ideal crestal
gual, mesiodistal, and apicocoronal positioning control, rotational bone topography prior to osteotomy site preparation and implant
timing control of the implant hex position became feasible, but placement. As a result, stereolithographic bone reduction cutting
was specific to the implant and/or guide manufacturer8,17,20,47,48 (Fig guides for precision osteoplasty became available (Fig 6-11).
6-9). Proprietary examples include NobelGuide (Nobel Biocare), With such a radical change in the surgical implant dentistry
Navigator (Zimmer Biomet), and Facilitate (Astra Tech). This next sector, the expectations of and within the clinical team also
step forward in static guided surgery became known as the changed. The concepts of “collaborative accountability”
“totally guided approach” to implant surgery20,49 and was made and “restorative leadership,” introduced by Rosenfeld and
possible by the invention of a concept that was initially known as Mandelaris in 2006,23,52 have come to represent a treatment
the “regulator” and later was termed prolongation.50 Prolongation philosophy whereby:
is a critical concept in determining feasibility, guide development/
fabrication, and realistic execution of vertical depth control in 1. Prosthetic outcomes determine surgical requirements that
computer-guided implant surgery using computer-aided design/ the implant surgeon must follow. This information should
computer-aided manufacture (CAD/CAM) stereolithographic be used to determine treatment limitations and costs
surgical guides (Fig 6-10).48,51 However, postextraction resid- preoperatively.
ual ridge resorption patterns do not allow for straightforward 2. Preoperative rather than intraoperative planning drives
implant placement in the maxilla or the anterior mandible. There- treatment.
97

In the prosthetic arena, software improvements in planning

Supporting surface
(bone or mucosa) applications included the ability to visualize and plan virtual
SurgiGuide
implants (specific to an implant manufacturer), virtual tooth
setups, and virtual (patient-specific) abutment designs (see Fig
Tube: 5 mm 6-9). Applications eventually became available to combine totally
IMPLANT guided implant placement with CAD/CAM design and fabrica-
PROLONGATION tion of abutments and provisional restorations prior to surgical
execution, importantly, without having to obtain a traditional
impression. Intraoral surface scanning for digital impressions of
Implant height intraoral structures became available (Fig 6-14), eliminating the
need for traditional impressions to secure preliminary impres-
sions and thereby improving the patient experience and reducing
chair time while maintaining a high level of accuracy.
A 2017 systematic review by Rutkunas et al concluded
that, while digital impressions offered a valid alternative to
Implant conventional impressions, most of the reviewed data were
from in vitro studies and reliable clinical data were lacking.54
Fig 6-10 The concept of prolongation, enabling totally guided static sur-
gery to become possible. (Reprinted from Mandelaris and Rosenfeld51 Randomized comparative clinical trials evaluating digital versus
with permission.) conventional implant impression techniques have centered on
impressions for single implant crowns and evaluating the pref-
erences of patients55 and operators56 (including dentists and
dental students): both patients and operators reported a prefer-
3. Stereolithographic modeling (with SurgiGuide) reduces the ence for intraoral scanning over conventional impressions. Both
surgical talent gap. In other words, the placement of dental of these studies reported greater time efficiency for intraoral
implants no longer relied on traditional mental navigation but scanning versus conventional implant impressions.55,56
rather on precise, computer-guided implant positioning that The use of intraoral scan bodies (ISBs) (implant abutments
is planned presurgically. designed for digital impression scanning) has also received
4. The restorative practitioner assumes a leadership role in inter- considerable attention as a modality to facilitate or enhance the
disciplinary collaboration by setting treatment performance digital scanning and transfer of complex intraoral spatial infor-
standards for those participating in patient care. mation (including implant positioning) into the digital implant
5. The collaborative process, by its nature, focuses on patient restoration workflow to produce 3D virtual and physically milled
outcome as the primary variable. definitive casts. A 2018 systematic review by Mizumoto and
Yilmaz57 concluded that ISBs are a potentially pivotal compo-
While static guided surgery was a major step forward in deliv- nent with high relevance to all phases of the digital implant
ering more accurate and precise outcomes through interactive restorative workflow, but reliable clinical data on their diverse
treatment planning and computer-generated surgical guides, the configurations, designs, and reliable applications are lacking. A
disadvantage of a totally guided surgical approach is, as previ- 2016 in vitro study by Flügge et al identified the following signif-
ously mentioned, that there is little or no opportunity for correc- icant discrepancies: (1) between scan bodies used intraorally
tion once the plan has been set. This is further complicated by and those used in the dental laboratory, (2) in scanning preci-
the fact that verifying the positional accuracy of the SurgiGuide sion according to the distance between the scan body and the
was still somewhat intuitive. Furthermore, Testori et al showed scanning device, and (3) in distance and angle measurements
that in most cases, the exact position of the stereolithographic among the three different scanning systems tested.58 In a 2014
surgical guide, whether bone-, tooth-, or mucosa-supported, is study, Joda et al reported a single case in which one scan body–
not consistent with the actual plan.53 based digital impression system (referred to as the individualized
As a natural evolution in surgical guide planning and fabrication, scanbody technique) facilitated transfer of the implant platform
some software programs enable the clinician to digitally plan bone and soft tissue emergence profile of the implant crown with a
reconstruction and print stereolithographic medical models, so favorable esthetic outcome.59
much of the surgical hardware required for space maintenance In the planning phase, these 3D models generated from
can be ready in advance of the surgical procedure. This reduces STL (stereolithographic) files are highly accurate and can be
operative time and increases efficiency of surgical execution. Digi- merged to DICOM data for more comprehensive planning.
tally guided bone regeneration applications (Fig 6-12) and stereo- Much of these digital modalities have been driven by DICOM
lithographic cutting guides became available as special requests, data obtained via CBCT scans and computer planning software
with combination applications incorporated in the same guide for on some level. A proprietary example of such an application
cutting paths of osteotomies along with implant osteotomy site breakthrough is the guided surgery and fabrication of CAD/
preparation and implant placement (Fig 6-13). CAM polymethyl methacrylate (PMMA) provisional restorations
98

a b c
Fig 6-11 (a) Medical model of mandible with unusable bone that requires precision osteoplasty.
(b) Stereolithographic bone reduction guide constructed for precision osteoplasty, which was
simulated on the medical model. (c and d) Intrasurgical views before and after digitally planned
precision osteoplasty using a bone reduction guide. (Reprinted from Mandelaris and Rosenfeld48
with permission.)
a b
c d e
Fig 6-12 (a) Preoperative imaging of edentulous bilateral maxillary lateral incisor sites demonstrating advanced bone atrophy requiring guided
bone regeneration prior to and as a prerequisite to implant placement. (b) Digitally guided bone regeneration planned at the lateral incisor sites.
(c) Stereolithographic medical model of preoperative anatomical situation of the maxillary lateral incisor sites showing significant deficiencies. (d)
Stereolithographic medical model of planned augmentation completed digitally. (e) Mesh presurgically formed to the area where tissue engineering
for site development is planned, reducing the surgical time.
a b
Fig 6-13 (a) Presurgical implant plan for totally guided surgery at the maxillary left first premolar position along with desired cutting path simulated on
3D rendering for planned open sinus elevation using a lateral window approach. (b) Stereolithographic medical model with combined totally guided
static surgical guide plus a cutting guide for precise placement of the lateral window. (Reprinted from Mandelaris and Rosenfeld48 with permission.)
99

6 | THE EVOLUTION OF IMAGING AND ASSOCIATED APPLICATIONS FOR IMPLANT SURGERY
a b c
d e f
Fig 6-14 An intraoral surface scan digital impression. (a) The patient had a primary
molar extracted and an implant placed to replace a congenitally missing maxillary
left second premolar. (b to e) A scan body is attached to the integrated implant, and
a digital diagnostic wax-up is created and interfaced with STL (stereolithographic)
files for fabrication of the prosthesis. (f and g) Definitive screw-retained prosthesis
and abutment created without taking a traditional impression. (Prosthesis by Dr Todd
Manolis, La Grange Park, Illinois.)
a b c d
e f
Fig 6-15 (a to d) Presurgical planning of implant placement to manage a failing primary canine. A maxillary stone cast has been interfaced with the
CBCT planning software. Cross-sectional analysis demonstrates that an angle correction is necessary to avoid site development. The presurgically
constructed gold-shaded titanium Atlantis abutment made with angle correction is shown, along with a PMMA immediate provisional restoration
fabricated prior to surgery and planned for placement out of occlusal function. (Reprinted from Mandelaris and Vlk60 with permission.) (e) Presur-
gical planning to replace a maxillary right central incisor. The virtual implant, abutment, and provisional tooth proportions have been established
for the digital workflow of planning totally guided surgery, gold-shaded titanium Atlantis abutment connection, and immediate provisionalization
using a flapless/minimally invasive approach. (f) Stereolithographic maxillary model mounted on a conventional stone cast of the mandible. The
custom zirconia Atlantis abutment has been designed and milled to minimize soft tissue changes and maintain the soft tissue form for implant
placement in the canine site.
100100

a b c
d e
Fig 6-16 (a) Preoperative view of a terminal dentition suffering from advanced, nonrestorable caries. (b) 3D CBCT-based treatment plan for imme-
diate loading in the mandible. (c) Medical modeling with PMMA Immediate Smile prosthesis fabricated. The PMMA prosthesis has been fabricated
without taking a traditional impression but rather using the CBCT imaging data and virtual tooth planning. (d) Medical modeling with soft tissue
rendering and cylinders in place to analyze implant positioning so that immediate loading is simplified. (e) Completion of full-arch extraction, bone
reduction, and totally guided static surgery in the mandible with placement of the PMMA Immediate Smile prosthesis in function. (Reprinted from
Mandelaris and Rosenfeld48 with permission.)
available with the Atlantis (Dentsply) abutment systems60 (Fig Previously, determining the quality and success of osseointe-
6-15). The SimPlant Immediate Smile application enabled direct gration was a qualitative and subjective procedure. The integra-
laboratory milling of PMMA provisional restorations suitable for tion of ISQ data into decision making allowed for quantification
immediate loading, using digital export (STL) files from intraoral of treatment and technique parameters, reproducibility of data,
scanning in conjunction with digital wax-ups, patient-specific and thus collaboration and accountability across specialties
abutment designs, and virtual teeth (Fig 6-16). Intraoral surface participating in an evolving interdisciplinary treatment paradigm.
scanners can be used to register landmarks and retrofit a trial In 2002, about the same time that static guides begin to
tooth setup to the existing CBCT-rendered regional anatomy for emerge into the marketplace, CBCT imaging was first being intro-
prosthetically directed planning. This has made guided, full-arch, duced into the private practice sector, the greatest advantage
immediate-function treatment for patients who are planned for being the ability to provide 3D diagnostic imaging with dramati-
full-arch extraction simpler and more predictable when the exist- cally less radiation exposure as compared to medical-grade CT.61
ing tooth position does not match the outcome goals (Fig 6-17). The additional capability to generate stereolithographic surgical
This era introduced measures to better predict osseointe- guides from CBCT-based software plans alleviated most radi-
gration with the use of resonance frequency analysis (RFA) ation exposure concerns related to elective therapies. Today,
and the implant stability quotient (ISQ)—the digital recording cross-sectional CBCT imaging for planning, often in combination
of a value obtained through RFA to measure the stability of with a stereolithographic surgical guide when executing dental
the implant in the bone. The higher the value, the more stable implant surgery, is considered as the standard of care in many
and the more suggestive of osseointegration. The Osstell ISQ geographic locations.12,13,62,63
system uses a SmartPeg that inserts into the implant body and As the period of 3D interactive, integrated computer soft-
its RFA is measured by a wand. RFA technology was introduced ware planning and static guided surgery applications came
around 1996 but did not gain use in private practice until the to a close, additional applications of digitally based diagnos-
period of 3D interactive, integrated computer software planning tic therapy emerged, such as T-scan (Tekscan) for occlusal
and static guided surgery. It provides an objective analysis of and temporomandibular joint evaluations; the multifaceted
implant stability and integration (Fig 6-18). Up until this time, beginning-with-the-end-in-mind approach to esthetic treatment
osseointegration analysis and confirmation were made through planning offered by Digital Smile Design; and high-precision,
clinical exam, reverse torque testing, and radiographic review. network-based approaches to guided surgery and prosthesis
101

a b
Fig 6-17 (a) CBCT-based 3D rendering of maxillary and mandibular dentition planned for extraction. Existing tooth position cannot be used for implant
planning because it does not represent the correct prosthetic tooth position for reconstruction. (b) Trial tooth setup optically scanned and interfaced
with the preoperative CBCT-based 3D rendering of the regional anatomy to demonstrate existing tooth position (pink) versus the desired optimal
final tooth position for the maxilla (purple) and mandible (green). Implant planning can now commence based on the planned prosthetic outcome.
a b c
Fig 6-18 (a) Intrasurgical image showing implant placement in the maxillary left central incisor position, 6 months after tissue engineering for implant
site development. A SmartPeg is in place. (b) Occlusal view with an Osstell ISQ wand taking an RFA reading. (c) Reading is 80 ISQ, indicating a highly
stable implant and verifying the use of immediate provisionalization as well as helping to determine the appropriate loading/osseointegration time.
delivery for immediate loading such as nSequence (NDX).64 imaged for the patient. These questions have been recently
The nSequence guided surgery and prosthetics system, the addressed by the American Academy of Oral and Maxillofacial
most recent improvement gaining use in totally guided static Radiologists65 as well as the American Academy of Periodon-
surgery, is a stacking guided approach (or an “all-in-one” system) tology in position papers.63,66
whereby the bone reduction (or foundation) guide, implant guide
for totally guided surgery, and the immediate load or defin-
itive prosthesis can be managed in one guide. The system Personalized precision dental medicine:
simplifies the approach to guided surgery in complex cases Dynamic, virtual, and interdisciplinary
and makes the prosthetic phase more predictable. However,
such a protocol increases the level at which the CBCT imag-
treatment planning and surgery
ing and planning must be as accurate as possible.64 While the (2016–present)
nSequence guided immediate protocol has improved totally
guided implant surgery, it increases the cost compared with The most recent period can be described as the period of per-
traditional immediate loading therapies and generally requires sonalized and precision dental medicine, which began around
more invasive surgery when bone-supported approaches are 2016 and continues to evolve today. This era represents dynam-
needed64 (Fig 6-19). ically based virtual and interdisciplinary dentofacial treatment
With the use of CBCT, which provides enhanced fields of planning and surgery. It comprises three areas:
view for diagnosis and patient management, becoming common
in the private practice setting, there is now increased overall 1. 3D imaging-based modalities for treatment planning and ther-
responsibility, oversight, and documentation required of the apeutic execution.
ordering dentist. While CBCT is a true breakthrough in the 2. The emerging scientific field of “-omics” (genomics, proteom-
profession, it also introduces significant medicolegal and safety ics, and metabolomics), which seeks to provide individual-
questions about who is responsible for DICOM data interpre- ized risk assessment using molecular biomarkers found in
tation and documentation for the entire field of view that was saliva and/or blood.
102

a b c
d e f
g h i
j k l
Fig 6-19 (a) Presurgical presentation of a patient suffering from generalized severe chronic periodontitis. Treatment plan is for extraction of all
teeth simultaneous with totally guided implant placement and immediate occlusal function of the maxillary and mandibular arches according to
the nSequence guided prosthetic protocol. (b and c) Maxillary and mandibular 3D planning. (d) Extraction of the entire maxillary natural dentition
and fixation of the foundation guide, which serves as a bone reduction guide. Positioning of foundation guide is verified using a replica of the
immediate load prosthesis in relation to the existing mandibular natural dentition. (e) Totally guided implant placement in the maxilla with rotation-
al timing demonstrated. (f) Abutments and temporary cylinders have been seated, and the PMMA metal-reinforced immediate load provisional
restoration is seated to the soft tissue simulation (gasket). The prosthesis is seated in centric relation during curing of the temporary cylinders
using a prefabricated occlusal index. (g) Maxillary arch completed. Complete extraction of the natural dentition in the mandible is performed, and
the foundation guide is seated and verified using a replica of the PMMA provisional against the completed maxillary arch. (h) Bone reduction
performed in the mandible and totally guided surgical guide seated to the foundation guide. (i) Totally guided implant placement performed. The
surgical guide is subsequently removed, and the abutments and temporary cylinders are placed. The soft tissue simulation (gasket) is placed, to
which the prefabricated PMMA immediate load prosthesis is seated and luted, and occlusion is verified. (j) Completion of maxillary and mandibular
full-arch guided immediate function surgery/provisional prosthetics. (k) Definitive prosthetic phase completed. (Prosthetics by Dr Avi Stein, Skokie,
Illinois.) (l) Panoramic radiograph following completion of the definitive prosthetic phase.
3. The use of telemedicine, which is an emerging health care CAM provisionalization and associated laboratory technology
field whereby remote diagnosis and treatment of patients efforts, as well as improve the consistency with which accu-
can be facilitated by means of telecommunications tech- rate and precise surgical outcomes are achieved (for implants
nology. The goal of these technologies is to further improve and other therapies) in real time and with the opportunity for
patient diagnosis and prognosis, provide treatment plan- global networking/access (no geographical barriers or bound-
ning opportunities, facilitate/simplify and streamline CAD/ aries restricting consultation or patient care).
103

6
104
Nevins/Wang_Chap_06.indd 104
Innovations in planning
Innovations in surgery
Breakthroughs The Evolution of Imaging and Associated Applications for Implant Surgery
Emerging fields
Future directions
Period of Analog Period of 3D Digital Period of 3D Interactive, Integrated Period of Personalized

Diagnostics and Diagnostics and Computer Software Planning and Precision Dental Medicine
Freehand Surgery Freehand Surgery and Static Guided Surgery
1982–1994 1994–2000 2000–2016 2016–Present
Artificial
Traditional Barium-coated nSequence intelligence
radiographs templates used in Osstell system Adoption of
CBCT guided Facially prioritized
used for implant diagnostics and implant The invention of prosthetics and airway-centric
dental surgery stability quotient "the regulator" 3D guided treatment planning Meaningful and
(ISQ) introduced (aka prolongation) bone augmentation (3D based IDT) essential
DentaScan and the SAFE planning applications Virtual treatment
Use of medical SurgiGuide articulators planning from a
modeling and system Totally guided co-discovery
Medical- SurgiGuides implantology, Telemedicine context
grade CT Totally guided CAD/CAM, PMMA
introduced surgery prosthetics Haptic simulation
SimPlant Improvements and robotically
in 3D planning Merged STL files, assisted dental
(masks) digital wax-ups surgery (Yomi) Facial scanning
16
00
94
82
20
20
19
19
CBCT invented
(adopted later) Digital Smile Design Dynamic
Specialized navigation
| The Evolution of Imaging and Associated Applications for Implant Surgery
cutting guides
Osseointegration T-scan for
introduced to OMFS Information
applications Manufacturer- occlusal
dentristry specific totally evaluation management
(Toronto, 1982) guided applications Fields of -omics Expanded and data
Guided (genomics, applications
ostectomy processing
2D cross- proteomics, of surgical
sectional Partially guided (bone reduction Osstell system
Prosthetically surgery adopted metabolomics) orthodontics Augmented/
tomography directed approach, guides) (SFOT) in IDT virtual reality
mental navigation patient care treatment planning
Fig 6-20 Summary of the evolution of imaging, 1982 to the present. OMFS, oral and maxillofacial surgery; SFOT, surgically facilitated orthodontic therapy.
2/28/19 12:34 PM
Dynamic Navigation
Multi-therapeutic diagnostic planning platforms such as individual surgeons were observed in the navigated placement.
Nemotec are emerging with the objective of digitally gather- In another study published in 2017, Block et al also compared
ing clinical specialties in a single integrated suite of software prospective data from 478 patients involving 714 implants placed
applications. Future directions will require an increased focus on freehand or using fully or partially guided dynamic navigation
total planning of the patient’s care, integrating multiple sources (X-Guide); the results showed significantly less deviation from
of imaging technology, clinical findings, and laboratory tests. the planned parameters using both dynamic navigation protocols
This repertoire extends beyond the use of CBCT to encom- compared with freehand placement.45 Data from both of these
pass intraoral scanning, facial scanning, virtual articulators, studies44,45 suggest that dynamic implant placement affords
and assessment of facial dynamics (through video recording greater accuracy than freehand placement.
of speech, laughter, and overall facial expression), in addition to The workflow of second-generation dynamic navigation
molecularly based individual patient information to help make systems (ie, stent, scan, plan, place) and a case report on the
treatment decisions. Navident system has been published by Mandelaris et al.69 In
Figure 6-20 summarizes the evolution of imaging and asso- a 2018 retrospective case review of 231 implants in 89 arches,
ciated applications in implantology/surgery. Stefanelli et al76 evaluated dynamic navigation surgery via
pre- and postsurgical CBCT scans to assess the accuracy of
a dynamic implant placement guidance system (Navident) by
measuring entry point and apex deviations as well as angle
DYNAMIC NAVIGATION discrepancies using registration software inherent in the system
(EvaluNav). Using EvaluNav, the preoperative planned and post-
Dynamic navigation (or “virtual”) surgery is relatively common operative CBCT scans are registered to each other, and the
in other areas of medicine, such as craniomaxillofacial surgery, position of each implant is detected in the postoperative CBCT
neurosurgery, and orthopedic/spinal surgery.19,20,67,68 Surgical (Fig 6-22). Angle deviations between the actual and planned
navigation systems are made possible by motion-tracking tech- positions are automatically computed and reported through the
nology, commonly referred to as a micron camera.19,20,67,68 The software application, a useful option that has not been readily
micron camera enables guided navigation by tracking and instan- available outside an academic or research center. The applica-
taneously relating changes in the position of the implant drill tion has been validated on models by the manufacturer. They
tip and mapping it in real time to a previously acquired CBCT concluded not only that the navigation system was accurate for
scan of the patient’s jaw. This allows for continuous, immedi- implant placement, but was proportional to the experience level
ate feedback on the mesiodistal, buccolingual, and apicocor- of the surgeon. This further underscores the emphasis made in
onal positioning of the implant drill. The surgeon is thus able this chapter regarding the necessary synergy of guided implant
to prepare the osteotomy and place the implant based on the surgery and substantive clinical expertise.76
preplanned, prosthetically directed implant position. The ability The use of dynamic navigation systems entails substan-
for real-time verification and validation of positional accuracy as tial change to existing clinical workflows and habits as well an
well as the ability to change or augment planning on the spot up-front investment in equipment, training, and skill acquisi-
is important for optimal esthetic and functional outcome pre- tion, which initially may burden the current practice model and
dictability69 (Fig 6-21). slow the adoption of this technology. However, improvements
Image-guided surgical navigation for implant surgery was in software design and future applications to simplify the work-
introduced, demonstrated, and validated by a group in Vienna flow demands of dynamic navigation surgery will involve the
in 2002.70 Soon thereafter, two other systems were commer- elimination of the need for a stent. The use of trace registra-
cially introduced: the Robodent system (Vector Vision 2)71 tion mapping technology of the dentition and/or gingiva as well
and the IGI system (Image Navigation).70 Unfortunately, their as skeletal landmarks (bone) as references will emerge in the
cumbersome nature and cost prevented widespread accep- maxilla since it is a immovable bone. In the mandible, a tag
tance. However, newer-generation navigation systems such as reference fixed to the dentition (or the jaw itself) may always be
Navident (ClaroNav), Inliant (Navigate Surgical Technologies), required as a method to track its position since it is moveable
and X-Guide (X-Nav Technologies) have made this technology (Fig 6-23). Current research is in progress to make these future
more operator-friendly and cost-effective for the private practice directions a reality and simplify the workflow while optimizing
arena. The literature of the first-generation navigation systems patient outcomes.
demonstrated in vitro accuracy comparable to that of CT-based Dynamic navigation approaches continue to demonstrate
static totally guided surgery, reporting similar averages in entry advantages compared to static guides, most importantly the
point deviation and angle discrepancies.19–22,70,72–75 ability to change the plan during the surgery and use real-time
A limited number of studies have evaluated the accuracy of feedback. The technology allows for real-time verification and
dynamic navigation systems in vivo. In 2017, Block et al reported validation of positional accuracy for on-the-spot transparency
on the placement accuracy obtained by three surgeons using that static guides fail to offer. In addition, dynamic navigation can
dynamic navigation (X-Guide) to treat 100 partially edentulous be used with the standard surgical kit of any implant system, can
patients.6,44 No statistically significant differences between be accomplished in 1 day (if diagnostic circumstances permit),
105

Surface-based registration Point pairs registration

Edentulous protocol
Optical
Tracer sensors
tool
Jaw tracker
Dimple fiducial points

a b
Calibration
Tracking
Registration
c d
Fig 6-21 (a) Dynamic navigation system (Navident, ClaroNav) registration in the mandible. The micron camera of the system detects the checker-
board targets of the tracer tag and jaw tag of the mandible and transmits information to the notebook computer system and software. With the
tracer tool, three starting points of the dentition are marked in a triangulated plane pattern and used to register the CBCT DICOM data set via the
Navident software. The tracer tool is then used to trace the surface of the dentition and registers 100 points per area. Turquoise is used to identify
the registered surface points. This registration protocol is referred to as surface-based registration in navigation surgery and is fiducial independent.
(b) Edentulous protocol for fiducial-independent CBCT registration for dynamic navigation surgery using point pairs registration. Dimple fiducial
points are incorporated to a customized tray and worn in the CBCT as well as during the registration process at the time of surgery. (c) The three
coordinate mapping steps that, when chained together, map the drill tip to the planning CBCT image volume for surface-based/trace registration
navigation surgery. (1) Registration, (2) Calibration, (3) Tracking. (d) The target view that contains all the information that the clinician needs to guide
the osteotomy and the implant placement during navigation surgery: patient’s anterior (1), drill (2), drill’s tip (3), patient’s right (4), patient’s posterior
(5), central axis of planned osteotomy (6), vertical distance between drill’s tip and apex of planned osteotomy (7), angle between drill and central
axis of planned osteotomy (8), horizontal distance between drill’s tip and central axis of planned osteotomy (9). (Republished from Mandelaris et
al69 with permission.)
Fig 6-22 EvaluNav software registration ap-

plication to enable registration of planned
and actual implant position.
106

Haptic Simulation and Robotically Assisted Dental Surgery
a b c
Fig 6-23 (a) Head tracker attached to patient’s head to allow tracking of the position of the maxilla. (b) Mandibular jaw tag bonded to the mandibular
natural dentition to allow tracking of the position of the mandible. (c) Operative view of dynamic navigation surgery.
and effectively eliminates the cost of constructing a static guide. to the user during the surgery. Visual and audial guidance is
Because these video systems are based on a micron camera also provided as confirmation. Physical guidance for robotically
that records live action during surgery, dynamic navigation tech- assisted surgery (ie, haptics) is provided via a guidance arm,
nology provides a modality of medicolegal documentation and which has a standard dental drill as a user interface. The guid-
an unprecedented level of surgical accountability to ensure ance arm does not move unless a manual force is applied to the
prosthetically directed surgical outcomes are achieved. Under drill, meaning that the user is in control of the robotic device at
this treatment context, the concept of “collaborative account- all times. Robotic assistance of stability and control is designed
ability” can be ensured.23 to allow the implant handpiece to be precisely manipulated using
As with the introduction of guided surgery in 2002, accuracy a light touch from the surgeon, promoting surgical ergonom-
and outcomes are largely proportional to planning and experi- ics. Varying resistance physically guides the user during oste-
ence. Dynamic navigation for dental implants is in its infancy but otomy site preparation and implant placement to the desired
provides some distinct advantages to freehand surgery or static orientation and location. This is the primary difference between
guidance. As all technology applications generally improve with robotics and navigation: There is no physical guidance (other
time and innovation, dynamic navigation has a promising future. than innate hand-eye coordination) during dynamic navigation
Further research is needed with a variety of clinical applications implant surgery. Once the operating surgeon provides manual
and validated, controlled, blinded, and randomized studies are guidance to the robot-assisted dental surgery (RADS) system by
required to demonstrate efficacy equivalent or superior to static using the stereotactic medical device, drilling and implant place-
guided surgery in patient care. Future decision tree analysis ment proceed as usual, with the system physically constraining
based on individual clinical situations for the patient will also the handpiece to the planned depth. While the primary input to
help determine which method of guidance is best indicated in the surgeon is the physical haptic guidance, visual confirmation
a given clinical situation (partially versus totally guided surgery of guidance is provided by 3D graphics and 2D cross sections
[tooth-, tooth/mucosa–, mucosa-, or bone-supported applica- that indicate the position and orientation of the drill in relation
tions] versus nSequence guided prosthetic and surgery protocol to the preoperative plan and scan.
versus dynamic navigation). Due to the digital nature of RADS guidance, the surgical plan
may be dynamically modified at any time during the surgical
procedure. If patient movement occurs during the surgical proce-
dure, the system will respond by altering the prescribed surgical
HAPTIC SIMULATION AND cutting angle and position to accommodate the patient move-
ment, which will maintain the accuracy of the drill placement.
ROBOTICALLY ASSISTED DENTAL
This real-time patient tracking is a mechanical feedback system
SURGERY that is connected to the patient via a splint that relays informa-
tion to the control software in order to track patient movement.
Haptic technology is the ability for a robotic system to pro- At the time of this publication, the first and only RADS system
vide physical guidance during surgery and execute it exactly as to be cleared by the US Food and Drug Administration and
planned relative to the patient’s CT scan. The CT-based surgical commercially available in the United States is branded as Yomi
plan is interpreted by the robotic system as physical feedback Robot-Assisted Dental Surgery (Neocis). Yomi is a stereotaxic
107

efforts from a craniofacial, airway, skeletal, temporomandibu-

lar joint, alveoloskeletal, dentoalveolar, periodontal, and dental
standpoint (in addition to a thorough medical workup and evalu-
ation) so that the correct problems are identified for the patient
and the right team is assembled to address them. This leads
to less compromise or camouflaging of core disharmonies,
discrepancies, or deficiencies, and prepares the patient for the
greatest opportunities for minimally invasive dentistry, optimiz-
ing the structural integrity of the dentition. From a biomechanical
and space appropriation perspective, interincisal angle of the
incisors and axial inclinations of the teeth should be positioned
from an inter- and intra-arch position so that stress distribution
is optimized. In this treatment-planning context, the horizontal
and vertical overlap of the anterior and posterior dentition should
be positioned to protect teeth (or neighboring implants if the
dentition is a combination of implants and natural teeth) during
working and nonworking envelopes of function.
A key context for optimizing this approach centers on the
collaborative focus of the periodontist and the orthodontist. In
collaboration with the primary restorative dentist and the oral
Fig 6-24 Yomi Robot-Assisted Dental Surgery. (Courtesy of Neocis.) and maxillofacial surgeon, using CBCT imaging as their basis,
they are able to plan and implement a sustainable, homeostatic
outcome that addresses tooth-to-tooth, teeth-to-jaw, jaw-to-jaw,
and jaws-to-face relationships.
medical device that provides robotic haptic guidance during The emerging role of surgically facilitated orthodontic therapy
dental implant surgery (Fig 6-24). (SFOT) in IDT fosters a synergy in the management of decom-
pensation of malocclusions and augmentation of the patient’s
individual dentoalveolar phenotype.77,78 This therapy is most
often undertaken to optimize the arch form (especially of the
THE IMPORTANCE OF PLANNING maxilla) and to create a sustainable alveolar bone volume (partic-
FOR PREDICTABLE THERAPY: ularly on the facial aspect of the teeth). This facilitates a reliable
expansion of the physiologic scope of what can be achieved
APPLYING A GLOBAL IDT through orthodontic therapy and improves oral cavity volume.
APPROACH In order to provide such a foundation for sustainable,
patient-centered outcomes in any type of implant surgery,
IDT is rooted in analyzing the craniofacial phenotype of the planning should occur via a global, multi-anatomical diagnostic
patient, which involves determining the relationships of the perspective that is envisioned prior to the start of treatment.
pieces of the anatomical puzzle that comprises the patient’s This requires incorporating facial dynamics of the smile and
head and neck skeleton. When all pieces of the puzzle fit in craniofacial phenotype78 and considering other facets of each
proper relationship, a complex IDT-based outcome is generally individual patient. The overall objective is to maximize such a
biologically sound, health-optimized, biomechanically stable, balance among all craniofacial structures and their optimal func-
and esthetically pleasing. tion relative to the airway, cervical spine, the temporomandibular
The integration of technologies is driving the continued evolu- complex, and the body as a whole.
tion of a true facially prioritized approach to treatment planning. In accordance with the points discussed above, the integra-
As more and more diagnostic data become available for process- tion of a facially prioritized treatment is emerging as a primary
ing and inquiry through CBCT and intraoral surface scanning driver and validator of this overarching concept. Facially priori-
technology, the clinician is forced to think through cases from tized treatment planning can be broken down into a step-by-step
a global and craniofacial perspective, even if limited treatment process whereby relationships are individually analyzed and then
involving a single dental implant is indicated and/or elected. This integrated together, now with the help of software systems
global and comprehensive approach to the diagnostic continuum that enable facial data–driven planning, such as Digital Smile
requires integrating orthodontic, periodontal/implant-related, Design. Facially prioritized treatment planning can be defined
endodontic, prosthodontic, and orthognathic clinical spheres as an objectively driven synergistic approach undertaken by
with a view to providing progressive and consistent IDT patient the IDT team to integrate the teeth-to-teeth, teeth-to-jaw,
care. The integration of these technologies takes a “big picture” jaw-to-jaw, and jaw-to-face relationships into a single, global,
approach to patient evaluation and requires treatment planning patient-centered treatment outcome that is sustainable over
108

The Importance of Planning for Predictable Therapy: Applying a Global IDT Approach
a b c
Fig 6-25 (a) 3D models from SureSmile CBCT-based orthodontic treatment planning software demonstrating a preoperative condition of Class II
malocclusion with dental compensations in an adult patient with obstructive sleep apnea. Maximizing oral cavity volume is essential to accomplish-
ing the airway-centric, facially prioritized orthodontic goals. (b) 3D simulation/modeling of the planned orthodontic decompensation movements to
correct malocclusion and any inherent risk to the periodontium/dentoalveolar bone. The required tooth movement exceeds orthodontic boundary
conditions. (c) Following SFOT correction with substantial augmentation to the dentoalveolar bone phenotype, facilitating orthodontic expansion.
(Orthodontics by Dr Iwei Huang, Chicago, Illinois.)
the long term. A paramount consideration is the relationship of of a discrepancy between the dentoalveolar component and
these factors to the patient’s airway. The clinician must be mind- the skeletal base.
ful of the likelihood of a sleep-disordered breathing condition, Teeth-to-jaw relationships involve malocclusion management
its impact on systemic health, and the sobering probability that by decompensating malpositioned teeth through tip, torque,
the patient may not be aware of its presence. Conditions such or bodily orthodontic tooth movement within the alveolus. It
as obstructive sleep apnea remain an undiagnosed epidemic in involves reversing dental compensations as a result of an under-
the United States.79–83 To this end, increasing oral cavity volume lying skeletal disharmony.
may play an even more important role in future treatment plans As a result of CBCT imaging and computer software planning
to encourage anterior tongue posturing, and possibly reducing applications such as SureSmile (OraMetrix), treatment possibil-
the incidence of sleep-disordered breathing conditions.84 This is ities can be scrutinized to determine if such tooth movements
in contrast to treatment plans that reduce oral cavity volume in are feasible given the patient’s presenting dentoalveolar bone
decompensation movements, such as retraction orthodontics volume and alveoloskeletal relationships (Fig 6-25). Recently,
involving extraction therapy.78 the American Academy of Periodontology (AAP) published a
As mentioned previously, these IDT relationships include: best evidence consensus (BEC) systematic review focusing
tooth-to-tooth, teeth-to-jaw, jaw-to-jaw, and, pivotally, on risk assessment of the changes to dentoalveolar bone influ-
jaws-to-face relationships. These relationships are outlined in enced by tooth movement.63 The 13 studies evaluated were
more detail in the following sections. categorized as:
1. Orthodontic expansion using conventional orthodontic ther-

Tooth-to-tooth relationship apy combined with orthognathic surgery (surgically-assisted
rapid palatal expansion)
Tooth-to-tooth relationship refers to the condition and position of 2. Orthodontic expansion using conventional orthodontic ther-
the natural dentition within each arch and between the arches. apy alone
Management of these relationships involves replacing miss- 3. Orthodontic expansion using corticotomy-assisted orthodon-
ing teeth, reshaping tooth anomalies, or restoring lost tooth tic therapy combined with bone augmentation
structure. 4. Orthodontic retraction of proclined maxillary incisors
Overall, it was shown that CBCT provided accurate measure-

Teeth-to-jaw relationship ments of alveolar bone thickness as well as buccal bone dehis-
cences that may alter decision making to avoid iatrogenic
Teeth-to-jaw relationship implies the condition and position of sequelae from orthodontic tooth movement.
the natural dentition to and within the local regional anatomy With the exception of corticotomy surgery involving bone
of each jaw. These relationships are evaluated and described augmentation to facilitate orthodontic expansion therapy
as dentoalveolar and alveoloskeletal. The dentoalveolar compo- (commonly recognized as SFOT or periodontally accelerated
nent is the relationship of the natural tooth and root to its cor- osteogenic orthodontics [PAOO]), the other three therapies
responding alveolus. Dentoalveolar bone is generally evaluated evaluated in this review showed strong evidence of vertical
as volume sufficiency and is described in terms of the presence bone loss that may trigger the development or progression
or absence of dentoalveolar deficiencies. The alveoloskeletal of gingival recession during or after orthodontic treatment.63
component is described in terms of the presence or absence The 2017 AAP BEC highlights the need to consider alternative
109

Fig 6-26 (a) Skeletal dishar-

mony malocclusion viewed
in the anteroposterior (A-P),
vertical, and transverse di-
mensions. (b) 3D simulation
of skeletal surgery planned
to correct the skeletal dis-
harmony and achieve maxil-
lomandibular correction. The
corrections show Le Fort I
osteotomy in the maxilla, bi-
a A-P Vertical Transverse lateral split sagittal osteoto-
my, and a sliding genioplasty
in the mandible. (Courtesy of
Dr Robert Relle, Los Angeles,
California.)
b A-P Vertical Transverse
Fig 6-27 (a) Skeletal disharmony viewed in the context

of the patient’s face for treatment-planning purposes. The
patient has maxillomandibular retrognathia and a cranio-
facial phenotype suggestive of obstructive sleep apnea.
(b) Illustration of planned outcome following correction via
double jaw orthognathic surgery with counterclockwise
rotation and advancement. Notice the skeletal structures
in relation to nasion here compared with the preoperative
situation. (c and d) Skeletal disharmonies assessed in the
context of facially prioritized treatment planning with 3D
orthognathic surgical planning for facial balance and harmo-
ny as well as a functional occlusion and airway. (Courtesy
of Dr Robert Relle, Los Angeles, California.)
a b
110

Future Directions
orthodontic strategies such as SFOT or PAOO for dentoalveolar consistent predictability in more complex or extensive restor-
bone volume augmentation to minimize the risk to the often ative cases can be ensured and proven as cost effective.
vulnerable periodontium as well as expand the capabilities of Despite such advances in planning capabilities, even the digi-
orthodontic tooth movement by enhancing the boundary condi- tal representation of the implant placement schema may not
tions within which teeth can be moved.63 be totally accurate, possibly leading to the overestimation of
the amount of available bone and/or other variables that can
jeopardize the surgical outcome or negatively influence plan-
Jaw-to-jaw relationship ning decisions.
Today’s technology provides a platform for the clinician to think
Jaw-to-jaw relationship refers to how each skeletal base (maxilla through cases on a much more comprehensive and global level.
or mandible) is positioned relative to the other (maxillomandib- However, technology must never be a substitute for sound judg-
ular relationships) from a bony landmark standpoint. This rela- ment, decision-making, and clinical awareness of the biologic
tionship is described as the presence or absence of a skeletal principles of wound healing. A critical consideration for the clini-
malocclusion but is somewhat limited in its focus since such cian to realize is that technology tends to engender a sense of
descriptions do not address how the skeleton then relates to false confidence based on a “wow factor” when in the inquiry
the face or airway conditions. Management of jaw-to-jaw dis- or planning phases. Almost inevitably, the tendency emerges
harmonies involves alignment of the maxillary and mandibular to use digital technology and information to overcome what
skeletons to each other and orthognathic surgery, commonly might be a lack of experience and enable a clinician to execute
via Le Fort I osteotomy and bilateral mandibular split osteot- treatments that he or she would not otherwise be comfortable
omy surgery with or without genioplasty. The focus here is on attempting (or perform in-house as opposed to a more prudent
aligning the mandible to the maxilla in the transverse, antero- choice of referral). Such a “digital intoxication” may foster a
posterior, and vertical dimensions for a stable skeletal relation- false sense of possibilities, potentially undermine the value of
ship (Fig 6-26). collaboration, and create the potential to undervalue or dismiss
one’s skillset, training, and expertise in elective implant and/
or dentoalveolar surgery or the subsequent management of
Jaws-to-face relationship complications. This has the potential to lead to compromised
outcomes and patient safety. Importantly, this tendency poten-
Jaws-to-face relationship is the most contemporary view of tially detracts from interdisciplinary collaboration and instead
dentofacial disharmony management and considers the position fosters isolation of the individual clinician in a context of false
of the skeletal bases to each other but in addition takes into confidence, which can jeopardize the outcome, the patient, and
account how the skeleton relates to the face and the airway. the integrity of the profession as a whole.
This also includes the condition and position of the temporo- To a large extent, all the disciplines in dentistry are somewhat
mandibular joint/complex. These relationships are described in unregulated (or at best, self-regulated) and are often not held
terms of the presence or absence of dentofacial disharmonies, accountable to high standards due to the lack of scrutinizing
and their management involves the alignment of the maxillo- validation, oversight, or credentialing. It is imperative that the
mandibular complex (in the transverse, anteroposterior, and dental profession use technology in a collaborative fashion, pool-
vertical dimension) to the patient’s face for the most balanced ing the knowledge and expertise of all the disciplines in order
outcome (Fig 6-27). The focus in this relationship is not only on to put patient safety first and foremost.
facial esthetics and harmony but also on airway (nasopharyn-
geal and oropharyngeal volume) optimization.
Dental implant diagnostics and related dentoalveolar bone
augmentation therapies fall under the tooth-to-tooth and FUTURE DIRECTIONS
teeth-to-jaw relationships. These relationships require spatial
planning relative to and within each other in addition to the Future directions in treatment planning likely will be centered
presenting craniofacial anatomy of the patient. Again, this also on comprehensive treatment planning that integrates multiple
includes the condition and position of the temporomandibular sources of technology as the period of personalized and preci-
joint/complex. sion dental medicine matures and expands. Virtual simulation
and augmented reality planning software and associated appli-
cations may emerge and improve therapies in the future.
It is not difficult to envision, in the not-too-distant future,
BALANCING TECHNOLOGY AND implant treatment-planning algorithms that operate on the prin-
CLINICAL SKILLSET ciples of artificial intelligence, blockchain cryptography for data
confidentiality, and decision tree analysis, as well as encom-
While advanced imaging technology and digital workups are pass the combined dataset of the DICOM imaging files, the
here to stay, some digital capabilities need to mature before patient’s medical history and genetic predisposition/molecular
111

markers, and other individualized variables for highly personal- ACKNOWLEDGMENTS

ized and precision therapy. This emerging capability offers the
clinician improved options via decision trees based on a particu- The authors would like to recognize and thank Dr Jeff Ganeles for
lar patient scenario that then use literature- and evidence-based his expert review of this chapter as well as Dr Robin Grandl for
guidelines from randomized clinical control trials to determine her assistance in the Haptic Simulation and Robotically Assisted
patient-specific viable or contraindicated treatment options. Dental Surgery section of this chapter. In addition, we would like
To this end, algorithms based on published decision tree to recognize Dr Robert Relle for his expertise and contribution
models from systematic reviews could provide the most predict- in helping define the IDT section.
able selection of patient care, given each patient's unique prob-
lem set, individual circumstances, and outcome desires. The
integration of haptic guidance and artificial intelligence planning/
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114

7 SVEN MÜHLEMANN • DAVID SCHNEIDER •
RONALD E. JUNG • CHRISTOPH H. F. HÄMMERLE
Decision Making for

Implant Therapy in the
Maxillary Esthetic Zone
Prosthetic Setup
Soft Tissue Assessment
Radiographic Imaging
Computer-Assisted Implant Planning and
Placement
Implant and Abutment Selection
Prosthetic Design Configurations
115

7 | Decision Making for Implant Therapy in the Maxillary Esthetic Zone
a b c
Fig 7-1 (a) The patient had lost his six-unit fixed dental prosthesis due to fracture of the abutment teeth. An intraoral optical scan was taken to
virtually design the prosthetic setup. (b) The dental technician used CAD software to design the prosthetic setup. Insufficient mesiodistal space
was available to align the prosthetic units in a perfect arch. (c) The integration of the prosthetic setup with the neighboring dentoalveolar and
facial structures was evaluated clinically. The CAD/CAM mock-up was stained by the dental technician in order to simulate as closely as possible
the esthetic outcome of the future implant reconstruction. Because the patient may not accept the chosen prosthetic setup, a try-in is mandatory
before initiation of implant therapy.
T
he rehabilitation of missing teeth in the maxillary Radiographs, photographs, and impressions complete the clinical
esthetic zone by means of fixed implant recon- examination. Thereafter, the clinician develops a treatment plan.
structions presents a challenging situation for the Ideally, the planned implant-supported reconstruction should
dental practitioner. Successful implant therapy is imitate the missing teeth and harmoniously integrate with the
based on a carefully developed treatment plan that integrates neighboring dentoalveolar and facial structures. Clinicians should
a comprehensive patient history, thorough clinical examination, be aware that papillae associated with implant-supported recon-
and appropriately chosen radiographic imaging. Additionally, structions generally do not obtain the same morphology as
implant treatment should be prosthetically driven, keeping the those adjacent to natural teeth.1 Thus, treatment options for
aim of therapy in mind during every step of the process. replacing missing teeth with tooth-supported reconstructions
Tools for visualization of the planned implant reconstruction as opposed to implant-supported reconstructions should be
play an important role and can help enhance the predictability carefully evaluated.
of implant therapy, particularly in the maxillary esthetic zone.
During the diagnostic phase, the treatment plan is developed
based on visualization of the future implant-supported recon-
struction. Different prosthetic designs may be possible for PROSTHETIC SETUP
each implant-supported reconstruction, and each design has
its advantages and disadvantages. The treatment plan deter- The planned implant-supported reconstruction can be simulated
mines the ideal number of implants, the location/distribution by a prosthetic setup. It combines the patient’s and the clini-
of implants, and the optimal type and dimensions (diameter/ cian’s desires for the outcome of therapy. The prosthetic setup
length) of implants. The correct choice of implants for fixed should present a shape, size, and position of the replacement
implant reconstructions in the maxillary esthetic zone is based teeth that is in harmony with the patient’s individual clinical
on biologic and prosthetic principles. situation. A traditional workflow encompasses the creation of
Because dentoalveolar structures are exposed during smil- study casts, mounting of the casts on an articulator, and man-
ing and speaking, patient expectations regarding esthetic ual wax-up of the prosthetic units. Today, digital technologies
outcomes of implant-supported reconstructions are generally offer the possibility of reducing manual working steps during
higher for the anterior maxilla compared with the posterior area. the fabrication process and thus may increase time efficiency.2
It is also important to understand that patient demands may The clinical situation can be directly recorded digitally by means
differ from the general esthetic parameters applied by dental of an intraoral optical impression or by scanning a conven-
professionals. It is therefore important for clinicians to correctly tional cast using a laboratory scanner. Computer-aided design/
understand the patient’s demands by taking a comprehensive computer-assisted manufacture (CAD/CAM) allows virtual
patient history. design of the model and the prosthetic setup (Fig 7-1).
Regarding patient desires, the diagnostic phase is essential For harmonious integration of the planned implant-supported
because it allows visualization of the prosthetic outcome before reconstruction into the neighboring dentoalveolar structures,
initiation of therapy and thus discussion of the aims of ther- recontouring and/or realigning of the neighboring teeth may
apy with the patient. During the initial clinical examination visit, be indicated. Therefore, the prosthetic setup is the result of a
periodontal and dental parameters of the teeth are assessed. multidisciplinary approach involving various dental specialties.
116

Soft Tissue Assessment
a b c
d e f
Fig 7-2 (a) The patient presented with a removable interim partial denture replacing the maxillary central and right lateral incisors. The teeth were lost
as a result of trauma. The patient was concerned because the provisional restoration did not satisfy his demands in terms of esthetic appearance.
He desired an esthetic improvement with an implant-supported reconstruction. (b) The tissues of the edentulous site and the neighboring teeth
were healthy. The esthetic evaluation revealed that the maxillary left lateral incisor was protruded. The mesiodistal space of the edentulous site
measured 27 mm. Based on esthetic parameters, the mesiodistal size of a central incisor is 9 mm, and that of a lateral incisor is 7 mm. Therefore,
the interim prosthesis was originally designed with a central diastema of 2 mm. (c) Buccal view of a CAD/CAM prosthetic setup. For a more har-
monious mesiodistal size of the missing teeth, the contour of the left lateral incisor was adapted. (d) Palatal view of the prosthetic setup in place.
Palatal wings on the neighboring teeth allowed the prosthetic setup to be temporarily fixed. (e) The esthetic outcome could be evaluated clinically
by both the patient and the clinician. The patient was satisfied with the simulation of the planned prosthetic outcome. He agreed on an additional
ceramic veneer for the left lateral incisor. (f) The prosthetic setup (purple) was visualized in the implant planning software. The recontouring of
the left lateral incisor influenced the mesiodistal position of the implant in the maxillary left central incisor site.
A prosthetic improvement of the contours of the neighboring SOFT TISSUE ASSESSMENT

teeth could potentially allow for a more harmonious mesiodistal
size of the teeth to be replaced (Fig 7-2). In addition, the realign- It is clinically important that the esthetic analysis also includes
ment of neighboring teeth by orthodontic appliances needs to be a separate evaluation of the quantity and quality of the muco-
considered in order to optimize the mesiodistal size of the eden- sal tissues in the edentulous site. Therefore, the prosthetic
tulous space for the planned implant-supported reconstruction. setup should be limited to the prosthetic units and should not
The orthodontic movement of teeth can be simulated by cutting include any improvement of the peri-implant tissues around the
the model into segments and repositioning these segments in planned implant-supported reconstruction. In this way, existing
an ideal position. As mentioned, this simulation can be done on deficiencies of mucosal tissues in the edentulous site can be
a conventional cast or virtually on a digital model. judged (Fig 7-3a). Later, in the radiographic evaluation, the same
For diagnostic purposes the prosthetic setup needs to be procedure allows assessment of the quantity of bone in relation
evaluated clinically. For the purpose of simulating the outcome to the planned prosthesis (Fig 7-3b). The prospective mucosal
of therapy in the patient’s oral cavity, the dental technician fabri- margin at the buccal aspect of the planned implant-supported
cates a mock-up. The higher costs of a laboratory-made mock-up reconstruction is the most important parameter regarding the
are justified by the importance of the esthetic appearance in correct vertical positioning of the implants.
the anterior maxilla. In a digital workflow, CAM enables the Correction of existing mucosal deficiencies is a prerequisite for
transfer of the virtual design into a digital mock-up by means esthetic success in implant therapy. Both soft and hard tissues
of milling or printing techniques. Alternatively, the clinician may contribute to the peri-implant tissue volume in the anterior maxilla.
fabricate a direct mock-up using a silicone key made on the A recent clinical study demonstrated that hard tissue augmenta-
cast with the prosthetic setup. The mock-up allows visualization procedures accounted for 57% of peri-implant tissue volume,
tion of the replacement of the teeth in the patient’s mouth and whereas soft tissue augmentation accounted for 43%.4 Clinicians
can be assessed by both the patient and the clinician. Esthetic need to decide whether these deficiencies can be successfully
parameters are clinically evaluated according to an esthetic corrected by augmentation procedures before, during, or after
evaluation protocol.3 implant placement. When performing such treatments, factors
117

a b
Fig 7-3 (a) The try-in of a prosthetic setup allows evaluation of mucosal tissue deficiencies. (b) The use of a radiopaque prosthetic setup allows its
direct visualization in a CBCT scan. Thereby, the quantity of bone in relation to the prosthetic setup also can be judged.
that should be considered include the risk for adverse reactions decision making for implant-supported reconstructions in the
and outcomes, the predictability of success, treatment costs, anterior maxilla and, therefore, increase the predictability of
longer treatment time, and the resulting morbidity.5 the therapy. Generally, capturing of CBCT scans is justified
For edentulous sites with multiple missing teeth, an alter- for implant-based therapy in the anterior maxilla. This is based
native to augmentation procedures may be the use of pink on the consensus that placing implant-supported reconstruc-
ceramics to compensate for peri-implant tissue deficiencies.6 tions in the esthetic zone is a complex procedure; additionally,
The decision to use pink ceramics can be made based on the anatomical structures such as the incisive canal may be relevant
location of the prospective transition zone between the artifi- to the decision as to where to place the implants.7 Preexisting
cial mucosa and the mucosal tissue of the edentulous site. If CBCT data should be used whenever possible to reduce patient
the transition zone is not exposed during smiling, the use of exposure to radiation.
pink ceramics may be preferential. Augmentation procedures
around implants in the esthetic zone should be limited to those
guaranteeing a high implant success rate. Virtual superimposition
The decision for an implant-supported reconstruction includ-
ing pink ceramics needs to be made during the diagnostic phase, 3D radiographic imaging has significantly enhanced the diagnos-
ie, before the initiation of implant therapy. The decision may influ- tic potential in implant therapy.8 Computer software is needed
ence the number and distribution of the implants to be placed. to visualize the alveolar ridge in all three dimensions in relation
A reconstruction that is supported by adjacent implants and to the prosthetic setup. Visualization of the prosthetic setup in
includes pink ceramics requires efficient oral hygiene measures the software can be obtained either by a radiopaque template
that many patients find quite difficult to perform. Hence, in of the prosthetic setup present during CBCT data acquisition or
such situations the distribution of the implants may need to be by virtually superimposing a 3D data set of the prosthetic setup
altered. Finally, when the use of pink ceramics is considered as onto the CBCT image after CBCT data acquisition (see Fig 7-2f).
a possible treatment option, it is important to adapt the preex- When using the latter procedure, preexisting CBCT scans can
isting mock-up with pink wax for simulation of the planned be used, and the fabrication of a radiographic splint is not nec-
reconstruction and for discussion with the patient. essary. The approach of virtual superimposition also reduces the
risk of inaccuracies resulting from manual working steps or from
displacements of the prosthetic template during radiographic
data acquisition. In a fully digital workflow, data transfer of the
RADIOGRAPHIC IMAGING virtual prosthetic setup is needed from the CAD software to the
implant planning software. Nevertheless, the virtual superim-
Once the number, position, and shape of the prosthetic units position can also be performed with a conventionally fabricated
for the implant-supported reconstruction have been decided, prosthetic setup that is digitized by a laboratory scanner.
radiographic imaging is performed. In the anterior max- A prerequisite for the virtual superimposition is that the refer-
illa, two-dimensional radiographs offer limited information ence structures are present in the prosthetic setup as well as in
about the anatomical structures. Three-dimensional (3D) radio- the CBCT data set and that these structures are clearly detect-
graphic imaging by means of cone beam computed tomogra- able in the CBCT scan without any artifacts. Ideally, the surfaces
phy (CBCT) will provide additional information that is helpful of neighboring teeth serve as such reference structures. The
for the treatment-planning phase. This information will improve virtual superimposition cannot be achieved when the surfaces
118

Computer-Assisted Implant Planning and Placement
a b c
Fig 7-4 (a) In an edentulous site with four missing incisors, a conventional template was used to place two implants adjacent to the neighboring
canines. The distance between the tooth and the implant was too large on both sides. Virtual implant planning with a CAIP protocol may have
helped to optimize the implant positioning. (b) The framework takes up the interdental space between the central and lateral incisors, leaving
no room for the papillae. (c) The esthetic outcome regarding the extension of the papillae between the lateral and central incisors is limited. The
impaired prosthesis design resulted from the slightly too mesial placement of the implants in the lateral incisor sites.
of neighboring teeth are not clearly visible in the CBCT scan, augmentation.11 As an alternative to vertical bone augmentation
eg, because of artifacts due to metallic reconstructions. As a procedures, pink ceramics may be used. Pink ceramics are indi-
consequence, the conventional approach needs to be executed, cated when the transition zone between the ceramic and the
ie, with the prosthetic setup in place during the CBCT scan. The mucosa is not exposed during smiling and speaking. If the vertical
superimposition is performed using the surfaces of radiopaque height of the alveolar ridge is deficient and remains unchanged, an
structures as reference; therefore, the prosthetic units need increased crown length will result. It must be determined during
to be made of radiopaque material, or a radiopaque reference treatment planning whether or not this solution will be acceptable.
structure must be added to the prosthetic setup (see Fig 7-9c). The precise 3D placement of implants in the anterior maxilla
The prosthetic setup, together with the radiopaque structures, is a prerequisite for optimal esthetic outcomes. In a conventional
need to be digitized by a laboratory scanner applying a so-called approach the clinician uses a surgical template that is derived
double-scan technique. from the prosthetic setup and serves as the prosthetic refer-
ence during implant placement. During the implant surgery, the
clinician needs to consider the information from the surgical
template, the clinical situation, and preoperative radiographs in
COMPUTER-ASSISTED IMPLANT order to place the implant in the correct 3D position. Decisions
PLANNING AND PLACEMENT made during implant surgery may be negatively influenced by
stress occurring during the procedure as a result of a multitude
Computer-assisted implant planning enables the virtual place- of factors12 (Fig 7-4). In contrast, computer-assisted implant
ment of implants and has contributed to the development planning allows determination of the best possible treatment
of computer-assisted implant placement (CAIP).9 The correct plan with respect to surgical and prosthetic needs before the
visualization of the prospective crown margin at the buccal surgical execution. As a result, the complexity of the decisions
aspect is important to allow for the correct vertical positioning to be made during surgery is greatly reduced, and stress is
of the implants. minimized, leading to better treatment results.
Implants may be divided into one- and two-piece implants. By The treatment concept of CAIP allows transferring the virtually
definition a two-piece implant only consists of the endosseous planned implant position into the patient’s mouth by use of the
portion. After placement of such an implant all further compo- surgical guide. Guided implant placement allows more precise
nents, ie, abutment and prosthesis, are attached to the implant at implant placement compared with the conventional approach.13
the level of the implant shoulder. This procedure allows for more In addition, CAIP improves time efficiency during implant surgery.
flexibility in dealing with soft tissue management, shaping of the Another advantage of CAIP is the guidance of the drill for implant
emergence profile, and angulation of the reconstruction. There- bed preparation. This guidance leads to a more precisely prepared
fore, a two-piece implant is generally the preferred implant in the implant bed. In situations where primary implant stability is crit-
anterior maxilla. The shoulder of a two-piece implant should be ical, eg, when extensive alveolar ridge deficiencies are present,
3 to 4 mm below the prospective mucosal margin to allow suffi- this guidance helps in obtaining good primary implant stability.
cient vertical space for shaping the emergence profile. In cases One disadvantage of the guides, however, is that they normally
with large bone deficits, vertical bone augmentation is performed do not provide information regarding the prosthetic setup. A
prior to implant placement. In general, the predictability of verti- recent clinical study reported that in nearly 50% of cases the
cal ridge augmentation procedures substantially depends on the optimal implant position deviated from the one determined by
clinical situation and the surgical technique applied.10 In addition, the surgical guide.14 This problem is especially frequent in situ-
a high rate of complications has been reported for vertical bone ations with multiple tooth gaps, where reference structures are
119

missing. When such problems occur and the guide is unusable, reconstructions can be either screw retained or cemented. A
the success of the intervention depends highly on the skills of systematic review has shown that neither fixation method is
the surgeon. Therefore, CAIP protocols do not reliably reduce clearly advantageous over the other.20 Cemented reconstruc-
surgical complexity in every case, even though companies may tions exhibited more serious biologic complications, whereas
promote the technology as safe and easy to use. screw-retained reconstructions exhibited more technical prob-
lems. For screw-retained implant reconstructions in the anterior
maxilla, the prospective screw access hole has to be positioned
at the palatal aspect of the reconstructions. Consequently, the
IMPLANT AND ABUTMENT angulation of implants supporting a screw-retained reconstruc-
SELECTION tion may result in fenestration/dehiscence defects of the bone
(see Fig 7-5b and Fig 7-9i). Angled abutments are now available
The position of the implants is planned according to the pros- and permit placement of anterior implants in the native bone
thetic setup. However, basic biologic principles also need to while still allowing for screw-retained reconstructions.
be respected. It has been demonstrated that the horizontal
distance between the implant and the adjacent teeth influ-
ences the esthetic outcome of treatment. The minimum dis-
tance between an implant and a tooth should be 1.5 mm at PROSTHETIC DESIGN
the shoulder of the implant.15 The distance between two adja- CONFIGURATIONS
cent two-piece implants should be at least 2 mm.16,17 Taking
these two measurements into account will ensure an optimal In an edentulous site with two missing anterior teeth, two dif-
treatment outcome regarding the peri-implant soft and hard ferent prosthetic design configurations are possible: two single
tissues and provide long-term stability. The appropriate implant crowns on two implants or a crown with a cantilever anchored
diameter is selected according to the mesiodistal gap size and to one implant. The advantage of two implants restored with
in relation to the size of the prosthetic unit. Implants with a single crowns is the segmentation of the reconstructions. How-
reduced diameter allow maintenance of the minimum distances ever, sufficient mesiodistal space needs to be available in order
between neighboring teeth and implants mentioned previously. to place two implants while respecting the minimum distances
Furthermore, narrow implants help avoid bone-grafting proce- between the implants and between the implant and the neigh-
dures at narrow ridges. In this context it is important to men- boring tooth.
tion that placement of the implant in the prosthetically optimal In a clinical situation with two missing central incisors, gener-
position is still a prerequisite. Generally, in the anterior max- ally two implants are placed (Fig 7-5). In case of a reduced
illa regular-diameter implants are used to replace central inci- mesiodistal space, the placement of two reduced-diameter
sors and canines, whereas for lateral incisors reduced-diameter implants is a valuable treatment option. The two implant crowns
implants are preferred. In case of limited horizontal ridge may be splinted to improve the mechanical stability of the
dimensions, reduced-diameter implants are a valuable option reconstruction supported by reduced-diameter implants. In
for replacing central incisors and canines. Clinicians should be contrast, if one of the two missing teeth is a lateral incisor, one
aware, however, that when using reduced-diameter implants implant may be sufficient, and a fixed dental prosthesis with
the dimensions of the prosthetic components are smaller. Thus, a cantilever design should be preferred (Fig 7-6). The implant
mechanical stability will be reduced, precluding certain pros- is placed underneath the prosthetic unit with the larger crown
thetic options, eg, cantilevers and large-span reconstructions. (central incisor or canine), whereas the cantilever replaces the
As stated previously, two-piece implants are preferred in the lateral incisor. Thereby, the lever arm is short, and the result-
anterior maxilla. The choice of abutment is based on clinical ing nonaxial forces are lower. In addition, regular-diameter
parameters. Generally, a customized abutment is used because implants are preferred in such situations. They exhibit appro-
in the anterior maxilla scalloping of the mucosa is pronounced priate implant-abutment dimensions, providing the mechan-
and highly individual. Customized abutments are also provided ical stability necessary for an implant reconstruction with a
in patient-specific colors. It has been demonstrated that the cantilever. Regarding the esthetic outcome, a clinical study
critical soft tissue dimension is 2 mm for optimal esthetics at showed that the papilla fill between lateral and central incisors
the buccal aspect of dental implants.18,19 In cases with deficient is reduced irrespective of the presence of one or two implants.21
soft tissue thickness, the choice of the reconstruction material Different advantages exist, however, for fixed dental prostheses
can significantly influence the esthetic outcome. These stud- with a cantilever design. Cantilevers offer increased flexibility
ies have shown that all-ceramic reconstructions render more regarding the use of pink ceramics to prosthetically compen-
favorable results compared with metal-ceramic reconstructions sate for the missing papilla volume between the implant crown
when the soft tissue thickness is less than 2 mm. and the cantilever (Fig 7-7). Furthermore, treatment costs are
In the anterior maxilla, the angulation and horizontal posi- lower, and patient morbidity is reduced. Finally, the dimensions
tion of implants depend on the mode of fixation of the of the alveolar ridge need to be taken into account when select-
planned implant-supported reconstruction. Anterior implant ing the optimal implant site. From a surgical point of view, the
120

a b c
d e f
g h
Fig 7-5 (a) The two central incisors were lost as a result of trauma. The left lateral incisor showed a combined enamel-dentin fracture. The
treatment plan was to replace the central incisors with two implants. The lateral incisor was planned for restoration with a composite filling. (b)
A conventional surgical template was used to place the implants according to the prosthetic plan. The most important parameter is the correct
vertical position of the implant shoulder approximately 4 mm below the prospective mucosal margin at the buccal aspect. (c) The implants were
placed in such a way that a screw-retained implant reconstruction could be designed. A conventional surgical template served as reference during
the implant surgery. (d) Clinical situation of the two implants before the delivery of the implant crowns. (e) Two screw-retained implant crowns
were fabricated. (f) Clinical view after delivery of the single implant crowns. (g) Periapical radiograph after delivery of the single implant crowns.
(h) Follow-up 1 year after delivery. Slight creeping of the papillae can be observed.
a b
Fig 7-6 (a) The treatment plan was to replace the missing lateral incisor with a cantilevered fixed dental prosthesis. The supporting implant was
placed in the site of the left canine to allow use of a regular-diameter implant and limitation of the lever arm to the mesiodistal size of the lateral
incisor. (b) A screw-retained, metal-ceramic implant reconstruction with a mesial cantilever was delivered.
121

a b c
d e f
Fig 7-7 (a) The treatment plan was to replace the missing maxillary right central and lateral incisors with a cantilevered dental prosthesis fixed on
a single implant. (b) The supporting implant was placed in the central incisor site with the help of a surgical template based on a prosthetic setup.
This site allowed a regular-diameter implant with appropriate implant-abutment dimensions to be placed. (c) Augmentation of the edentulous site
was limited to guided bone regeneration simultaneous with the implant placement. (d) The shape of the emergence profile and the ovate pontic
were conditioned by means of a fixed interim prosthesis. (e) Pink ceramics was used for the screw-retained, cantilevered fixed dental prosthesis
to compensate for the missing papilla between the lateral and central incisor. (f) The transition zone from the artificial mucosa to the peri-implant
mucosa is not exposed during the patient’s smile. The use of pink ceramics allows mimicking of the papilla of the contralateral site.
implant should be placed at the site where more bone volume design. This will lead to a conventional three-unit fixed dental
is present to ensure primary stability and to reduce the need prosthesis for the missing canine, lateral incisor, and adjacent
for bone augmentation. central incisor and a single implant crown for the contralateral
The same design principles apply for maxillary edentulous incisor; ie, two separate implant reconstructions are inserted.
spaces with three or four missing teeth. In general, two implants Segmentation of implant reconstructions has the advan-
are sufficient to support a three- or four-unit fixed dental pros- tage that any biologic/technical complications are limited to
thesis. One treatment option is to place the implants adja- the segment affected. As a consequence, repair or replacement
cent to the neighboring teeth. Thereby, a conventional implant of the affected segment is easier. Generally, as the number of
reconstruction can be designed with abutments at each end segments increases, more implants are necessary. The place-
and pontics replacing the missing teeth between the implants. ment of additional implants is usually more challenging. In addi-
Again, the use of cantilevers may be considered a valuable tion, horizontal bone augmentation procedures are often needed
treatment option. The decision regarding where to place the when more implants are placed. Finally, the more implants that
implants is based on the quantity of bone volume present and are present, the higher the risk for biologic and technical compli-
the prosthetic setup. cations during function.22
When all of the central and lateral incisors are missing, two In edentulous sites with multiple missing teeth in the ante-
implants may be placed at the sites of the central incisors, rior maxilla, CAIP clearly offers clinical advantages. Larger tooth
resulting in a fixed dental prosthesis with two crowns for the gaps mean that references for guiding implant placement during
central incisors and two cantilevers for the lateral incisors. The surgery are reduced. CAIP allows integration of anatomical and
placement of the implants in the central incisor sites may allow prosthetic information during planning as well as transferring
biologic principles to be more easily respected. In addition, in of this information, through the use of a surgical stent, to the
such four-tooth gaps, sufficient mesiodistal space is usually site of implant placement. In multiple-tooth gaps in the ante-
available to allow placement of regular-diameter implants. rior maxilla, this procedure offers significant advantages over
In an edentulous site with four missing teeth involving the freehand implant placement (Figs 7-8 and 7-9).
canine, one lateral incisor, and both central incisors, one addi- For any prosthetic design selected, hygiene access to
tional design configuration may be applied: Two implants are the reconstruction needs to be provided. The definitive
placed in the sites of the canine and central incisor adjacent to implant-supported reconstruction should be designed in such
the missing lateral incisor. This will result in a four-unit partial a way that effective oral hygiene is possible. The patient’s
denture with a cantilever replacing the contralateral central manual skills may be a limiting factor and must be taken into
incisor. A third implant may be chosen instead of a cantilever account. A clinical study demonstrated that 48% of implants
122

a b c
d e f
Fig 7-8 (a) A failing tooth-supported reconstruction was planned to be replaced by an implant-supported reconstruction. (b) The edentulous space
presented with four missing teeth. A CBCT scan was acquired to properly evaluate the ideal location, distribution, and diameter of the implants
and the prosthetically driven 3D position. (c) A conventional prosthetic setup was digitized by a laboratory scanner. Neighboring tooth structures
served as reference for the virtual superimposition onto the CBCT data. In total, three implants were planned in both central incisor and the right
canine sites. Reduced-diameter implants were chosen to avoid dehiscence and fenestration defects. Biologic and prosthetic principles determined
the 3D position of the implants. (d) A CAD/CAM surgical guide was used to accurately transfer the virtual implant position to the patient’s mouth.
(e) A one-piece, screw-retained implant reconstruction was designed. The prosthetic units between the central incisors were splinted to improve
mechanical stability because reduced-diameter implants were placed. (f) Definitive implant-supported reconstruction after delivery.
a b c
d e f
Fig 7-9 (a) A patient presented with tooth-supported reconstructions in the anterior maxilla. At this stage, the acquisition of a CBCT scan would
result in artifacts from the metallic reconstructions. Therefore, the CBCT scan was postponed until after the pretreatment. (b) The right central and
lateral incisors and the canine were planned for replacement by an implant-supported reconstruction, whereas a tooth-supported reconstruction
was planned for the contralateral site. (c) A CBCT scan was taken with the prosthetic setup (purple) in place during data acquisition. A radiopaque
brick was fixed to the prosthetic setup as a reference structure because neighboring teeth were missing to serve as reference structures for
superimposition. (d) The implant planning software allows the superimposition of the prosthetic setup (purple line) through the radiopaque brick.
Also, the palatal soft tissues are anatomical landmarks and can be used as reference structures. (e) The implant in the right canine site was placed
according to the prosthetic setup and allowed a screw-retained fixed dental prosthesis. Consequently, a fenestration defect needed to be taken
into account. (f) The implant (jagged red outline) in the right central incisor site was virtually placed according to the prosthetic setup. Anatomical
structures such as the incisive canal need to be preserved. The vertical position of the implant is determined by the prospective mucosal margin
of the planned implant reconstruction at the buccal aspect. The sleeves of the surgical guide (red rectangles) are located 4 mm above the implant
shoulder and can serve as reference objects for the correct vertical positioning of the implant.
123

g h i
j k l
Fig 7-9 (cont) (g) A CAD/CAM surgical guide was used to place the implants guided. A palatal support was designed to improve the stability of
the guide during the implant surgery. (h) The implants in the right central incisor and canine sites were placed with a 3D printed guide. (i) The virtual
planning allowed anticipation of the fenestration defects at the implants. (j) Guided bone regeneration was performed to cover the fenestration
defects. Simultaneously, the horizontal width of the alveolar ridge was improved. (k) The emergence profile at the implant sites and the ovate
pontic at the sites of the lateral incisors were shaped with the help of an interim fixed prosthesis. (l) Clinical view after delivery of the definitive
reconstructions. An implant-supported reconstruction was fixed on two implants in the right central incisor and canine sites. A tooth-supported
reconstruction was fixed on the left central incisor and canine abutments.
with peri-implantitis were found at implant reconstructions with REFERENCES

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125

8 GUSTAVO AVILA-ORTIZ • HOMAYOUN H. ZADEH
Management of the
Extraction Site:
Socket Grafting
Healing of the Extraction Site
Postextraction Contour and Dimensional Changes
of the Alveolar Ridge
Alveolar Ridge Preservation
Alveolar Ridge Preservation via Socket Grafting
127

8 | Management of the Extraction Site: Socket Grafting
Pre-extraction 0–24 hrs 1 wk 4 wks 8 wks 20 wks

Pre-extraction 0 - 24 hrs 1 wk 4 wks 8 wks 20 wks
Hemostasis
Inflammatory phase
Hemostasis
12 hrs
Proliferative phase
3 wks 14 wks
Inflammatory phase 12 wks
Maturation and remodeling phase
20 wks
12 hrs
Fig 8-1 Extraction socket healing sequence. Proliferative phase
3 wks 14 wks
Maturation and remodeling phase
12 wks 20 wks
T
ooth extraction remains one of the most commonly tives to alveolar ridge preservation procedures when immedi-
indicated clinical procedures in daily dental practice. ate implant placement is not indicated, with an emphasis on
The detrimental consequences of tooth extraction socket grafting.
go beyond the esthetic, functional, and psychologic
ramifications that, depending on the clinical scenario, may be
derived from tooth loss. Tooth extraction also triggers a cascade
of local biologic events that directly impact the homeostasis and HEALING OF THE EXTRACTION
structural stability of the periodontal tissues, particularly the SITE
alveolar bone. The inevitable surgical trauma sustained during
tooth extraction, coupled with the subsequent deprivation of Understanding the sequence of biologic events that take place
masticatory stimulation to the alveolar bone proper, typically in the alveolar socket and surrounding structures as part of
causes the initiation of a resorptive process that affects the bony the normal healing processes that follow tooth extraction is
walls of the socket. The extent of alveolar bone atrophy may fundamental to making substantiated clinical decisions that
vary from site to site and from individual to individual, depend- lead to predictable outcomes. Clinical and preclinical research
ing on local and systemic factors, but it commonly results in a conducted since the 1930s1 has continued to shed light on the
certain degree of alveolar ridge reduction in both the horizontal sequence of molecular and cellular events that occur during
and vertical dimensions (Fig 8-1). Clinical management of defi- this process under normal conditions of healing, from the very
cient alveolar ridges oftentimes requires ancillary reconstructive moment of tooth extraction until complete maturation of the
procedures. These include bone and/or soft tissue grafting inter- site is reached. It is important to remark that, although the
ventions in an attempt to re-create the original architecture prior sequence of biologic events observed in humans and in animal
to implant placement or the delivery of a tooth-supported fixed models is similar, it is well established that the healing rate in
dental prosthesis involving an edentulous pontic site. However, canine models is significantly faster than in humans, to a mag-
the execution of site development procedures is associated nitude of three- to fivefold, which is in direct correlation with the
with a higher risk for complications and patient morbidity as shorter life span of these species.2 Consequently, the timing of
well as increased expenses and total treatment time. Hence, healing generally observed in animal models cannot be purely
understanding how to properly manage the extraction site in interpolated in clinical practice. A judicious and juxtaposed eval-
order to minimize the detrimental effects of tooth extraction on uation of the best available clinical3–6 and preclinical7–11 evidence
the remaining periodontal structures is of utmost importance is necessary to understand the timing of biologic events that
in the context of contemporary clinical practice. normally take place after tooth extraction.
This chapter aims to provide a comprehensive overview of The healing of the extraction site can be divided in four differ-
the essential principles that form the basis of optimal treatment ent phases: hemostasis, inflammatory phase, proliferative
planning and management of the extraction site, including a phase, and maturation and remodeling phase. These phases
description of the healing events and dimensional changes that partially overlap and culminate at different time points depend-
normally follow tooth loss as well as discussion of the rationale ing on the topographic location within the alveolar socket (eg,
and evidence supporting the indication for therapeutic alterna- it is well established that maturation is typically faster in apical
128

Healing of the Extraction Site
regions of the socket)8,9 and on inherent patient-related local Additionally, the overlying mucosa progressively migrates from
and systemic factors not yet fully understood.5 the boundaries of the socket orifice in order to form a natural
soft tissue seal, which is essential for adequate bone formation
and maturation. Rapid epithelial and connective tissue down-
Hemostasis (approximately 0 to 24 hours) growth usually leads to partial invagination of the soft tissue
into the compartments previously occupied by the tooth root
Immediately after tooth extraction, the alveolar socket is filled and the crestal bone.
with blood that primarily emanates from the severed vessels
of the periodontal plexus. In normal conditions of healing, the
coagulation cascade is initiated, and a stable coagulum (ie, Proliferative phase (approximately
blood clot) that completely fills the alveolar socket is formed 3 to 14 weeks)
in direct contact with the Sharpey fibers and the supracrestal
soft tissue within the first 24 hours. The coagulum is essentially As the site matures, the granulocytic infiltrate progressively
constituted by a mesh of nonglobular proteins, such as fibrin disappears, largely due to apoptotic processes. Mesenchymal
(the main constituent of the clot), fibronectin, and vitronectin, stem cells (MSCs) and differentiated mesenchymal cells, such
among other plasma proteins, and contains a large quantity of as osteoblasts and fibroblasts, migrate from native adjacent tis-
entrapped erythrocytes, while platelets and immune cells are sues. These cells actively participate in ECM deposition, which
present in a lower proportion. leads to a progressive increase in collagen density. In response
This intricate matrix has two main functions: (1) to promote to tightly regulated molecular signaling pathways,6,10 subpopu-
hemostasis and (2) to allow for the attachment of cells from the lations of MSCs present in the collagen-rich scaffold undergo
environment that participate in the subsequent healing phase. osteoblastic differentiation. Osteoblasts are responsible for the
initiation of early mineralization following an intramembranous
ossification pattern, which is characterized by the formation of
Inflammatory phase (approximately fingerlike woven bone structures within the ECM that typically
12 hours to 4 weeks) originate from the bony boundaries. These woven bone projec-
tions contain a high proportion of osteocytes and are lined by
Shortly after its consolidation, the coagulum is progressively osteoblasts with flat morphology and polarized nuclei. Although
infiltrated by a large quantity of inflammatory cells. This inflam- in lower proportions than osteoblastic cells, osteoclasts (multi-
matory infiltrate, rich in neutrophilic granulocytes, originates nucleated, bone-resorbing cells) also appear on the surface of
from the periphery, including the bony and soft tissue struc- the woven bone. The spaces between and within the mineralized
tures that surround the socket. The essential functions of the structures are occupied by marrow spaces, rich in mesenchymal
inflammatory infiltrate are to eliminate debris and bacteria and and inflammatory cells, adipocytes, and vascular structures.5
to participate in the degradation of the fibrin mesh, which is
progressively replaced with a provisional extracellular matrix
(ECM), mainly constituted by collagen, among other matricel- Maturation and remodeling phase
lular proteins. The ECM is produced by cells of mesenchymal (approximately 12 weeks and onward)
lineage that primarily migrate from niches within remnants of
the periodontal ligament (PDL) and from bone marrow spaces Following a natural process of tissue remodeling, mediated by
adjacent to the socket. The process of angiogenesis, which is complex actions and interactions of osteoblasts, osteoclasts,
initiated from vascular sprouts located in the boundaries of the and osteocytes, woven bone structures undergo further mat-
alveolar socket, progresses in parallel to the formation of the uration and are eventually replaced with lamellar bone. These
provisional ECM. structural changes are the result of a more organized distribution
The biologic events described previously (ie, cell migration, of the collagen fibers contained within the bone matrix into par-
formation of a provisional extracellular matrix, and neovascular- allel sheets (from Latin: lamellae) as well as increased mineral
ization) lead to the formation of a richly vascularized granulation deposition. Lamellar bone is capable of sustaining biomechan-
tissue that advances from the lateral to the central aspect of ical challenges more efficiently than woven bone, as long as
the socket. This tissue takes its name from the heavy neutro- certain physiologic thresholds are not surpassed. Interestingly,
philic cell infiltrate (ie, granulocytes) observed histologically. the number of osteocytes contained in lamellar bone is signifi-
The formation of granulation tissue is a normal component of cantly lower as compared with woven bone, which illustrates
the healing process, and it should not be mistaken with granu- the crucial role of the osteocyte as the orchestrator of the late
lomatous tissue or a granuloma, which is inflamed tissue that stages of ossification. Upon maturation, proper bone homeo-
forms in response to an insult, oftentimes a bacterial infection. stasis requires a balance between bone apposition and resorp-
During this phase, there is also intense osteoclastic activity tion. This physiologic equilibrium is determined by molecular
on the periphery of the socket that results in partial or complete and mechanical stimuli that regulate the activity of temporary
degradation of the alveolar bone, particularly at the crestal level. anatomical structures known as basic multicellular units.
129

POSTEXTRACTION CONTOUR was found in sites grafted with an allograft at 18 to 20 weeks

postextraction as compared with 8 to 10 weeks (ie, 47.4%
AND DIMENSIONAL CHANGES OF versus 32.6%),19 suggesting that alveolar bone remodeling is
THE ALVEOLAR RIDGE part of a biologic continuum that does not plateau in the early
weeks of healing. Therefore, expanding on the existing knowl-
In addition to understanding the normal sequence of healing edge, there is emerging evidence indicating the existence of
events, it is of paramount significance to recognize the typical a more extensive resorption pattern of the alveolar bone that
patterns of alveolar ridge remodeling that take place in response extends up to 6 mm from the alveolar crest and for up to 20
to tooth extraction, considering topographic and dimensional weeks. The buccal/facial bony wall of the alveolar bone process
aspects as well as the influence of critical local and systemic is typically the thinnest region, ranging from 0.4 to 0.8 mm in
factors. the crestal 5-mm region of single-rooted teeth in humans.20–22
The alveolar process is a tooth-dependent structure that This contrasts with the typical thickness range reported for
develops in conjunction with tooth eruption. The structural lingual walls, which is 0.5 to 1.8 mm.20,22 In spite of these dimen-
features of the alveolar process are directly influenced by genet- sional differences, according to Ryu et al, the resorptive process
ics, functional dynamics, anatomical location, and the shape and does not seem to be concentrated at the facial-coronal aspect
contour of the tooth (particularly the coronal third of the radic- of the alveolar bone.18 This observation suggests that factors
ular component),12 among other factors. The outer surface of other than the mere dimensions of the alveolar bone may be
the alveolar process is constituted by compact lamellar bone. responsible for the pattern of postextraction remodeling. None-
The inner aspect is lined by the alveolar bone proper, which is theless, sites with a thin facial alveolar bone phenotype appear
a less mineralized structure of approximately 250- to 400-µm to be more prone to undergo more rapid and more extensive
thickness that is rich in bundle bone and permeated by Sharpey bone resorption. The studies by Chappuis and coworkers16,17
fibers from the PDL.13 have demonstrated that the dimensional loss of the alveolar
As a direct consequence of tooth removal, which inevitably bone is partially compensated by mucosal thickening, partic-
involves severing the PDL and the subsequent interruption of ularly in sites presenting a thin facial wall, which can mislead
biomechanical stimulation of the bony walls as well as the initi- unwary clinicians in the process of implant therapy planning
ation of a local inflammatory response, the alveolar process in healed sites.
undergoes irreversible remodeling. This resorptive process is Aside from the important prognostic value of alveolar bone
characterized by vertical and horizontal dimensional changes thickness, other local factors that may play a significant role in
that affect both the soft and the hard tissues. socket-healing dynamics after tooth extraction are: bone defects
The initial animal studies conducted in this area employed (ie, fenestrations or dehiscences),12 excessive surgical trauma,23
histologic evidence to document the dimensional changes the number of contiguous teeth extracted simultaneously,24
that affect the alveolar bone after tooth extraction.7,14,15 These presence of concomitant pathology (eg, abscesses),25 and the
studies suggested that most of the postextraction volumetric dimensions of the socket.26,27 Other potentially influential factors,
changes occur in the early stages of healing and mainly affect such as history of periodontal disease28 and glycemic control,29
the facial-coronal aspect of the ridge. However, since histologic do not seem to affect socket-healing outcomes on the basis of
studies are inherently end-point analyses, it is not possible to current evidence.
examine the dynamics of other dimensional changes affecting The magnitude of the effect of tooth extraction, in terms
different locations of the same alveolar ridge in subsequent of linear and volumetric changes to the coronal aspect of the
stages of healing. Additional human studies have conducted alveolar ridge, has been thoroughly studied in humans. In a
serial examinations of the same sites to document changes systematic review by Tan et al,30 including a total of 20 stud-
occurring in postextraction alveolar ridges. These studies limited ies that evaluated linear changes in molar and nonmolar sites
their analyses to the facial bone and the initial stages of healing after up to 12 months of healing, the average horizontal ridge
(up to 8 weeks).16,17 Serial analyses of cone beam computed reduction was 3.79 ± 0.23 mm, whereas the vertical reduction
tomography (CBCT) scan images taken immediately prior to was 1.24 ± 0.11 mm on the midfacial, 0.84 ± 0.62 mm on the
and at various intervals following extraction of teeth in a nonhu- mesial, and 0.80 ± 0.71 mm on the distal aspect. In recent clin-
man primate model have demonstrated that bone resorption is ical studies utilizing surface scanners, the average volumetric
not limited to the facial-coronal aspect but also encompasses reduction in sites undergoing extraction after a healing period
lingual and interproximal areas. These analyses showed that, of 4 and 6 months has been reported as ranging from 20.0%
by 6 weeks after extraction, 45% of the crestal 3 mm and 30% to 46.4%.31–33 This wide variation may be explained by meth-
of the zone between 3 and 6 mm from the crest are resorbed. odologic differences, such as the selection of the volumes of
At 12 weeks, it was observed that 70% of the crestal 3 mm interest, and specific anatomical features, but these findings
and 44% of the zone between 3 and 6 mm from the crest are unequivocally indicative of significant dimensional changes
was resorbed.18 Human histologic data has demonstrated that in sites that undergo natural healing after tooth extraction in the
a significantly higher proportion of newly formed vital bone absence of interceptive therapeutic interventions.
130

ALVEOLAR RIDGE PRESERVATION which is employed to seal the socket access and/or to compart-
mentalize the mucosa from the underlying alveolar bone, but
Implant site development interventions are aimed at re-creating this is not the only possible ARP-SG approach. This final section
the ideal structural and biologic properties of a deficient eden- of the chapter provides a general overview of ARP-SG treatment
tulous site or ridge in order to allow for proper implant place- modalities, including discussion of important technical aspects
ment. Oftentimes implant site development involving hard and/ and a brief overview of relevant available evidence, with the aim
or soft tissue augmentation is indicated when tooth replacement of aiding clinicians in making judicious clinical decisions. It must
therapy using dental implants is desired. Implant site develop- be recognized, however, that the provision of a comprehensive
ment procedures, whether they are performed in a simulta- and precise method to determine the most effective ARP-SG
neous or delayed fashion, are associated with a higher risk of approach for a given clinical scenario is an insurmountable task,
complications, increased treatment time, more expenses, and given the plethora of treatment modalities and biomaterials
decreased patient acceptance. Early and adequate management that have been proposed and tested in the literature, each of
of fresh extraction sites can minimize the detrimental impact them with their inherent potential advantages and drawbacks.
that tooth extraction typically has on the structural integrity of When tooth extraction is indicated, an important initial consid-
the alveolar ridge. eration is to determine which sites are at the greatest risk of
Alveolar ridge preservation (ARP) can be defined as a thera- alveolar ridge atrophy. This is particularly important when consid-
peutic intervention carried out with the goal of attenuating the ering whether to indicate immediate implant therapy or ARP-SG
loss of ridge volume that typically follows tooth extraction. It is and delayed implant placement. As previously discussed, it
important to remark that, although they may share similarities, appears that the key determinant of alveolar ridge resorption is
ARP is conceptually different from alveolar ridge reconstruction, the thickness of the facial alveolar wall. Multiple clinical studies
which is generally indicated in sites exhibiting significant alveolar have reported the existence of two distinct alveolar bone pheno-
bone damage (eg, bony wall dehiscence) upon extraction.34 Like- types (ie, thin and thick) with divergent postextraction heal-
wise, ARP should be distinguished from interventions designed ing patterns.16,43,44 These studies also demonstrated an inverse
to extend the bone housing beyond its natural envelop at the correlation between alveolar bone crest thickness and postex-
time of extraction, as in, for example, buccal overbuilding tech- traction alveolar ridge resorption. In fact, sites with a thin bone
niques,35 which fall in the category of alveolar ridge augmen- phenotype, ie, presenting bone thickness < 1 mm, appear to
tation procedures. exhibit significantly more alveolar bone loss.16,44 This correlation
Alveolar ridge preservation encompasses three distinct ther- was also observed in clinical studies involving immediate implant
apeutic modalities: (1) partial extraction protocols (eg, complete placement,45–48 which deconstructs the once widespread clini-
root submersion36 or the so-called socket shield technique37,38), cal myth that immediate implant placement may contribute to
(2) slow, forced orthodontic tooth extrusion,39,40 and (3) socket the preservation of the alveolar ridge architecture after tooth
grafting.41,42 Although all these alternatives have been shown to extraction.49,50
be predictable, the latter is most commonly indicated in daily In addition to buccal bone thickness, it is crucial to assess the
practice. This is likely because socket grafting is generally associ- integrity of the alveolar bone upon extraction. Although success-
ated with lower technical complexity, less treatment time, higher ful immediate implant placement outcomes in extraction sock-
patient acceptance, and greater cost-effectiveness. ets presenting extensive bone defects have been reported in
the literature,51–53 clinicians should proceed with caution when
treating sites presenting significant dehiscences and/or coro-
nal fenestrations, as illustrated in the first clinical case (Fig 8-2).
ALVEOLAR RIDGE PRESERVATION In these clinical scenarios, alveolar ridge reconstruction and
VIA SOCKET GRAFTING delayed implant placement may be a more predictable approach,
particularly in the anterior esthetic zone, as shown in the second
ARP via socket grafting (ARP-SG) essentially consists of filling clinical case (Fig 8-3).
the alveolar socket with a biocompatible material or structure It is also important to discuss the effect of flap elevation in
that takes most or some of the space that would otherwise the context of ARP-SG. Mucoperiosteal flaps are often elevated
be occupied solely by the blood clot upon tooth extraction. The in clinical practice in order to improve surgical access. Flap
rationale behind this approach is to alter the accelerated heal- reflection and advancement may be also indicated to achieve
ing capacity of postextraction sites by filling the socket with primary soft tissue closure over the extraction site with the
a biomaterial whose primary function is to serve as scaffold. goal of protecting the biomaterials employed for ARP-SG and/
Once the alveolar process undergoes the inevitable resorp- or implants placed into extraction sockets, depending on the
tion, the presence of the biomaterial filler is expected to act as clinical situation. The effect of flap elevation on the outcomes of
a space-occupying matrix to maintain the dimensions of the ARP-SG has been investigated in preclinical and clinical studies.
ridge contour, which otherwise would be infiltrated by mucosal In a canine model, the comparison of flap versus flapless tooth
tissues. Socket grafting is commonly performed using particu- extraction, with or without ARP-SG, showed significantly less
late bone-grafting materials combined with a barrier element, alveolar bone resorption in the flapless group, both in sites that
131

a b c
d e f g
Fig 8-2 Clinical scenario illustrating a maxillary premolar presenting an extensive buccal bone dehiscence. (a) Frontal view. (b) Occlusal view.
(c) Periodontal probe demonstrating the vertical extent of the buccal defect. (d) Periapical radiograph. (e) Sagittal section from a CBCT scan that
clearly shows the presence of the buccal dehiscence (yellow arrow). (f) Tooth immediately after extraction. (g) Occlusal view of the extraction site.
received ARP as well as in those that underwent unassisted using particulate bone-grafting materials on the dimensions
healing.54 However, the difference between flap and flapless of the alveolar ridge, as compared with extraction alone, have
surgery has been shown to be negligible in other preclinical14 and shown that ARP-SG is associated with an attenuation of ridge
clinical studies.55,56 This concept is also supported by the findings resorption of approximately 2 mm in the buccolingual dimen-
reported in a systematic review, indicating that flap elevation sion and 1.5 to 2 mm in the midbuccal aspect.57,61 Furthermore,
does not play a significant role in postextraction dimensional placement of a bone-grafting material in the socket appears to
changes in humans.57 Therefore, although a minimally invasive negate the correlation between alveolar bone crest thickness
surgical intervention is always preferred, whenever additional and postextraction alveolar ridge resorption.43 Similar obser-
access is required for adequate performance of the surgical vations were reported by Sanz and collaborators following the
intervention, flap elevation may be performed. However, clini- conduction of a multicenter randomized clinical trial involving
cians should pay careful attention to avoid unnecessary trauma immediate implant placement in 86 participants.62 In these clin-
to the alveolar bone.23 Also, coronal flap advancement does not ical studies, when sockets presenting a thin bone phenotype
seem to provide any additional ridge preservation benefits and underwent ARP-SG, with or without immediate implant place-
may lead to undesirable changes in the soft tissue architecture.58 ment, the healing response resembled that of sites exhibiting
a thick bone phenotype.
An array of bone-grafting materials has been proposed for
Bone grafting materials and barriers ARP-SG, including allogeneic bone (eg, mineralized and deminer-
alized), xenografts (eg, bovine, porcine, and equine), and alloplas-
The body of evidence supporting the effectiveness of ARP-SG tic particulate and nonparticulate materials (eg, tricalcium phos-
using bone-grafting materials is robust. Multiple clinical trials phate, hydroxylapatite, and biphasic grafting materials). All of
and systematic reviews have consistently rendered positive these materials are biocompatible and osteoconductive and
results in favor of this approach as compared with undisturbed have a slower resorption rate than the blood clot. Additional
natural socket healing. These studies have reported superior properties can be leveraged for the selection of a biomaterial
clinical, radiographic, histologic, and patient-centered outcomes in specific clinical scenarios. Xenografts and cortical allografts
in favor of ARP-SG, including a reduced need for further ridge have been attributed a slow resorption rate and, for that reason,
augmentation prior to or at the time of implant placement, which are commonly utilized in an effort to maintain the alveolar ridge
is arguably the most relevant endpoint of ARP.57,59–61 Specific volume in highly compromised extraction sites.63 Demineralized
systematic reviews aimed at assessing the effect of ARP-SG allografts have been purported to possess osteoinductive poten-
132

a b
d e c
f g h
i j
k l
Fig 8-3 Presurgical visit of a patient in need of extraction of the maxillary left central incisor. A buccal vertical root fracture was
suspected. (a) Frontal view demonstrating the presence of a submarginal abscess. Probing depth was 6 mm, and the site was
positive for bleeding on probing and suppuration. (b) Occlusal view of the maxillary anterior sextant. (c) Periapical radiograph. (d to j)
Clinical photographs illustrating the severe buccal dehiscence after tooth extraction, a high-density polytetrafluoroethylene (d-PTFE)
membrane trimmed to size, and the positioning of the d-PTFE membrane between the buccal bone and mucosa. (k) Particulate
bone allograft material filling the defect. (l) d-PTFE membrane covering the socket access.
133

m n o
p q r
s t u
v w x
y z
aa bb cc
Fig 8-3 (cont) (m and n) Stabilizing sutures. (o) An interim removable appliance (Essix-type) was delivered with special attention to prevent direct
impingement of the tissue. (p to u) Buccal and occlusal images of the surgical site at 1 (p and s), 2 (q and t), and 5 (r and u) weeks postoperatively.
Management of the site at 5 weeks. (v to z) Removal of the d-PTFE membrane. (aa and bb) Buccal and occlusal aspects of the site after mem-
brane removal and gentle swabbing with 0.12% chlorhexidine. (cc) Control periapical radiograph showing slight crestal overbuilding of the graft.
134

dd
ee ff gg
hh ii
Fig 8-3 (cont) (dd) Two-dimensional sections and three-dimensional reconstruction (lower left) of the site of interest in order to assess the bone
volume for future implant placement. (ee) A circular punch (4-mm) was used to mark the surgical access for a flapless approach. (ff) Excess kera-
tinized mucosa was removed. (gg) A 2.5-mm trephine was used to initiate the osteotomy. (hh) Frontal view of the trephine in place. (ii) Part of the
bone core biopsy was retrieved in this case.
135

jj
kk ll
Fig 8-3 (cont) (jj) Microphotograph of the

core biopsy obtained (hematoxylin and eo-
sin stain; original magnification ×4). Three mm
different tissue compartments can be iden-
tified: mineralized tissue (green triangles),
nonmineralized tissue (red stars), and residual
allograft particles (yellow squares). (kk) Oc-
clusal view of the restorative platform upon
implant placement. (ll) Occlusal view of the
healing abutment; a one-stage approach was
possible in this case. (mm) Control periapi- nn
cal radiograph demonstrating a subcrestal
implant position, leaving the restorative plat-
form at approximately 3.5 mm from the ce-
mentoenamel junction of the maxillary right
central incisor. Clinical outcome at 1 year after
functional loading. (nn) Frontal intraoral view.
Note that the crown on the maxillary right
central incisor was also replaced. (oo) Fron- pp
tal view of smile. (pp) Periapical radiograph
demonstrating stable marginal bone levels.
oo
136

tial, which may promote faster healing rates,64,65 although the collapse of the bony walls82 is unsubstantiated on the basis of
clinical relevance of this possible feature has not been proven current evidence. Similarly, overbuilding of the buccal aspect of
to date. Alloplastic materials are commonly indicated when the alveolar ridge with a grafting material at the time of extraction,
patients reject the application of xenografts or allogeneic bone. which was originally proposed as an effective approach to mini-
Since tricalcium phosphate has a higher resorption rate than mize ridge remodeling,35,83,84 has not been proven to provide
hydroxylapatite, combined alloplastic materials (ie, biphasic any additional benefits to conventional ARP-SG approaches.79,85
materials) may allow for controlled biomaterial resorption, which Finally, it is important to remark that, although ARP-SG seems
could be advantageous in certain clinical situations.66 Unfortu- to contribute to maintenance of the alveolar ridge dimensions
nately, there is little evidence resulting from direct comparisons after tooth extraction, it is not a predictable therapy to completely
of different grafting materials in similar clinical scenarios in the avoid bone resorption, and a certain degree of ridge reduction is
context of ARP-SG. To date, no specific bone-grafting material, usually inevitable.57,61 Therefore, it is advisable to inform patients
or combination thereof, has been proven to be consistently undergoing ARP-SG that additional site augmentation may be
superior for ARP-SG indications.67 required to facilitate implant therapy and/or improve esthetics.
ARP-SG is typically performed using a particulate bone-grafting
material in combination with an occlusive element (eg, a barrier
membrane,68 autologous soft tissue graft,69 collagen matrix,70 Ridge preservation devices
acellular dermal matrix,71 or slow-absorbing scaffold72) that
obliterates the socket orifice. Among these options, barrier One of the most common technical challenges of ARP-SG is
membranes are most commonly employed. The use of a wide the adaptation of the barrier membrane to protect the grafting
variety of membranes with different properties (eg, absorbable material. Early exposure of the biomaterial as a consequence of
versus nonabsorbable, natural versus synthetic, fast- versus possible discrepancies between the membrane and the under-
slow-absorbing) has been proposed in the literature. According lying bone may lead to suboptimal ridge preservation. In an
to the results of a meta-analysis, the use of a barrier membrane attempt to overcome this potential clinical problem, devices
in conjunction with a bone-grafting material appears to be asso- that provide clinicians with more predictable therapeutic options
ciated with more favorable midbuccal and midlingual ridge height have been developed. One of these devices, SocketKAP (Regen
preservation as compared with the application of a bone-grafting immune), which is made of polypropylene, is intended for the
material alone.57 This observation seems to be supported by the obturation of the extraction socket orifice. There is significant
findings from recently published randomized clinical trials.73,74 preclinical and clinical evidence demonstrating the effective-
However, whether there is a particular barrier that is superior to ness of SocketKAP.18,86–91 Compared with unassisted healing,
the rest still remains unclear, since very few randomized clinical the application of SocketKAP was associated with improved
trials directly comparing different socket-sealing options have surface contour preservation.91 The results were superior when
been conducted to date.75–79 Nevertheless, the use of a barrier SocketKAP was combined with socket grafting using anorganic
to occlude the socket in combination with an osteoconductive bovine bone particles.87
material appears to be associated with a predictable outcome, Another challenge that clinicians commonly face when
as illustrated in the case shown in Fig 8-4. managing extraction sites is the treatment of alveolar bone
Different theories have been proposed to explain the effec- defects (eg, dehiscence). Previous studies have demonstrated
tiveness of ARP using bone-grafting materials in combination the use of resorbable or nonresorbable barrier membranes
with a barrier.80 Although the exact mechanism of action is not to manage the grafting of extraction sockets with facial bone
yet fully understood, the most plausible explanation may be dehiscence.34,92 However, one disadvantage of membranes
twofold. On the one hand, the application of a barrier to occlude is their relatively low mechanical strength. A specific device
the socket access seems to limit soft tissue downgrowth into with enhanced structural properties, referred to as SocketKAGE
the bone compartment. The presence of a barrier membrane (Regenimmune), has been developed for the management of
during the early stages of healing also contributes to minimize dehiscence defects, as illustrated in the final case (Fig 8-5).
the extravasation of the grafting material from the socket and
the infiltration of microorganisms and debris from the oral cavity.
On the other hand, the occupation of most of the alveolar socket Autologous blood-derived products
space by the bone-grafting material, instead of a blood clot,
directly interferes with the normal healing processes, resulting Since the introduction of platelet-rich plasma in dentistry by
in a slower healing pattern. Interestingly, this phenomenon of Robert Marx in 1998,72 multiple similar autologous-derived
delayed bone formation has been observed in conjunction with products (eg, plasma rich in growth factors,93 platelet-rich fibrin
a marked reduction of alveolar bone resorption in histologic [PRF],94 or leukocyte-PRF [L-PRF]95) have been developed. Their
studies conducted in human and animal models.14,81 application has been proposed in different clinical scenarios,
The widely circulated misconception that the aggressive including extraction sockets. The rationale for the use of these
compaction of a grating material into the extraction site would autologous blood-derived products essentially consists of the
create a “root retention effect” that can help to prevent the local delivery of a fibrin matrix containing a supraphysiologic
137

a b c
d e f g h
i j k
2–3 mm 2–3 mm
l m n
Fig 8-4 This patient was referred for extraction of the maxillary right lateral incisor and replacement with a dental implant. (a) Frontal view. (b) Lat-
eral view. (c) Occlusal view. (d) Periapical radiograph. On clinical and radiographic examination, no alveolar ridge defect was suspected. (e) Tooth
immediately after minimally traumatic extraction using a special device. The complete integrity of the alveolar bone was verified. (f to h) Sequence
illustrating the use of a blunt instrument that was used to create a tissue “pouch” after careful mucoperiosteal elevation on the facial and the
lingual mucosa. The extension of the pouch was 3 to 4 mm apically on both sides. (i) Insertion of an oval-shaped, nonabsorbable (high-density
polytetrafluoroethylene [d-PTFE]) membrane on the facial. (j) A particulate xenograft material was used to fill the socket up to the level of the alveolar
crest. (k) The d-PTFE membrane was then tucked in the lingual pouch. (l) A cross mattress suture (4-0 d-PTFE) was applied to gently stabilize the
overlying mucosa. (m) Control periapical radiograph that demonstrates the even distribution of the grafting material in the socket. (n) Illustration
of the design and dimensions of the nonabsorbable membrane employed in this case. Note that an extension of 2 to 3 mm beyond the dimen-
sions of the socket access both buccally and lingually is recommended to facilitate the insertion and adaptation of the barrier in the tissue pouch.
138

o p q
r s t
u v
w x
Fig 8-4 (cont) (o to t) Buccal and occlusal images of the surgical site at 1 (o and r), 2 (p and s), and 5 (q and t) weeks postoperatively. The site
was reevaluated at 12 weeks. Excellent healing could be observed from a buccal (u) and an occlusal (v) perspective. (w and x) A CBCT scan was
obtained at 20 weeks to plan the implant placement. The preservation of the bone appeared to be excellent, which favored the planning of pros-
thetically driven implant placement following a computer-guided surgery protocol.
139

y z
aa bb
cc dd
ee ff
Fig 8-4 (cont) At approximately 28 weeks from the time of tooth extraction, the implant placement surgery was
performed. (y and z) The adaptation of the stereolithographic surgical guide was excellent. (aa and bb) A circular soft
tissue punch was employed to excise the mucosa, following a flapless approach. A trephine bur with a diameter of
2.75 mm was used to obtain a bone core biopsy. (cc and dd) Subsequently, the preparation of the osteotomy was
completed according to the manufacturer’s recommendations, and a 3.6 × 9–mm implant was placed through the
guide. Primary stability was excellent. (ee and ff) A 4-mm-tall straight healing abutment was placed.
140

gg hh ii
jj kk
ll mm
Fig 8-4 (cont) (gg to ii) Microphotographs at low (gg, ×4) and high (hh,×10; ii, ×20) magnification
of the bone core biopsy (hematoxylin and eosin stain). Three different tissue compartments can
be identified: mineralized tissue (green triangles), nonmineralized tissue (red stars), and residual
xenograft particles (yellow squares). Clinical outcome after 6 months of functional loading. (jj)
Frontal intraoral view. (kk) Occlusal view of the anterior sextant. (ll) Frontal view of smile. (mm)
Lateral view demonstrating the use of a periodontal probe on the distofacial aspect. Neither ab-
normal probing depths nor bleeding on probing was noticed. (nn) Periapical radiograph. Marginal
bone levels were excellent.
nn
141

a b c
d e
f g h
i j k
l m
Fig 8-5 This case illustrates the management of a patient with a failing maxillary central incisor that was replaced with an implant. (a) Frontal
view. (b) Lateral view. (c) Occlusal view. (d and e) The tooth exhibited 3 mm of midfacial gingival recession, 9-mm pocket depth, and approximately
75% radiographic bone loss. The adjacent teeth also presented gingival recession. After minimally traumatic tooth extraction, vestibular incision
subperiosteal tunnel access (VISTA) was used to visualize and manage the dehiscence defect (f), which extended approximately 10 mm in the
vertical dimension (g). Following careful debridement of the site, a SocketKAP (h) was loosely attached to the peripheral mucosa with polytetraflu-
oroethylene sutures (i). The gingival margins of adjacent teeth were coronally advanced and fixed to each tooth with the aid of flowable composite.
Bovine xenograft particles were applied to fill the socket. A SocketKAGE (j) was placed over the socket and affixed with sutures to closely adapt
the device to the mucosa surrounding the socket access (k). The VISTA approach was also used to simultaneously repair the gingival recession
on adjacent teeth. A pontic was bonded to the palatal aspect of the adjacent teeth for interim replacement of the extracted central incisor (l and
m). Initial healing was uneventful.
142

n o p
q r
s t u
v w x
Fig 8-5 (cont) After 6 months of healing, the alveolar bone and mucosal contour were favorable for implant placement, as illustrated in the CBCT
scan images and virtual implant planning (n to r). An incision was made on the tissue crest for access to the alveolar crest in order to perform a
minimally invasive osteotomy and subsequent implant placement. VISTA was again used to provide vestibular access to verify that the implant
osteotomy was in good position relative to the facial and crestal alveolar bone. This approach also allowed for coronal advancement of the gingival
margin of the right lateral incisor and for the insertion of a connective tissue graft to repair the gingival recession on the adjacent tooth (s and t).
A control radiograph was obtained several weeks later after implant provisionalization (u). The clinical (v and w) and radiographic (x) images taken
1 year after implant placement show favorable peri-implant alveolar bone and mucosal contour.
143

concentration of molecular mediators (eg, growth factors CONCLUSION

released by degranulation of platelets) and/or cells (eg, leuko-
cytes) to promote hemostasis locally and to enhance the healing Tooth extraction triggers a cascade of biologic events that ulti-
outcomes. For example, the use of L-PRF as a biologic scaffold mately results in a dimensional reduction of the alveolar ridge.
for the treatment of fresh extraction sockets of third molars has These resorptive events tend to be more marked in sites pre-
been associated with reduced dimensional loss of the alveo- senting a thin bone phenotype. Severe ridge deficiencies may
lar bone as well as less postoperative pain.96,97 However, the significantly complicate tooth replacement therapy with dental
preparation protocols, the presumed mechanism of action, and implants. ARP-SG is a predictable approach to attenuate the
the associated therapeutic benefits claimed by their proponents resorption of the alveolar ridge after tooth extraction. Multiple
reported in the literature widely vary. Additionally, the wide range treatment modalities and biomaterials for ARP-SG have been
of outcomes reported for autologous blood-derived products proposed and tested in the literature, but no specific approach
employed for ARP purposes are equivocal.98–101 The increasing has been proven to be superior.
interest in the application of autologous blood-derived products Clinicians interested in performing ridge preservation proce-
will possibly lead to the generation of stronger evidence in the dures should have a thorough understanding of the biologic
future, which can be employed to develop specific indications events that normally take place in the alveolar socket after tooth
and clinical practice applications. extraction and carefully analyze the local and systemic factors
that pertain to specific clinical scenarios for successful case and
therapy selection and optimal treatment outcomes.
Biologics
Local delivery of biologics, such as recombinant human platelet-

derived growth factor BB (rhPDGF-BB) or recombinant human ACKNOWLEDGMENTS
bone morphogenetic protein 2 (rhBMP-2), has been proposed
to promote faster and more predictable healing outcomes after Dr Gustavo Avila-Ortiz would like to acknowledge the Amer-
tooth extraction. Although the amount of available evidence ican Academy of Periodontology Foundation for the support
on this particular topic is limited compared with the use of provided to pursue an academic career and Dr Chris Barwacz,
conventional bone-grafting materials and barrier membranes, Department of Family Dentistry at the University of Iowa Col-
the observed effects of local delivery of biologics in extraction lege of Dentistry, for his restorative work in the cases shown
sockets appear to be positive.99 in Figs 8-2 to 8-4.
The application of rhPDGF-BB in conjunction with a bone- Dr H. H. Zadeh gratefully acknowledges the numerous collab-
grafting material in human extraction sockets has been associ- orators from many countries around the world who contributed
ated with positive outcomes in some clinical studies, including to the data used in this chapter.
increased vital bone formation and reduced residual grafting
material, possibly indicating an enhanced healing response.102–105
The local delivery of rhBMP-2 appears to be associated with
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147

9 DAVID M. KIM • JERRY CHING-YI LIN •
CHIA-YU (JENNIFER) CHEN
Placement of
Dental Implants into
Extraction Sockets
Decision Making for Immediate Implant
Placement
Bone Remodeling After Tooth Extraction
Clinical Considerations for Immediate
Implant Placement
149

9 | Placement of Dental Implants into Extraction Sockets
a b
c d
Fig 9-1 (a and b) A 45-year-old female patient

presented for maxillary right second premolar
extraction, and immediate implant placement
was offered as a treatment option. Due to the
length of the remaining root, delayed placement
was chosen. (c and d) The patient returned af-
ter 8 weeks with complete gingival healing. (e)
However, due to immature bone quality, the
implant followed the existing socket morphol-
ogy. This case demonstrates the difficulty of
e implant placement with both the immediate
and early approaches.
T
he use of endosseous dental implants for rehabili- protocol in clinical practice.4–6 The primary stability of immedi-
tation of missing teeth has become a routine treat- ate implant placement relies on the anchorage of the implant
ment option.1 Originally implants were placed into in native bone apical to the extraction socket, the surrounding
completely healed edentulous ridges several months alveolar walls, or interradicular septa.
after tooth extraction and then left submerged for 3 to 6 months The advantages of immediate implants include fewer surgi-
before stage-two surgery and definitive restoration.2 This classical interventions, shorter overall treatment time frame, optimal
cal delayed implant surgical protocol is not indicated in all clinical availability of existing bone for stabilization of the implant and
situations. Contemporary timing of implant placement can be as a guide for implant position, and most importantly the possi-
classified into immediate, early, or delayed placement according bility of immediate fixed provisionalization. On the other hand,
to various degrees of hard tissue healing.3 Early implant place- immediate implant placement is a highly technique-sensitive
ment generally takes place between 4 to 16 weeks following procedure, and many factors must be considered, such as site
tooth extraction, with the advantage of soft tissue healing, while morphology, proximity to adjacent root, vertical bone quality and
delayed placement refers to placement more than 6 months quantity, adjacent root morphology, and availability of keratinized
after extraction. mucosa for flap adaptation (Fig 9-1).
Human clinical and histologic evaluations of immediately
placed dental implants have demonstrated an average of 66.2%
bone-implant contact (BIC)7 (Fig 9-2). This BIC appeared to be
DECISION MAKING FOR approximately 10% less when compared with the same implants
placed into healed ridges.7,8 Nonetheless, a retrospective study
IMMEDIATE IMPLANT
of immediate implants with a mean follow-up duration of 6 years
PLACEMENT demonstrated a high cumulative survival rate of 96.5%.9 The
position of the implants (anterior versus posterior and maxilla
First introduced in 1976 and later popularized by Lazzara in 1989, versus mandible) and the timing of prosthetic loading did not
immediate implant placement has become a common surgical make a significant difference.10
150

Decision Making for Immediate Implant Placement
a b c d e
Fig 9-2 (a to e) Histologic specimens of immediately placed implants demonstrating significant BIC.
Patient considered for immediate implant placement
Comprehensive evaluation of medical and dental history

Complete oral and radiographic exams
No
Presence of infection—manageable? Early/delayed implant placement
Yes
Plan proper implant 3D (apicocoronal, buccolingual, and mesiodistal)
positioning according to diagnostic wax-up
No
Is implant stability attainable? No
Early/delayed implant placement
Yes
Assess extraction socket morphology:
Is the buccal bone plate intact?
Yes
No
Immediate implant placement Early/delayed implant placement
Grafting if the gap is ≥ 2 mm Immediate implant placement with GBR
Consider additional soft tissue grafting Consider additional soft tissue grafting
for thin tissue biotypes for thin tissue biotypes
Consider immediate provisionalization Consider immediate provisionalization
Fig 9-3 Decision tree for immediate implant placement. 3D, three-dimensional; GBR, guided bone regeneration.
Clinicians must exercise caution when proceeding with imme- computed tomography (CBCT), judicious case selection, and a
diate implant treatment as it depends on a number of patient-, meticulous treatment regimen ensure a predictable treatment
surgery-, and prosthetic-related factors. A careful preoperative outcome with long-term success (Fig 9-3).
work-up with the use of diagnostic tools such as cone beam
151

a b c
Fig 9-4 (a and b) The patient presented for maxillary right central incisor
extraction. The tooth was extracted without a grafting procedure. (c
and d) Soft tissue healing at 4 weeks masked the underlying bone loss.
This case shows that early implant placement may not be indicated in
all clinical situations.
a b c
Fig 9-5 (a and b) Patient presented for maxillary right first molar extraction, and an immediate implant was placed. Note the gap between the
inner surface of the socket wall and the implant. (c) The gap was grafted with freeze-dried bone allograft.
BONE REMODELING AFTER grafts or membranes and found that during a 4-month heal-
ing period, the alveolar ridge underwent significant changes.
TOOTH EXTRACTION While the marginal gap healed with new bone formation and
defect resolution, the resorption of the buccal bone dimen-
It is well established that physiologic bone resorption occurs sion amounted to about 56%.14 It is clear that physiologic bone
following tooth extraction; a considerable decrease of alveolar resorption will occur following tooth loss, and immediate implant
height (11% to 22%) and an even greater decrease in alveo- placement fails to counteract alveolar bone remodeling, in partic-
lar width (29% to 63%) have been reported during the first 6 ular on the buccal aspect. It can be speculated that the apical
months after extraction11,12 (Fig 9-4). In a study investigating the shift of the buccal bone plate may contribute to midfacial reces-
fate of the buccal wall following extraction with and without sion following immediate implant treatment.15,16
alveolar ridge augmentation, it was demonstrated that with Human histologic studies showed that when the horizon-
the use of a xenograft, the loss of the buccal plate could be tal gaps were 2 mm or less, the degree of BIC of immedi-
reduced to less than 20%.13 ate implants was comparable to conventional implants even
The diameter and morphology of the tooth is greater than without the use of a barrier membrane or grafting material.17,18
that of most implants, resulting in a gap between the inner There appear to be benefits to grafting the gap surrounding
surface of the surrounding bony walls and the implant surface the immediate implant if this distance is greater than 2 mm. A
(Fig 9-5). The effect of immediate implant placement on alveo- human histologic and histometric analysis of four experimental
lar ridge alteration has been investigated in clinical studies.14,15 immediate implants 6 months after placement found that when
Botticelli et al examined hard tissue changes following imme- a horizontal defect dimension of 4 mm was not grafted, the BIC
diate implant placement without the use of bone replacement was only 17%.18 Chen et al demonstrated that simultaneous
152

Clinical Considerations for Immediate Implant Placement
a b c
d e f
g h i
Fig 9-6 Immediate implant placement into the extraction socket and concomitant bone grafting. (a) The CBCT scan demonstrated an apical lesion,
but adequate bone beyond the root apex allows for stabilization of an immediate implant. (b and c) Note the buccal dehiscence and large buccal gap
following immediate implant placement. (d) Grafting with freeze-dried bone allograft. (e) Coverage with a collagen barrier membrane. (f) Suturing
done without primary closure. (g) Definitive restoration. (h and i) Twelve-year follow-up.
regenerative procedures with immediate implant placement sider include the presence of periapical infection, the need for
significantly reduced bone dimensional change by 15% to 20%.19 additional hard and soft tissue grafting, and immediate versus
In conclusion, alveolar ridge dimensional changes following delayed loading.
immediate implant placement are significantly affected by the
position of the implant, thickness of the buccal bone crest, and
the size of the initial gap.20 Thus, clinicians must assess the Infected sites
three-dimensional positioning of the implant as well as the thick-
ness of the buccal plate at the extraction site before performing In regard to immediate implants placed into infected sites, a
immediate implant placement. cumulative survival rate of 97.8% has been reported. This is
comparable to that of implants placed in sites without periapical
pathology.21 However, Lefever et al investigated the etiology of
periapical lesions around dental implants and reported a higher
CLINICAL CONSIDERATIONS FOR occurrence (odds ratio of 7.2) when implants were placed into
IMMEDIATE IMPLANT PLACEMENT sites with previous endodontic treatment or a periapical lesion.22
Evidence suggests that with meticulous debridement of the
Clinical application of the immediate implant protocol can gener- infected site, immediate implants can achieve a high success
ally be divided according to placement into the anterior esthetic rate (Fig 9-6).
zone or posterior premolar/molar sites. Other factors to con-
153

a b I II III IV
Fig 9-7 (a) A maxillary right central incisor with no Fig 9-8 Sagittal root position classification. Class I: root positioned against the labial corti-
discernible buccal bone plate. (b) A maxillary right cal plate. Class II: root is centered in the middle of the alveolar housing without engaging
canine with no discernible buccal bone plate. the labial or cortical plates at the apical third of the root. Class III: root is positioned against
the palatal cortical plate. Class IV: at least two-thirds of the root is engaging both labial
and palatal cortical plates. (Modified from Kan et al26 with permission.)
a b c
d e
Fig 9-9 (a) Buccal view of a failing right maxillary lateral incisor. (b) Note the buccal gap after immediate implant
placement, which can collapse if grafting is not performed. (c) Buccal gap grafted with freeze-dried bone allograft. (d)
Immediate provisionalization obviated the need for the use of a barrier membrane. (e and f) Definitive restoration and
radiograph at 3 years.
Maxillary anterior sites implant placement25,26 (Fig 9-8). It was revealed that in 81.1% of
the 600 samples investigated the root was positioned against
A thin buccal bone plate (< 1 mm) was found in the majority the labial cortical plate (Class I) with adequate bone palatal
of the examined teeth (62.9% to 80.1%) in a CBCT study eval- to the root, allowing for immediate implant placement and
uating the thickness of the anterior maxillary facial bone wall23 provisionalization.
(Fig 9-7). Furthermore, a thin buccal bone plate (< 1 mm) was The proper positioning of the implant to avoid esthetic compli-
associated with severe midfacial vertical bone loss in extraction cations is especially important in the anterior maxilla. As a rule
sites in the anterior maxilla.24 A CBCT study was performed of thumb, the implant should be placed within the curvature
to establish a classification of the sagittal root position in rela- of the continual arc to minimize resorption of the buccal bone
tion to the anterior maxillary alveolar housing for immediate plate27 (Fig 9-9).
154

a b
c d e
f g
Fig 9-10 Immediate implant placement in an extraction socket with nonsubmerged healing. (a) Gingival swelling noted at the distobuccal area of
the mandibular right second premolar. (b) CBCT scan showing adequate distance between the root apex and mandibular canal. (c and d) Imme-
diate implant placement with nonsubmerged healing. (e) An excellent treatment outcome was obtained. (f and g) Stable outcome at 12 years.
Posterior premolar/molar sites come these difficulties, placement of an ultrawide-diameter

(> 6 mm) implant and pre-extraction interradicular implant
Although immediate implant placement in the anterior zone has bed preparation have been suggested.29,30 A contemporary
become a frequent treatment modality, premolar/molar sites study that included a total of 85 immediate implants and 147
require careful anatomical, occlusal, and biomechanical con- delayed implants placed in the premolar/molar area found that
siderations. Clinicians face challenges such as larger extraction immediate implant placement had good clinical and radio-
sockets and poorer quality of bone in the maxillary posterior graphic outcomes.31 A recent systematic review examining
region compared with the maxillary anterior region. Furthermore, the outcomes following immediate molar implant placement
the proximity of the maxillary premolars/molars to the maxil- reported high implant survival of 98% with no difference
lary sinus and the mandibular premolars/molars to the inferior between the maxilla and mandible.32
alveolar canal (Fig 9-10) limit the availability of bone apical to
the socket for primary stability.28
To achieve primary stability with immediate implant place- Concomitant soft and hard tissue grafting
ment in molar sites, implants are placed in one of the molar
root sockets or into the interradicular septum (Figs 9-11 and Simultaneous hard and soft tissue augmentation should be
9-12). The former approach would lead to significant prosthetic considered to overcome hard and soft tissue defects following
and maintenance complications, while the latter is challeng- tooth extraction and immediate implant placement. The distance
ing but more ideal in terms of prosthetic design.29 To over- between the implant to the buccal plate serves as a diagnostic
155

a b c
d e f
Fig 9-11 (a) Preoperative CBCT demonstrating adequate bone between the furcation and the sinus floor. (b) Intact interradicular septum following
tooth extraction. (c and d) Immediate implant placed into the interradicular septum and grafted with freeze-dried bone allograft. (e and f) Definitive
restoration and radiograph at 12 years.
a b c
d e f
Fig 9-12 Immediate implant placement into the

interradicular septum. (a) Buccal view of a man-
dibular right first molar with severe caries and
insufficient crown structure. (b) CBCT demon-
strating adequate bone between the root apex
and inferior alveolar nerve. (c) Extraction socket
with intact interradicular septum. (d) Note the
gaps around the implant following immediate
placement into the septum. (e and f) The gaps
were grafted with freeze-dried bone allograft
and covered with a barrier membrane. (g and
g h h) Definitive restoration and radiograph.
156

a b c
d e f
g h i
Fig 9-13 (a) Failing left maxillary lateral incisor. (b)

CBCT revealing buccal dehiscence but availability
of bone apical to the root apex. (c) Extraction sock-
et with a V-shaped defect confined to the midfacial
aspect. (d) Immediate implant placement into the
extraction socket; note that the distance between
the implant and the buccal bone housing is less
than 4 mm. (e) Bone grafting with freeze-dried
bone allograft within and outside of the buccal
housing. (f and g) A resorbable collagen mem-
brane is placed. (h and i) Occlusal and buccal views
of the lateral incisor restored with a customized j k
zirconia abutment. (j and k) Two-year follow-up
with satisfactory esthetic result.
parameter in selecting the appropriate grafting procedure.27,33 Immediate provisionalization for

When the distance is less than 4 mm, a graft is placed within
preserving soft tissue dimensions
and beyond the buccal bone housing, while for a distance greater
than 4 mm, the graft is placed inside the gap33 (Fig 9-13).
Patients with a thin gingival biotype present with a higher The use of surgical and restorative interventions to minimize
risk of peri-implant recession; thus, a soft tissue grafting proce- complications such as midfacial mucosal recession should be
dure with the use of a connective tissue graft, acellular dermal considered.34 One advantage of immediate implant placement
matrix, or other substitute should be performed at the time of is the possibility of immediate provisionalization to provide sup-
immediate implant placement26 (Fig 9-14). port to the peri-implant soft tissue, which plays an important
157

a b c
d e f
g h i
j k
Fig 9-14 (a) The patient presented with a failing maxillary left central incisor. The gingival margin appeared highly scalloped, and a severe buccal
recession was noted. (b) CBCT revealing buccal dehiscence but availability of bone apical to the root apex. (c) Extraction socket with buccal plate
deficiency. (d) Immediate implant placement into the extraction socket; note the implant was placed within the buccal housing. (e) Bone grafting
with freeze-dried bone allograft within and outside of the buccal housing. (f) A resorbable collagen membrane placed to cover the bone graft. (g
and h) To overcome soft tissue deficiency, a subepithelial connective tissue graft was harvested and grafted on top of the resorbable collagen
membrane. (i) Occlusal view with a customized abutment inserted, showing the buccal tissue expansion. (j and k) Follow-up at 8 years demon-
strating a satisfying esthetic result and stable bone level.
role in soft tissue conditioning during healing. Moreover, imme- optimal outcomes and compensate for compromised situa-
diate provisionalization has a positive effect on the esthetic out- tions, different combinations of surgical protocols (flap versus
come following immediate implant placement.35–37 In a study flapless), grafting (bone and/or connective tissue grafts), and
comparing the esthetic outcome following immediate implant loading protocols (immediate versus early or delayed loading)
placement with and without immediate provisionalization, it was have been proposed. It has been demonstrated that the most
found that immediate provisionalization demonstrated superior predictable outcomes may be obtained with immediate implant
midfacial soft tissue levels and better bone volume maintenance placement and provisionalization using a flapless extraction in
than delayed restoration37 (Fig 9-15). combination with bone and connective tissue grafting.26
A proper diagnosis is a prerequisite to successful treatment
planning and recognition of unfavorable conditions. To achieve
158

Conclusion
a b c
d e f
g h
i j
Fig 9-15 (a) The patient presented with a failing maxillary right central incisor. (b) Following extraction, a slight buccal dehiscence was noted on
the mesiobuccal aspect. (c) Immediate implant placement engaging the apical and palatal bone. Note the large buccal gap. (d) Bone grafting with
freeze-dried bone allograft within the buccal housing. (e) An immediate customized abutment was used. (f) A provisional prosthesis was fabricated.
(g) Immediate provisionalization. (h) Tissue healing with preservation of the interdental papilla and cervical margin. (i and j) Definitive prosthesis
at 5 years.
CONCLUSION • Immediate implant placement does not prevent ridge alter-

ation following tooth extraction; therefore, it is important to
Immediate implant placement should be planned judiciously. A graft the gap to avoid collapse of the buccal plate and esthetic
logical review of various clinical considerations, risk factors, con- complications, particularly in the anterior zone.
sequences, and alternatives are presented in Fig 9-3 to assist • Soft tissue augmentation should be considered in patients
clinicians before commencing treatment. with a thin gingival biotype.
A review of the current knowledge concludes the following: • When possible, immediate provisionalization should be
considered because it positively influences the esthetic
• Immediate implant placement is a viable option for patients. outcome.
159

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160

10 DANIELE CARDAROPOLI
Seeking the Optimal

Esthetic Result in the
Maxillary Anterior
Diagnosis and Treatment Planning
Implant Placement
Timing of Implant Placement Following Extraction
Evaluation of the Edentulous Space
161

10 | Seeking the Optimal Esthetic Result in the Maxillary Anterior
a b c
Fig 10-1 Ideal outcomes of an implant-supported rehabilitation in the anterior esthetic area. (a) Baseline image
showing the natural tooth still in place in the maxillary left central incisor position. The relationship between the
sound tooth structure and the marginal soft tissues is ideal, with the free gingival margin located at the level of the
cementoenamel junction and the interdental papillae filling the interdental embrasures. (b) After tooth extraction
due to a root fracture, an osseointegrated implant is inserted in order to deliver a single crown. The final esthetic
outcome is similar to the initial situation, fulfilling what nowadays is expected from dental implant treatment. (c) The
white and pink esthetic results in the peri-implant tissues are maintained over the long term, 9 years after implant
placement, while the adjacent natural teeth experienced some recession of the free gingival margin. Both the mar-
ginal mucosa and the interdental papilla are stable. (d) The radiographic evaluation after 9 years shows the stability
of the marginal bone levels.
C
ontemporary clinicians have focused on the osse- DIAGNOSIS AND TREATMENT
ointegration of implants as well as their survival
rates.1 But when evaluating implant placement in PLANNING
the anterior area, esthetics becomes crucial to the
success of the definitive restoration. Esthetics refers to natu- Implant placement in the esthetic area requires preoperative
ral beauty and can be defined as the science of beauty that is diagnosis and treatment planning combined with excellent clin-
applied in nature and in art. ical skills and knowledge to achieve successful esthetic out-
The pursuance of optimal soft tissue integration with perfect comes. Preoperative assessment of the patient’s expectations
pink esthetics may represent an obligation, and this is related to is also of paramount importance.10 If the patient is found to have
patients’ increasing demand for restorations that are as esthetic unrealistic expectations, a careful explanation might be neces-
as they are functional. Consequently, more studies have begun sary to clarify the results that should be expected.
to concentrate on implant treatment outcomes in esthetically
important areas.2,3
In a long-term retrospective study evaluating implants placed Risk assessment
in partially edentulous patients, no differences were found in
survival rates of implants with regard to their anatomical loca- A detailed preoperative analysis should be performed to outline
tion.4 These findings were confirmed when it was reported the individual risk profile for each patient. This assessment can
that implants in the anterior maxilla have an overall survival and help clinicians to understand the level of difficulty of the ther-
success rate similar to those reported for implants inserted in apy and the specific risk of negative results. Risk assessment
other areas.5 These data show that dental implants in the ante- in the anterior maxilla includes many factors8: systemic medical
rior maxilla present satisfactory success rates, but an esthetic anamnesis, history of periodontal disease, smoking habits, oral
failure rate of about 9% has also been reported.6 This indicates hygiene compliance, and occlusion.
the importance of esthetics as a key factor in implant success
and patient satisfaction.
Implant-supported restorations that replace teeth in the Site analysis
esthetic area represent a challenge for clinicians, especially in
sites with multiple missing teeth and soft tissues defects.7,8 The A comprehensive evaluation of the edentulous site must be per-
preservation or the creation of an optimal soft tissue contour in formed. Facial and dental status must be evaluated to accom-
order to reproduce the natural architecture of the gingival tissues plish ideal implant placement and esthetic evaluation.10 The
is always a priority (Fig 10-1). At the same time, suboptimal facial assessment provides general esthetic parameters, such
implant positioning may lead to esthetic failure and subsequent as orientation of occlusal plane and symmetry, lip support,
patient displeasure and frustration.9 gingival architecture, and smile line. The dental evaluation pro-
This chapter analyzes options for addressing clinical situations vides three-dimensional (3D) information about the edentulous
involving implant placement in the anterior maxilla. site and information related to adjacent teeth.
162

Diagnosis and Treatment
Diagnosis and Treatment Planning
Planning
a b c
d e f
Fig 10-2 Conventional treatment plan in the

maxillary anterior area. (a) A 39-year-old woman
presented with an old metal-ceramic fixed partial
denture extending from the maxillary right central
to the maxillary left lateral incisor. The esthetic
appearance is unpleasant, and the ceramic mar-
gin is no longer acceptable. (b) The occlusal view
shows deficient soft tissue support in the area
corresponding to the left central incisor. (c and
d) The wax-up includes the creation of artificial g h
gingiva in the area of deficient volume in order
to show the need for soft tissue augmentation.
(e and f) From this conventional wax-up with soft
tissue evaluation, a surgical stent is created, with
the implant axis moved palatally. (g and h) After
the old partial denture has been removed, the
presurgical analysis confirms the soft tissue de-
fects, with the need to increase the volume in the
vertical as well as in the horizontal dimension. (i)
A flap is elevated, and a tapered implant is insert-
ed, placed 4 mm from the right central incisor, 3 i j
mm from the lateral left incisor, and 3 mm apical
to the free gingival margin of the neighboring
teeth. After insertion, the coronal third of the
fixture shows a bone dehiscence corresponding
to the area where the bone ridge was thin. (j)
Horizontal bone augmentation is performed us-
ing autogenous bone and bovine bone mineral in
a 30:70 ratio, mixed with fibrin glue and covered
with a resorbable collagen membrane. (k and l)
Six months later, at stage-two surgery, a defin-
itive titanium abutment is connected, and new k l
single provisional crowns are placed to allow the
soft tissue to heal, obtaining good architecture,
papillary height, and horizontal support.
Prosthetic evaluation where it can be properly restored. If the site presents a bone
or soft tissue defect, then augmentation procedures must be
Implant restoration is considered a complex procedure and employed to re-create an adequate volume. Following this con-
requires comprehensive preoperative planning and precise sur- cept, the implant should be considered the apical extension
gical execution.9 Implant insertion should be planned consid- of the restoration, and the preferred design of the restoration
ering the optimal prosthetic position. This concept is known should guide the surgical placement of the implant.11,12 A con-
as restoration-driven implant placement, in contrast to the pre- ventional diagnostic wax-up (Fig 10-2) or computer-aided digi-
viously accepted concept of bone-driven implant placement.10 tal planning (Fig 10-3) to highlight the final gingival margin and
In restoration-driven implant placement, the implant is placed crown position is mandatory to achieve the esthetic goal. A
163

m n
o p
Fig 10-2 (cont) (m and n) The definitive ceramic crowns can be created according to the proper soft tissue architecture and support. (o and
p) The final evaluation, after cementation of the ceramic crowns, shows an optimal esthetic outcome, with proper integration between the white
esthetics of the crowns and the pink esthetics of the gingiva and mucosa.
a b
c d
e f
Fig 10-3 Computer-aided digital treatment plan in the anterior area. (a and b) A 35-year-old man presented with external root resorption on the
maxillary left central incisor. The patient requested an implant-supported single-tooth restoration. (c and d) The CBCT analysis was performed
to evaluate the bone volume availability in three dimensions. The original Digital Imaging and Communications in Medicine (DICOM) files were
uploaded into dedicated digital planning software, where the different hard structures (crowns, roots, and bone) are evaluated separately in the
three planes of the space. (e and f) Implant 3D positioning was planned and simulated accordingly to the bone availability.
164

Implant Placement
g h i
j k l
Fig 10-3 (cont) (g) Once the planning stage was complete, a customized surgical guide was created for implant positioning. (h) The surgical guide
fits perfectly. (i) Using the dedicated system of drills for computer-aided implant surgery, the implant was placed as digitally planned. (j) An imme-
diate screw-retained provisional crown was delivered in order to support the soft tissue contour. (k and l) The final evaluation, 1 year after implant
placement, showed an ideal outcome. The peri-implant mucosa was healthy and esthetic, and the marginal bone level was stable.
conventional surgical template or a computer-guided surgical and preview the position of the implant, selecting proper length,
stent help clinicians to execute correct 3D implant placement, diameter, and morphology.
making anterior esthetics more predictable.
Radiographic evaluation IMPLANT PLACEMENT

The need for specific radiographic imaging assists implant Implant surgery should be carefully planned and executed, con-
planning based on the characteristics of the specific case, as sidering the implant as the apical extension of the restoration in
related to the clinician’s need for information supplemental to the esthetic area. Optimal esthetic implant restoration depends
that already obtained from the clinical examination.13 on proper 3D implant positioning.16 Four positional parameters
The use of imaging modalities for presurgical dental implant contribute to the success of the restoration, and all must be
planning should provide adequate information regarding the carefully considered during implant placement. These are the
morphologic characteristics of the residual alveolar ridge. Specif- buccolingual, mesiodistal, and apicocoronal positions relative to
ically, information related to vertical bone height, horizontal bone the implant platform as well as the angulation of the implant.10
width, and the dimension of the edentulous ridge should be avail-
able from radiographic examination.14,15 Conventionally, these
data have been obtained from two-dimensional (2D) imaging Buccolingual positioning
such as intraoral periapical and panoramic radiography. Since the
introduction of 3D imaging, maxillofacial cone beam computed An ideal placement in the buccal-lingual dimension should con-
tomography (CBCT) has become important in treatment-planning sider and compensate for the eventual peri-implant bone remod-
decisions, revealing details that are not evident from clinical eling. This remodeling may be related to the need of creating
examination and 2D examination. Three-dimensional imaging a biologic width in the soft tissues. An implant placed too far
may be useful in detecting the orientation and residual volume buccaly often results in a bone dehiscence of the buccal corti-
of the alveolar ridge and in identifying anatomical anomalies, cal plate and subsequently creates a high potential for gingival
adjacent structures, or local pathologies. Following accurate 3D recession. An erroneous positioning complicates the restoration
evaluation, clinicians may carefully plan implant site preparation protocol, impeding the delivery of a screw-retained crown. A
165

10
a b c
d e f g
h i j k l
m n
Fig 10-4 Implant positioning for a case of congenitally missing lateral incisors. (a) A 19-year-old man
presented with bilateral congenitally missing lateral incisors. The two primary teeth were still in place,
but the roots were completely resorbed. The patient requested two single crowns. (b and c) The intraoral
radiographs showed a mesiodistal dimension of 5 to 6 mm in the coronal portion, with a slight reduction
in the apical portion. (d and e) A conventional wax-up was created to preview the new crowns from both
esthetic and functional points of view. Based on this wax-up, a surgical guide was created, mimicking
the ideal implant axis on the palatal surface. The surgical guide, made of barium sulfate, provided a
radiologic guide to visualize the implant position. (f and g) The placement of a tapered implant, 3.3 mm
in diameter and 14 mm in length, was simulated on the CBCT, which showed the need for horizontal
augmentation to counteract the buccal concavity of the alveolar ridge due to the lack of eruption of
the permanent teeth. (h and i) In order to respect the interdental papillae and the periodontium of the
o p neighboring teeth, a trapezoidal flap was elevated with two vertical releasing incisions. Implant sites
were prepared, following the axis provided by the surgical guide. After implant placement, a bone
fenestration was present in the ridge concavity. (j and k) A lateral ridge augmentation procedure was
performed using autogenous bone and bovine bone mineral in a 30:70 ratio, mixed with fibrin glue and
covered by a double layer of resorbable collagen membrane. (l) The flap was advanced and closed by
primary intention using polytetrafluoroethylene nonresorbable sutures. (m) The clinical image after 6
months shows optimal soft tissue healing. Following stage-two surgery, an impression was made at
the implant level to build two screw-retained provisional crowns that would initiate proper soft tissue
conditioning. (n) After 4 months, two full-ceramic crowns were manufactured, perfectly following the
soft tissue contour created by the provisional restorations. The definitive crown was also screw retained
on the palatal surface, as guaranteed by the prosthetically guided implant placement. The final clinical
evaluation shows an optimal outcome with perfect soft tissue integration at both the facial mucosa
and papillae. (o and p) The intraoral radiographs demonstrate stability of the marginal bone levels.
166

fixture placed too far lingually often requires a ridge-lap resto- should be located approximately 3 mm apical to the line connect-
ration that can create an impaction to the tongue and result in ing the midfacial CEJ of the adjacent teeth.
poor esthetics with difficulty in oral hygiene. In case of gingival recession, the point of reference becomes
The buccal bone wall should maintain a thickness of at least the midfacial gingival margin.
2 mm in order to prevent the formation of dehiscence.17,18 Start-
ing 1 mm palatal to the point of emergence of the adjacent
teeth and/or planned restoration there is a “comfort” zone Implant angulation
where the implant shoulder should be placed to allow for a
restoration with a proper emergence profile.8 Similar consid- The prosthetic prolongation of the implant axis should be
eration should be done when an implant is placed in a fresh located palatal to the incisal margin of the crown. In case
extraction socket. The implant should be placed 2 mm from the of screw-retained restorations, this allows for correct palatal
buccal bone wall, creating an adequate bone-to-implant gap. placement of the screw with positive esthetic outcomes. When
The grafting of the gap with a bone substitute will compensate the implant angulation is buccally oriented, the screw hole will
for marginal bone contraction and maintain the profile of the be on the buccal surface of the crown, creating a negative effect
ridge.19,20 on esthetics. With cement-retained restorations, this problem
can be overcome using custom or angled abutments.
In case of immediate implant placement in fresh extraction
Mesiodistal positioning sockets, the choice of a proper implant angulation is extremely
important. It is unusual to be able to place the implant at the orig-
The available mesiodistal space must be carefully measured to inal axis of the natural tooth. The primary stability of the fixture
select implants of the proper diameter and avoid poor esthetic should be obtained in the triangle of bone that is located apically
outcomes. Placement of an implant too close to adjacent natu- and palatally to the apex of the natural root. The axis of the implant
ral teeth may result in resorption of the interproximal bone with is moved in the palatal direction, and the platform remains at
subsequent loss of the interdental papilla. It is recommended least 2 mm from the buccal bone plate, creating a bone-implant
that the implant shoulder and the adjacent natural root surface gap to be filled with graft material. A palatal axis may allow for
should be at least 1.5 mm apart. The surgical approach can be immediate delivery of a screw-retained provisional crown with the
important when this space is small, and it is suggested to use screw hole on its palatal surface. In this way, immediate implant
flapless surgery and avoid incisions into the papilla. placement will be surgically, prosthetically, and biologically driven.
In case of adjacent implants, a space of 2 mm at the implant- A case demonstrating proper 3D implant positioning is shown
abutment level should be maintained between the fixtures.21 in Fig 10-4.
If the available space is insufficient to allow the placement of
one implant per tooth, a treatment plan with an implant-
supported fixed partial denture should be considered.
TIMING OF IMPLANT PLACEMENT
FOLLOWING EXTRACTION
Apicocoronal positioning
Different scenarios can be related to the timing of implant place-
It is generally stated that the more apical the placement ment relative to tooth extraction. From the clinical point of view,
of the implant, the better the emergence profile.22 This is all decisions should consider the dynamics of healing of postex-
true from an esthetic point of view; however, location of traction sites.23
the implant-to-abutment junction too far apically may create The development of the alveolar process is directly related
a difficulty in maintaining proper health of the peri-implant tis- to the presence of the natural dentition, and it follows different
sues, given the long emergence profile, especially for periodon- degrees of atrophy after tooth extraction. Mainly, the limited supply
tally compromised patients. When considering the two chief of cells from the periodontal ligament causes resorption of bundle
parameters in implant dentistry, health and esthetics, there is bone. When the cortical buccal bone plate is thin, the alveolar bone
an inverse relationship: an apical implant placement may favor is resorbed buccally to a greater degree than lingually.24 This physi-
an esthetic restoration but possibly unhealthy tissues, while ologic remodeling results in horizontal and vertical ridge resorption.
a coronal implant placement may favor healthy tissues but a In the first 6 months following tooth extraction, the alveolar ridge
possibly unattractive restoration. For these reasons, the verti- can develop a mean horizontal width resorption of 3.8 mm and
cal position of the implant should represent a balance between a mean vertical height resorption of 1.24 mm.25 Moreover, 1 year
health and esthetics. after tooth extraction, the ridge can lose up to 50% of its original
In patients where the free gingival margin is located at the horizontal width.26 Following the biologic, anatomical, and clinical
level of the cementoenamel junction (CEJ), the CEJ of the adja- principles that dictate the dynamics of postextraction site healing,
cent teeth may be used as a reference point to determine the it is essential to attempt to maintain the original volume of the
positioning of the implant. Commonly, the implant platform ridge and compensate for marginal bone remodeling.
167

a b c
d e f
g h
Fig 10-5 Immediate postextraction implant placement. (a) A 45-year old woman was feeling pain at her maxillary left
central incisor. From a clinical point of view, the tooth is stable with no sign of caries or trauma. The soft tissues are
healthy, without inflammation or apical displacement. (b and c) The intraoral radiograph shows internal root resorption,
confirmed by the CBCT image. Because the tooth was hopeless, and considering the integrity of the neighboring
natural teeth, an implant was planned. The intact soft tissue, the absence of gingival recession, the presence of the
buccal bone plate (even if thin), and a more than adequate quantity of bone apical and palatal to the tooth apex created
the indication for immediate implant placement. (d) The tooth was extracted via a flapless approach, and the implant
site was prepared palatal to the natural alveolus. The implant was inserted with a primary stability of 55 Ncm, and the
bone-implant gap was grafted using a bovine bone mineral. (e and f) A provisional abutment was connected at the implant
level to deliver an immediate screw-retained provisional crown that supported the soft tissues in the healing phase.
(g) After 3 months, the soft tissue contour was considered to be stable. The facial mucosa and the interdental papillae
were at the baseline levels, while the horizontal dimension of the soft tissues presented adequate thickness to provide
i stability. (h) The final evaluation shows a good esthetic outcome with a ceramic crown that is a perfect replica, in terms
of shape, contour, and color, of the original natural tooth. (i) After 1 year of loading, the marginal bone level is stable.
Based on clinical principles, implant placement following intact and there is no gingival recession. In addition, an ade-
tooth extraction in the anterior area can be immediate, early, quate volume of bone should be present apically and palatally
delayed, or late.27 to the extracted root in order to achieve primary stability. The
advantages of an immediate implant placement are the reduced
number of surgical procedures along with a reduced overall
Immediate implant placement treatment time. A disadvantage is that the site morphology
may complicate optimal implant placement, creating the pos-
An implant inserted into the socket during the same surgical sible need for adjunctive surgical procedures.27 For optimizing
session as tooth removal can be classified as immediate. This the final esthetic outcomes, an atraumatic extraction is rec-
timing of insertion is indicated when the facial bone wall is ommended, and a flapless approach is preferred. From a 3D
168

point of view, the implant should be placed slightly palatal in (depending on the size of the extracted tooth), an open-flap
the alveolus in order to create a gap of at least 2 mm between implant surgery is recommended.30 At this point in time the
the implant and the internal surface of the buccal bone. This implant shoulder should be placed approximately 1 mm palatal
space should receive an osteogenic material in order to com- to the future point of emergence and roughly 3 mm apical to
pensate for physiologic marginal bone remodeling.19 In cases of the mucosal margin on the midfacial aspect. In order to manage
immediate implant placement, the concomitant use of a bone the peri-implant bone defect, a simultaneous bone augmenta-
graft to fill the bone-implant gap limits the amount of horizontal tion procedure is required.30,31
and vertical soft tissue alteration when compared with implant
placement alone. The surgically driven implant placement may
correspond to prosthetically driven implant placement. When Delayed implant placement
the implant platform is moved more to the palatal side of the
socket, the implant axis is modified in respect to the axis of the Delayed implant placement is planned when substantial clinical
natural tooth. Ideally, the new implant axis should be placed on and/or radiologic bone fill of the socket must be achieved (typi-
the palatal side of the crown in order to further facilitate pros- cally after at least 16 weeks from extraction). The advantages of
thetic results. When there is primary stability, with an insertion this approach are that the healing of the bone tissue may facili-
torque ≥ 35 Ncm, immediate crown delivery can be considered. tate implant placement and the mature soft tissues may facilitate
The esthetic evaluation for immediate implants in the esthetic flap management. The disadvantages are that treatment time is
zone is of significance because the survival rates of implants increased and, even more importantly, socket walls may exhibit
placed immediately postextraction are equivalent to those of varying amounts of resorption.27 According to current knowl-
delayed implants.28 Soft tissue contour changes seem to be pos- edge concerning the dynamics of postextraction site healing,
itively influenced by immediate prosthetic restoration following the buccal alveolar process is markedly reduced with respect to
postextraction implant placement. Mesial and distal papillae, both the vertical and horizontal dimension compared with the
midfacial mucosal level, and horizontal soft tissue dimensions lingual/palatal bone walls. If implant insertion has been planned
remain more stable when an immediate provisional restoration following this spontaneous healing of the alveolus, generally
is planned.20 Clinically, a screw-retained provisional crown is major bone augmentation procedures are needed to counter-
always preferred to a cement-retained provisional crown since act the lack of adequate bone volume.32 On the other hand, if
cementation into an open alveolus could be a challenge. a ridge preservation procedure has been performed the day of
Figure 10-5 shows a case of immediate postextraction implant extraction, about 90% of the original volume of the ridge can
placement. be maintained so that no bone augmentation procedures are
needed the day of implant placement.33 Due to these clinical
considerations, a delayed approach is recommended when a
Early implant placement ridge preservation procedure can be used concomitant to tooth
extraction so that adequate bone volume is present on the day
The concept of early implant placement refers to cases in which of implant placement and an optimally guided implant place-
soft tissue healing of 4 to 8 weeks is allowed between tooth ment can be performed. After loading, these implants usually
extraction and the day of implant placement. The advantages of present success rates and marginal bone levels comparable to
this staged approach are that soft tissues will have the time to those of implants inserted in native bone.32
heal spontaneously, increasing their thickness, and local acute Figure 10-6 shows a case of delayed implant placement.
or chronic infections with or without fistulae (of endodontic or
periodontal origin) may resolve, reducing the risk for bacterial
contamination of the surgical site. The disadvantages are that Late implant placement
treatment time is increased, socket walls may exhibit varying
amounts of resorption, and adjunctive surgical procedures may When an implant is inserted into a fully healed extraction site
be required.27 In the case of flapless tooth extraction with no after 4 to 6 months of spontaneous healing, this is classified as
attempt to have soft tissue primary closure with the displace- late implant placement. Due to an increase in treatment time
ment of the mucogingival line, between 3 and 5 mm of kera- and the large variations in available bone volume, this proce-
tinized mucosa in the future implant site can be anticipated.29 dure is not a primary clinical choice. When clinicians encounter
Clinical indications for early implant placement are sites with sites where tooth extraction has been performed previously,
a thin or damaged facial bone wall or sites with recession of implant placement in these sites also can be considered late.
the free gingival margin, in which immediate implant place- Bone augmentation procedures can be executed at the time of
ment is contraindicated. After a healing period of 4 to 8 weeks implant placement or with a staged approach.
169

a b c
d e
Fig 10-6 Delayed implant placement following ridge preservation/augmentation. (a) A 62-year-old woman present-
ed with a maxillary lateral incisor requiring extraction because of combined prosthetic and endodontic failure. An
immediate implant was contraindicated because of the loss of the buccal plate and apical displacement of the
free gingival margin. (b) Following flapless tooth extraction, the socket was grafted with a bovine bone mineral and
protected with a resorbable collagen membrane sutured to the surrounding soft tissues. (c) After 4 months, the
soft tissue appeared to be completely healed, with an increase in the width of the keratinized mucosa. (d) After flap
elevation, adequate bone volume was present, suitable for prosthetically driven implant placement. (e) The definitive
restoration presented a good outcome, with a coronal displacement of the facial mucosa compared with baseline.
(f) The radiographic image shows stability of the marginal bone levels.
EVALUATION OF THE is independent of the proximal bone level next to the implant.
When the distance from the contact point to the crest of bone
EDENTULOUS SPACE is 5 mm or less, the papilla is always almost present.34,35 From a
surgical point of view, both flap design and surgical site prepara-
Single-tooth replacement tion should respect the integrity of the interdental papillae and
the periodontium of the natural teeth. The available mesiodis-
For anterior single-tooth replacement in sites without tissue defi- tal space, at both the crestal and apical levels, should be well
ciencies, predictable treatment outcomes, including esthetics, considered when planning single-implant insertion. Papilla for-
can be achieved because tissue support is provided by adjacent mation is mainly determined by bone attachment on adjacent
teeth.5 In case of tissue deficiencies, bone regeneration pro- teeth.18 Formation of the biologic width after loading may lead
cedures as well as soft tissue grafting re-create an acceptable to a circumferential crater around implants. Bone thickness on
architecture. The integrity of the interproximal bone and inter- the facial side and interproximal bone should support the gin-
dental papillae, related to the level of the periodontium of the gival margin and papillae despite this crater formation.17 A min-
adjacent teeth, creates support during the healing phase of both imum distance of 2 mm between the implant shoulder and the
bone and soft tissues. The presence or absence of a peri-implant bone attachment on the natural tooth has always been recom-
papilla depends on the vertical distance between the alveolar mended to avoid lateral and crestal bone loss.34 The introduction
crest and the contact point. In single-tooth gaps, the bone height of narrow-diameter implants as well as the use of rough tita-
at adjacent teeth determines the status of the papilla, which nium surfaces and platform switching changed old paradigms,
170

Evaluation of the Edentulous Space
a b c
d e f
Fig 10-7 Single-tooth replacement of a maxillary central incisor. (a) A 43-year-old

man presented with an old fixed partial denture in the anterior maxilla, extending
from the right central incisor to the left lateral incisor. The crown margins were
not consistent, the acrylic resin was discolored, and the free gingival margin
was apically displaced on both natural teeth. The patient request is to have three
new single crowns. (b) The radiographic evaluation showed an adequate height
of bone in the site corresponding to the left central incisor. (c) After flap eleva-
tion, a tapered implant was inserted into adequate bone volume. (d) After the
osseointegration period, three single provisional crowns were inserted in order
to guide the soft tissue maturation. (e) After 3 months, an acceptable soft tissue
architecture was created, with an ideal scalloped profile and papillary height. (f) g
The definitive intraoral radiograph shows stability of the marginal bone levels. (g)
The definitive full-ceramic crowns fit perfectly with the gingival contour, providing
an optimal esthetic outcome.
and today a minimum space of 5 mm can be accepted at the the interdental papilla between two implant restorations, creat-
crestal level, as long as the periodontium at the neighboring ing an unesthetic black triangle. A minimal mesiodistal distance
teeth has been respected. of 2 mm, considered the interimplant distance, is recommended
Figure 10-7 shows a case of single-tooth replacement. to allow the formation of the biologic width and avoid interim-
plant bone resorption.21 The available space may be too narrow
to place two implants next to each other while still allowing a
Multiple-tooth replacement good esthetic outcome. When more than two teeth are miss-
ing, fixed partial denture restorations can be considered as a
The replacement of multiple missing maxillary anterior teeth valuable option in order to not stress the interimplant bone.
with fixed implant restorations is poorly documented. In this If three natural teeth are to be replaced, two implants can be
context, esthetic outcomes may not be predictable, particularly inserted with one pontic unit in the middle, while if four natural
regarding the contours of the interimplant soft tissue.5,9 Due to teeth need to be replaced, two implants can be inserted with
the lack of the periodontal apparatus that is present on a natural two pontic units in between. A prosthetically driven approach
tooth, the creation of the interdental papilla between two adja- needs to be considered when multiple adjacent teeth are miss-
cent implants is a major challenge for clinicians. Interimplant ing in the anterior area. During the surgical planning, all aspects
support, both by soft and hard tissues, may be unpredictable of esthetics and function should be taken into consideration.
because a small interimplant distance can create marginal bone Figures 10-8 and 10-9 show the replacement of multiple maxil-
remodeling. This will provide insufficient bone height to support lary anterior teeth.
171

a b c
d e f
g h i
j k
Fig 10-8 Esthetic rehabilitation on implants and natural teeth. A 54-year-old man presented with a ceramic fixed partial denture in the anterior
maxilla, extending from the right lateral incisor to the left canine (a). The intraoral radiographs (b and c) showed adequate vertical bone in the
edentulous sites. The patient’s request was to have a single-tooth metal-free rehabilitation. After the removal of the preexisting crowns, the clinical
evaluation showed properly scalloped soft tissues with horizontal tissue deficiencies at the level of the missing teeth (d). Implant surgery would
avoid intrasulcular incisions with papillae involvement to preserve the optimal level of interdental papillae. After placement of the implant in the
central incisor site, a severe bone dehiscence was found on the buccal bone (e) that required guided bone regeneration (f). The implant in the lateral
incisor site was placed inside the bone (g), but the cortical plate was thin and required horizontal bone augmentation (h). After 6 months, single
provisional crowns were delivered to create a positive soft tissue architecture. After 3 more months, the soft tissues were mature, stable, and
healthy. The definitive impression was taken to create five individual metal-free crowns. The final evaluation revealed a satisfactory outcome from
both esthetic and functional points of view (i). Stability of the peri-implant marginal bone levels was confirmed by intraoral radiographs (j and k).
172

References
a b c
d e f
g h i
Fig 10-9 Replacement of four maxillary incisors. (a and b) A 65-year-old woman lost her four maxillary incisors due to periodontal disease. When she
was young, the two maxillary impacted canines were surgically removed, and the spaces were orthodontically closed. After wearing a removable
partial denture for years, the patient requested a fixed rehabilitation. (c) A wax-up was created to determine the treatment options. The position of
the four incisors was planned to obtain an optimal esthetic appearance based on the mesiodistal space available. From the wax-up, a radiographic
and surgical guide was created. (d and e) In order to provide adequate support to the soft tissues and avoid implant proximity, two implants were
planned for insertion in the sites corresponding to the lateral incisors. After flap elevation, the two implants were inserted in the exact position
previously planned. (f) After 3 months, healing abutments were connected, and provisional crowns were delivered to provide soft tissue contour
and support. (g) The final clinical evaluation of the four-unit screw-retained partial denture showed an optimal esthetic result. (h and i) After 1 year
of loading, the marginal bone level was stable.
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174

11 JOSÉ CARLOS MARTINS DE ROSA •
LUIS ANTONIO VIOLIN PEREIRA
Predictable Esthetic
Anterior Maxillary
Reconstruction with Dental
Implants and Maxillary
Tuberosity Grafts
Maxillary Tuberosity as a Soft and Hard Tissue
Graft Donor Site
Evaluation of Connective Tissue and Bone
Availability
Connective Tissue Graft
Bone Graft
Triple Graft
175

11 | Predictable Esthetic Anterior Maxillary Reconstruction with Dental Implants and MT Grafts
T
he maxillary tuberosity contains hard and soft tissues alveolar ridge or the maxillary sinus prior to or simultaneously
that may be harvested for autogenous grafting proce- with implant insertion.8
dures. As a grafting source, the maxillary tuberos- Bone harvested from the MT has been used in the recon-
ity provides clinicians the opportunity to restore a struction of compromised sockets for immediate implantation9
patient’s dentition with excellent clinical results without the as well as in the effective management of intrabony defects.
requirement of comparatively expensive and complicated surgi- Various defects from trauma, infection, or bone recession often
cal restorative procedures. The aim of this chapter is to present result in suboptimal alveolar bone structure that is unsuitable
the periodontal, surgical, prosthetic, implant-related, and biologic for implant placement without grafting procedures. Bone grafts
aspects of maxillary tuberosity grafting for bone and soft tissue harvested from the MT provide a superb source of autogenous
reconstruction in association with dental implant placement in bone to augment the alveolar ridges and sockets without the
the anterior maxilla. In addition, indications and techniques for need for more invasive intraoral surgical harvesting procedures
this approach are discussed. in which bone is obtained from the chin or the ramus.6
Biologic aspects
MAXILLARY TUBEROSITY AS A
Even with the extraction or loss of all maxillary teeth, the MT
SOFT AND HARD TISSUE GRAFT
usually undergoes only minor resorption, which is likely due to
DONOR SITE the loading forces of the medial pterygoid muscle during masti-
cation. Bone resorption in the palatal direction and a narrowing
Implant dentistry has been definitively established as a predict- of the MT is generally only observed when tooth loss is sec-
able treatment modality for replacing missing or nonrestorable ondary to pronounced periodontal disease. Thus, the convex
teeth, and it yields excellent clinical success rates. Over the anatomy of the MT should always be considered in traditional
last decade, the focus of implant research has shifted from the denture design, as the medial and lateral walls resist the hori-
functional stability of the implant to its esthetic integration in zontal and torquing forces that would move the denture base
the smile. Two fundamental components dictate the esthetics in a buccopalatal direction.8,10
of implant restorations: the reproduction of natural tooth char- The MT currently serves as an underutilized region of the
acteristics on the implant crown and the establishment of a maxilla that has the potential to be a critical area for bone
healthy and harmonious soft tissue framework. Therefore, suc- harvesting. The maxillary cortical bone is thinner, and the cancel-
cessful implant rehabilitation heavily relies on the preservation lous bone is softer than that of the mandible; bone density
or augmentation of peri-implant soft and hard tissue by means decreases posteriorly in the MT. MT bone is predominantly type
of periodontal surgical procedures. 3 and 4 with profuse bone marrow penetration.11
Various soft and hard tissue grafts incorporating autoge- The choice of the MT as a donor site in bone reconstruction is
nous, allogeneic, xenogeneic, and alloplastic materials, as well supported by its macro- and microscopic characteristics and graft
as different combinations of these, have been used in dental incorporation principles at the receptor site. Using an autoge-
implant treatment. The current gold standard is the autogenous nous bone graft, the remodeling and regeneration of bone in the
graft because of its biocompatibility, lack of antigenicity, and the receptor bed occurs through three potential mechanisms: osteo-
presence of growth factors and cells. Autogenous soft and hard genesis, osteoinduction, and osteoconduction. Osteogenesis
tissue grafts may be harvested from various locations, including occurs when surviving osteoprogenitor cells within a grafted
the maxillary tuberosity (MT). material differentiate into osteoblasts and form new bone within
The donor sites most routinely used for intraoral autogenous the receptor bed. Currently, autogenous bone grafts represent
bone grafts include the ramus of the mandible and the chin1; the only available graft with osteogenic capability. Osteoinduc-
however, following the removal of these grafts, these areas tion involves new bone formation through the recruitment and
may be associated with postoperative complications such as stimulation of osteoprogenitor cells at the recipient site using
paresthesia or hypoesthesia, high morbidity, and bleeding risks.2 bone growth factors transplanted within the grafted material.
As an alternative to other intraoral donor sites, the MT may be Osteoconduction occurs when grafted material functions as a
an advantageous therapeutic choice because it presents bone scaffold for the ingrowth of vascular tissue and undifferentiated
tissue with great osteogenic potential3 and low postoperative cells from the receptor bed.2
morbidity.4 MT bone grafts have been harvested for augmenta- The MT presents several unique characteristics as a donor
tion procedures for several years5,6 with minimal complications.7 site, as outlined in the following sections.
The MT can function as a soft and hard tissue autogenous
source because there frequently is an abundance of connective
tissue and bone mass, even in patients with bone loss through-
out the rest of the maxilla. In clinical practice, MT bone has been
used in particulate grafts for the augmentation of a deficient
176

Evaluation of connective tissue and bone availability
Thin layer of cortical bone and cancellous bone EVALUATION OF CONNECTIVE

with low trabecular density TISSUE AND BONE AVAILABILITY
The cortical plate of the MT is very thin, whereas the internal
region is essentially trabecular with a highly porous structure that To avoid misjudging the MT as a potential graft donor site, it is
resembles a scaffold. Compared with other maxillary and man- important to locally examine the area through clinical evaluation
dibular bone, the bone density at the buccal, palatal, and basal and palpation in addition to periapical and panoramic radiography
cortical MT is the lowest.11 Quantitative analysis shows that MT and cone beam computed tomography (CBCT).
bone presents approximately 70% porosity, which allows it to Among all of these examinations, CBCT most accurately
act as a scaffold for cellular and vascular growth.12 As a result of evaluates the amount of bone and soft tissue available in the
its thickness and low density, an MT graft is easily shaped, and MT, the best location for bone harvest, and the relationship
its cortical structure acts as a biologic barrier that stabilizes the between the MT and the maxillary sinus. Pneumatization of
soft tissue and the particulate bone graft around the implant.13 the maxillary sinus and the presence of third molars are not
considered contraindications to harvesting bone from the MT.
CBCT enables the surgeon to determine the exact location of
Rapid incorporation
bone available and the correct insertion position of the chisels
Cancellous bone contains high concentrations of osteoprogeni- for removing the MT graft. Although limited mouth opening may
tor cells derived from the trabecular endosteum and bone mar- make graft harvesting difficult, buccal or palatal access may be
row. The cancellous bone graft (block or particulate) is incor- used to remove the lateral portion of the MT.9
porated by a process referred to as rapid incorporation, which Typical CBCT scans and panoramic imaging may provide suffi-
involves the rapid revascularization of the grafted bone, with cient preoperative assessment of the MT to determine whether
the large trabecular spaces within the cancellous graft enabling the bone volume is appropriate for grafting. The removal of bone
the unobstructed invasion of vascular tissue and the diffusion from the MT is the least invasive alternative for intraoral grafting
of nutrients within the grafted bone. Rapid incorporation is and does not require extensive repair at the donor site; more-
thought to promote osteoprogenitor cell survival, thus conveying over, it provides more than adequate bone volume to correct
increased osteogenesis. Compared with their cortical counter- anterior ridge deficiencies.15
parts, cancellous grafts possess more osteogenic activity, allow Barriviera et al16 described a method to obtain high-quality
more rapid and complete revascularization, and are ultimately CBCT images that consistently enable the determination of the
completely replaced with new bone within weeks to months.2 dimensions of the palatal mucosa and the dimensions of soft
tissue at the buccal aspect, including the MT. Using this meth-
odology, at the time of CBCT scanning, patients wear a plas-
High revascularization capacity
tic lip retractor, and wooden spatulas are employed to retract
The total porosity (ie, area occupied by bone marrow) of 70% soft tissues away from the teeth and gingiva. The thickness of
of the MT volume12 indicates that MT autogenous bone graft the palatal mucosa may be obtained at different locations. Soft
contains a wealth of bone marrow with substantial potential tissue retraction enables clear observation and measurement
for angiogenesis. of the thickness of the buccal and palatal masticatory mucosa
as well as that of the MT. This reliable, simple, and reproducible
method provides important benefits in treatment planning, thus
Maintenance of viable cells
enabling the surgeon to accurately measure the dimensions of
Cells extracted from fragments of the MT and maintained in hard and soft tissues.
culture were capable of proliferating and increasing the cell num- CBCT evaluation of bone volume is ideal; however, a combi-
ber, expressing an osteoblastic phenotype confirmed by alkaline nation of panoramic and periapical radiographs may provide
phosphatase activity, and forming a mineralized extracellular adequate preoperative data when CBCT is unavailable.17
matrix. Similarly, these cells exhibited increased gene expres-
sion of runt-related transcription factor 2 and osteocalcin, which
indicates that cells derived from the MT displayed osteogenic Complications in graft harvest from the MT
features.12 One advantage of autogenous bone grafts is that a
significant number of cells survive in the graft and significantly Detailed planning and bone mapping are advised on a per-patient
contribute to the formation of new bone in the recipient bed.14 basis to avoid surgical complications in bone harvesting. Com-
pared with other donor sites (such as the chin and lateral ramus
of the mandible), the advantages of harvesting bone grafts from
Release of growth factors
the MT are accessibility and limited postoperative complica-
The MT presents an ideal structure for bone regeneration tions. However, complications such as oroantral communication,
because it is a natural scaffold filled with osteoblastic cells and bleeding (formation of a hematoma), and tethering of the ptery-
growth factors.3 goid muscles have been reported in the literature.4 Nevertheless,
177

the surgical procedure can be performed without complications able for harvest. In addition, graft removal in the palatal area is
and yields an excellent postoperative recovery when a rigorous a sensitive technique and unpleasant for patients, and in some
protocol and the correct instruments are applied.9 cases the harvested graft is limited in size.
Sites grafted with connective tissue from the palate or the
MT 1 year after a surgical procedure for ridge augmentation
Types and indications of grafts harvested were investigated in a 2014 study.24 The collagen content and
from the MT matrix metalloproteinase-1 and -2 expression were similar in both
tissues; however, cultured fibroblasts from the palate and MT
The MT provides a low to medium amount of bone as a donor showed interindividual differences. The gingival tissues grafted
site; however, when bilateral MT sites are considered, a larger with palatal mucosa showed a significant initial shrinkage or
amount of bone may be harvested. Thus, grafts harvested contraction; however, they remained stable over time with a
from the MT are suitable for reconstructing hard and soft tis- good esthetic result. In contrast, the gingival tissues grafted with
sue defects, covering exposed implant threads, reestablishing MT SCTG were dimensionally stable in the initial several months
alveolar bone architecture, and filling postextraction sockets for and then progressively tended to a hyperplastic reaction in some
further implant placement with or without immediate loading. patients. From a clinical point of view, when choosing an SCTG
Although other intraoral donor sites may be used, there are from the MT, it is advisable to thin it to a thickness of 3 mm to
considerable advantages to harvesting bone from the MT. One avoid a fibrotic response, which may lead to an unesthetic result.24
advantage is related to the low frequency of postoperative signs In another study, the results indicated similar esthetic outcomes
and symptoms; less edema and pain are observed when bone for both groups, ie, SCTG from the palate or the MT. Although
is grafted from the MT. investigations have reported unpleasant esthetic outcomes
Surgical management and graft configuration depend on the related to a hyperplastic response when using SCTG from the
alveolar ridge or socket defect to be reconstructed and the MT, this phenomenon was not observed in any of the studies.25
limitations of the donor site. Several graft types are feasible Soft tissue volume gain around single-tooth implants with
when harvesting from the MT, including connective tissue graft, SCTGs from the lateral palate or the MT was compared.
bone graft, and triple graft (cortical and cancellous bone added Thirty-two patients with 36 implants with buccal volume defi-
to connective tissue in a single piece).9 ciencies were randomly assigned to receive an SCTG from the
lateral palate or the MT. In terms of volume gain values, no
significant differences were identified, with the exception of
the values at 6 and 7 mm apical to the healing abutment, which
CONNECTIVE TISSUE GRAFT favored the MT. Regarding the keratinized tissue width, signifi-
cant differences were identified that favored the MT. Therefore,
The inevitable alteration of the alveolar ridge dimensions that when the lack of volume is associated with limited keratinized
follows tooth extraction often results in the placement of the tissue, SCTG from the MT may be a better option.25 In another
implant in a site that has undergone a reduction in soft and hard investigation, SCTGs of 3.5-mm thickness from the MT and the
tissue volume compared with its neighboring dentate sites.18,19 lateral palate harvested between the first and second premo-
This discrepancy is particularly pronounced in single-implant lars were compared for ridge augmentation procedures around
sites in anterior maxillary edentulous areas, where a concavity teeth, with better values in soft tissue volume obtained with
forms between the edentulous site and the root prominences of the SCTG from the MT at 12 months.24
the neighboring dentition. Subepithelial connective tissue grafts The rationale for the use of an SCTG from the MT area is
(SCTGs) may be employed in these cases to reconstruct the based on the properties of the harvested tissue, which is thick
buccal dimensions of the site, thus improving the tissue thick- and dense and appears to contain more collagen and less fatty
ness. In addition, SCTGs create the illusion of root prominences and glandular tissue than that harvested from the palate. Due to
and increase the width of the crestal peri-implant mucosa to its tissue composition, it might be hypothesized that an SCTG
provide an emergence profile for the restoration, enabling the from the MT could be less prone to shrinkage.26 Histologic
constructed site to closely resemble a natural tooth.20 In a sys- evidence indicates that compared with more apical areas, which
tematic review, it was concluded that SCTG is the treatment seem to contain more glandular and fatty tissue, the area clos-
of choice for soft tissue volume augmentation.21 est to the palatal gingival margin contains higher amounts of
The most common intraoral donor sites for harvesting connec- lamina propria. In contrast, the MT appears to contain more
tive tissue grafts are the MT and palatal area,22 with the free lamina propria in its whole dimension. Areas with more lamina
gingival graft method often being used in the palate.23 The pala- propria may be less prone to shrinkage, thus leading to more
tal area, between the first premolar and the first molar, most volume gain.27
commonly serves as the primary donor site for soft tissue grafts. Based on this information, the quality of the SCTG harvested
This scenario is not always the case for patients with a greater from the MT seems to be superior to that obtained from the
palatal artery with a diminished dimension or rate of blood flow, palate because the MT provides a graft composed of dense
which may lead to limited quantities of connective tissue avail- connective tissue, whereas the palatal connective tissue donor
178

Connective tissue graft
Fig 11-1 Connective tissue graft harvested

from the MT. (a) An incision with a bilaminar
double blade is made from the end of the MT
to the distal aspect of the last tooth present
in the arch of the maxilla. (b) A second inci-
sion is made distally, perpendicular to and
joining the two linear incisions to release
the graft. The SCTG is removed from the
MT. (c) Once the graft has been obtained,
it is de-epithelialized, and a 15c blade, mi-
croblade, or microscissors is used to shape a b
the graft according to the defect size. (d) A
uniform thickness of approximately 1.5 mm
is confirmed using a periodontal probe.
c d
site typically consists of adipose tissue.20 Obtaining an SCTG connected to the distal surface of the last molar via a sulcular
from the MT typically permits the harvesting of a significantly incision, and the palatal flap is raised. A 15c surgical blade is
thicker graft than that obtained from the palate.28 This broad piece then used to meticulously dissect the connective tissue from
of MT may be longitudinally sectioned to reduce the thickness the flap and the underlying periosteum. Once the graft has been
and increase the amount of soft tissue from the donor tissue. obtained, it is stored in saline solution to prevent dehydration
Based on scientific publications and well-controlled studies, while the recipient bed is prepared. The donor site flap is pref-
the use of SCTGs from the MT has gained popularity because erably sutured using nylon monofilament 6-0 suture and a con-
of the need for long-term stability in soft tissue dimensions tinuous or single interrupted suturing technique.20
around teeth and implants in esthetic areas. However, although Another method to harvest soft tissue from the MT is to use
surgical access is in some cases more difficult than that in the a bilaminar technique using a double-bladed scalpel to obtain
palatal region, the MT provides better postoperative recovery a graft thickness of approximately 1.5 mm, harvesting the soft
and results.18 tissue precisely, rapidly, and with less pain and swelling (Fig
In conclusion, the MT has also been considered a poten- 11-1). The double incision is made from the distal end of the
tial donor site for soft tissue augmentation procedures around MT to the distal aspect of the last tooth present in the maxilla.
implants, and SCTGs from the MT may be used throughout the A second incision is made distally and perpendicular to the
oral cavity in a manner similar to other traditional SCTGs with two linear incisions, joining them. After removal, the graft is
comparable success rates.13,29 de-epithelialized, and a 15c blade, microblade, or microscis-
sors is used to shape the graft according to the defect size.
A continuous suturing technique or single interrupted sutures
Technique for harvesting connective tissue are subsequently used to approximate the wound margins in
the donor area.25
from the MT
Evaluation of soft tissue availability Clinical indications for an SCTG
Prior to surgery, it is mandatory to evaluate the MT through 1. Gingival recession
CBCT scans in combination with clinical evaluation and digital 2. Missing papilla
palpation to evaluate soft tissue availability. 3. Exposure of implant threads as a result of bone loss around
the implant
4. Deficient soft tissue volume in edentulous areas
Soft tissue graft harvesting
On the distal aspect of the MT, a single beveled crestal incision The gingival tissue of the MT is an excellent source of soft
is made from the mucogingival junction to the distofacial line tissue for coverage of gingival recession in anterior regions
angle of the distal tooth. The incision is located midcrestally and of the maxilla and mandible. In a 2008 study, the transplanta-
179

tion of MT connective tissue to anterior esthetic gingival areas The different approaches presented in the literature for
demonstrated improvement of the tissue biotype over the heal- ridge preservation include the use of bone fillers and barrier
ing period to match the surrounding gingival tissue in texture membranes.38,39 Compared with dental extraction without
and color.18 socket preservation, the use of bovine bone mineral and porcine
The MT graft, which is free of adipose tissue, may represent collagen membrane for socket preservation following tooth
a better option than one from the palate. The results of a recent extraction considerably limits but does not completely elim-
study showed a mean coronal soft tissue growth of 0.76 mm inate horizontal and vertical bone resorption.40 The choice of
with no recession, and the authors concluded that the MT graft a resorbable versus a nonresorbable barrier membrane does
is an excellent alternative for immediate placement of anterior not appear to affect the clinical or histologic outcome of ridge
maxillary implants.30 preservation treatment41; moreover, it remains inconclusive
Another study showed that an SCTG can be harvested from whether some alveolar ridge grafting materials demonstrate a
the MT and sutured within a pouch in areas of localized gingi- clear benefit over others.42
val recession with few to no complications in the treatment of In conclusion, ridge preservation techniques (with bone fillers
buccal soft tissue dehiscence around single implants.31 and/or membranes) are effective procedures to prevent most of
the loss of the horizontal ridge dimension associated with tooth
extraction,39,43,44 and it is mandatory to preserve the dimensions
of the tooth socket after extraction, particularly if rehabilitation
BONE GRAFT with an osseointegrated implant is planned.45 Furthermore, in an
untreated postextraction socket, even with immediate implant
Clinical indications for a bone graft harvested from the MT placement, a mean 56% of socket width reduction has been
include the following: demonstrated.46 In another study, 96 implants were placed in
fresh extraction sockets in anterior maxillary regions and imme-
1. Socket preservation. diately loaded. No regenerative procedures were performed in
2. Socket reconstruction. any sites. At 3 years, all sockets presented considerable bucco-
3. Socket reconstruction and immediate provisionalization. palatal crestal reduction.47 Thus, even with implant placement
4. Bone thickness/height augmentation. and immediate loading of the implant, the alveolar bone ridge
5. Guided bone regeneration. resorption cannot be completely prevented.
6. Peri-implant bone regeneration. In intact alveolar sockets, it is feasible to perform socket pres-
7. Maxillary sinus elevation. (This indication is not discussed ervation immediately after tooth extraction using bone harvested
in this chapter because the focus is reconstruction of the from the MT to maintain the remaining bone and soft tissues
maxillary esthetic area.) in the same position. In socket preservation, using autogenous
bone harvested from the MT, it is mandatory to use particulate
bone, which works as a natural scaffold and biologic barrier that
favors faster and better bone graft incorporation.48,49
Socket preservation
Technique using an MT graft (Fig 11-2)
A clinical study of 46 patients investigated bone healing and soft
tissue contour changes after tooth removal without a socket Evaluation of the socket and MT. Prior to surgery, it is manda-
preservation technique. An approximate 50% reduction in the tory to evaluate the recipient and donor areas using CBCT scans
buccolingual width of edentulous sites after 12 months was to assess the indications for socket preservation, the dimension
identified.32 The alveolar bone resorption after tooth extraction of the socket, and bone availability in the MT.
is greater on the buccal compared with the lingual aspect.33
Moreover, the greatest loss of soft tissue contour, which is Dental extraction. A minimally invasive dental extraction and
approximately 3 to 5 mm, occurs during the first months after careful curettage and cleaning of the socket are performed to
tooth extraction and stabilizes after 6 months.32 Previous reports remove the granulation tissue and remains of the periodontal
have shown that dental extraction alone leads to a mean loss of ligament. The socket is assessed using a periodontal probe to
3.7 mm or 45% of the horizontal ridge dimension.34–36 confirm the presence of the facial bone.
Socket preservation is a bone regeneration technique used to
minimize the dimensional changes in soft and hard tissues after Bone graft harvest from the MT. See Box 11-1.
tooth extraction. Similar to the dynamics of spontaneous heal-
ing at a postextraction site, the socket preservation technique Bone filling of the socket. Immediately after corticocancellous
may enhance the stability of the blood clot, which reorganizes bone graft removal, it is crushed using a rongeur to obtain bone
and is subsequently replaced by a provisional connective tissue particles. The particulate bone graft is inserted in the socket and
matrix and woven and lamellar bone.37,38 packed using a bone compactor (Schwert IDR kit, A. Schweick
hardt) to completely fill the socket. It is not recommended to
180

Bone graft
a b c
Fig 11-2 Bone graft harvested from the MT for

socket preservation. (a) CBCT scan confirmed an
intact socket housing the compromised maxillary
right first premolar. (b) The tooth was extracted,
and careful curettage of the socket was performed
to remove the remaining periodontal tissue. The
particulated cancellous bone harvested from the
MT was crushed and packed into the socket to
completely fill the socket. The socket was covered
and sutured using an SCTG harvested from the
same donor area to promote primary closure. (c)
Immediate periapical radiograph showing bone
entirely filling into the socket. After 3 months, the d e
implant was inserted with immediate provisional-
ization. (d) The soft tissue healed with sufficient
thickness after 3 months. Maintenance of the an-
atomical contour of soft tissue can be observed.
(e) The CBCT scan confirmed the stability of the
bone thickness at the buccal aspect after 2 years.
BOX 11-1 Maxillary tuberosity bone graft harvesting technique
The MT is assessed to harvest bone and, if necessary, soft tissues. To harvest a graft, a posteroanterior crestal incision in the distal
part of the MT is used and extended to the maxillary second molar (or the most distal tooth present in the molar area). Prior to raising
the flap, a connective tissue graft may be harvested from the MT using a scalpel with a parallel double blade. The flap is subsequently
raised using a full-thickness mucoperiosteal flap. With the aim of harvesting the bone graft, the osteotomy is performed using straight
or gouge-shaped chisels. The incision can be displaced slightly palatally, depending on the amount of bone graft required. An intrasul-
cular incision is made around the distal aspect of the distalmost molar proportional to the grafting area to be removed. In cases of limited
mouth opening or when more bone graft is required, a vertical releasing incision can be placed on the buccal aspect, distal to or between
the two distalmost teeth. Raising a mucoperiosteal flap may be accomplished with a no. 2/4 Molt elevator in an anteroposterior direc-
tion from the distal aspect of the distalmost molar to the edge of the horizontal incision to adequately expose the bone at the donor
site. Providing adequate irrigation is recommended for optimal field visibility. With the aim of harvesting the bone graft, the osteotomy
is performed using straight or gouge-shaped chisels (Schwert IDR kit, A. Schweickhardt). The chisel selection is made according to
the alveolar defect size in the recipient bed, the bone volume to be harvested, and ease of access to the donor site. The active portion
(cutting edge) of the chisel is available in different sizes (6-, 8-, and 10-mm widths). As a rule, the selected chisel must be at least 2
mm wider than the graft to be removed. Chisels with a millimeter-scale cutting edge facilitate graft measurement on its removal. The
initial positioning of the chisel depends on the mouth opening of the patient and the bone volume to be harvested. Ideally, the chisel
is held perpendicular to the bone structure. After preliminary deepening (approximately 2 mm) using a surgical hammer, the chisel can
be angulated according to its length and thickness. The chisel can be used to remove a thin bone lamina or a bulky bone block when
good surgical access is available. Prior to suturing, the floor of the maxillary sinus is inspected. Single interrupted sutures can be
performed with nylon monofilament 6-0 suture.9
All grafting material must be maintained in a container with blood collected from the MT to preserve the cell vitality. The graft should
be positioned as rapidly as possible in the recipient bed. Rapid manipulating and transferring to the recipient bed may be essential for
the maintenance of cell vitality and adequate healing.
181

a b c
Fig 11-3 Bone graft harvested from the MT for

socket preservation. (a) The patient presented
with a maxillary left central incisor requiring ex-
traction. (b) The CBCT scan confirmed an intact
socket and root resorption in the maxillary left
central incisor. (c) The implant was placed pal-
atally, leaving a gap of approximately 3 mm at
the buccal aspect. Primary stability of 50 Ncm
was obtained. (d) The particulated cancellous
bone harvested from the MT was crushed
d e and packed to completely fill the socket. The
three-dimensional (3D) positioning of the im-
plant allowed a thickness of 3 mm of bone fill at
the buccal aspect. A screw-retained provisional
restoration was placed out of occlusion imme-
diately on the implant. (e) Three months after
the procedure, maintenance of the anatomical
contour of the soft tissue was observed. (f)
Clinical follow-up after 2 years showing stability
of soft tissue volume and maintenance of the
gingival architecture. (g) A CBCT image after 2
years highlights the stability of the thickness
and height of the buccal wall.
f g
suture the buccal and palatal flaps without connective tissue implant and the buccal wall. The provisional restoration should
graft to avoid changes in the position of the buccal gingival be fabricated immediately over the implant (Fig 11-3).
tissue. The socket is covered by the connective tissue graft
harvested from the MT and sutured with single stitches using
nylon monofilament 6-0 suture to promote primary closure. Socket reconstruction
Another method to close the socket with soft tissue is to per-
form rotation of the flap from the palatal to the buccal aspect. In compromised alveolar sockets, regardless of the extension
The donor site is closed with single interrupted sutures of nylon of the bone defect, a socket reconstruction may be performed
monofilament 6-0 suture. During the surgical procedure, if there immediately after tooth extraction, with or without implant place-
is remaining bone at the height of the apex of the socket, the ment at the same time. The goal is to maintain the soft tissues
implant may be inserted at the same time as bone filling. If not, (gingival margin, papillary height, and soft tissue volume) in the
the implant should be inserted after 3 months. same position using bone harvested from the MT.
Provisional crown fabrication. To maintain the gingival archi-

Technique using an MT graft (Fig 11-4)
tecture in the same position, a fixed provisional restoration with
an ovate pontic directly in contact with the soft tissue graft is Evaluation of the socket defect and MT. Prior to surgery, it
recommended. is mandatory to evaluate the donor and recipient sites using
In cases where the implant is inserted immediately after tooth CBCT scans to assess the indications for socket reconstruction
extraction, the cancellous bone harvested from the MT is particu- and evaluate the dimensions of the defect and bone availabil-
lated, crushed, and packed to completely fill the gap between the ity in the MT.
182

Bone graft
a b c
Fig 11-4 Bone graft harvested from the MT

for socket reconstruction. (a) The patient pre-
sented with a periodontally compromised
maxillary right lateral incisor with severe
bone loss along with a thin periodontal
biotype. Periodontal probing determined a
height of approximately 11 mm at the pala-
tal aspect and 8 mm at the buccal aspect.
(b) The CBCT image confirmed the partial
loss of the buccal wall and total loss of the
palatal wall. (c) After tooth extraction, careful
curettage of the socket was performed to d e
remove the granulation tissue and remain-
ing periodontal tissue. The bone graft was
harvested from the MT. (d) The socket was
grafted using two pieces of corticocancellous
graft to restore the buccal and palatal walls.
The remaining cancellous bone was subse-
quently crushed and packed into the socket
to completely reconstruct and fill the socket.
The socket was covered and sutured using
an SCTG harvested from the same donor
area to promote primary closure. (e) Periapi-
cal radiograph taken immediately after graft-
ing, showing bone entirely filling the socket.
After 3 months, the implant was placed. (f) f g
Soft tissue healing after 1 year showed main-
tenance of the anatomical contour of the soft
tissue. (g) CBCT scan after 1 year highlighting
bone stability around the implant.
Dental extraction. A minimally invasive dental extraction and using a bone compactor until it completely fills the socket. As a
careful curettage and cleaning of the socket are performed to result of the lesser thickness of the cortical bone and the lower
remove the granulation tissue and the remains of the periodon- density of the trabecular bone in the MT compared with that
tal ligament. A periodontal probe is inserted in the socket to in other intraoral sites, MT corticocancellous grafts are easily
assess the bone defects. shaped, and the cortical structure may act as a biologic barrier
that stabilizes the soft tissue and the particulate bone graft.13
Bone graft harvest from the MT. See Box 11-1. Suturing the buccal and palatal flaps without connective
tissue graft is not recommended to avoid any changes in the
Bone reconstruction of the socket. Immediately after cortico- position of the buccal gingival tissue. The socket is covered
cancellous bone block graft removal, the graft is shaped accord- by connective tissue harvested from the MT and closed with
ing to the defect size using a rongeur and inserted in the recip- single stitches of nylon monofilament 6-0 suture to promote
ient site to restore the lost anatomical walls. The block should primary healing. Another method to close the socket with soft
be stabilized by a perfect fit and compression contact with the tissue is to perform rotation of the flap from the palatal to the
remaining walls of the bony defect. The remaining bone graft is buccal aspect. The donor site is closed with single interrupted
crushed to reduce the size of the bone particles and compacted sutures using nylon monofilament 6-0 material. During the surgi-
183

cal procedure, if there is remaining bone at the height of the and bony defects were grafted with autogenous bone chips
apex of the socket, the implant may be inserted at the time of harvested at the mandibular ramus and particulated in a bone
bone reconstruction; otherwise, the implant should be inserted mill or were retrieved by collecting bone particles by a disposable
after 3 months. filter. Additional soft tissue grafts were not used. The implants
were immediately provisionalized. According to the second
Provisional crown fabrication. To maintain the gingival archi- endpoint definition that combined the success criteria estab-
tecture in the same position, a fixed provisional restoration with lished by Buser et al51 with the criterion of bone loss less than
an ovate pontic directly in contact with the soft tissue graft is or equal to 1 mm, the cumulative success rate was 70%.54 The
recommended. following key factors are thought to explain the good results
obtained with immediate and flapless implant insertion and
provisionalization using autogenous bone grafts in the esthetic
Socket reconstruction and immediate zone: (1) the flapless procedure may preserve the blood supply
provisionalization of the facial lamellae; (2) the sole use of autogenous bone with-
out any bone substitutes and without membranes may prevent
Single-tooth replacement in the esthetic zone has been one of the resorption due to foreign body reactions; and (3) the placement
most common indications for dental implant placement. Compro- of the implants along the palatal cortical border of the extraction
mised teeth are removed using atraumatic principles and imme- socket increases primary stability and avoids any crossing of
diately replaced by an implant-supported provisional restoration, the bony envelope.54
often with excellent esthetic, biologic, and functional results. The first publication of the immediate dentoalveolar resto-
However, in cases of compromised sites with bone loss and/ ration (IDR) technique was in 2009.55 The IDR, a one-stage tech-
or gingival recession, the clinical scenario becomes more diffi- nique, enables extraction, implant placement, and provisional-
cult. Until recently, all the developed surgical recommenda- ization to occur in the same procedure, and the flapless bone
tions required long-term treatment with potentially undesirable reconstruction uses a corticocancellous bone graft harvested
complications in the tissue architecture. Different surgical alter- from the MT.15,56 The MT has become the only choice as a
natives for bone augmentation in compromised postextraction grafting source in IDR because a corticocancellous graft from
sockets have been described50; however, many of these tech- the MT may be shaped to the size of the defect and inserted
niques require longer periods for rehabilitation and are typically in the recipient bed to restore lost bone mass.13,15,57 The IDR
costly.51 technique, which is associated with lower overall cost and treat-
A technique that combines a mucoperiosteal flap; dental ment time, has been shown clinically and radiographically to
extraction; immediate implant placement; guided bone regen- be effective with regard to both soft and hard tissue stability in
eration (GBR) with an autogenous, xenogeneic (Bio-Oss, Geist- compromised sockets,58,59 with implant success and prosthe-
lisch), or allogeneic (Puros Allograft, Zimmer Biomet) graft and a sis survival rates of 100% (the success rate was considered
membrane (Bio-Gide, Geistlisch); autogenous bilaminar SCTG; a progressive marginal bone loss of less than 1 mm during
immediate provisionalization; and a coronally positioned flap was the first year of implant placement and less than 0.2 mm per
devised to achieve more stable peri-implant tissue in facial osse- year in subsequent years).56 The advantages of IDR include: the
ous defect situations. The authors concluded that the favorable harvest of the MT is easily performed; the malleability of bone
initial results reported with this treatment modality suggest it fragments enables adequate adaptation to the recipient site;
may represent a viable treatment option.52 and the corticocancellous graft acts as a biologic membrane,
Another technique, which combines a mucoperiosteal flap, thereby promoting effective hard and soft tissue healing. Further-
atraumatic tooth extraction, immediate implant placement with more, the trabecular nature of grafts harvested from the MT
GBR with a freeze-dried bone allograft (Raptos, Citagenix) and contributes to increased revascularization capacity and release
membrane (Bio-Gide), an SCTG harvested from the palate, of growth factors to the receptor site.48
immediate provisionalization, and a coronally positioned flap,
was performed for esthetic assessment in buccal osseous Technique using an MT graft (IDR). (Fig 11-5). According to
defect situations. The authors concluded the cumulative survival the IDR protocol for tissue loss, the corticocancellous graft har-
rate of implants was 100%, whereas the success rate (maxi- vested from the MT is shaped to the defect size and inserted
mum 1.5 mm of marginal bone loss in the first year and not between the implant and the remaining soft tissue, without
more than 0.2 mm of bone loss in each successive year) was opening the flap, regardless of whether it is missing one or
88% after a mean follow-up of 29 months (12 to 48 months). more bony walls.13,15,55 Particulate bone is then compacted until
The results imply that the combined GBR and connective tissue it completely fills the gaps between the main corticocancellous
graft procedure may only partially compensate for buccal bone graft and the implant surface.15 After bone reconstruction using
deficiencies. In addition, recession and incomplete papillae were bone from the MT, peri-implant tissue remains stable using this
frequently observed.53 surgical protocol, which has yielded satisfactory and predictable
Recently, extraction sockets with and without facial bone esthetic outcomes in a prospective case series.48
deficiencies were treated by a flapless approach. Facial gaps
184

Bone graft
a b c
Fig 11-5 IDR technique. (a) Clinical evaluation

showed a very poor quality of soft tissue due to
fracture and infection at the maxillary right lat-
eral incisor and the loss of buccal bone wall. (b)
The corticocancellous graft and particulate bone
were obtained from the MT using IDR chisels.
(c) The corticocancellous graft was reshaped
according to the defect configuration using a
rongeur and then inserted and stabilized in the
receptor site by a perfect fit and compression
contact with the remaining walls of the bony d e
defect. (d) Particulate bone was compacted to
completely fill the gaps between the marrow
portion of the corticocancellous graft and the im-
plant. The 3D positioning of the implant allowed
a gap of 3 mm between the implant and the buc-
cal wall. A screw-retained provisional crown was
immediately placed on the implant but out of
occlusion. (e) Stable soft tissue presenting with
sufficient thickness after 3 months. (f) Clinical
follow-up after 2 years showing stability of the
gingival margin and papillae. (g) CBCT scan after
2 years highlighting bone stability and adequate
thickness at the buccal aspect.
f g
Evaluation of bone defects and the MT. Prior to surgery, it is age, the implant is placed 3 mm from the gingival margin apically
mandatory to evaluate the donor and recipient sites using CBCT in the correct 3D position, achieving primary stability over 30
scans to assess the dimensions of bone defects in the recipi- Ncm, with a gap of approximately 3 mm at the buccal aspect.
ent site, the indications for IDR, and bone availability in the MT.
Provisional crown fabrication. A screw-retained provisional
Dental extraction. Minimally invasive dental extraction and restoration with an ideal emergence profile is fabricated for
careful curettage and cleaning of the socket are performed to simultaneous placement. The proper anatomical contour of
remove the granulation tissue and remains of the periodontal the prosthetic emergence profile is mandatory to guide the
ligament. The socket is assessed using a periodontal probe to soft tissue healing.56
evaluate the dimensions of the bone defects.
Bone graft harvest from the MT. See Box 11-1.
Selection and positioning of the implant. The position of the
implant in IDR, as in other techniques, should be considered as Bone reconstruction. Immediately after graft removal, the cor-
one of the main factors in obtaining stability of hard and soft ticocancellous graft is shaped according to the defect size using
tissues. The protocol for selecting the diameter and position of a rongeur and inserted in the receptor site to restore the lost
implants placed in the esthetic zone uses the buccopalatal dis- anatomical walls and stabilized by juxtaposition. The remaining
tance from the socket opening as a reference.60 Regardless of bone graft is crushed using a rongeur and compacted using a
the tooth to be replaced, a gap of approximately 3 mm between bone compactor until it completely fills the gaps. The graft is
the buccal implant surface and the outer buccal bone wall is placed at a biologic distance of 2 mm apical to the gingival mar-
expected.48 After proper preparation at the site of palatal anchor- gin and is 3 mm in thickness.
185

a b c
d e f
g h
Fig 11-6 Bone graft harvested from the MT for alveolar ridge thickness augmentation. (a) This patient underwent bone graft reconstruction using
bone harvested from the retromolar area 10 years previously. Gingival recession occurred at the left central incisor, causing a lack of harmony in
the gingival margin level between the two central incisors. (b) The flap was raised and it was possible to notice the loss of bone at the buccal as-
pect. (c) The failed implant was replaced with a new implant placed in the palatal bone. The implant threads were completely exposed. (d) A block
bone graft with compatible dimensions to the defect size was harvested from the MT using IDR chisels. (e) The receptor site was prepared with
multiple perforations. Immediately after graft removal the corticocancellous block graft was shaped according to the defect configuration using a
rongeur and stabilized by a graft screw. The particulate cancellous graft was inserted underneath the block graft. The bone graft was covered and
sutured using an SCTG harvested from the same donor area to promote primary closure. (f) Three months after bone reconstruction the bone is
completely incorporated and stable in thickness. The graft screw was removed, and a healing abutment was placed. (g) Two months after provi-
sional crown placement, the soft tissue was stable in volume and had adequate thickness. (h) Clinical follow-up after 4 years showed stability of
the gingival architecture.
Provisional crown placement. The screw-retained provisional from the MT have been harvested for use in bone augmenta-
restoration is immediately placed in position and adjusted to tion for several years.5
be out of occlusion. For localized bone deficiencies, among autogenous bone
sources, as compared with composite grafts, the greatest verti-
cal gains are frequently obtained from MT blocks.7,8,61 Among
Bone thickness/height augmentation monocortical onlay block bone grafts from the ramus, the chin,
and the MT (in 37 vertical and 65 horizontal defects), blocks from
Many clinical studies support the use of block bone grafts and the MT and the ramus resulted in the greatest gains in horizon-
other techniques that involve several surgical stages for the tal and vertical bone: 4.3 and 3.7 mm, respectively. MT block
reconstruction of bone defects in compromised alveolar sock- bone grafts may be a valuable source of bone in the augmen-
ets during or after tooth removal.50,51 These cases could be suc- tation of alveolar ridges that are deficient in thickness and/or
cessfully treated using a corticocancellous bone graft harvested height.4 A considerable advantage of bone grafts from the MT,
from the MT, resulting in effective stability of the soft and hard compared with other intraoral donor sites, is the relative simplic-
tissues with lower overall cost and treatment time.57 Bone grafts ity of harvest and the minimal complications.
186

Bone graft
a b c
d e f
Fig 11-7 Bone graft harvested from the MT for alveolar ridge thickness and height
augmentation. (a) The CBCT scan confirmed the failure of the implant in the maxillary
right lateral incisor site in combination with a substantial defect and the need for bone
thickness and height augmentation. (b) After raising the flap, the failure of the implant
and the defects requiring reconstruction were confirmed. The implant was removed.
(c) A full-thickness mucoperiosteal flap was raised in the MT donor area. (d) The bone
block harvested from the MT was stabilized over particulate bone harvested from the
same donor area using a screw, restoring the thickness and height of the defect. The
graft was not covered by a membrane. (e) The implants were placed 3 months after bone
grafting with a remarkable clinical outcome in terms of bone graft incorporation at the
recipient site and in proximity to the maxillary right canine. (f) CBCT scan highlighting
bone graft incorporation and implant placement 3 months after the bone reconstruc-
tion surgery. (g) Clinical follow-up after 3 months showed soft tissue volume stability. g
Technique using an MT block bone graft copious irrigation with saline solution from the cortical to the
(Figs 11-6 and 11-7) medullary bone to facilitate angiogenesis.
Evaluation of bone defects and the MT. Prior to surgery, it is Bone graft harvest from the MT. Using straight chisels at dif-
mandatory to evaluate the donor and recipient sites using CBCT ferent angulations is the first option for bone block harvesting
scans to assess the dimensions of bone defects and indications from the MT. To obtain an MT block bone graft, a midcrestal
for thickness and/or height augmentation in the recipient area incision is used and extended to the second maxillary molar
as well as to evaluate bone availability in the MT. area with 4-mm vertical releasing incisions; the full-thickness
mucoperiosteal flap is subsequently raised. The osteotomy is
Preparation of the recipient bed. The recipient site is accessed confined to the most distal segment of the MT posteriorly and
through a full-thickness mucoperiosteal flap over the keratinized the distal aspect of the second molar anteriorly. It is recom-
tissue and intrasulcular mucosa in the teeth adjacent to the mended to harvest a block bone graft from the MT with dimen-
defect followed by one or two vertical releasing incisions at sions compatible with the defect dimensions using straight
least one tooth away from the surgical site. Following these chisels 6, 8, and 10 mm in width in different positions, such
incisions, a no. 2/4 Molt elevator is used to raise a full-thickness as apicocoronally or laterally. The inclination of the chisels is
flap beyond the mucogingival tissue. The surface irregularities changed according to the bone availability. Ideally, the chisel
in the receptor bed are smoothed, and the site is prepared with would be perpendicular to the bone structure. The chisel can
multiple perforations with a small-diameter cylindrical bur under be angulated according to the required length and thickness of
the bone defect. After the bone block is removed, the donor
187

site is closed with nylon monofilament 6-0 suture using a single posterior maxilla was assessed in a study using data from 14
interrupted suturing technique. patients who were divided into three groups according to the
technique by which the bone block was used.4 The first group
Bone reconstruction. Immediately after graft removal, the cor- had a block graft from the alveolar MT covered with titanium
ticocancellous block graft is shaped according to the defect con- mesh (titanium mesh group); the second group had the block
figuration using a rongeur. After the block bone graft is adapted bone covered by platelet-rich fibrin and collagen membrane
and its fit in the recipient bed is confirmed, bone particles are (platelet-rich fibrin group); and in the third group, the block graft
inserted and packed over the defect to completely cover it, thus was covered only with periosteum (periosteum group). The
forming a uniform layer of particulate bone. The block bone har- MT bone block grafts were covered by particulate graft (natu-
vested from the MT is placed over the particulate bone graft to ral bovine bone mineral) in all cases. The primary width of the
restore the defect in thickness and/or height and is subsequently bone was recorded at the time of graft placement, and changes
stabilized by graft screws. The flap is mobilized to enable primary were evaluated after 4 to 6 months when the implant was
closure without tension, and incisions are required to release inserted. Changes in the width of the bone were 4.1, 3.3, and
the periosteum until complete passive adaptation of the edges 2.5 mm in the platelet-rich fibrin, titanium mesh, and periosteum
of the primary incision is achieved. The flap of the receptor site groups, respectively. The difference in bony change among the
is closed with nylon monofilament 6-0 suture, using a horizontal groups was not significant, with the exception of between the
mattress suture in combination with single interrupted sutures. platelet-rich fibrin and periosteum groups. MT block bone graft
was concluded to be a good potential source of bone for the
Implant placement. The implant is placed at the same time as augmentation of deficient ridges, with more favorable results
bone reconstruction if there is stable bone available or 3 months possibly expected with the addition of resorbable membranes.4
after the bone grafting. The provisional implant restoration is Bone harvested from the MT can be used alone or supple-
fabricated 3 months after implant placement. mented with bone substitutes (composite grafts) in situa-
tions in which only minimal amounts of hard tissue can be
harvested from the MT. Bone substitutes, when embedded in
Guided bone regeneration osteoprogenitor cells of the MT, may improve the amount of
bone formation in vivo.74 The employment of composite grafts
GBR uses a resorbable or nonresorbable membrane to create using biomaterials and autogenous bone from the MT expands
and maintain a space over the bony defect and under the peri- patient candidacy by reducing the total amount of patient bone
osteum. Ideally, osteoprogenitor cells should colonize the space required for grafting procedures, while retaining the benefits of
over the defect; however, these cells grow relatively slowly. The utilizing autogenous bone. In this respect, the hard tissue of the
membranes used in GBR prevent the ingrowth of rapidly prolifer- MT can be manipulated in a plethora of ways to overcome the
ating epithelial and connective tissue cells into the defect.62 GBR problems of bone deficiency throughout the maxilla (Romanos
is an extensively described alveolar ridge augmentation technique GE et al, unpublished data, 2018).
that produces excellent, reproducible results and high long-term
success rates based on high-evidence-level publications.63–65
Technique using an MT bone graft (Fig 11-8)
The use of GBR together with onlay autogenous bone block
grafts has resulted in improved retention of bone and up to Evaluation of bone defects and the MT. Prior to surgery, it
4.6-mm bone gain with good efficacy and predictability.66 This is mandatory to evaluate the recipient and donor areas, using
finding may be attributed to the cortical nature of the outer CBCT scans to assess the dimensions of the defects in the
portion of the autogenous onlay graft as well as the protective recipient site and indications for GBR as well as bone availabil-
effect of the membrane.67 Although these studies have indicated ity in the MT.
that membranes have a positive influence on graft healing, other
authors dispute the benefit of this practice.68 Preparation of the recipient site. Assessment of the recipient
GBR with particulate autogenous bone graft69 or particu- site is performed by raising a full-thickness mucoperiosteal flap
late inorganic bovine bone graft,70 as well as a mixture (1:1) of over the keratinized tissue and intrasulcular mucosa at the teeth
particulate inorganic bovine bone and particulate autogenous adjacent to the defect followed by one or two vertical releasing
bone71,72 has been used to increase horizontal bone in the alve- incisions at least one tooth away from the surgical site. After inci-
olar ridge. Analyses of the three types of grafts for horizontal sions, a no. 2/4 Molt elevator is used to raise the full-thickness
bone augmentation in the alveolar ridge have been reported in flap beyond the mucogingival junction, and at the palatal aspect,
a systematic review and meta-analysis.73 However, the literature a detachment is performed to allow the insertion and stabiliza-
lacks an analysis that demonstrates the comparative perfor- tion of the membrane. The surface irregularities in the recipient
mance, clinical and histologic, of autogenous, xenogeneic, and bed are smoothed, and the site is prepared with multiple per-
combination bone grafts. forations using small-diameter cylindrical burs under copious
The efficacy of the GBR with autogenous bone graft harvested irrigation with saline solution from the cortical to the medullary
from the MT in the augmentation of adjacent defects in the bone to facilitate angiogenesis.
188

Bone graft
a b c
d e
Fig 11-8 Guided bone regeneration (GBR) with a bone

graft containing MT (50%) and anorganic bovine bone
(50%). (a) CBCT scan 4 months after tooth extraction;
the need for bone thickness augmentation is evident.
(b) The flap was raised, and the defects were inspected.
(c) A full-thickness mucoperiosteal flap was performed
at the MT donor area. The bone graft osteotomy was
performed using straight chisels. (d) The bone graft
harvested from the MT was completely particulated
using a rongeur, mixed with an equal amount (1:1) of
anorganic bovine bone, and positioned over the bone
defect. (e) The particulate bone graft was covered by
a collagen membrane. (f) The implants were placed 4 f g
months after bone grafting. (g) CBCT scan showing bone
graft incorporation and implant placement 4 months after
the GBR procedure.
Bone graft harvest from MT. See Box 11-1. 2. The bone graft removed from the MT is completely particu-
lated using a rongeur, mixed with an equal amount (1:1) of
Bone reconstruction. Bone harvested from the MT may be inorganic bovine bone and positioned over the bone defect.
used in two different ways in GBR: The bone graft is covered by a collagen membrane and
stabilized by fixation pins.
1. The block bone fragment removed from the MT is divided
into two parts. The first part is particulated using a rongeur The flap is mobilized to enable primary closure without
and positioned on the bone defect; the second part is main- tension, and incisions are required to release the periosteum
tained as a corticocancellous bone block, positioned over until complete passive coaptation of the edges of the primary
the particulated bone layer, and fixed to the receptor bed incisions has been achieved. The flap of the receptor site is
with the aid of graft screws. The corticocancellous bone closed with nylon monofilament 6-0 suture, using horizontal
block should be covered by a collagen membrane and, if mattress sutures from the buccal angle of the flap in combina-
necessary, stabilized by fixation pins. tion with single interrupted sutures throughout the length of
the incisions.
189

Peri-implant bone regeneration TRIPLE GRAFT

For various reasons, there is a frequent need for compensatory The MT allows the harvesting of a single graft containing both
surgery around previously placed and loaded dental implants hard and soft tissue using handheld instruments. This graft is
that present bone defects. Hard and soft tissue grafting meth- referred to as a triple graft because it involves cortical bone,
ods should be used for clinical cases in which the implants cancellous bone, and connective tissue in a single graft.55
were placed in an ideal position but present bone loss. In such Clinical indications for a triple graft harvested from the MT
cases, bone grafts using bone harvested from the MT may be include the following:
recommended.
1. Compromised sockets with loss of the buccal wall in
combination with gingival recession or very thin periodon-
Technique using an MT bone graft (Fig 11-9)
tal biotype (IDR technique)
Evaluation of bone defects and the MT. Prior to surgery, it 2. Peri-implant hard and soft tissue loss
is mandatory to evaluate the recipient and donor sites, using
CBCT scans to assess the dimensions of defects around the The adequacy of the blood supply from the recipient bed to
implant, indications for peri-implant bone loss regeneration, and the graft depends on the structure of the graft. In the triple graft,
bone availability in the MT. the outside (connective tissue graft) and the inside (trabecular
bone) are in contact with mucosa and remaining bone, respec-
Preparation of the recipient bed. After a full-thickness flap is tively, thus enabling revascularization of the graft from the recip-
performed in combination with releasing incisions in the recipient bed. The structure of the triple graft may be responsible for
ient site, it is mandatory to perform complete removal of the faster and more efficient bone graft incorporation and healing
granulation tissue around the implant, disinfection of the implant, as well as the maintenance of the graft volume.
and cleaning of the area with saline solution. Autogenous bone graft and SCTG from the MT have been
used to decrease the distance between the bone crest and
Bone graft harvest from the MT. See Box 11-1. the interdental contact point to restore the interdental papilla,
simultaneously achieving a change in the periodontal biotype
Bone reconstruction. The bone graft harvested from the MT is and augmenting the papillary height.76
used to cover the exposed threads of the implant and increase Corrections to the bone walls and gingival imbalance in
bone thickness in the region. The bone block harvested from postextraction sites are provided in a single surgical proce-
the MT is shaped according to the defect configuration around dure; there is also considerable improvement in local hard and
the implant and is subsequently checked in the recipient site. soft tissues when the triple graft is applied around previously
The remaining bone is crushed using a rongeur to reduce the placed implants that present tissue deficiencies, particularly at
size of the particles, which are subsequently placed around the the buccal aspect.13
implant to form a uniform layer of particulate bone. The bone The triple graft associated with a coronal sliding flap may over-
block harvested from the MT is adapted over this layer of par- come certain local drawbacks of immediate implant placement
ticulate bone to restore the defect in thickness and horizontally and loading, such as gingival recession and compromised alve-
stabilized by a screw. The autogenous bone graft is covered by olar bone walls, possibly involving total or partial buccal bone
a collagen membrane and, if necessary, stabilized with fixation plate loss. Correct graft positioning and an adequate emergence
pins. Performing a simultaneous soft tissue compensatory pro- profile of the crown guide soft tissue healing.76
cedure is often necessary. The soft tissue graft may be removed Recently, 16 consecutive patients who had a bony defect
during bone reconstruction surgery using connective tissue har- resulting from implant removal in the esthetic region that was
vested from the same donor area of the MT and sutured in the immediately reconstructed with a combined autogenous bone
inner part of the flap of the recipient bed. The flap is mobilized and soft tissue graft harvested from the MT were evaluated.76
to allow primary closure without any tension, and incisions are After implant removal, the soft and hard graft tissues were
required to release the periosteum until complete passive coap- compressed in the defect and healed without complications.
tation of the edges of the primary incisions is achieved to allow After a healing period of 3 months, implants were inserted. One
coronal displacement of the flap. The flap of the receptor site is year after the placement of the definitive restoration, no implants
closed with vertical mattress sutures in combination with single had been lost, and the peri-implant tissues were healthy. With
interrupted sutures using nylon monofilament 6-0 sutures. The this technique, the immediate reconstruction of the hard and
donor site is closed with single interrupted sutures, also using soft tissue components with a combined bone–soft tissue graft
nylon monofilament 6-0 sutures. after the removal of an implant appears to be a feasible treat-
ment option from the perspectives of both patients and profes-
sionals. This approach enables rehabilitation, reduces morbidity,
and results in a favorable esthetic outcome.76
190

Triple graft
a b c
d e
f g
h i
Fig 11-9 Peri-implant bone regeneration with bone graft harvested from the
MT. (a) The patient had undergone GBR with anorganic bovine bone alone, and
1 year after loading, the implant in the maxillary right central incisor site was
determined to be in the ideal position but presented bone loss at the buccal
aspect. (b) A full-thickness mucoperiosteal flap was raised at the recipient
site, preserving the gingival architecture with respect to the gingival margin
and the papillae. The granulation tissue around the implant was removed. (c)
After the area around the implant was cleaned, the site was prepared with
multiple perforations. (d) A block bone graft was harvested from the MT. (e)
The block bone harvested from the MT was adapted over a layer of particulate
bone graft to restore the defect in thickness and stabilized by a screw in the
horizontal direction. (f) The autogenous bone graft was covered by collagen
membrane and stabilized with a fixation pin. (g) Three months after the surgery,
the bone formation at the buccal aspect of the recipient site is remarkable.
(h) The SCTG was harvested from the MT and sutured in the inner part of j
the flap of the recipient site to improve the soft tissue volume. (i) The CBCT
scan shows adequate thickness of soft tissue and the new buccal wall well
incorporated around the implant. (j) Maintenance of the anatomical contour
of the buccal soft tissue is shown after 1 year.
191

Limitations of harvesting a triple graft Provisional crown fabrication

from the MT
A screw-retained provisional restoration with an ideal emer-
The limitations of triple graft removal from the MT include dif- gence profile is simultaneously manufactured. The proper ana-
ficulty in accessing the donor site, particularly in patients with tomical contour of the prosthetic emergence profile is manda-
a small mouth opening; pneumatization of the maxillary sinus; tory to guide the soft tissue healing.56
or the presence of a third molar. Another limitation is the poor
availability of bone and soft tissue in the MT when large defects
Provisional crown placement
require reconstruction. In these cases, harvesting the graft from
both MTs should be considered.13,77 Although surgical access The screw-retained provisional restoration is immediately placed
to the MT can be difficult in some cases, a triple graft is highly in position and adjusted to be out of occlusion.
beneficial for recipient beds that simultaneously lack bone and
connective tissues.50
Triple graft harvest from the MT
A mucoperiosteal incision is made at the MT by following the
Technique for harvesting a triple graft distal contour of the most distal molar, 2 or 3 mm from its dis-
tal side. This incision is followed by two mucoperiosteal vertical
from the MT (Fig 11-10) releasing incisions in the posterior direction, thus reproducing
Evaluation of defects and bone availability the shape of the defect in the recipient region. After these first
three mucoperiosteal incisions, the flap is divided starting at
Prior to surgery, it is mandatory to evaluate the recipient and the buccal line angle, then the blade is directed to the most
donor areas using soft tissue CBCT scans to assess the dimen- posterior portion of the releasing incisions, maintaining connec-
sions of the defects in the recipient area, the indications for a tive tissue 1 to 2 mm in thickness to cover the bone tissue. A
triple graft, and the soft and hard tissue availability in the MT. straight chisel is inserted along the releasing incisions to define
the bone fracture line. The chisel is initially positioned perpen-
dicular to the bone structure on the incision line surrounding
Dental extraction
the distal part of the last molar. After it has been inserted 2 or 3
Minimally invasive dental extraction and careful curettage and mm with a surgical hammer, the chisel’s angulation is changed
cleaning of the socket are performed to remove the granulation to be parallel to the outer surface of the connective tissue. The
tissue and remains of the periodontal ligament. The socket is chisel is gradually deepened as far as the distal limit of the
assessed using a periodontal probe to confirm the presence or releasing incisions to obtain a uniform bone/gingival graft. After
absence of bone walls and particularly the loss of facial bone. the bone is fractured, an incision is made in the distal portion
The tissues should be raised for visual access, and the dimen- of the connective tissue to remove the triple graft (cortical and
sions of the soft tissue (gingival recession) and bone defects cancellous bone and soft tissue in one single piece), with care
should be measured with a millimeter-scale probe. taken to maintain an epithelial pedicle to ensure better nutrition
for the flap that will cover the donor site. Harvesting particulate
bone graft from the same donor area to fill the gaps between
Selection and positioning of the implant
the marrow portion of the triple graft and the implant surface is
The position of the implant should be considered one of the main also necessary. Closure can be performed by single interrupted
considerations in obtaining stability of hard and soft tissues. The sutures using nylon monofilament 6-0 suture.
protocol used for selecting the diameter and position of implants
placed in esthetic zones uses the buccopalatal distance from
Hard and soft tissue reconstruction
the socket opening as a reference.60 Regardless of the tooth to
be replaced, a gap of approximately 3 mm between the buccal Immediately after graft removal, the triple graft is shaped accord-
implant surface and the outer buccal bone wall is expected.48 ing to the defect size using microscissors or a scalpel blade and
After proper site preparation at the palatal anchorage, the rongeur. The bone portion of the graft should reproduce the
implant is placed 3 mm from the gingival margin, apical to the anatomical shape of the alveolar defect. The connective tissue
contralateral tooth, and in the correct 3D position, achieving a part should extend beyond it, so that the soft tissue covers the
primary stability of over 30 Ncm and leaving a gap of approxi- recipient bed laterally and coronally. The flaps are repositioned
mately 3 mm at the buccal aspect. The contralateral side is used coronally by a vertical mattress suture using nylon monofila-
as a guide for implant positioning in the coronoapical direction ment 6-0 suture in combination with single stitches.
because most clinical cases treated using triple graft present
gingival recession or lack of harmony in the gingival margin levels.
192

Triple graft
a b c
d e f
g h
i j
Fig 11-10 Triple graft harvested from the MT. (a) Clinical evaluation showing a compromised socket at the maxillary right central incisor with the
loss of the buccal wall in combination with gingival recession and very poor gingival tissue. (b) Minimally invasive dental extraction as well as
careful curettage and cleaning of the socket were performed to remove the granulation tissue and the remains of the periodontal ligament. (c) The
implant was placed at the palatal wall anchorage 3 mm from the gingival margin apical to the contralateral tooth, leaving a gap of approximately
3 mm between the implant and the gingival tissue at the buccal aspect. (d) Clinical evaluation of the MT. (e) Using a soft tissue CBCT scan, the
dimensions of the hard and soft tissues of the MT were assessed. (f) The triple graft (connective tissue, cortical bone, and cancellous bone in a
single graft) and particulate bone were harvested from the MT. (g) The triple graft was shaped according to the defect and inserted at the buccal
aspect. Particulate bone was packed between the cancellous bone portion of the triple graft and the implant. (h) A screw-retained provisional
crown was inserted out of occlusion immediately over the implant. The triple graft was sutured. (i) The porcelain crown placed after 4 months. (j)
A CBCT scan after 4 years highlighting the stability of the buccal wall (thickness and height).
193

MEDICATION AND 6. Singh S. Management of infrabony defects in mandibular molars

in a patient with generalized aggressive periodontitis using autoge-
RECOMMENDATIONS FOR ALL nous bone graft from maxillary tuberosity. J Indian Soc Periodon-
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ized bone augmentation with cortical bone blocks tented over
Postoperatively, patients are administered amoxicillin 500 mg different particulate bone substitutes: A retrospective study. Int
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three times daily for 7 days (or clindamycin 300 mg twice daily),
8. Tolstunov L. Maxillary tuberosity block bone graft: Innovative tech-
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ophen codeine 300/10 mg for severe pain), dexamethasone 4 1723–1729.
mg (once per day for 3 days), and 0.2% chlorhexidine mouth- 9. da Rosa JCM. Immediate Dentoalveolar Restoration: Immediately
Loaded Implants in Compromised Sockets. Chicago: Quintes-
wash and topical application twice per day for 1 week. In sites
sence, 2014.
that become infected due to the contamination of the affected 10. Candel E, Peñarrocha D, Peñarrocha M. Rehabilitation of the atro-
area, antibiotic therapy should be prescribed for 5 days prior phic posterior maxilla with pterygoid implants: A review. J Oral
and 7 days after surgery. The sutures are removed after 7 days. Implantol 2012;38:461–466.
Patients are seen twice weekly for the first month, and exam- 11. Park HS, Lee YJ, Jeong SH, Kwon TG. Density of the alveolar and
basal bones of the maxilla and the mandible. Am J Orthod Dento-
inations are continued on a monthly basis thereafter. After facial Orthop 2008;133:30–37.
implant loading, patients are included in a maintenance program 12. Martins W, Ferraz EP, Beloti MM, Rosa L, da Rosa JCM. Imme-
with 3-month follow-up visits during the first year, followed by diate dentoalveolar restoration technique (IDR). Autograft charac-
every 6 months during the following years. terization and a case report. J Osseointegration 2017;9:
305–309.
13. da Rosa JCM, Rosa AC, Fadanelli MA, Sotto-Maior BS. Immedi-
ate implant placement, reconstruction of compromised sockets,
and repair of gingival recession with a triple graft from the maxil-
CONCLUSION lary tuberosity: A variation of the immediate dentoalveolar resto-
ration technique. J Prosthet Dent 2014;112:717–722.
14. Yano K, Yasuda H, Takaoka K, et al. Fate, origin and roles of cells
The MT is an alternative intraoral donor area of hard and soft within free bone grafts. J Orthop Sci 2015;20:390–396.
tissue that can be harvested for autogenous grafting proce- 15. da Rosa JC, Rosa AC, da Rosa DM, Zardo CM. Immediate dentoal-
dures. Grafts from the MT may be an advantageous therapeutic veolar restoration of compromised sockets: A novel technique.
Eur J Esthet Dent 2013;8:432–443.
choice because they provide bone tissue with great osteogenic
16. Barriviera M, Duarte WR, Januário AL, Faber J, Bezerra AC. A new
potential and are associated with low postoperative morbidity method to assess and measure palatal masticatory mucosa by
and minimal complications. Due to the biologic characteristics cone-beam computerized tomography. J Clin Periodontol
of the MT, which are difficult to find in other intraoral graft donor 2009;36:564–568.
17. Lopes LF, da Silva VF, Santiago JF Jr, Panzarini SR, Pellizzer EP.
sites, there are broad clinical options for the indications of grafts
Placement of dental implants in the maxillary tuberosity: A system-
removed from the MT. atic review. Int J Oral Maxillofac Surg 2015;44:229–238.
18. Jung UW, Um YJ, Choi SH. Histologic observation of soft tissue
acquired from maxillary tuberosity area for root coverage. J Peri-
odontol 2008;79:934–940.
19. Farmer M, Darby I. Ridge dimensional changes following
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196

12 TIZIANO TESTORI • FABIO GALLI • RICCARDO SCAINI •
MATTEO DEFLORIAN • ANDREA PARENTI •
HOM-LAY WANG • MASSIMO DEL FABBRO
Immediate Loading of
Implants in Edentulous
and Partially Dentate
Patients
Literature Review
Authors’ Clinical Research in Immediate Loading
Biology and Biomechanics
Clinical Procedures
197

12 | Immediate Loading of Implants in Edentulous and Partially Dentate Patients
A
mong the innovative procedures that have repre- end of the follow-up in each study ranged from 0.3 to 1.7 mm.
sented significant steps forward in implant dentistry, Overall, these data suggest that the immediate loading procedure
immediate loading stands out for its importance in is a very predictable technique, with a high implant survival rate
routine clinical applications.1 Immediate loading is and limited marginal bone loss, both comparable to the results
defined as the “application of functional or nonfunctional load obtained with the traditional delayed loading technique.
to an implant at the time of surgical placement or shortly there-
after; it is generally considered to be loading within 48 hours
of implant placement.”2 Immediate functional loading means
that the implant prosthesis is seated at the time of implant AUTHORS’ CLINICAL RESEARCH
placement and immediately subjected to functional occlusal IN IMMEDIATE LOADING
loading. Conversely, if the prosthesis is kept out of direct occlu-
sal contact, it is defined as nonfunctional loading. In this case, The clinical research activity of the authors in implant dentistry
loading occurs from lip and tongue pressure and contact with is mainly oriented toward the reduction of treatment times (early
food, but not from contact with the opposing teeth. The ultimate and immediate loading), the extension of implant treatment
goal of an immediate loading protocol is to reduce the number to patients with insufficient quantity and quality of bone, and
of surgical interventions and shorten the time frame between the evaluation of the efficacy of various bone substitutes for
surgery and prosthesis delivery, all without compromising the improving bone regeneration. Immediate implant loading allows
success rate of the procedure. These protocols will ultimately for simplification of the protocols for the surgical team as well
lessen patient reservations about implant treatment, resulting as reduction of cost and discomfort for the patient, while main-
in increased acceptance. Different indications for immediate taining high rates of implant and prosthetic success and patient
loading have been documented over the years, ranging from satisfaction. This latter aspect includes achieving good esthetic
implant placement in the fully edentulous mandible and maxilla results as well as efficient masticatory and phonetic function
to single-tooth applications in extraction sockets.3 assessed using specific indexes and questionnaires. Table 12-1
The most suitable technique in the immediate provisional- summarizes the main scientific research of the authors regard-
ization of implants should meet many criteria, in particular the ing implant loading procedures and outcomes.7,37–57
survival of implants and prosthetic restorations and the preser- The initial approach to immediate loading was of the progres-
vation of marginal bone levels. This leads to the first objective of sive type, that is, the first patients were treated according to the
this chapter, which is assessing the survival rates of immediately Schnitman protocol,58 which entails inserting both immediately
loaded implants and the marginal bone level changes after a loaded and submerged implants in edentulous mandibles. In the
minimum of 5 years of function based on the published litera- case of failure of some of the immediately loaded implants, the
ture. In addition, an overview of the scientific production of the patient could be rehabilitated with fixed prostheses supported
authors regarding immediate loading is presented, a few biologic by the submerged implants, for which osseointegration predict-
and biomechanical concepts supporting the rationale for loading ability had been fully demonstrated. Some of both immediately
the implants immediately after placement are provided, and the loaded and submerged implants were scheduled for removal and
fundamental clinical and prosthetic procedures for immediate histologic analysis to evaluate the quality of the newly formed
loading of full-arch and partial reconstructions are described bone. These implants were removed with a trephine drill after 2
based on the authors’ experience. months of loading in one patient and after 4 months of loading
in another patient. The results of the histologic analysis demon-
strated that good-quality bone formed around implants that
are loaded immediately, with bone-implant contact sometimes
LITERATURE REVIEW even higher than with submerged implants in the same patient.
Histologic evidence supports that immediately loaded
In order to assess the predictability of the immediate loading implants could be successfully applied to many clinical situa-
protocol, a systematic review of the literature has been performed. tions.37,38,59–62 In addition to complete edentulism in the mandi-
Prospective clinical studies reporting the outcomes (implant and ble, immediate loading has been successfully applied in more
prosthesis survival and success as well as marginal bone loss) of biomechanically challenging clinical conditions such as partial
immediately loaded restorations after at least 5 years of follow-up edentulism or cases with suboptimal quality and quantity of
and with a sample size of at least 10 patients were included. A bone, eg, alveolar maxillary atrophy. The surgical and reconstruc-
total of 33 studies presenting the results of immediately loaded tive procedures for the atrophic maxilla frequently carry high
rehabilitations with at least 5 years follow-up were analyzed.4–36 morbidity rates and are associated with a nonnegligible risk of
Either complete prostheses, partial prostheses, or single crowns intraoperative and postoperative complications.
were represented. Collectively these studies, published between Therapeutic approaches first applied to the fully edentulous
2007 and 2017, reported on 5,686 implants in 1,775 patients. The mandible, in which implants are tilted with regard to the occlu-
mean follow-up was 72.4 months with a mean weighted implant sal plane and loaded immediately, have been extended to cases
survival of 97%. The mean peri-implant bone level changes at the of maxillary atrophy. In this way, implant treatment combined
198

Biology and Biomechanics
TABLE 12-1 Main characteristics of the authors’ scientific research on immediate loading
No. of IL No. of IL Type of Duration of

Reference patients/total implants/total prosthesis Site Implant survival rate follow-up (mean)
Testori et al 200137 1 6/12 Full-arch Md NA NA
Testori et al 200238 1 6/11 Full-arch Md NA NA
Testori et al 200339 15 92/103 Full-arch Md 98.9% 12–60 mo
Testori et al 200340 14/32 52/101 Partial Mx and Md 96.15% Up to 24 mo
Testori et al 200441 62 325 Full-arch Md 99.4% 12–60 mo
Testori et al 2004 42 19 116 Full-arch Md 97.4% 8–65 (37.8) mo
Testori et al 2005 43 1 4 Partial Mx NA NA
Zuffetti et al 2006 44 28 149 Full-arch Mx and Md 96.6% 12–48 mo
Del Fabbro et al 200645* 2,977 10,491 All types Mx and Md 96.39% Up to 3 y
Capelli et al 200746 65 342 Full-arch Mx and Md 97.6% Mx, 100% Md Up to 40 (22.5) mo

(41 Mx, 24 Md) (246 Mx, 96 Md) Up to 52 (29.1) mo
Testori et al 200747 25 52 Partial Mx and Md 97.9% 12 mo
Testori et al 2008 48 41 246 Full-arch Mx 99.4% 18–55 (37.5) mo
Galli et al 200849 25 52 Partial Mx and Md 97.9% 12 mo
Franchini et al 2009 50 1 6 Partial Mx 100% 12 mo
Capelli et al 20107 25 52 Partial Mx and Md 98.8% 5y
Del Fabbro et al 201251* 462 1,992 Partial/ Mx and Md 97.9% Mx, 99.9% Md Min 12 mo
Full-arch
Del Fabbro et al 201452* 670 1,832 Partial/ Mx and Md 97.4% Mx, 99.1% Md Min 12 mo
Full-arch
Testori et al 201453 59 385 Partial Mx and Md 95.1% 4y
Del Fabbro et al 201554* 1,170 1,974 Partial Anterior Mx 97.6% Min 12 mo
Zuffetti et al 201655 25 (22) 52 (46) Partial Mx and Md 97.83% 10 y
Testori et al 201756 21 22 Partial Mx and Md 90.3% Min 6 y
Testori et al 2017 57 27 162 Full-arch Mx 95.1% Min 10 y
IL, immediate loading; Mx, maxilla; Md, mandible; NA, not applicable; min, minimum.
*Systematic review of the literature.
with immediate loading may be successfully applied without the The review highlighted the predictability of immediate loading
need for bone grafts. The authors have performed prospective for overdentures and full-arch fixed prostheses in the mandible.
multicenter studies in which four intraforaminal implants are Although the implant survival rate was excellent in other types
placed in the mandible and four to six are placed in the maxilla, of prostheses (full-arch maxillary prostheses, partial prostheses,
with the two distal ones being tilted, to support a full-arch fixed and single-tooth restorations), the documentation was still too
prosthesis loaded within 48 hours of implant placement. The limited, and it was suggested that further studies should be
results were excellent, with implant survival rates and marginal undertaken. The review also indicated that implants with a rough
bone resorption comparable to those of conventional rehabili- surface are correlated with better survival rates than are those
tations (Toronto and Brånemark types) in the short to medium with a machined surface, in all types of rehabilitation, and that this
term. The use of tilted implants proved to be a valid therapeutic difference is more relevant in the posterior regions of the jaws.
alternative to surgical techniques that are more onerous, both for
the surgeon and for the patient, as is shown in the literature.53,63
Recently, the authors have presented excellent outcomes in a
series of cases treated with tilted implants with a follow-up of BIOLOGY AND BIOMECHANICS
more than 10 years.57
In 2006, an early systematic review of the literature analyzed The bone healing process after implant placement is compa-
the clinical evidence on the survival rate of implants subjected to rable to the primary healing of stable fractures.64 The phase
immediate loading in various types of prosthetic rehabilitation.45 immediately subsequent to implant placement is initiated by
199

a b c d
Fig 12-1 Histologic analysis of implants retrieved after 4 months. (a) The recipient site was of good bone quality. Bone is
reaching the internal core of the screw, between the threads. The vestibular side is on the left (Paragon staining; original mag-
nification ×1.5). (b) Direct bone apposition at implant surface shows osseointegration and the presence of old (light stain) and
new (darker stain) bone. The vestibular side is on the left (Paragon staining; original magnification ×25). (c) Bone quality at the
recipient site was good; during surgery, it was identified as normal bone. On the vestibular side, bone reaches the internal core
of the implant screw. The implant is well integrated and presents a high level of osseointegration (Paragon staining; original
magnification ×1.5). (d) Direct bone apposition at the implant surface shows osseointegration and the presence of old (light
stain) and new (darker stain) bone. Bone remodeling occurs as well at a distance (Paragon staining; original magnification ×25).
a b c d
e f g h
Fig 12-2 (a to d) Histologic section obtained at a submerged implant. The vestibular side is on the right. (a) Low-magnification
view (toluidine blue and basic fuchsin stain; original magnification ×1.5). (b) Higher magnification of the crestal region. Islands
of dense bone are found mainly at the tip of the threads (toluidine blue and basic fuchsin stain; original magnification ×10).
(c) Higher magnification at the spongious level. Discontinuous bone trabeculae cover the Osseotite surface (Zimmer Biomet).
Separation from the implant surface is an artifact (toluidine blue and basic fuchsin stain; original magnification ×10). (d) Higher
magnification of c shows the discontinuous arrangement of the bone trabeculae. Separation from the implant surface is an
artifact (toluidine blue and basic fuchsin stain; original magnification ×20). (e to h) Histologic section obtained at the immediately
loaded implant. (e) The poor bone quality is evident. Old bone is more purple (toluidine blue and basic fuchsin stain; original
magnification ×1.5). (f) Higher magnification of the crestal area. Note the large marrow space beneath the crestal bone and
the thin shell of trabecular bone covering the implant surface (toluidine blue and basic fuchsin stain; original magnification ×5).
(g) Higher magnification at the junction of the crestal and trabecular bone. In continuation with the crest, thin bone trabeculae
cover the implant surface (toluidine blue and basic fuchsin stain; original magnification ×15). (h) Higher magnification at the
apical implant region. Note that new bone appears to be flowing over the surface and is interposed between the old bone and
the implant surface. Bone remodeling and bone apposition occurred despite healing under loading (toluidine blue and basic
fuchsin stain; original magnification ×15).
200

Clinical Procedures
the surgical trauma of implant site preparation,65 and it occurs retrieved for histologic analysis (Fig 12-1), without compromising
independently of whether an implant has been inserted or not. their rehabilitation. Furthermore, in another clinical study, loaded
With optimal site preparation, the bone walls of the implant and unloaded implants were histologically comparable38 (Fig
site provide the necessary primary stability. Immediately after 12-2). Therefore, the hypothesis that immediate implant loading
implant insertion, resorption of the peri-implant bone occurs, a may have a favorable effect on osseointegration is supported
natural process that is needed to create the space for the new by a biologic rationale and histologic evidence.
bone that will eventually replace the original bone. Therefore, the
bone remodeling process implies a decrease of the implant’s
initial stability, and a certain period of healing time is necessary
before a new secondary stability, due to newly formed bone, is CLINICAL PROCEDURES
achieved. The time required can differ depending on peri-implant
bone density and on the implant micro- and macrogeometry. Partially dentate patients
Histologic and biomechanical analyses suggest that, if
implants are subjected to immediate loading, the peri-implant The impending loss of a single tooth in the esthetic zone in
bone undergoes rapid and intense resorption between the a patient with an otherwise healthy periodontium can be a
second and fourth week of functional loading. Consequently, the distressing experience.70–73 An inevitable loss of soft and hard
primary stability is reduced and may reach a critical threshold. tissue after tooth extraction often results in a compromised
It might be risky to perform prosthetic maneuvers on implants site for anterior implant esthetics. Various surgical augmenta-
during this period since they might compromise implant stability tion techniques have been advocated as corrective procedures,
and cause early failure. For this reason, the conclusive phase of but they are strenuous and unpredictable.74–77 Since 1998, when
the prosthetic rehabilitation should preferably be postponed to Wöhrle first demonstrated success with immediate implant
at least 2 to 3 months after implant placement. At this stage, placement and provisionalization of single anterior maxillary
the newly formed bone should provide adequate secondary implants,78 numerous studies have further substantiated the
stability to the implant in order to withstand the procedures of viability of such treatment.72,79–90
screwing and unscrewing the abutment. According to the analysis the authors have proposed,91 the
Local bone density is one of the most important factors affect- factors to be considered in the diagnostic phase when designing
ing the achievement of implant stability and its preservation during a treatment plan that includes immediate implant placement
the healing process at a level compatible with optimal function. to replace hopeless teeth in an esthetic area are the following:
Studies have demonstrated that as bone density decreases,
the degree of micromobility at the implant-bone interface under • Predictability of obtaining adequate primary stability
loading conditions increases.66,67 Therefore, great care must • Presence/absence of the buccal bone plate
be taken in planning immediate loading of implants in condi- • Periodontal biotype
tions of poor bone quality. A careful analysis of bone density is • Absence/presence of recessions
recommended through a computed tomography (CT) examina-
tion.68 Should CT reveal very low Hounsfield values in the region In order to obtain primary stability in a postextraction site in
intended for implant placement, it would be wise to avoid applying the anterior maxilla, it is fundamental to observe the anatomical
the immediate loading protocol. However, cone beam CT (CBCT) characteristics of the site to be treated in relation to the prosthet-
is currently incapable of accurately assessing the bone density. ically guided positioning of the implant. Among the anatomical
A number of histologic and biomechanical studies of bone features, the following must be considered:
healing suggest that early or immediate mechanical stimulation
like that produced by functional loading (as long as it does not 1. Parallelism between the long axis of the tooth and the alve-
induce excessive micromotion at the bone-implant interface, olar process
compromising implant stability), may effectively stimulate osteo- 2. Presence/absence of a bone portion apical to the root apex
blast bioactivity (migration, proliferation, and deposition of oste- 3. Amount of palatal bone available after extraction
oid tissue), thereby favoring rather than hindering osseointegra- 4. Extent of the buccal concavity of the anterior maxilla between
tion of the implant.69 Some histologic studies in monkeys that the two canine sites
compared samples from osseointegrated implants in the poste-
rior mandible under delayed loading with those restored imme- After the analysis of these points, achievement of primary
diately found a similar interface.59–61 Conversely, the histologic stability can be expected when there is the following:
analysis of the interface at a zone close to (but not in contact
with) the implant surface demonstrated greater bone density 1. At least 3 to 4 mm of bone apical to the implant apex
when implants were loaded immediately rather than after a 2. At least 3 to 4 mm of palatal bone for implant anchorage
healing period.59,62 Preclinical results have been confirmed by 3. An undersized osteotomy preparation
clinical evidence derived from patients who agreed to have addi- 4. Use of conical implants with sharp threads instead of cylin-
tional implants placed, loaded immediately, and subsequently drical implants
201

a b c
Fig 12–3 (a and b) Intraoral and extraoral vision

of the case. Patient complains about mobility
of the primary maxillary right lateral incisor and
unpleasant esthetics because of the morphology
and gingival contour of that tooth as well as the
permanent maxillary central incisor and left lateral
incisor. (c) Periapical radiographs show radicular
resorption on the primary maxillary right lateral
incisor. (d and e) Atraumatic extraction of the pri-
d e mary maxillary right lateral incisor and detection
of the buccal bone plate at the soft tissue level.
In the absence of adequate palatal and apical bone volume, trial7,55 shows the time of loading (immediate or early) does
implants of greater diameter are used, seeking stability in the not appear to have any significant clinical impact on marginal
mesiodistal portions of the alveolus. In this case it is necessary to peri-implant bone or soft tissue levels. While an average of 1.2
maintain an adequate distance between the implant shoulder and mm of peri-implant bone was lost over 10 years, virtually no
the buccal bone layer92 and between the implant shoulder and the buccal soft tissue recession occurred from the placement of the
root of the adjacent dental elements.93 If the amount of residual definitive restorations up to 10 years after implant placement.
bone present after extraction offers the possibility to stabilize the The decision-making process is summarized in Fig 12-6.
implant in the correct position, the clinician must evaluate the
possibility of performing simultaneous implant placement. The
presence of chronic periapical lesions, if properly managed, is not Edentulous patients
an absolute contraindication to immediate implant placement.94
In the case of a thick biotype, simultaneous implant placement Members of a prosthetic-implant team should always approach,
is always carried out.95 If the thick biotype is in conjunction with plan, and execute implant cases together, integrating the specific
a complete cortical bone cortex, no flap will be raised, and the skills and professional capabilities of each team member. This
additional maneuvers will have as their sole purpose the filling collaboration should begin in the diagnostic phase, which is the
of the postextraction gap with biomaterials, limiting the surgical most important phase in the planning of a case, the moment when
invasiveness. If, on the contrary, the cortical bone is incomplete, decisions begin to guide the therapeutic options in a specific direc-
a procedure with or without a flap will be necessary to carry out tion. The success of a prosthetic-implant rehabilitation depends
guided bone regeneration (GBR) with the placement of an absorb- not only on the professional skills of each team member, but
able membrane and a graft.96 Simultaneous implant placement is even more so on their diagnostic, planning, and prognostic skills.
also possible with a thin periodontal biotype that has no recession The main purpose of every implant rehabilitation should
(a clinical sign of integrity of the vestibular cortex). This scenario always be the restoration of the patient’s original condition prior
is managed with a minimally traumatic extraction, favored by to tooth loss. Care must be taken in all details to enable the
the use of microblades, periotomes, long diamond burs, or axial restoration of the patient’s masticatory function, focusing at the
traction to be performed with the extraction pliers, followed by same time and with equal commitment on the esthetic aspect,
implant positioning, biomaterial insertion in the alveolar gap, and given its highly important social implications. In fully edentulous
connective tissue grafting (CTG) with tunnel or flap techniques.97 or transitional patients, before attempting immediate loading it is
Finally, in the presence of a thin biotype and recession (a sign a fundamental prerequisite to evaluate if the existing prosthesis
of absence of the vestibular cortex), although implant positioning has the correct functional and esthetic parameters (Box 12-1).
is possible, the authors prefer a cautious approach; therefore,
the clinical protocol requires delayed positioning with simultane-
Mandibular surgery
ous correction of hard tissues (with GBR) and soft tissue (with
CTG). The prosthetic protocols in these situations may be differ- The template is checked in one session preceding surgery to
ent. It is advisable to perform provisional rehabilitations with assess stability, correct maxillomandibular relationship, and
immediate loading only in the most favorable cases or in situa- proper occlusion.39 During the surgery phase, detachment is
tions where there is a thick to medium biotype and no gingival carried out in the area where implants will be placed but not
recessions (Figs 12-3 to 12-5). A long-term multicenter clinical in the retromolar area. Intervention is preceded by an accurate
202

Clinical Procedures
f g
h i j
k l m
n o p
q r s
Fig 12–3 (cont) (f and g) The implant site is prepared with the use of a surgical guide, based on a diagnostic wax-up. (h to j) Intrasurgical clinical
and radiographic views. (k to m) The provisional crown is prepared after implant insertion. A CTG is inserted to augment the buccal soft tissue
volume before its connection. (n and o) Clinical healing at the 6-month follow-up. (p and q) Definitive prosthetic phase. Zirconia implant abutment
and maxillary central incisors and left lateral incisor prepared for veneers. (Courtesy of Dr Lorenzo Vanini, Chiasso, Switzerland.) (r) Follow-up clinical
appearance at 5 years. Peri-implant tissue appears stable around the implant site, and the maxillary central incisors and left lateral incisor are now
in accordance with dental esthetic guidelines. (s) Final periapical radiograph.
203

a b c
d e
ff g
h i j
k l m
o o p
Fig 12-4 Preoperative extraoral (a to c) and intraoral views (d) and periapical radiograph (e). The
maxillary right first premolar presents a vertical root fracture. (f and g) Preoperative CBCT scan
and virtual implant planning. (h) Placement of implants with a laser-textured collar. (i) Temporary
cylinders are screwed onto the implants. (j) Provisional restorations are fixed to temporary cylinders
by light-curing resin. (k) Postoperative periapical radiograph. (l and m) Postoperative intraoral views.
(n and o) Extraoral views of the definitive restoration. (p) Posttreatment periapical radiograph. The
prosthodontist decided to remove the intermediate abutment and manufacture a new post, starting
directly from the implant neck.
204

Clinical Procedures
b c
a d e f
g h i
j k l
m n o
Fig 12-5 (a to c) Extraoral and intraoral examination. A fistulous tract can be seen apical to the central incisors. (d to f) Radiographic examination
reveals root fracture of the maxillary left central incisor and external root resorption of the coronal third of the maxillary right central incisor. (g and
h) The teeth were atraumatically extracted using small periotomes. Two tapered implants were placed into the osteotomies created by position-
ing the bur against the palatal wall, in alignment with the future restorative incisal edge. The implants were torqued to 90 Ncm, and a 2-mm gap
remained on the buccal side of each. (i and j) Two provisional polyether ether ketone (PEEK) abutments were screwed onto the implants. Using a
surgical scalpel to minimize any contamination of the surgical site, the posts were reshaped, and the provisional crowns were glued to the post
with a flowable composite. (k) While the provisional crowns were finished in the lab, the surgeon filled the 2-mm gap on the buccal side of each
implant using deproteinized bovine bone in small particles. (l) Previously prepared provisional restorations were hollowed out to passively seat on
the abutments, luted to them, finished in the lab, and screwed into place. (m) Postoperative periapical radiograph. (n and o) Occlusal view of the
final zirconia abutments and definitive restorations shows the excellent buccal bone contours achieved by ridge augmentation.
205

p q s
t u
Fig 12-5 (cont) (p to u) Follow-up at 8 years. Extraoral and intraoral follow-up views. Periapical radiographs and CBCT
scan showing preservation of the buccal ridge thickness.
Hopeless
tooth
Primary
Primary
stability
stability
Not
Predictable
predictable
OK No
Thick Thin
Vestibular Vestibular
biotype biotype
bone bone
OK No OK No
Thick Thin Thick Thin
Vestibular Vestibular Vestibular Vestibular
biotype biotype biotype biotype
bone bone bone bone
Socket Socket
Imp type 2 Exo Imp type 1 Exo
preserv preserv Imp type 1 Imp type 1
+/- GBR Imp type 3 Bone graft Imp type 3
Imp type 2 Imp type 3 Bone graft GBR
+ CTG GBR + CTG + CTG GBR + CTG
GBR CTG
Immediate Immediate Immediate

Loading Loading Loading
Fig 12-6 Decision making for partially dentate patients. exo, extraction; imp type 1, immediate implant; imp type 2, early implant (6 to 8 weeks
after extraction); imp type 3, delayed implant (12 weeks after extraction); preserv, preservation.
206

Clinical Procedures
BOX 12-1 Prosthetic assessments
Esthetic Functional Phonetic

• Anterior tooth exposure of 1 to 5 mm in rest • Vertical dimension of occlusion • M: Vertical dimension of
position evaluation occlusion indications
• Smile line: high (gummy smile), medium, low • Overbite and overjet • S: Dynamic type: vertical or
• Smile width: how many teeth • Occlusal plane parallel to the horizontal (eg, increasing the
visible in patient’s smile? Camper plane laterally length of the incisors in a
• Buccal corridors • Occlusal plane parallel to the horizon horizontal dynamic may cause
• Incisal crest: convex and parallel frontally problems with the S phoneme)
to the lower lip outline during • Discrepancy between maximal • F: Anteroposterior position of
maximum smile intercuspation and centric relation the maxillary incisors
• Soft tissue support • Protrusion and lateral movement • I: Anterior teeth exposure

intraoral palpation to clinically assess mandibular anatomy and Regardless of the type of edentulism, type of surgery, or
emergence of the mandibular foramen. Protecting the tongue number and position of implants, during the diagnostic phase
and oral floor with sterile gauze, a full-thickness crestal incision the surgeon has to decide whether to proceed with delayed or
is made in the gingiva corresponding to the symphysis area. immediate loading. Indications for a delayed implant surgery
In the median line, a releasing incision is made to increase are the following:
visibility of the basal bone following detachment. The detach-
ment of flaps begins with a releasing incision in the median • Need to re-create a band of adherent peri-implant tissue that
line. Maintaining the flaps in tension with surgical forceps, the allows proper home oral hygiene and satisfactory esthetics
bone cleavage plane is assessed by careful detachment via • Requirement to thicken tissues
delicate rotary movements, maintaining the periosteum intact. • Necessity to deepen the fornix to allow adequate oral hygiene
Any adherences encountered must be incised with a scalpel at home
and detachment continued afterward.
In the proximity of mandibular foramen, the detachment In the mandible, depending on the clinical situation, two
procedure has to be carried out cautiously to avoid damaging distinct techniques can be carried out.
nerve endings that have to be isolated to place the more distal If there is sufficient keratinized tissue in the crestal zone, an
implants correctly. apical flap can be realized, dividing in two parts the initial kerati-
Once the mandible is skeletonized, a surgical-prosthetic index nized tissue; if necessary a CTG, taken from the palate or tuber-
is positioned to prepare implant sockets with a 2-mm rose-head osity, can be integrated into this technique using conventional
bur in the presurgically planned implant sites. methods to increase the thickness of the peri-implant tissues.
The sequence of implant site preparation is influenced by In cases where there is only alveolar mucosa above the
the quality of bone detected in the pilot drilling. Generally, in implants, a CTG is often recommended.99,100 Clinical cases with
dense bone, rotary instruments used in the classic protocol are the complete surgical and prosthetic procedures are shown in
employed, including tapping. Underpreparation is the norm in Figs 12-7 and 12-8.
case of little mineralization; this is not frequent in the symphy-
sis area but is more common in the lateroposterior regions of
Maxillary surgery
the mandible.
In cases where immediate loading is planned, implants have The reduction in the number of implants for atrophic maxillary
to reach a final insertion torque of at least 32 Ncm. This value rehabilitation has been described by numerous authors,101–106
is achievable in the mandible, where the interforaminal bone who suggested an arrangement that exploits residual bone
is usually classified as dense or normal.98 As for the number volumes by placing implants tilted at 30- to 35-degree angles
of implants, the scientific literature includes clinical cases with to allow a correct rehabilitation from a prosthetic point of view.
five or six implants with an orthogonal insertion axis to the bone The bone volume of surgical interest is limited to the lateral
crest or four implants, of which two are tilted distally (eg, All-on-4 wall of the nose, from the anterior recess of the maxillary sinus
treatment concept, Nobel Biocare). The clinical choice between and residual alveolar crest. Patients presenting bone resorption
the two therapeutic options is determined by the shape of the extending to the first and second premolars cannot take advan-
mandible, the linear intraforaminal development, and the antero- tage of this treatment. Planning involving tilted implants starts
posterior arrangement of the implant platforms. at the premolar zone. From three-dimensional (3D) radiographic
At the end of the surgical phase, healing abutments are placed exams, buccopalatal thickness of the crest must be at least 6
to guide the soft tissue healing process and on which provisional mm to allow the placement of implants with a diameter of 4 mm.
prosthesis will be rebased. Once osseointegration takes place, If the crest does not have this thickness, a bone reduction in the
the definitive prosthesis is placed after 5 to 6 months. apical direction should be considered to achieve an adequate
buccopalatal dimension. Emergence of the tilted implant will
207

b c
a d
e f g
h i j
k l m
Fig 12-7 (a) Frontal view of the patient with existing prosthesis in place. (b) Sagittal view without prosthesis. (c) Sagittal view with existing pros-
thesis. (d) Intraoral view with maxillary prosthesis in place without mandibular prosthesis. (e and f) The occlusal plane is checked with a Fox plane
plate in frontal and sagittal views. Incorrect plane of existing prosthetic rehabilitation is shown. (g) The facebow is connected to the bite fork. (h)
Cast mounted with the existing maxillary and mandibular prostheses. (i) Mandibular wax interocclusal record. (j) Cast mounted with prostheses.
(k) A surgical stent is made at the new vertical dimension. Three occlusal stops are made in order to create centric relation. (l) The surgical stent
is placed intraorally, and centric relation is checked. (m) Occlusal view after implant placement.
208

Clinical Procedures
n o
p q
r t
u v
Fig 12-7 (cont) (n) Temporary cylinders are attached to the prosthetic stent by self-curing acrylic resin. (o) The master cast is made and mounted
on the semi-adjustable articulator, transferring the vertical dimension and the centric relation. (p and q) Frontal and occlusal views of the provisional
restoration screwed onto the implants. (r) Extraoral view of the rehabilitated patient. (s) Intraoral views of the definitive restoration. (t) Hygiene
instructions are given to the patient. (u and v) Radiographs taken the day of delivery of the definitive restoration.
209

a b d
e f g
h i j
k l m
Fig 12-8 (a and b) Preoperative extraoral views. (c and d) Radiographic and periodontal evaluation. The remaining teeth are diagnosed as hopeless
from the periodontal and restorative point of view. (e and f) Extraoral close-ups of the dentolabial relationship. (g) Intraoral frontal view. (h) An os-
tectomy stent is made. (i) Ostectomy is performed using a piezoelectric device, and the implants are placed. (j) After sterile rubber dam is placed,
a polyether impression is taken. (k to m) Delivery of the provisional prosthesis.
210

Clinical Procedures
n o
p q
r s
t u
Fig 12-8 (cont) (n) Occlusion is checked using articulation paper. (o) Postoperative panoramic radiograph. (p to t) Extraoral and intraoral
views of the definitive restoration. (u) Panoramic radiograph taken at the 1-year recall visit.
211

have to be planned at a point where there is at least 4 to 5 mm During the diagnostic phase, it is necessary to assess the
of residual alveolar crest height in the apicocoronal dimension. width of the keratinized mucosal tissue horizontally and buccally
Following planning of the tilted implant design, the position, and consequently establish how palatal the horizontal incision
length, and diameter of two to four axial implants, which will should be. When proceeding with partial-thickness flap dissec-
be placed using the classic method with adequate interimplant tion, the blade is held parallel to a line tangent to the bone plane.
space distribution, will have to be assessed. It is necessary to deepen the incision apically in the fornix until
The first horizontal incision is midcrestal; this procedure brings a width is established that will allow obtainment of a passive
adequate blood supply, while to improve visibility of the opera- flap that can be repositioned in the new site.
tory field, vertical releasing incisions can be made. The detach- After having replaced the cover screws with healing abut-
ment is full thickness. Any crestal connective tissue fiber adher- ments of appropriate size, the need to increase the buccal
ences require incision to avoid flap laceration. If implants are soft tissue thickness with a CTG has to be ascertained. CTGs
not being placed using a stereolithographic surgical template, may be obtained by the palatal thinning technique, making
it is advisable to check on the 3D image carefully to locate the two parallel incisions (one superficial and one deeper) with the
area of maxillary sinus mesiodistally. These measurements are blade moving in the apicocoronal direction, remaining inside
helpful during surgery, at the crestal level indicating the mesial the mucous thickness, without severing the palatine artery
extension of the anterior wall of the maxillary sinus with good running apically (usually 12 mm below the alveolar crest). This
approximation. In cases of thin buccal cortical bone, the maxillary technique allows the patient to have one surgical site because
sinus is clearly visible as a gray area beneath the bone table. In the donor site coincides with the recipient site. Clinical cases
cases where a surgical guide is not employed, a rose-head bur with the complete surgical and prosthetic procedure are shown
mounted on a straight handpiece and/or piezoelectric instru- in Figs 12-9 and 12-10.
ments could be used to create an antrostomy in the vestibular
wall of the maxillary sinus mesially, which exclusively serves
Postoperative prosthetic procedures
to visually control implant placement.
To facilitate implant placement, it is possible to extend the The duplicate prosthesis (see Fig 12-9q) is used as a surgical
antrostomy mesially to expose the anterior wall of the maxil- template and enables information concerning the position of
lary sinus, which makes the antrostomy appear T shaped. The implants, the vertical dimension, and the correct maxilloman-
mucosa in the maxillary sinus is then detached using sinus curet dibular relationship to be communicated to the technician. It
instruments. The implant site is prepared following conventional is important, if possible, to try out the template at a session
methods. Before placing the implant, verification of its position prior to the surgical phase to evaluate its stability, the maxillo-
with a direction indicator is required. Normally an inclination of mandibular relationship, and the occlusal harmony. After having
30 degrees with respect to the occlusal plane is considered positioned the implants, the temporary cylinders connected to
adequate for correct prosthesis placement. the implants act as impression copings. They will be attached
A variation of this technique developed in recent years involves to the surgical template with a self-curing or light-curing resin.
a wider detachment of sinus membrane directed posteriorly and The patient is guided into the correct maxillomandibular rela-
insertion of bone graft biomaterials; this allows distalization from tionship, and the resin is allowed to set completely in this posi-
the mesial wall of the maxillary sinus, obtaining a greater antero- tion. The stent is then removed and sent to the dental techni-
posterior spread. The implant will engage the anterior cortical bone cian in order to fabricate the master cast and the provisional
of the maxillary sinus with its apical portion and residual alveolar prosthesis with a rigid metal framework passively glued to the
bone with its coronal portion; the central portion of the implant temporary cylinders.
will be intrasinusal and surrounded by biomaterials.107 After placing Once the provisional prosthesis has been placed, usually
the first tilted implant, an implant is placed in the anterior zone 48 hours after surgery, and occlusion has been checked, it is
with an orthogonal axis. The intermediate implant is positioned advisable not to remove the prosthesis for at least 45 days.
corresponding to the canine site. Collagen is placed in the small During this period, bone turnover causes a decrease in primary
antrostomy. Absorbable sutures are used to close the flap with- stability and, consequently, in the reverse torque required to
out tension, using either a single and/or a horizontal mattress unscrew the implant. To assess the passivity of the provisional
approach. Such an arrangement with tilted implants connected structure it is necessary to employ a precise screw-tightening
with a titanium bar without the employment of any intermediate arrangement. Once the prosthetic structure has been screwed
abutments has been termed the Toronto modified bridge. in, the definitive tightening is carried out by using the torque
Also when addressing the maxilla, it is necessary to estab- indicated by the implant manufacturer. It is imperative to employ
lish whether to plan implant placement with one or two surgi- the torque intended for the type of screws used to avoid loos-
cal phases. The diagnostic procedure is the same as the one ening of the prosthesis. Once the period of osseointegration
described for the mandible, while the surgical approach varies. is completed, which ranges from 6 to 8 weeks, the definitive
The surgical technique of choice for a proper stage-two prosthetic phase can be completed. The workflow for full-arch
surgery in the maxilla consists of a partial-thickness flap repo- rehabilitations in different clinical situations is presented in
sitioned apically with possible simultaneous CTG. Fig 12-11.
212

Clinical Procedures
a b d
e f g
Fig 12-9 Sagittal views of the patient with-

out a prosthesis (a) and with a try-in denture
(b). Intraoral views without a prosthesis (c)
and with a try-in denture (d). Frontal views
of the patient without a prosthesis (e) and
with a try-in denture (f). (g) Patient’s smile.
(h) Wax-up and acrylic resin duplicate. (i and j)
A radiologic stent is made, and a CBCT scan
is done with a CBCT marker.
h
i j
213

k l m
n o p
q r s
t u
v w x
Fig 12-9 (cont) Occlusal (k) and frontal (l) views of 3D implant planning. (m) A master cast and surgical stent are manufactured before surgery. (n)
A prosthetic stent is made on the master cast and laboratory analogs are placed by virtual planning. (o) Surgical stent is tried in before surgery. (p)
Implants are placed in fully guided surgery. (q) Prosthetic stent is placed in position, and occlusal stops are checked in order to take the real implant
position. (r) Temporary cylinders are splinted to the prosthetic stent by light-curing resin. (s) Laboratory analogs are connected to the temporary
cylinders. (t) Casts are mounted in a semi-adjustable articulator. (u) Provisional prosthetic restoration with a rigid metal framework passively glued
to the temporary cylinders. (v) Intraoral view of the patient with prosthetic restoration in place. Hygiene instructions were provided to the patient.
(w) Panoramic radiograph at the delivery of the provisional prosthesis. (x) Extraoral view of the patient.
214

Clinical Procedures
a b c
d e f
g h i
j k
Fig 12-10 (a to c) Extraoral views of the patient. (d to h) Intraoral examination. (i) Radiographic evaluation. The teeth are diagnosed as hopeless from
periodontal and restorative points of view. (j and k) After having evaluated the prosthetic parameters (see Box 12-1) and completed the laboratory
phases, virtual implant planning is performed.
215

l m n
o p q
r s
t v
Fig 12-10 (cont) ( l to n) The master cast is mounted in a semi-adjustable articulator, and the provisional PMMA prosthesis is made prior to sur-
gery. (o) The surgical stent is guided in place by a positioning index. (p) Implants with a laser-textured collar are placed with fully guided surgery.
(q) Provisional restoration in place 24 hours after surgery. (r and s) Definitive restoration screw-retained on the implants. (t) Extraoral view of the
patient. (u and v) Panoramic and periapical radiographs at the 2-year follow-up.
216

Clinical Procedures
First consultantation
Evaluate
ESTHETIC: FUNCTIONAL: PHONETIC TEST:

• Anterior tooth exposure: 1 to 5 mm in rest position • Vertical dimension of occlusion (VDO) evaluation • M: VDO indications
• Smile line: High (gummy smile), medium, low • Overbite/overjet • S: Dynamic type: vertical or horizontal (eg,
• Smile width: How many teeth visible in the • Occlusal plane parallel to the Camper plane increasing the length of the incisors in a hori-
patient’s smile? laterally zontal dynamic may cause problems with the S
• Buccal corridors • Occlusal plane parallel to the horizon frontally phoneme)
• Incisal crest: Convex and parallel to the lower lip • Discrepancy between maximal intercuspation • F: Anteroposterior position of the maxillary
outline during maximum smile (MI) and centric relation (CR) incisors
• Soft tissue support • Protrusion and lateral movement • I: Anterior teeth exposure
CORRECT FUNCTIONAL AND ESTHETIC PARAMETERS INCORRECT FUNCTIONAL AND ESTHETIC PARAMETERS
Natural dentition or Preexisting removable prosthesis Fully edentulous or natural dentition with
Preexisting
fixed prosthesis with hopeless teeth (transitional patients)
removable
hopeless teeth
prosthesis
(transitional patients)
The existing prosthesis is used as a custom impression tray
Preliminary impressions for new prosthesis
Reline the existing prosthesis. Use Fox plane to evaluate whether
the occlusal plane is parallel to the bipupillary line and Camper
Preliminary impressions plane. If not, correct the plane by relining the articulator bite fork Second appointment
with bite registration material; perform final check with Fox plane.
Mounting of the cast in

MI using existing VDO Wax interocclusal record with resin base:
Second appointment height, 18 to 20 mm.
Reduce to 6 to 11 mm.
Wax-up
Evaluate VDO and CR.
An acrylic resin duplicate of the

wax-up is made. Third appointment
Duplicate is used as a radiographic stent. Try-in of anterior teeth. Phonetic

evaluation of F and V. Check lip support.
CBCT and implant planning

Fourth appointment
Surgical stent
Complete try-in
Custom impression tray to take

implant position, CR, and VDO An acrylic resin duplicate of the wax-up is made.
Duplicate is used as a radiographic stent.

Surgical intervention
CBCT and implant planning

Delivery of the immediate
provisional prosthesis. Functional
and esthetic parameters are
taken from wax-up. Surgical stent
Custom impression tray to take implant position, CR, and VDO
Surgical intervention
Delivery of the immediate provisional prosthesis. Functional

and esthetic parameters are taken from wax-up.
Fig 12-11 Workflow for full-arch rehabilitations. Patient appointments are in red; laboratory phases are in yellow.
217

CONCLUSION 7. Capelli M, Esposito M, Zuffetti F, Galli F, Del Fabbro M, Testori T.

A 5-year report from a multicentre randomised clinical trial: Imme-
diate non-occlusal versus early loading of dental implants in partially
Evidence-based medicine aims to provide patients with the
edentulous patients. Eur J Oral Implantol 2010;3:209–219.
best possible treatment by integrating the clinician’s skill with 8. Prosper L, Crespi R, Valenti E, Capparé P, Gherlone E. Five-year
the best available scientific evidence from the literature and by follow-up of wide-diameter implants placed in fresh molar
taking the patient’s preferences and needs into consideration. extraction sockets in the mandible: Immediate versus delayed
loading. Int J Oral Maxillofac Implants 2010;25:607–612.
According to modern views, patients are not inert subjects who
9. Malchiodi L, Corrocher G, Cucchi A, Ghensi P, Bissolotti G, Nocini
passively accept the doctor’s decisions; rather, they actively and PF. Long-term results of immediately loaded fast bone
knowledgably participate in the decision-making process about regeneration-coated implants placed in fresh extraction sites in
their treatment. This may lead to an improvement in quality of the upper jaw. J Oral Implantol 2010;36:251–261.
10. Balshi TJ, Wolfinger GJ, Wulc D, Balshi SF. A prospective analy-
life and treatment outcome and may reduce overall treatment
sis of immediate provisionalization of single implants. J Prostho-
cost as well. As a result of this shift in patient-clinician relations, dont 2011;20:10–15.
it has become evident that treatment outcomes need to be 11. Calandriello R, Tomatis M. Immediate occlusal loading of single
assessed through patient-based parameters, considering the lower molars using Brånemark System Wide Platform TiUnite
patient as the center of attention and the unit of analysis. Involv- implants: A 5-year follow-up report of a prospective clinical multi-
center study. Clin Implant Dent Relat Res 2011;13:311–318.
ing the patient in treatment outcome assessment is becoming 12. Malo P, de Araújo Nobre M, Lopes A, Moss SM, Molina GJ. A
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221

13 STEPHEN S. WALLACE • TIZIANO TESTORI
Sinus Elevation in the

Posterior Maxilla via the
Lateral Window Approach
Indications and Contraindications
Basic Sinus Anatomy
Preoperative Diagnosis and Treatment Planning
Grafting Materials
Surgical Technique
Complications
223

13 | Sinus Elevation in the Posterior Maxilla via the Lateral Window Approach
P
hysiologic changes that occur in the maxilla following the bone-implant contact at the crestal level prior to the consol-
the loss of teeth often do not allow for the placement of idation of the graft material. Early exposure of implants is more
dental implants in the posterior maxilla. Loss of alveolar frequent in thin soft tissues (less than 1.0 to 1.5 mm) or in tissues
height due to periodontal disease and tooth extractions compressed by improperly conditioned removable prostheses.
combined with the possibility of secondary sinus pneumatization In cases of residual crestal bone of 3 mm or less, it is advisable
limit the available bone height for implant placement. to plan a delayed approach after graft consolidation. Use of short
Maxillary sinus augmentation has evolved as a predictable implants is an appropriate therapeutic option when bone quantity
solution to correct this deficiency. It has been part of the authors’ is 7 mm or more; however, the data from current literature do not
surgical armamentarium for more than 30 years1 and has under- support the routine clinical use of ultra-short implants (5 mm).
gone many changes in surgical protocol over this time as a result Aside from the usual contraindications for advanced surgical
of ongoing clinical and scientific research, the development of therapy, specific thought must be given to the status of sinus
new products and technologies, the desire for higher proce- health. Health of the maxillary sinus, like the other paranasal
dural success rates and reduced complication rates, and the sinuses, is assured by a properly functioning mechanism that
demand for minimally invasive surgical approaches. There have produces and transports sinus secretions and proper oxygen-
been numerous transcrestal sinus elevation techniques devel- ation of the epithelium that lines the sinus cavity. Drainage of
oped that have proven to be the equal to the lateral window sinus secretions produced by serous and mucous glands (muco-
approach in outcome; however, when less than 4 mm of resid- ciliary clearance) is a complex function that depends on the
ual crestal bone is available, the lateral window remains the quality and quantity of mucus produced, the efficiency of the
procedure of choice. ciliary transport, and unobstructed communication between the
This chapter will begin with a discussion of indications and sinus and nasal cavities. Sinus ventilation, facilitated by the ostia,
contraindications, followed by basic sinus anatomy. Preopera- allows normal functioning of the clearance mechanism. Appro-
tive treatment planning will be presented in a manner that will priate mucus production in terms of quality, efficient mucociliary
provide the clinician with a means of determining whether an transport, unobstructed drainage, and adequate sinus ventilation
interdisciplinary consultation with an ear, nose, and throat (ENT) ensure optimal sinonasal homeostasis.
physician is indicated and to determine the difficulty level of Clinicians may observe alterations in one or more of the afore-
the case in question. mentioned factors, whose etiology may be local, systemic, or
traced to environmental conditions (Box 13-1). Such alterations
can compromise ciliary activity, resulting in ideal conditions for
bacterial infection as well as edema, hypertrophy of the sinus
INDICATIONS AND mucosa, and narrowing of sinonasal drainage pathways with
CONTRAINDICATIONS consequent compromise of sinonasal function and acute sinus-
itis. Maxillary sinus elevation, even when properly performed,
Maxillary sinus augmentation is indicated in situations involving inevitably causes edema in the sinus mucosa with resulting
mild to moderate atrophy of the posterior maxilla that results ciliastasis of an unpredictable duration.
in insufficient height for the placements of dental implants. For these reasons, it is important to preoperatively assess
For the lateral approach, this could be described as having less sinus health to diagnose preexisting disease.2,3 A normal, healthy
than 4 mm of residual crestal bone. If atrophy has resulted in sinus, from both anatomical and functional points of view, has
a ridge width of less than 6 mm or has created a significant a good probability of restoring homeostasis (high compliance)
increase in the interarch space and a fixed prosthetic rehabilita- without developing sinusitis, even in the case of membrane
tion is planned, more extensive maxillary reconstructive surgery, perforation during surgery. In other words, the lesser the compli-
including sinus elevation, is likely indicated. ance, the higher the risk for postoperative sinusitis.
Further, the quantity and quality of residual alveolar bone is The most common ENT contraindications are of two types:
an important factor in choosing either simultaneous or delayed potentially reversible contraindications (ie, those that can be
implant placement. The indications for choosing a surgical tech- resolved preoperatively) and presumably irreversible contrain-
nique (lateral versus crestal; simultaneous versus delayed) solely dications (Boxes 13-2 and 13-3).4
on the basis of residual crestal bone is under debate given the It should be realized that all potentially reversible patholo-
numerous variables involved and the development of protocols gies may not require preoperative resolution. Allergic rhinitis,
designed to reduce treatment time. Although it is technically for example, may be ruled out by treating the patient during
possible to stabilize implants with residual crestal bone of 2 mm the inactive seasons. Benign mucous retention cysts may be
or less, the risk of early implant failure is high if implants are spon- ignored if small. If of a size that may lead to blockage of the
taneously exposed before graft material consolidates. In case ostium upon elevation, they may be aspirated at the time of
of exposure, the physiologic process of biologic width forma- sinus elevation surgery.
tion begins, leading to crestal bone resorption of about 1.5 to 2 Partnering with an ENT specialist may prove to be a vital asset
mm. This phenomenon may result in the loss of primary stability in the treatment of these “at-risk” patients. A relationship with
prior to the establishment of secondary stability due to loss of an ENT, therefore, is another arrow in the clinician’s quiver, so
224

Basic Sinus Anatomy
BOX 13-1 Risk factors affecting sinus homeostasis
Harmful pathogens Systemic disease Anatomical anomalies (ostia patency)

(mucociliary transport) (mucociliary transport) • Hyperplasia of uncinate process
• Environmental factors: • Cystic fibrosis • Concha bullosa of middle turbinate
pollution, irritants, alteration • Kartagener syndrome • Stenosis of maxillary ostium
in humidity of inhaled air • Mounier-Kuhn syndrome • Severe deviation of septa affecting middle meatus
• Viral, bacterial, or fungal • Young syndrome • Paradoxical curvature of middle turbinate
infection • Hypertrophy of agger nasi cells
• Ciliastatic drugs • Infraorbital Haller cell
• Radiotherapy • Rhinosinusitis polyps obstructing the middle meatus
• Rhinosinusitis neoformations obstructing the middle meatus
• Postoperative or posttraumatic scar tissue in the middle
meatus
BOX 13-2 Potentially reversible ENT contraindications
Anatomical alterations in maxillary drainage Infective flogistic rhinosinusitis Antro-ethmoidal foreign bodies
mechanism (associated with objective • Rhinosinusitis • Dental implants
anamnesis of sinus disease in course or in • Acute bacterial or viral rhinosinusitis • Dental materials (amalgam,
regression) • Chronic rhinosinusitis coinciding endodontic cement)
• Concha bullosa of middle turbinate with maxillary drainage anomalies
• Paradoxical curvature of middle turbinate Oroantral fistula (without
• Allergic rhinosinusitis
• Infraorbital Haller cell conspicuous bone discontinuity)
• Noninvasive fungal rhinosinusitis
• Postoperative or posttraumatic scar tissue in • Polypoid rhinosinusitis Localized benign rhinosinusitis
the middle meatus (Stammberger groups I to IV) neoplasm obstructing maxillary
• Severe deviation of septa affecting middle drainage
meatus • Mucosal cysts
• Hypertrophy of agger nasi cells • Choanal polyp
• Postoperative scarring following OMC surgery • Cholesterol granuloma
BOX 13-3 Presumably irreversible ENT contraindications
Extensive anatomical Rhinosinusitis infection Rhinosinusitis Localized benign Malignant

alterations in the associated with associated rhinosinusitis rhinosinusitis
maxillary drainage congenitally altered with systemic, neoplasm massively neoplasm obstructing
system that cannot mucociliary clearance granulomatous obstructing maxillary maxillary drainage
be repaired • Rhinosinusitis (polypoid) disease drainage • Primitive neoplasm
• Postoperative or associated with: • Wegener • Inverted papilloma in the epithelium,
posttraumatic –– Cystic fibrosis granulomatosis • Maxillary ethmoid neuroectoderm,
scarring –– Kartagener syndrome • Sarcoidosis myxoma bone, soft tissue,
• Postradiotherapy –– Young syndrome • Maxillary ethmoid teeth, or lymphatic
consequences –– Hypersensitivity to angiofibroma tissue
acetylsalicylic acid • Metastasis
(Widal syndrome)
–– Immunodeficiency
to speak, in the prevention and treatment of intra- and postop- sinuses. It is a quadrangular, pyramid-shaped cavity surrounded
erative complications. by bony walls. The medial wall of the sinus is also the lateral wall
of the nasal cavity, and the superior wall also serves as the floor
of the orbit.5 The maxillary sinus is the first part of the parana-
sal sinus to develop (days 65 to 70 of gestation). It continues
BASIC SINUS ANATOMY to increase in size until approximately age 20 in women and
age 30 in men, reaching a volume of 15.9 mm3 and 24 mm3 in
The maxillary sinus is the largest of the interconnected parana- the former and latter, respectively.6 There is some debate as to
sal cavities, which include the ethmoid, frontal, and sphenoid whether the sinus undergoes a significant secondary stage of
225

a b
c d
Fig 13-1 The maxillary sinus and its relationship Fig 13-2 Autopsy evidence. (a and b) Frontal view showing the removal of the lateral wall of
with the surrounding anatomical structures. The the sinus, allowing an internal view of the sinus cavity. (c and d) Lateral view of the OMC and
arrows indicate the mucociliary transport system a posterior accessory ostium in the area of the fontanelles. The mucus drains via the OMC
toward the natural ostium and on to the nasal cavity into the middle meatus. The medial wall is removed to show the middle concha.
(middle meatus).
encompass the ostiomeatal complex [OMC]) toward the middle

meatus of the nasal cavity. The patency of the nasal cavity/OMC
is a determining factor in the maintenance of normal sinus
physiology (Figs 13-1 and 13-2). All of the paranasal sinuses
communicate with the nasal cavities and therefore, indirectly,
with each other. Their main function is to humidify and warm
inhaled air. They also reduce the weight of facial bones, protect
the base of the skull from possible trauma, insulate the brain,
and influence phonation (indirectly functioning like a voice box).
Additionally, the paranasal sinuses produce a large quantity of
nitric oxide, which is an important factor in regulating ciliary
activity along with having antibacterial properties.
Sinus membrane
Fig 13-3 Diagram of the sinus mucosa with various cell components. The mucosal lining of the sinus walls is a three-layer membrane
Sinus secretions consist of a deep sol phase (liquid) that maintains (Fig 13-3) with a thickness of 80 to 100 μm in a healthy patient:
contact with the cilia and a superficial gel phase (viscous) that traps
and conveys contaminants to the drainage ostium.
• The first layer corresponds to the respiratory epithelium
(cylindrical, ciliated, pseudostratified), composed of basal
pneumatization after the loss of the posterior teeth. A recent cell units, columnar ciliates, and calciform cells (the so-called
study, utilizing pre- and postextraction cone beam computed goblet cells attached to the basal membrane).
tomography (CBCT) scans of the same patient, has shown that • The middle layer is a loose connective tissue that can become
88% of the change in alveolar height following tooth loss comes edematous (lamina propria) in reaction to inflammation. It is
from crestal remodeling, and only 12% is due to movement separated from the overlying basal membrane epithelium
of the sinus floor in a coronal direction (3.07 and 0.47 mm, and is permeated by a dense network of blood vessels that
respectively).7 ensure abundant nourishment of the mucosa. The lamina
The sinus communicates with the nasal cavity via a natu- propria houses the serous mucous glands, which are most
ral ostium in an anterosuperior location on the medial wall. abundant in the region of the ostium.
Mucus is discharged by ciliary activity through the natural • The deepest layer is a periosteal layer that separates the
ostium, ethmoidal infundibulum, and semilunar hiatus (which connective tissue from the bony walls.
226

Basic Sinus Anatomy
a b c
Fig 13-4 (a to c) Small perforations do not influence the mobility of the membrane coinciding with breathing movements.
The mucous film lining the sinus mucosa consists of two difficult to supply empirical data, it is advisable to request an ENT
overlapping layers: a deeper serous layer (sol phase), where the consultation when a thickening of over 3 to 4 mm is encountered.
ciliary movement takes place, and a superficial, denser layer (gel
phase). Various contaminants (eg, dust, environmental pollut-
ants, germs) that may enter the sinus are trapped in the gel Septa
phase, transported by ciliary action to the natural ostium and
expelled from the nasal cavity. In the absence of sinus disease, Sinus septa (Underwood septa) are often found within the sinus
this mechanism keeps the nasal cavity sterile. Under normal cavity. The presence of septa has been reported to range from
conditions, the mucociliary transport mechanism allows the 16% to 58%.8,9 This large range is most likely due to the dif-
renewal of the antral mucous film in 20 to 30 minutes, with ferences in minimal septal height to be included in the study,
a flow rate of around 1 cc per minute. The mucus is the most as defined by the author. A clinical average for encountering a
important protection mechanism of the sinonasal complex. The septum during a sinus elevation might be 30%. In one study,
quality and quantity of the mucus depends on hydration, envi- two septa were present in 16% of cases9 (Fig 13-5).
ronmental humidity, and consumption of drugs (eg, atropine Septa are thicker at the base, tapering to a sharp spine at
and similar substances). the top. They may, however, take unusual forms. Septal height
At the sinus level, the mucociliary transport has a geneti- varies from almost indiscernible to a height that may divide the
cally determined characteristic; it starts star-shaped at the sinus sinus into anterior and posterior compartments at the working
floor and progresses along the anterior, medial, posterior, and level of the elevation procedure. They mostly course in a lateral
lateral walls and the sinus roof until the ostium opening. Neither to medial direction, generally being higher on the medial wall.
the maxillary sinus septa nor the occasional narrow recesses Atypically, they may run in an anteroposterior direction.
created by the sinus walls obstruct the flow of mucus. Even Septal anatomy and location are best observed on CBCT
perforations of around 1 mm in diameter do not impede the scans. Presurgical knowledge of septal location is necessary
mucociliary transport produced by the sinus membrane; it in order to properly plan the lateral antrostomy. This antrostomy
continues to maintain the physiologic mobility synchronized is best located to provide both anterior and posterior access
with breathing movements during sinus elevation. This, however, to the septum to achieve maximum access and visibility for
depends on the quality of the mucus; if it is afflicted by infec- uncomplicated membrane elevation.
tion, the increased viscosity will hinder its free movement, and
it will not overcome these obstacles (Fig 13-4).
The mucus transport system has another peculiarity: Even Vascular supply
in the presence of an accessory ostium, whether natural or
surgically created, the mucus is always transported toward the The vascular supply to the maxillary sinus is quite extensive; this
natural ostium, avoiding these alternative drainage canals. This is most likely one reason for the sinuses’ ability to support the
has rendered surgical ostia in the inferior meatus to restore neovascularization required for vital bone formation. It may also
normal sinus physiology obsolete. The membrane may undergo be responsible for the complication of intra- and postoperative
pathologic modification, often due to inflammatory processes bleeding during and after sinus elevation surgery.
that cause a thickening observed in radiographs. A thickening This network consists of the following:
of the sinus membrane is not sufficient to diagnose sinusitis. It
should also be noted that sinusitis is a clinical condition and a 1. Greater palatine artery
diagnosis cannot be made only with radiography. Although it is 2. Infraorbital artery
227

Fig 13-5 (a) Radiograph of sinuses with numerous Underwood septa. (b and c) The clinical
view shows the particular shape of the antrostomies prepared for the complete detachment
of the membranes from the septa.
Fig 13-6 Blood supply to the lateral sinus wall (internal and
external branches of the posterior superior alveolar artery
along with the infraorbital artery).
a b
Fig 13-7 (a to d) Radiographic and clinical views of an

intraosseous alveolar antral artery with a diameter ex-
ceeding 2 mm. This requires both mesial and distal liga-
tion of the vessel if it needs to be sectioned to allow for
appropriate surgical procedures.
c d
228

Preoperative Diagnosis and Treatment Planning
3. Alveolar antral artery (posterior superior alveolar [PSA] artery; PREOPERATIVE DIAGNOSIS AND
Fig 13-6)
4. Posterior lateral nasal artery TREATMENT PLANNING
The PSA artery most often has an intrabony anastomosis Once the decision has been made that a lateral window approach
with the infraorbital artery at an average distance of 19 mm sinus augmentation is a necessary requirement to accomplish
from the crest of a dentate patient.10 This forms what Solar the previously determined prosthetic treatment plan, the first
et al termed an arterial arcade in the lateral sinus wall.11 In step should be obtaining a properly formatted CT or CBCT scan.
cadaveric specimens, this artery was present in 100% of cases. A request for a CBCT is in agreement with implant dentistry
CBCT studies show the PSA artery to be visible in a portion of guidelines.16 In fact, the authors propose that a preoperative CT
the lateral sinus wall in 47.5% to 52% of cases.10,12–14 Further, should be considered the standard of care. When compared to
Elian et al12 showed that in 20% of observed cases, the artery a two-dimensional exam (ie, panoramic radiography), it allows
was found in the location of the proposed antrostomy. Another for an accurate assessment of septal anatomy, the diameter and
study10 described the intra- and extraosseous pathways of the course of blood vessels, possible bone dehiscence, and sinus
PSA artery as well as its diameter in both a cadaver and CBCT disease. The field of view for a sinus scan is more extensive than
study. The artery is present in 100% of cases and can be iden- that of a scan for conventional implant placement. It is manda-
tified in the lateral wall in 47% of cases. The canal diameter tory that the scan include the full maxillary sinus as well as the
was < 1 mm in 55.3% of cases, 1 to 2 mm in 40.4% of cases, adjacent paranasal sinuses and the adjacent nasal structures. A
and 2 to 3 mm in 4.3% of cases. In cases where the artery is clear view of the OMC is required to rule out any inflammatory
intraosseous, it is readily seen in paraxial (cross-sectional) CBCT or other pathologic conditions that may interfere with sinus drain-
images. It should be noted that the PSA has both an internal age. The literature shows that approximately 38% of patients
and external branch, with the external branch being subject to present with some form of sinus pathology.3,17 Some of these
injury when long vertical incisions are made. may be minor and of minimal significance when planning for a
Fortunately the PSA is of small diameter, being generally in sinus elevation procedure. Others are potentially reversible and
the range of 1 mm. In 5% of cases, this vessel may exceed 2 may indicate that an ENT consultation or preliminary therapy may
mm in diameter and may present the potential for excessive be required. Please refer to Box 13-2 for a description of these
bleeding if injured. If this vessel is located in the area of the conditions. It is important to remember that the first step toward
proposed antrostomy, and it can not be safely dissected with avoiding complications is to start with a healthy, compliant sinus.
piezoelectric surgery, it may be advisable or become necessary There are many anatomical factors that deserve consideration
to ligate it both proximally and distally prior to sectioning it to as part of presurgical treatment planning. These factors address
gain access and prevent bleeding10,15 (Fig 13-7). surgical access and visibility as well as important external and
The vascular supply to the medial sinus wall is also from the internal anatomical features that determine how relatively simple
maxillary artery. This branches to the sphenopalatine artery or difficult a case may be. The authors have developed what may
and then the posterior lateral nasal artery. It courses within the be called a “maxillary sinus elevation difficulty score,” which
medial sinus wall, but it may on occasion be found inside the takes into consideration a host of important variables. The score
sinus adjacent to the sinus membrane. This exterior branch is gives numerical ratings for ease or difficulty of each situation.
uncommonly injured during sinus membrane elevation. Certainly, a high score would indicate a difficult case that might
require a greater experience level from the operator. The best
feature of this score is that reviewing all conditions presented
Innervation allows the clinician to address and plan for most of the situations
that may be encountered while performing surgery (Box 13-4).18,19
Innervation is from the maxillary branch of the trigeminal nerve.
The posterior, middle, and anterior superior alveolar branches
innervate the posterior sinus floor and the molar and premolar Antibiotic coverage and infection control
teeth. The anterior branch reaches the anterior sinus wall. Other protocols
branches leaving the infraorbital nerve before exiting the fora-
men innervate the medial wall of the sinus. Branches involving Sinus augmentation surgery, as with any surgery that employs
the sinus mucosa are those of the pterygopalatine and spheno- grafting materials, should be carried out under antibiotic prophy-
palatine ganglions with long and short sphenopalatine nerves. laxis with continued postoperative coverage as seen in Table 13-1.
Posterior teeth, on the other hand, are innervated and receive There has always been a trend in implant dentistry that favors
blood supply from neurovascular ramifications deriving from the the use of prophylactic antibiotics to reduce the possibility of
maxillary tuberosity, which forms the posterior wall of the sinus. postoperative infections. The pharmacologic regimen presented
in Table 13-1 is based on clinical experience and indirect evidence.
Patients who are allergic to penicillin generally must use an
antibiotic that has a more limited spectrum than does amoxi-
229

BOX 13-4 Maxillary sinus elevation difficulty score
A: Extra- and Intraoral Evaluation • B5: Alveolar antral artery diameter

• A1: Face type –– < 1 mm: 0 points
–– Long or normal face: 0 points –– > 1 mm, < 2 mm: 1 point
–– Short face: 2 points –– > 2 mm: 2 points
–– Note: A long face usually has a thin sinus wall and more –– Note: This parameter is important only if the artery inter-
apically positioned zygomatic process, while a short face has feres with the execution of the antrostomy. (If the artery is
a thicker sinus walls and more coronally oriented zygomatic not involved, enter 0 points.)
process (see B7). • B6: Angle between the buccal and palatal walls
• A2: Mouth opening –– > 30 degrees: 0 points
–– > 42 mm: 0 points –– < 30 degrees: 1 point
–– < 42 mm: 1 point –– Note: The lesser the angle the more difficult it is to
perform the antrostomy.
• A3: Type of edentulism
–– Fully edentulous: 0 points • B7: Zygomatic process morphology
–– Partially edentulous (missing premolars and molars): 1 point –– Apically positioned: 0 points
–– Partially edentulous (missing only molars or missing one –– Coronally positioned: 1 point
tooth in between natural teeth): 2 points –– Note: The zygomatic process of the maxilla could be more
apically or coronally located with respect to the ridge. If it
B: Radiographic Evaluation is apically located and there is a vertical wall, it is easier
• B1: Wall thickness for the clinician to perform the antrostomy. If it is coronally
–– Thin (≤ 1 mm): 0 point located and there is an inclined wall, it is more difficult for
–– Medium ( >1 mm, < 2 mm): 1 point the surgeon to perform the antrostomy.
–– Thick (≥ 2 mm): 2 point
• B8: Osteoma/exostosis
• B2: Sinus membrane thickness –– Absent: 0 points
–– ≤ 1.0 mm: 0 points –– Present: 1 point
–– ≥ 1.0 mm: 1 point
• B9: Bone dehiscence
• B3: Septa direction –– Absent: 0 points
–– Absent: 0 points –– Present at the level of the buccal wall: 1 point
–– Bucconasal direction: 1 point –– Present at the level of the ridge: 2 points
–– Mesiodistal direction: 2 points –– Present at the level of the nasal wall: 3 points
• B4: Septa location • B10: Palatonasal recess
–– Middle recess: 0 points –– Absent: 0 points
–– Posterior recess: 1 point –– Present: 1 point
–– Anterior recess: 2 points
TABLE 13-1 Prophylaxis and postoperative drug therapy for sinus elevation
Patient allergy status Prophylaxis Postoperative therapy
Not allergic to penicillin Amoxicillin (875 mg)/clavulanic acid (125 mg) twice a day by mouth Amoxicillin (875 mg)/clavulanic acid (125 mg) twice a day by mouth
starting 24 hours before surgery for 7 days
Clarithromycin (Biaxin, AbbVie) 250 mg twice a day + metronidazole Clarithromycin (Biaxin) 250 mg twice a day + metronidazole 500 mg
Allergic to penicillin
500 mg three times a day by mouth starting 24 hours before surgery three times a day by mouth for 7 days
cillin with clavulanic acid (Augmentin, GlaxoSmithKline). Levo- Infection prevention is a cornerstone of modern health care.
floxacin (Levaquin, Ortho-McNeil-Janssen Pharmaceuticals) is When sterile conditions are mentioned in dentistry, the term
a bactericidal fluoroquinolone that has a very broad spectrum. sterile refers to surgical tools, surgeons and assistants, and
Unfortunately, the numerous side effects of this drug (Achilles covering of surfaces and patient with sterile cloth. A sterile envi-
tendon rupture, peripheral neuropathy, gastrointestinal perfora- ronment cannot be achieved within the oral cavity even after
tion, aortic dissection, and aortic aneurysms) make its use prob- careful removal of plaque and bacteria both mechanically and
lematic.20,21 Azithromycin (Zithromax, Pfizer) and clarithromycin chemically. For these reasons, the term aseptic, instead of ster-
(Biaxin, AbbVie), both bacteriostatic macrolides, may be consid- ile, is often used. A reduced (clean) preparation in cases where
ered as alternatives. Many clinicians have found clindamycin biomaterials are used is not recommended. The superiority of
(a bacteriostatic lincosamide) to be ineffective for prophylaxis aseptic operating conditions over clean conditions, in terms of
in sinus augmentation, and its use cannot be recommended. success rate in implant surgery, is still controversial. Operating
230

Surgical Technique
under clean conditions may be viable in traditional implantol- A further consideration is the relative size of the particulate
ogy to treat limited edentulism when the use of biomaterials is bone granules. Most bone replacement grafts come in small
not required. Aseptic operating conditions are recommended and large particle sizes that usually include small particles (0.25
in complex surgery or implant placement using regenerative to 1.0 mm) and large (1.0 to 2.0 mm) options. A randomized
techniques. The authors maintain a postoperative infection rate controlled clinical trial has shown greater bone formation with
of 2% in complex cases following an aseptic control protocol the larger particles. A likely explanation for the difference would
as previously published.22 be that the greater interparticle spacing of the large particles
allows for increased vascular ingrowth and hence more vital
bone formation.27
Tissue-engineered regenerative medicine has seen expand-
GRAFTING MATERIALS ing use in regenerative implant dentistry procedures in the last
decade. Blood-derived product, mesenchymal stem cells, recom-
Maxillary sinus elevation began as a hospital-based surgical binant growth factors, and bone morphogenetic proteins have
procedure that used extraorally harvested autogenous bone as all been used in studies and clinical practice. An evidence-based
a preferred grafting material. After much debate, today there review of the literature was performed by the Academy of Osse-
are 12 evidence-based reviews that conclude that particulate ointegration in 2014.28 While the clinical guidelines resulting from
bone replacement grafts are as effective as autogenous bone the review support the use of blood-derived products, mesen-
when grafting the maxillary sinus.23,24 While autogenous bone chymal stem cells, and bone morphogenetic proteins in sinus
may be considered the gold standard of bone-grafting materials augmentation, this clearly was not supported by the data in the
(depending upon its source and harvesting technique, it may review. Further, an editorial in the subsequent issue of the Inter-
support osteoinduction, osteogenesis, and osteoconduction), national Journal of Oral and Maxillofacial Implants stated, “It has
it is not necessarily the gold standard for grafting in the maxil- now been shown that non-inductive materials with slow resorp-
lary sinus. The evidence in the previously mentioned reviews tion profiles can work better at forming and maintaining bone
supports the conclusion that the osteoconduction pathway by than inductive materials such as maxillofacial or extremity auto-
itself is sufficient to support bone formation in the sinus. grafts and allografts. Therefore, the need for biologic enhance-
A present theory is that the three factors necessary for new ment with growth factors and morphogens may be limited.”29
bone formation are the following:
1. Space making: with an osteoconductive, slowly resorbable,

or nonresorbable graft material SURGICAL TECHNIQUE
2. Blood supply: provided by proper sinus membrane elevation
to expose the sinus wall Anesthesia
3. Time
An ideal local anesthetic for the surgical procedure would be
An additional supporting factor would be the choice of a textured one with a short onset and long duration. In a study comparing
implant surface as opposed to a smooth, machined-surface lidocaine 2% with 1:100,000 epinephrine to articaine 4% with
implant. This is made particularly clear in an evidence-based either 1:100,000 or 1:200,000 epinephrine, the shortest onset
review that clearly showed the superiority of textured implants.25 and longest duration were recorded with articaine 4% with
It therefore seems appropriate to consider space-making 1:100,000 epinephrine (1.4-minute onset, 66.3-minute dura-
ability as a key factor in the selection of a graft material. Follow- tion).30 This long duration is appropriate for the projected length
ing is a list of graft materials and mean (± standard deviation) of a sinus elevation procedure. Two carpules should be sufficient
observed volume reduction reported during graft maturation26: for this procedure. In addition to the facial and palatal infiltration
anesthesia, a block through the greater palatine foramen will give
• Autogenous bone: –48.0% ± 23.0% more profound anesthesia to the medial sinus wall (Fig 13-8).
• Allograft: –30.3% ± 11.9%
• Composite: –21.8% ± 7.3%
• Anorganic bovine bone matrix/biphasic calcium phosphate: Flap design
–18.3% ± 2.3%
More than just the location of the sinus must be kept in mind
The clear advantage of using a nonresorbable graft material during flap design for a lateral window antrostomy. Consider-
becomes readily apparent. Giving up the osteoinduction and ation must be given to the following:
osteogenesis pathways of bone formation does not change the
outcome of the procedure, but more time will likely be needed • Mesiodistal location of the sinus (especially the sinus floor
to reach the desired outcome. and anterior wall)
• Ideal location of the antrostomy
231

a b c
Fig 13-8 (a and b) Appropriate anesthesia is achieved by slow injection (1 mL/minute) in the arch to favor a deep diffusion of the anesthetic, making
it more effective and longer lasting. (c) A swelling under the mucosa indicates that the procedure was flawed.
Fig 13-9 (a) Vertical re-

leasing incision should be
placed 3 to 4 mm mesial
to the planned antrosto-
my. (b) Flap design and
proper elevation allow
excellent control of he-
mostasis.
a b
• Projected size of the antrostomy required for the number of profile, to perform a split-thickness flap and mobilize the flap
implants to be placed with Metzenbaum scissors. This will aid in avoiding damage
• Potential changes in the antrostomy position due to presence to branches of the infraorbital nerve (Figs 13-10 and 13-11). It
of septa and other irregularities should be kept in mind that making longer releasing incisions
• Presence of fixed prosthesis in surgical area may be less traumatic than the constant trauma inflicted with
• Location of mucogingival junction overzealous flap retraction.
• Space required for placement of a collagen membrane over If there is a dehiscence in the lateral wall due to either
the window extraction trauma or a previous sinus augmentation attempt,
• Sufficient distance of incisions from antrostomy so that they it will be necessary to make a split-thickness incision over the
are not over window or barrier membrane defect. Should a dehiscence be present at the crestal level, it will
be necessary to modify the crestal incision to a split-thickness
The preoperative CBCT scan and clinical evaluation should design (Fig 13-12).
allow for accurate determination of the proper location for a
full-thickness mucoperiosteal flap to expose the lateral sinus
wall. The flap should be broad-based for adequate vasculariza- Lateral window preparation (antrostomy)
tion and be at least 3 to 4 mm distant from the antrostomy as
well as the overlying collagen barrier membrane to avoid the The antrostomy should provide unencumbered access to the
possibility of membrane exposure. The crestal incision should sinus cavity in the best possible location to allow for the suc-
be in keratinized tissue to facilitate closure (Fig 13-9). This may cessful elevation of the sinus membrane. In order to provide
involve moving the incision from the midline toward the palate the best visual and working access to the sinus, one should
when the mucosa extends toward the midline. Vertical inci- consider the following when locating and designing the antros-
sions should be directly to the bone surface to avoid tearing the tomy: thickness of the lateral wall, location of the PSA artery,
periosteum during flap elevation. An exception would be the location of the sinus floor and anterior sinus wall, the internal
superior aspect of the mesial releasing incision. When reach- sinus anatomy (septa number and location, mediolateral sinus
ing the level of the mucosa, it may be prudent, especially in width), and the proposed anteroposterior dimension of the graft.
cases of extensive alveolar loss or the presence of a short facial The discussion that follows focuses on window size, location,
232

Surgical Technique
Fig 13-10 Cadaver

dissection of the in-
fraorbital nerve.
a b
Fig 13-11 (a) After a total-thickness vertical releasing incision of keratinized tissue
and partial-thickness incision beyond the mucogingival junction, the alveolar mu-
cosa is dissected using Metzenbaum scissors to avoid damaging any infraorbital
nerve branches. (b) In vivo view of a branch of the infraorbital nerve.
a b c
Fig 13-12 (a to d) Bone dehiscence situated in the crestal position with fusion of the sinus
membrane with the periosteal flap layer. A partial-thickness flap is raised to separate the two
layers. It is then possible to begin sinus membrane elevation.
and design. Discussion of the various surgical techniques is If this is of concern, one only has to wait longer to achieve an
provided in subsequent sections. equal percentage of bone.
Window dimensions Window location

It is obvious that a relatively large window will provide better The location of the window should be dictated by a desire to
access for the elevation of the sinus membrane. The presence gain access and perform the membrane elevation while limiting
of anatomical obstacles such as septa will be easier to instru- the incidence of the intraoperative complications of bleeding
ment if the window is sufficiently large to allow direct visual and membrane perforation. It has been shown that membrane
access. It should also be apparent that the removal of large perforations are more likely to occur in areas of restricted anat-
amounts of the lateral sinus wall may reduce the vascular sup- omy, such as the narrow anterior portion of the sinus.19 An acute
ply to the graft that originates from the sinus wall microvas- angle between the medial and lateral walls at the sinus floor
culature. This will have an effect on the amount of vital bone (narrow sinus) creates the need for significantly greater manip-
formed in the sinus in a given period of time. Avila-Ortiz et al ulations of sinus curettes in the narrow, access-restricted site.
has shown there to be an inverse relationship between win- Making the window in an anterior location provides both direct
dow size and vital bone production.31 While this may be true, visual access and results in greater predictability for successful
there is no evidence that this delay in bone formation has an membrane elevation. Likewise, making the window close to the
effect on implant survival, as the minimal amount of vital bone sinus floor reduces the coronal movements required to reach
required for successful osseointegration remains an unknown. the sinus floor. Keeping these factors in mind, an ideal window
233

a b c
Fig 13-13 (a to c) Window location depends on the sinus anatomy. The antrostomy is placed both mesial and distal to the septum.
preparation would be 3 mm distal to the anterior sinus wall and osteotomy, or it can be removed completely with a curette
2 to 3 mm apical to the sinus floor. Window dimensions are (complete osteotomy).
then determined by the internal sinus anatomy and the size of A complete osteotomy by an osteoplasty technique
the proposed graft (Fig 13-13). The presence of a septum can (completely eroding the window) is the preferred technique
alter the anteroposterior location of the window as well as its when the vestibulopalatal width of the sinus is too narrow to
size. For best access, the window should straddle the septum allow internal reflection of the window to a horizontal position.
so that the membrane can be elevated with curettes in a lateral
to medial direction on both the anterior and posterior aspects
Window preparation with rotary
of the septum. This is much more predictable than attempting
instrumentation
to elevate in an anteroposterior direction over a sharp septal
spine. Modifications in window location were frequently made The use of a laboratory-sized carbide bur32 was modified quite
with rotary window techniques to protect the integrity of the early to the use of smaller-diameter diamond or carbide burs
PSA artery. This is now less of an issue with the advent of piezo- with low-speed implant motors, with most operators subse-
electric techniques that, due to their low-frequency ultrasonic quently switching to high-speed air turbine handpieces. The
vibration, protect the integrity of both the vasculature and the window outlining procedure is accomplished with a round car-
membrane even when the clinician is carefully working directly bide or diamond bur of various sizes.
over and in light contact with them. While rotary instrumentation with carbide or diamond burs
has been used successfully for many years, there were inherent
complications associated with this technique. Multiple studies
Window design
report that the intraoperative complications of bleeding (mean
Many lateral widow designs have been proposed, and for the incidence of 2% to 4%) and membrane perforation (mean inci-
most part the choice may be based on operator preference. Cer- dence of 20% to 25%) are relatively high with this technique due
tain designs, however, can offer a clinical advantage in select to the inability of a rotary instrument to differentiate between
cases. The designs include the elevated hinge, elevated island, hard and soft tissues. Rotary instruments can create “drag”
island removed, complete osteotomy via osteoplasty, crestal when contacting soft tissues, and this pulling force results
approach, palatal approach, and a new technique proposed by in vascular and membrane damage. One of the most signifi-
the authors, the simplified antrostomy design (SAD). cant innovations in maxillary sinus elevation was the introduc-
First published in 1980, the original lateral window technique tion of the piezoelectric and the Dentium Advanced Sinus Kit
involved the complete elimination of the window via osteoplasty (DASK, Dentium) surgical techniques for window preparation
with a laboratory carbide bur.32 The hinge osteotomy was first and membrane elevation. The advent of these more sophisti-
published as involving a rotary bur in 1988.33 In this technique, cated techniques, which are more respectful of soft tissues,
the two lateral and the coronal osteotomy cuts go directly to the has dramatically reduced the incidence of the above-mentioned
membrane, while the apical cut is partial or consists of small complications. Antrostomy preparation via complete osteotomy
isolated bone perforations to the membrane level. The window can now be performed with very low perforation rates with
is then infractured by tapping the window at the coronal aspect, either the more selective piezoelectric device or a DASK drill.34
thereby creating the superior hinge. Generally, it is advisable to
round the corners of the window as sharp corners may create
Piezoelectric window preparation
an inadvertent membrane perforation.
The island osteotomy is a modification to the hinge tech- Piezoelectric techniques utilize low-frequency ultrasonic vibra-
nique that avoids the above-mentioned tapping by completing tions (29 kHz, 2.8 to 16 W power, modulations of 10/30/60
the osteotomy circumferentially with a rotary or piezoelectric cycles/minute, 60- to 200-µm micrometric vibration) to selec-
device. The window can then be elevated as with the hinge tively cut hard tissues without damaging adjacent soft tissues.35
234

Surgical Technique
a b c
d e f
Fig 13-14 (a) An “island” osteotomy made with

a round piezoelectric diamond insert. (b) Island
elevated. (c) Osteoplasty insert in place. (d) Par-
tial removal of window bone. (e) Osteotomy to
refine outline. (f) Antrostomy complete, artery
intact. (g) Trumpet elevator. (h) Elevator against
internal sinus wall.
g h
This technique has been applied in both oral and orthopedic less in thickness as this technique can be quite time consuming
surgical procedures. In oral surgery, it has been found to be when the wall is thick; additionally, it will quickly wear out the
especially useful in maxillary sinus elevation where the integ- diamond osteotomy inserts. The osteotomy is accomplished
rity of both the internal branch of the PSA artery and the sinus with blade-like or round diamond-covered inserts. Osteoplasty,
membrane can be predictably maintained.36 Perforation rates accomplished with a spoon-shaped metal insert, is more effi-
with piezoelectric surgery reported in the literature range from cient when a thicker lateral wall is present. In cases where the
3.6% to 5%.37–39 This compares favorably to the frequently doc- wall is very thick, such as in the area of the malar eminence, it
umented average perforation rates of 20% to 25% with the ear- is appropriate to consider reduction of the bulk of the thickness
lier rotary techniques. This safety factor is in part due to the fact with rotary instrumentation prior to completing window prepa-
that ultrasonic vibration does not produce the “drag” or tearing ration with piezoelectric osteoplasty and/or osteotomy inserts.
effect that is produced by traditional rotary instrumentation. Fur- A recent study compared all forms of lateral window preparation
thermore, the technique introduced a unique trumpet-shaped and reported that the piezoelectric osteoplasty technique had
elevator that can provide an approximate 2 mm of circumfer- the lowest perforation rate (4.7%).40
ential internal membrane release that then allows hand instru-
ments to be safely introduced to the sinus without accidently
DASK window preparation
stretching and tearing the sinus membrane. This internal elevator
is used at a low-power setting with cavitating water spray. The The DASK technique is a slow-speed (800 to 1,200 rpm) modifica-
cavitation effect of piezoelectric devices maintains a blood-free tion of the rotary technique that uses a 6- or 8-mm dome-shaped
operating field, which further enhances instrument control and diamond drill to perform the antrostomy. The technique, which
procedural safety. can be called a lateral bone-planing antrostomy, can be used
There are two distinct protocols for performing a piezoelectric to create a small 6- or 8-mm round window by using it in
antrostomy: an osteotomy (outlining) technique and an osteo- an up-and-down motion, or it can be used in a lateral direction
plasty (grinding) technique (Fig 13-14). The outlining technique to shape a window that is reflective of internal sinus anatomy.
should be restricted to cases where the lateral wall is 1 mm or An additional modification uses a trephine drill to remove a
235

a b c
d e f
Fig 13-15 (a) An 8-mm DASK drill in place. (b) Lateral wall thinned. (c) Window completed. (d) Dome-shaped initial elevator. (e) Straight elevator
in place. (f) Elevation up lateral wall completed.
bone core from the lateral wall to the level of the membrane site. In these cases, one might consider alternate window loca-
(or very close to it). The core is then gently removed with a tions such as the alveolar crest or the palatal wall.
curette or an elevator, and the membrane elevation is started
with the 180-degree back-angled elevator provided with the kit.
Crestal window
The DASK drill is used at 800 to 1,200 rpm to create an
osteotomy to a level exposing a portion of the membrane. A When there is a defect in the lateral wall as a result of prior trau-
dome-shaped elevator, either a hand- or a motor-controlled matic extraction or previous failed lateral window attempts, the
version with irrigation, can then be used to circumferentially periosteum and sinus membrane are joined over the opening
free the membrane from the antrostomy margin prior to further with multiple adhesions present around the bony circumference
enlarging the site with the dome-shaped drill. The combina- (Fig 13-17). This would result in the need for a careful split-thickness
tion of slow speed and very broad surface area allows the drill dissection and a difficult membrane elevation. Similarly, a defect
to safely contact the membrane without creating drag, which may be present on the crest that would make elevation of the
would result in a membrane perforation. The membrane eleva- sinus membrane difficult with a lateral approach as the sinus
tion can then be completed with standard hand instrumenta- membrane and crestal mucosa are conjoined in the crestal area.
tion (Fig 13-15). It is possible to create small windows using Manipulation of a large-diameter PSA artery could also be avoided
a 6- or 8-mm-diameter DASK drill in a straight up-and-down or with a crestal approach (Fig 13-18). A disadvantage of this pro-
larger windows with a side-to-side motion to customize the cedure is the possible breakdown of the crestal split-thickness
antrostomy design (Fig 13-16). As the antrostomy can be rela- closure, exposing the underlying barrier membrane and graft and
tively small, the first membrane release is circumferential on thereby introducing the risk of graft contamination.
the lateral wall. This is simplified by the utilization of a unique
elevator that turns back 180 degrees to reach the lateral wall
Palatal window
adjacent to the window. The perforation rate with the DASK
technique is similar to that of piezoelectric surgery at 5.6%.41 There are additional situations in which a lateral window may not
In certain instances, access to the sinus via a lateral window be an appropriate choice. Consider the case of a previous lateral
antrostomy can be hindered due to anatomical factors such window attempt that failed to elevate the sinus membrane fully
as lateral wall fenestrations from prior extractions or previous across the sinus floor and up the medial wall. The resulting sit-
attempts at window preparation, the presence of a large artery, or uation would be a very thick lateral wall with insufficient medial
a septum that runs in an anteroposterior direction. An additional height to place an implant (Fig 13-19). A palatal approach would
hindrance to access might be a previously placed graft that did not eliminate the need to obliterate the previous graft and newly
extend to the medial wall, leaving a void in the proposed implant formed bone by providing direct access to the medial void.42
236

Surgical Technique
a b c
Fig 13-16 (a) Antrostomy with 6-mm DASK drill. (b)

Membrane reached in two locations. (c) Initial mem-
brane release with unique DASK instrument. (d) Eleva-
tion initiated. (e) Elevation up medial wall completed.
d e
a b c
Fig 13-17 (a to d) Case with bone dehiscence on the lateral wall of the sinus. The periosteum is
carefully detached from the sinus membrane.
Fig 13-18 (a and b)

Case with crestal
window.
a b
237

a c
Fig 13-19 (a) Incomplete sinus grafting. (b) Reentry from the palatal aspect. (c) Implant placed in the correct position. (Courtesy of Dr Sang-Choon
Cho, New York, New York.)
Fig 13-20 Incomplete sinus grafting. The implant is placed in the available bone (alternate
therapy).
Another solution could be placing the implants in the available A CT study has shown that the palatal approach is generally
bone and correcting the inclination with an angulated abutment feasible in 93.6% of sinuses with alveolar bone heights up to
(Fig 13-20). Another situation where a palatal approach might 4 mm, while sinuses with crestal heights of ≥ 5 mm or thick
be indicated is that of a high and long anteroposterior septum. palatal walls limit this approach.45
Depending upon the location of the septum, a graft might only
be needed in the medial sinus compartment in order to place an
Simplified antrostomy design (SAD)
implant. Utilization of a lateral approach would necessitate making
a “window within a window” to reach the medial compartment. It has been the experience of the authors that clinicians new
Studies have shown results similar to those of the lateral to sinus elevation tend to make the antrostomy in a less than
approach with regard to implant survival and perforation rates ideal location. Specifically, the antrostomy is made too far supe-
(19%). There was less postoperative inflammation and less rior and too far distal. As the anterior extension of the sinus is
scarring in the palatal tissue than that observed in the vestib- generally narrow and has a reported history of greater perfora-
ular incision group.43,44 tion rates, it would seem that membrane elevation would be
When contemplating a palatal approach, the CT scan should simplified if the window was situated to give the clinician the
show sufficient vertical access to the sinus between the resid- most favorable access to this area. With this in mind, the authors
ual crestal bone and the palatal vault. This would generally be have always advised that the antrostomy be made 3 mm distal
a case with extensive pneumatization and a high palatal vault. to the anterior wall and 2 to 3 mm above the floor of the sinus.
238

Surgical Technique
a b c
Fig 13-21 (a to c) SAD virtual planning on CT scans.
This would both facilitate and reduce the internal manipula- 3. Allows for creation of a smaller antrostomy, preserving lateral
tions required for successful membrane elevation. An experi- wall blood supply
enced operator can determine this approximate location using 4. Reduces morbidity by requiring a less invasive flap reflection
measurements from a CBCT scan combined with clinical visu-
alization. The goal of the SAD approach is to create a protocol
that would predictably locate the antrostomy in the most desir-
Membrane elevation
able location and, additionally, allow for the making of a smaller
antrostomy while achieving this goal. Variations in sinus anatomy as well as procedural decisions made
The SAD is a modification of a previously published technique by the clinician can either simplify membrane elevation or make
for use with the tilted, trans-sinus technique.22 The rationale for it more difficult. Anatomical factors such as size and location of
this procedure was that a significant increase in the anteropos- the window, width of the sinus, and the presence of septa have
terior spread could be achieved by placing the distal implant in been previously discussed. The patient’s facial profile, muscle
a tilted location in the anterior portion of the sinus. mass, and ability to open also may make access difficult.
As a small window was all that was required for this proce- A problem is often encountered when making the first entry
dure, it was appropriate to start the window at the anterior into the sinus to start the membrane elevation. The elevator
wall, as opposed to starting distal to it and reaching forward. may “roll over” the membrane, compress it against the internal
This technique proved to be simple and readily duplicated and aspect of the sinus wall, and tear it on the elevation attempt.
was therefore worth considering as the starting point for the This untoward outcome has been negated by the use of the
majority of lateral window procedures. From this starting point, trumpet-shaped piezoelectric elevators. This instrument, when
the window could be expanded as required to adapt to varying used at a low power setting with a cavitating water spray will
internal sinus anatomy. result in a predictable circumferential membrane separation
The SAD is accomplished in a three-step procedure: of about 2 mm. This will allow the next elevator to be placed
in direct contact with the bone, avoiding any possibility of a
1. Use the best CBCT and clinical measurements available to roll-over perforation.
make a small window 3 mm wide by 6 mm long just distal An unpublished study at New York University has shown
to the envisioned location of the anterior sinus wall. that membranes with a thickness of ≤ 1 mm (as shown on
2. Extend the window in the anterior (mesial) direction to locate CBCT) have a 2.5 times greater perforation rate than those
the anterior sinus wall that are thicker, hence the greater need for care and accuracy
3. Enlarge the antrostomy distally as required by the internal in the elevation technique with thin membranes. A number of
anatomy (septa) and the number of implants to be placed. published studies were in agreement with this46,47; however,
Extend it coronally to be 2 to 3 mm from the sinus floor and a recent systematic review reported that there was inconclu-
roughly 10 mm in the anteroposterior direction (Fig 13-21). sive data to correlate membrane thickness to perforation rate,
although it seemed that thicker membranes might be more
The benefits of this procedure for a routine lateral approach prone to perforation (P = 0.14).48
are the following: Almost all membrane elevation procedures should commence
from lateral to medial in direction, using either the 45- or
1. Provides ideal location of antrostomy for preventing 90-degree piezoelectric sinus elevators, or alternatively it can be
membrane perforations accomplished with hand elevators. A difference of opinion exists
2. Guarantees that anterior compartment will be reached and as to whether membrane elevators should be sharp or dull. The
grafted authors prefer to use sharp elevators as opposed to dull ones.
Dull elevators have the potential to roll over the membrane as
239

a b c
Fig 13-22 (a to c) Elevators are used on both the anterior and posterior aspects of the septum.
BOX 13-5 Factors influencing the sinus membrane perforation rate
• Bony dehiscences • Sinus anatomy • Operator skill

• Membrane thickness –– Angle between the buccal and palatal wall • Instrumentation used:
• Sinus septa: direction and –– Osteoma/exostosis piezoelectric/DASK versus burs
location –– Nasopalatal recess • Sharp vs dull elevators
opposed to elevating it, which is likely to result in a tear. When membrane. It should be mentioned that a final perforation repair
adhesions of the membrane are present on the sinus floor, it is best made with a somewhat stiffer membrane that is able to
may be appropriate to use a Goldman-Fox or similar sharp peri- maintain its shape and better resist packing pressure, such as
odontal knife to free the membrane. Of course, when using BioMend (Zimmer Biomet), or Dentium collagen membranes.
sharp elevators, it is imperative to keep them in direct contact Many elevators being offered as designed specifically for
with the bone surface at all times to prevent perforating the sinus elevation are improperly designed for that task. Clinically,
membrane. When elevating the membrane from septa, it is the only part of the elevator that should touch the internal sinus
important to have direct access to both sides of the septum walls is the tip. It is from the tip that the clinician gets the haptic
(anterior and posterior) so that elevation can be performed from feedback from direct contact with the sinus wall. If the instru-
lateral to medial as opposed to an anteroposterior direction (Fig ment has a long shank, this shank will contact the wall at the
13-22). It is most difficult to keep an elevator in contact with window entrance and give a false feedback, indicating incorrectly
bone while moving in an anteroposterior direction over a sharp that there is contact at the tip. This will increase the chance of
septal spine. The membrane can easily be elevated by moving an inadvertent perforation.
medially in a slow progression from each side in succession.
Box 13-5 lists some important factors that directly contribute
Graft placement
to membrane perforations.49–51
A brief discussion of grafting materials was presented earlier in
the chapter. The authors generally use particulate xenografts,
Continuing elevation in the event of perforation
allografts, or biphasic calcium phosphates hydrated with saline,
In the event of a perforation, one can proceed cautiously to con- blood, or L-PRF. This section is presented with these particulate
tinue the elevation. The direct area of the perforation should be grafts in mind.
avoided because it is a weak spot, with the perforation likely to The most common postoperative infection following sinus
expand if disturbed. Further membrane elevation should take augmentation is that of an infected sinus graft; therefore, some
place at a distance from the perforation, possibly going com- thought should be given to prevention of this untoward occur-
pletely around it. You will likely notice the perforation getting rence. Sinus graft infections may result from internal bacterial
smaller as tension on the membrane is relieved by this further contamination from untreated periapical lesions near the sinus
release. floor or by external contamination by bacteria from untreated
Another way to facilitate further elevation is to cover the periodontal lesions and/or the local oral flora. Preoperative anti-
perforation with a collagen membrane. A membrane with a biotic therapy is essential to establish effective antibiotic blood
rough side, such as a Bio-Gide membrane (Geistlich; Fig 13-23) levels prior to the temporary disturbance in vascularization asso-
or a leukocyte-platelet-rich fibrin (L-PRF) membrane, if avail- ciated with the surgical procedure. The authors favor Augmentin
able, will work well to stabilize the tear due to binding by the 875 mg twice a day for 7 to 10 days for non-penicillin-allergic
rough collagen membrane surface or the tackiness of the L-PRF patients and either Zithromax or Biaxin for those who are aller-
240

Surgical Technique
a b
Fig 13-23 (a and b) Sinus membrane perforation repaired via resorbable suture and collagen membrane.
gic to penicillin with the desired dosage to begin the day before tion with xenografts of different particle size, it was shown that
the surgery. more vital bone was formed when large-particle xenograft was
The placement of antibiotics, such as clindamycin, within the utilized.26 The difference is likely due to the reduced compres-
graft is not an evidence-based treatment and would not provide sion of the larger particles and the preservation of interparticle
sufficient blood levels immediately following surgery.52 A CT space with resultant increase in vascular ingrowth and bone
study was performed to determine the effectiveness of the formation along with the more favorable maintenance of volume.
inclusion of a low dose of metronidazole in the sinus graft to A potential downside of large graft particles might exist in
reduce contamination by anaerobic bacteria.53 The test group did cases of less than adequate perforation repair. It is more likely
not show the postoperative presence of air bubbles (tomoden- that large graft particles could block a smaller-sized ostium and
sitometric change) within the graft that were present in the result in a postoperative sinusitis or infection.
control patients without metronidazole inclusion. However, one In addition to the preoperative treatment of adjacent periapical
might say that in the majority of cases presenting with the early lesions and other pathologies, along with the administration of a
postoperative presence of air bubbles, these may be the result preoperative antibiotic regimen, a protocol should be developed
of the packing procedure as well as the presence of anaerobic to prevent local contamination of the graft material at the time
bacteria. There is no mention if any of these cases resulted in of placement. Steps to be taken may include flushing the sinus
sinus graft infections. The authors have performed more than with saline after membrane elevation is complete, surround-
6,000 sinus elevation procedures with a postoperative infection ing the window with gauze to prevent salivary contamination,
rate of less than 2% without the inclusion of antibiotics in the placement of the graft material with a syringe directly into the
graft and feel that the utilization of appropriate preoperative case window, and having the patient remain with mouth open until
selection along with appropriate oral antibiotic and local infec- the graft and membrane are placed and the flap is replaced over
tion control is sufficient to produce this successful outcome. the grafted site (Fig 13-24).
When placing particulate grafts into the sinus, it is important Another potential source of graft contamination is the utili-
to fill the space entirely and not to leave voids. An osteoconduc- zation of nonsterile instruments either directly in the sinus or
tive graft material is also a more favorable space maintainer than to manipulate the particulate graft material. Instruments that
a blood clot and therefore better at maintaining volume. Another have been sterilized before the procedure do not remain sterile
consideration when placing graft material in the maxillary sinus once they have been introduced into the oral cavity. A common
is the possible effects of packing pressure at placement on procedural error is to use an instrument such as a periosteal
the eventual volume that is created. While this has not been elevator that has previously been in the mouth to hydrate/mix
addressed directly, there is some evidence that may be used to the graft material or carry it to the sinus. This breakdown of
establish a guideline. All volumetric studies show that there is a sterile protocol should be avoided at all costs. It is best to use
loss of volume from the time of graft placement to the time of separate surgical trays (and suction tips) for those instruments
graft maturation.26 Loss of graft volume of 10% has even been used in the oral cavity and those used in the sinus.
observed with supposedly nonresorbable graft materials such
as xenografts.54 It is quite possible that some of the volume
Placement and stabilization of membrane
loss is not due to resorption of the graft but to compression
of the graft from intrasinus pressure. Theoretically, small graft While controversy exists in the literature regarding vital bone
particles would be more prone to compression than large graft formation with and without a membrane, there is no question
particles. This would lead to graft volume loss at the expense that membrane placement will deter both soft tissue enclefta-
of interparticle space. In a controlled trial of vital bone production and graft material migration.
241

a b c
Fig 13-24 (a) Isolation with gauze. (b) Rinse with sterile saline. (c) The graft is placed into the sinus with a syringe.
Fig 13-25 (a and b) Membrane placed inside

the window.
a b
Fig 13-26 (a) Sutures are performed apicocoronally on

the vertical releasing incision in order to move the flap
coronally. (b) Closure for healing by primary intention.
a b
BOX 13-6 Clinical recommendations to increase predictability of sinus elevation surgery
• Assessment of patient’s medical history, noting any • Placement of the incision lines distant from the antrostomy
pharmacologic therapy • Prevention of contamination of the graft and membranes
• Proper selection of patients with healthy, ventilated sinus • Intra- and postoperative control of hemostasis
• Preventive resolution of possible periodontal or endodontic • Keeping surgical instruments sterile (one set is
pathologies recommended for sinus elevation and a different set for flap
• Adequate antibiotic prophylaxis preparation)
• Maintenance of the plaque index and bleeding score below 15% • Abundant irrigation of the surgical site with physiologic
• Removal of provisional crowns and cleansing of the abutment solution
with antiseptic solution (iodine derivatives or chlorhexidine), • Containment of surgical time
removal of all cement from gingival sulcus and prosthetic • Postoperative rinsing with chlorhexidine
abutment • Adequate postoperative antibiotic therapy
• Disinfecting the skin with iodine derivatives or chlorhexidine • Monitoring of patient: weekly during the first month and
and oral rinsing with chlorhexidine monthly during the following 3 months
• Preparation and maintenance of a sterile environment and
conditions
242

Complications
The membrane is typically placed to cover the borders of COMPLICATIONS

the antrostomy by approximately 2 to 3 mm. This will allow for
complete coverage in the event of a minor membrane displace- Sinus elevation surgery via the lateral window approach is a
ment from flap manipulation during suturing. It would be prudent complex procedure that requires the clinician to be proficient
to avoid placing the membrane beneath an incision line as the in both diagnostic and clinical skills. Even the most experienced
possibility for membrane exposure due to incomplete wound clinician will at times encounter complications both during and
closure would be lessened by this precautionary measure. after the procedure. Complication avoidance has been incorpo-
Nonresorbable membranes, such as the expanded polytet- rated in the first part of this chapter. Treatment of complications
rafluoroethylene (e-PTFE) varieties, are generally stabilized via is addressed in this section.
tacking. This is both to prevent movement from over the window Given the relative complexity of lateral window sinus eleva-
site and, more importantly, to prevent lifting and soft tissue invag- tion surgery, one would expect there to be multiple and frequent
ination of the membrane and possibly soft tissue encleftation complications. It is therefore important to state that the relative
into the graft space. In the past, it was not uncommon to have frequency of the majority of these complications is quite low
to dissect e-PTFE membranes from surrounding soft tissues in and that most are the result of either poor case selection or
order to remove them at implant placement or stage-two surgery. surgical difficulties encountered during the course of the proce-
Resorbable membranes, because of their adaptability and dure. They may be due to the presence of complex anatomical
lack of the need for fixation and subsequent removal, allow situations (eg, thin or unhealthy membranes; blood vessels
for a less demanding surgical protocol. A prospective study located in the antrostomy site; incomplete, thick, or convex
reported no significant differences between Gore-Tex (W. L. lateral walls; septa; presence of large cysts), the choice of less
Gore) and Bio-Gide membranes in either vital bone formation predictable treatment options (poor choice of window loca-
or implant survival.55 tion, choice of a less predictable surgical protocol), poor surgi-
Resorbable membranes generally require no stabilization if a cal access (minimal oral access, malar eminence near crest),
membrane with the proper handling characteristics is utilized. or inadequate preoperative systemic and/or local anatomical
The best membrane would be one that, once hydrated, conforms diagnosis (poor case selection), or operator error (poor incision
to and adheres to the irregular bony surface. Some membranes design, bacterial contamination of graft, undetected or poorly
are too thick and rigid to conform; therefore, they may slide out repaired membrane perforation).
of position or lift from the surface, thereby allowing soft tissue
invagination to occur.
If necessary, resorbable membranes can be stabilized by the Intraoperative complications
use of overlying horizontal mattress suturing or by changing the
membrane placement location. An alternative protocol is to place The most common intraoperative complication by far is sinus
the cut-to-size collagen membrane directly inside the window, membrane perforation. Other less common complications
covering the graft material and stabilized against approximately include soft tissue or bone bleeding and perforation of the buc-
2 mm of the internal lateral wall56 (Fig 13-25). cal flap. Much less frequently, injury to the infraorbital nerve,
damage to the adjacent dentition, perforation of the medial or
orbital wall, implant displacement into the maxillary or parana-
Flap management (closure)
sal sinuses, and fracture of the residual alveolar ridge (usually
Tension-free primary closure is considered the norm for regener- in simultaneous placement with less than 3 mm crestal bone)
ative procedures, and in this regard periosteal releasing incisions may occur. Following is a discussion of the major intraopera-
are frequently made. These split-thickness incisions will increase tive complications of sinus membrane perforation, intraopera-
patient morbidity and, in the case of a severely resorbed max- tive bleeding, and a method for remediation of large mucous
illa, may damage branches of the infraorbital nerve. It should be retention cysts.
realized that releasing incisions are only needed in cases with
simultaneous ridge augmentation, where the alveolar external
Sinus membrane perforation
dimensions have been enlarged. They are not required for rou-
tine sinus elevation procedures because the outside dimensions Incidence, etiology, and prevention. The incidence of mem-
have not been changed. brane perforation varies depending on the instrumentation being
Suturing may be accomplished using interrupted or continu- used. The incidence varies from 8.6%50 to 56%57 (mean: 20%
ous suturing techniques. Resorbable or combinations of resorb- to 25%) with rotary instrumentation, from 3.6% to 5%37–40 with
able and nonresorbable sutures may be used. The vertical inci- piezoelectric devices, and 5.6%41 with DASK. Perforations are
sions are best closed with finer resorbable sutures because more likely to occur when there is a dehiscence in the lateral
suture removal in the vestibule is quite uncomfortable for the wall or difficult internal sinus anatomy is encountered. This may
patient (Fig 13-26). Box 13-6 presents a summary of clinical be in the form of a thin sinus membrane, the presence of septa,
recommendations designed to increase the predictability of or a sinus with a narrow vestibulopalatal dimension (Figs 13-27
the lateral window procedure. to 13-30). As discussed earlier in this chapter, it is most import-
243

a b
Fig 13-28 (a) Axial CT view of a relatively low septum

taken close to the sinus floor. (b) Axial CT view of
same septum taken at a higher level. (c) Clinical view
of septum shown in a and b.
Fig 13-27 Sinus with thin

membrane, dehiscence in the
lateral wall, and acute angle in
c
the palatonasal recess.
Fig 13-29 Exceptionally broad septum. Fig 13-30 Septum dividing sinus into anterior and posterior com-
partments to a height of 18 mm.
ant to make the antrostomy in a location that maximizes access medial wall of the sinus. If this angle is acute and is located
to these difficult areas. within approximately 10 mm of the floor of the sinus (an area
There are two areas within the sinus that create obstacles where graft material is likely to be placed), care must be taken
to membrane elevation due to the acute convergence of sinus in keeping the elevator on the bone surface while not trapping
walls. In a retrospective CT study,19 the perforation rate was and thus tearing the membrane (Fig 13-32).
shown to be related to sinus width or, to be more specific, Defects in the lateral wall created by traumatic extractions
the angle made by the medial and lateral walls at the floor of or previous lateral window attempts create a situation where
the sinus. The perforation rates were 62.5% for the narrow the sinus membrane and the periosteum are joined over the
anterior part of the sinus (angle < 30 degrees), 28.6% for the bony defect. This situation requires a split-thickness flap to be
wider middle part of the sinus (angle = 30 to 60 degrees), and made over the lateral wall defect so as not to perforate the
0% for the widest posterior portion (angle > 60 degrees) (Fig membrane with the initial flap elevation. After isolation of this
13-31). A recent CT study58 identified another angle, defining “patch” of combined membranes, the authors suggest making
the shape of the palatonasal recess, which must be taken into a new antrostomy, slightly larger than the original where possi-
consideration when elevating the sinus membrane from the ble, and then elevating the patch along with the surrounding
medial wall. It is the angle made where the alveolus meets the bone. This is done to avoid the multiple membranous adhe-
244

Complications
Fig 13-31 An acute angle at the floor of the sinus in Fig 13-32 An acute angle in the palatonasal recess
the anterior region. at the junction of the alveolus and medial sinus wall.
a b
Fig 13-33 (a) Cross-sectional CT scan showing defect in lateral wall. (b) Cross-sectional CT scan showing defect in
lateral wall following extraction and healed oroantral fistula.
Fig 13-34 (a) Split-thickness flap over

previous window location. (b) The
membrane can now be elevated along
with a small amount of periosteum.
a b
sions likely present at the location of the former window (Figs will also gain information relative to sinus health and patency of
13-33 and 13-34). the OMC. The best way to treat perforations is not to have them.
A thorough knowledge of the three-dimensional anatomy
of the sinus is essential if the perforation rate is to be kept to Treatment. The primary function of the elevated sinus mem-
a minimum. A CT analysis will give information relating to the brane is its role in the containment of graft material. It may
thickness of the lateral walls; presence of discontinuities in the play a minimal role in being the source of neovascularization
bony walls; width of the sinus; internal angles; membrane thick- of the graft space. The elevated membrane forms the superior
ness; and the presence, size, and location of septa. Clinicians and distal walls of the created graft compartment. A breach in
245

13 | Sinus Elevation in the Posterior Maxilla via the Lateral Window Approach Complications
this compartment may lead to graft particle migration into the Small perforation repair. For perforations larger than 5 mm, it
sinus with the possibility of blockage of drainage through the is advisable to use a collagen repair membrane that retains its
ostium with subsequent congestion, inflammation, and possi- shape when wet (Bio-Gide) or remains stiff when wet such as
ble sinusitis. BioMend or Dentium collagen membrane. Stability of this repair
Very small perforations on the order of 1 mm may require is achieved by contact with the surrounding intact Schneiderian
no treatment at all as releasing the membrane reduces tension membrane; the greater the contact, the greater the stability.
and the perforation may self-seal with a blood clot. Perforations Keep in mind that it has been shown, in both human and ani-
of a larger size will require corrective therapy in the form of a mal studies, that the elevated sinus membrane does not play
repair. A number of methods for repair have been proposed. a significant role in vascularization of the bone graft; therefore,
Perforations have been closed by suturing (difficult) and stability has priority over size of repair membrane.64,65
“patching” with a variety of materials. The most practical Figure 13-35 presents two examples of small perforation
method for making repairs is with the use of a bioabsorbable repairs, the first simple, the second more complicated. Note
collagen membranes or, if readily available, an L-PRF membrane. in both cases that the repair membrane is horizontal, indicat-
Two important considerations to bear in mind are the following: ing elevation of the sinus membrane from the medial wall prior
to the placement of the repair. In the second case, a cut was
1. The sinus membrane must be reflected from the floor and made to accommodate the septum for proper placement. In
medial and anterior walls prior to completing the repair. both cases, the repair membrane is stabilized by forming a new
Because the membrane is weak in the area of the perfora- roof to the graft compartment.
tion, it is best to work around the perforation, releasing the
membrane tension prior to working directly over the perfora- Large perforation repairs. With larger perforations, use of a
tion. At times it may be advisable to make a temporary repair nonstabilized repair becomes problematic as the repair mem-
over the perforation to help stabilize it during the completion brane tends to shift in position during graft placement and pos-
of membrane elevation. sibly after completion of the procedure. Repair membranes tend
2. The repair must be stable. If the repair does not remain in to shift apically as a result of the pressure exerted during graft
place, the graft material may be partially or completely lost placement and a lack of sinus membrane integrity. In so doing,
in the sinus with further complications as a result. they move away from both the medial and lateral walls as the
curved rather than straight shape does not provide sufficient
It is always an option to abort the procedure and reenter after length to maintain contact with the bony walls.
allowing the membrane to reform. This may be a 2- to 4-month To stabilize a repair membrane over a perforation close to a
delay. If the repair breaks down and the graft is lost, this will convex lateral wall, measure the vestibulopalatal depth of the
likely require two surgical entries to resolve: one to clean out sinus and cut a membrane that is large enough to leave a portion
the sinus and a second to repeat the grafting process. outside the lateral wall and still be long enough to drape down
The authors almost always attempt to perform a stable repair a portion of the medial wall (Fig 13-36).
as this does not extend the treatment time and the majority In the case shown in Fig 13-37, the remaining sinus membrane
of studies have shown that repaired membrane perforations cannot be counted upon to support the repair, so a combina-
do not alter the outcome of the procedure when measured by tion of suturing and tacking were used to compensate. The
implant survival rate.59–61 A contradictory study reported that torn membrane was first reflected off the floor and medial
the implant survival rate is inversely proportional to the size walls. Three holes were drilled in the coronal aspect of the
of the perforation62; however, this was again contradicted in lateral wall to accommodate chromic sutures that picked up
a later study that showed no significant difference in survival torn remnants of the sinus membrane hanging from the medial
rates when considering perforation size.63 wall. No attempt was made to close the perforation with the
The following generalizations are helpful when attempting sutures since any tension on the torn membrane would further
repairs: the tear. Essentially, three “struts” were made with the sutures
to support a collagen membrane that was cut large enough to
• Very small perforations may self-repair by membrane both stay outside and also drape onto the medial wall. The tacks
fold-over or clot formation. prevent the repair from being pulled inside as it tents apically
• Large perforations will require large repairs for stability. when the graft material is placed.
• Large repairs must be of sufficient size to account for the The last case shows an almost catastrophic perforation
fact that they tend to tent superiorly when grafts are placed. (Fig 13-38). The entire anterior and superior portions of the
• Repair membranes placed near the lateral wall tend to shift membrane are gone. The repair, a Loma Linda pouch, utilizes
medially when the graft is placed. a 40 × 60–mm soft, moldable collagen membrane that can
• Repair membranes that are soft and shapeless when wet be formed into a graft-containment pouch within the sinus.
are not ideal for large repairs. The tacks are placed to keep the membrane from being pulled
completely inside the sinus. If there is any doubt about keep-
246

Complications
a b
Fig 13-35 (a) Small-sized perforation. (b) Collagen

repair membrane forming a new roof for the graft
compartment. (c) Multiple septa seen in panoram-
ic CBCT scans. (d) Clinical view showing full and
partial septa. (e) Collagen repair with cut made to
allow for proper placement.
d e
Fig 13-36 (a) Stabilization achieved

by folding the membrane outside the
lateral wall. (b) Graft material and mem-
brane in place.
a b
a b c
d e
Fig 13-37 (a) Sutures in place from medial sinus membrane to holes in lateral wall. (b) Collagen repair resting on suture struts with additional
folding and tacking stabilization. (c) Nine-month cross-sectional CT view showing ideal graft placement. (d) Nine-month panoramic CT view (right
side) showing containment of the graft. (e) Nine-month histologic view showing 30% vital bone formation.
247

a b c
d e f
Fig 13-38 (a) Large anterior and superior tear. (b) A 30 × 40–mm Bio-Gide membrane in position. (c) Particulate Bio-Oss graft in place. (d) Six-month
postoperative panoramic CT view. (e) Six-month postoperative cross-sectional CT view. (f) Six-month histology (yellow, Bio-Oss; purple, new bone).
a b c
Fig 13-39 (a) L-PRF membrane formed by compression. (b) Two sinus membrane perforations. (c) Perforation biologically sealed with multiple
L-PRF membranes. (Courtesy of Dr R. Miller, Delray Beach, Florida.)
ing the membrane in place internally, the authors have used CollaTape (Zimmer Biomet) was inserted against the sinus floor,
an intraosseous suture to retain the pouch on the sinus floor. and the flap was closed. Reentry in 4 to 6 weeks showed the
Another repair technique involves the use of autogenous L-PRF development of a thickened membrane (ingrowth into the
membranes fabricated with the IntraSpin System (Intra-Lock) CollaTape), which was then elevated from the floor following
and associated protocol. The patient’s blood is drawn and spun a split-thickness flap entry, and the procedure was completed
in a calibrated centrifuge, and a fibrin clot is then expressed by (Fig 13-40).
compression. The compressed fibrin clot is resilient and pliable
and can be cut or pieced together to fabricate a biologically
Intraoperative bleeding
active repair membrane that is rich in platelets, leukocytes,
growth factors, and cytokines.66–68 These membranes have a Incidence, etiology, and prevention. The vascularization of the
strong adhesiveness that allows them to be joined together via sinus is described in the previous section on sinus anatomy. Of
suturing for the repair of large perforations (Fig 13-39). particular concern during surgery is the internal branch of the
A novel technique for sinus membrane repair with a 4- to PSA artery, which follows a course within or adjacent to the
6-week delayed reentry was recently reported.69 Once a lateral sinus wall. Bleeding may occur from either the external
moderate to large perforation occurred, membrane elevation (soft tissue) branch of this artery when making flap incisions or
was terminated, the window was enlarged, a double layer of from the internal (lateral wall) branch when making the antros-
248

Complications
Fig 13-40 Diagrammatic representation of CollaTape repair with 4- to 6-week

reentry. (Courtesy of Dr Sang-Choon Cho, New York, New York.)
Fig 13-41 PSA artery dissected with a piezoelectric device. Fig 13-42 Visualization of the PSA artery in cross-sectional (paraxial)
CT views.
tomy. Measurements show that this artery may be located in that in 100% of cases the PSA artery was found to be partially
the area of the planned antrostomy in 20% of cases.12 intraosseous. The artery was present anatomically in 100%
Incidences of moderate to profuse bleeding from damage to of cases and could be identified in the lateral wall in 47% of
this artery are uncommon. One study reported this occurrence cases. The canal diameter was < 1 mm in 55.3% of cases, 1
in 2% of cases performed with rotary instrumentation.70 Another to 2 mm in 40.4% of cases, and 2 to 3 mm in 4.3% of cases.
study reported no incidences of artery laceration in 72 patients A recent systematic review and meta-analysis71 reported that
whose antrostomies were made with a piezoelectric device.40 the artery can be detected by CT and CBCT in at least some of
It appears obvious that routine use of piezoelectric surgery is the cross-sectional views of the lateral wall in 51% and 78%
a preventive measure that will enable the operator to avoid the of cases, respectively (Fig 13-42).
majority of bleeding occurrences resulting from injury to the inter- In many instances, the artery can be visualized within the
nally positioned PSA. It is a routine procedure to dissect the artery lateral sinus wall once the flap has been elevated. Once iden-
from the lateral wall with piezoelectric devices (Fig 13-41). The tified, the artery can be avoided by relocating the window (Fig
low-frequency ultrasonic vibrations do not damage soft tissue 13-43).
with proper use of the device. The artery, however, is not always
located within the lateral wall. It can be located just internal or even Treatment. Bleeding during antrostomy preparation may be
external to the lateral wall and can pass in and out of the bony gently flowing or pulsating. It generally appears to be worse
wall throughout its anteroposterior course. If located outside the than the severity of the condition would indicate. In many cases,
lateral wall, it is susceptible to damage from both rotary and hand the bleeding will stop spontaneously as the injured vessel con-
instruments. The external branch of the PSA artery may also be stricts or a local clot forms and blocks the channel.
severed when making vertical releasing incisions for flap elevation. Many techniques, ranging from simple to more complex, can
Prevention of bleeding from the internal branch should begin be used to control vascular bleeding in sinus elevation surgery.
in the diagnostic phase. A cadaveric and CT study10 reported These include the following, in order of simplicity:
249

Fig 13-43 (a) PSA

artery visible in the
lateral wall after flap
reflection. (b) Antros-
tomy positioned cor-
onal to artery.
a b
• Direct pressure on the bleeding point will necessarily be longer, thereby increasing the likelihood of
• Use of a localized vasoconstrictor infection. Postoperative bleeding may occur, with intrasinus
• Bone wax bleeding displacing graft material and extrasinus bleeding lead-
• Crushing the bone channel that houses the vessel (hemostat) ing to hematoma formation in the soft tissues.
• Use of electrocautery (with care near membranes) For these reasons, the surgeon is advised to the following:
• Suturing of the vessel proximal to the bleeding point
• Obtain preoperative CT images to locate the vessel
Vasoconstrictors, such as lidocaine with 1:50,000 epineph- • Visualize the vessel clinically
rine, are more useful with soft tissue bleeding. This is the type • Avoid the vessel, if appropriate, when designing the window
that may occur following vascular damage that occurs while • Use piezoelectric surgery to avoid trauma to the vessel
making releasing incisions. Direct injection and/or direct pres- • Have materials on hand to control bleeding (electrocautery,
sure with epinephrine-soaked gauze may be all that is required local anesthetic with 1:50,000 epinephrine, bone wax)
to achieve control.
Electrocautery can be effective with both soft and hard tissue
bleeding. Caution should be used when close to the Schneider-
Intraoperative remediation of large mucous
ian membrane as electrocautery may damage thin membranes,
retention cysts
resulting in a perforation.
Bone wax compressed over a bleeding point in bone may The presence of mucous retention cysts is easily detected in the
prove a simple solution if the vessel is inside the bony wall. presurgical radiographic work-up. These are benign lesions that
Once the bleeding is controlled, the bone wax can be left in are generally asymptomatic. They are radiopaque and of various
place while the procedure continues. sizes, typically originating from the sinus floor. They can be dis-
The most common area for profuse bleeding will be the cut tinguished from polyps, which tend to be pedunculated and arise
edge of the antrostomy. This is generally a problem specific from the sinus walls (Figs 13-44 and 13-45). Cysts are usually
to the use of rotary instrumentation and is almost completely filled with a yellow serous fluid, which is pathognomonic for this
avoided with a piezoelectric antrostomy. The damaged vessel lesion. A CT study17 revealed radiographic abnormalities in 38%
is in a difficult location to safely address. If bone wax does not of observed cases, with 10% being mucous retention cysts.
resolve the issue, the authors usually continue with the antros- If the cyst is asymptomatic and relatively small, it is of no
tomy, gaining vision by having an assistant suction directly over concern. If the cyst is large enough to block the ostium once the
the bleeding vessel to divert its flow from the surgical site. sinus floor has been elevated, the ostiomeatal blockage could
The sinus membrane is then elevated from the bone directly lead to congestion, infection, and/or sinusitis. One can make a
beneath the artery. It is then safe to insert a hemostat to crush generalization that if the cyst occupies two-thirds of the sinus
the vessel, which will stop the bleeding while not damaging the volume, postsurgical blockage of the ostium is a possibility.
elevated membrane. If access to the artery can be established As a general rule, ENT physicians prefer not to perform func-
adjacent to the bleeding point by osteoplasty, the bleeding can tional endoscopic sinus surgery (FESS) on an asymptomatic
be controlled by constricting the vessel with a suture. patient; however, this remains an option. Another option would
While intraoperative profuse bleeding is uncommon, as the be to perform the elevation with the cyst in place, referring the
saying goes, “The better part of valor is discretion.”72 While patient to an ENT should postsurgical symptoms occur. If this
control of bleeding is possible, although at times difficult, there option is chosen, the patient should be made aware of this
are numerous reasons to avoid its occurrence. Treatment times possibility during the presurgical consultation.
250

Complications
Fig 13-44 Healthy sinus with thin membrane

and patent ostium.
a b c
Fig 13-45 (a) Mucous retention cyst in panoramic CT view. (b) Mucous retention cyst in cross-sectional CT view. (c) Polyps on sinus walls in axial
CT view.
a b c
Fig 13-46 (a) Preoperative panoramic CT view showing

mucous retention cyst. (b) Aspiration needle through sinus
membrane into cyst. (c) Yellow serous cyst aspirant. (d)
Postoperative cross-sectional CT view showing graft and
implant in place with the cyst not visible. (e) Postoperative
panoramic CT view showing graft and implant with no
visible cyst.
d e
A third option is to aspirate the cyst at the time of elevation Another study74 followed 15 patients after cyst aspiration during
surgery. The lateral window should be made via a complete oste- sinus elevation surgery. Only cysts larger than 1 cm in the long
otomy (eradication of the window) to afford the best access. A axis and located in the area to be elevated were treated. Post-
22-gauge needle is then inserted through the sinus membrane operative disappearance of the cysts was radiologically docu-
into the cyst, and its contents are removed by aspiration (Fig mented in 12 of the 15 patients. In the remaining three patients,
13-46). the residual cysts at 6 months postoperative were of dimin-
The above aspirating technique does not remove the cyst, ished size and asymptomatic. Thirty-one implants were placed
only its contents. This is unlike FESS, in which the cyst is either 6 months after sinus elevation surgery with one failure, giving
removed completely or marsupialized. A follow-up study73 a cumulative survival rate of 96.8% (Fig 13-47).
showed a 3% reformation of cysts treated endoscopically.
251

Fig 13-47 (a) Preoperative cross-sectional CT showing a mu-

cous retention cyst. (b) Cross-sectional CT showing graft and
implant, placed simultaneously at 6 months after grafting and
cyst aspiration.
Postoperative complications in the etiology of postoperative sinus infection. A healthy sinus

is considered to have a high compliance, which may be defined
Postoperative edema, ecchymosis, hematomas, mild to mod- as the ability of the sinus to respond and recover from a bacte-
erate discomfort, minor nosebleed, minor bleeding at the inci- rial or inflammatory threat. An unhealthy sinus does not have
sion line, and mild congestion are within the scope of expected the same level of innate ability to respond (low compliance).
patient responses to a lateral window sinus elevation. These In cases where inflammation and/or infection from a recog-
responses are the result of manipulation of the facial flap and nized etiology is present (eg, periodontal, periapical, or aller-
the sinus membrane with the expected postoperative inflam- gic), presurgical antibiotic/anti-inflammatory therapy, along with
matory response. The majority of these symptoms disappear removal of the etiology, will in many cases resolve the problem
by day 3 or 4 following surgery. Symptoms that are not resolved prior to augmentation surgery. In the case shown in Fig 13-48,
within 3 weeks require close monitoring as these may mark the the etiology of the sinus pathology was the infected molar teeth.
onset of a postoperative complication. These were removed, and the patient was placed on a course of
Major postoperative complications after sinus elevation Augmentin and prednisone therapy, leading to almost complete
surgery are relatively uncommon. They include graft infections, resolution of the sinus pathology.
sinus infections, sinusitis, profuse postoperative bleeding, flap Patients presenting with a history or symptoms of acute
dehiscence, oroantral fistula formation, formation of inadequate sinusitis or acute chronic sinusitis should be referred to an ENT
graft volume for implant placement, loss of graft material contain- for appropriate presurgical evaluation and therapy, and medical
ment as a result of either sinus membrane rupture or exfoliation clearance should be obtained before sinus elevation surgery
of graft material through the sinus window, maxillary cyst forma- is performed. Pharmacologic therapy might be in the form of
tion,75 migration of dental implants into the sinus graft or sinus antibiotic therapy or combined antibiotic and anti-inflammatory
cavity proper, and failure of dental implants. Improper handling therapy. One such regimen might include Augmentin (amoxi-
of complications may lead to more serious adverse outcomes, cillin/clavulanic acid, 875/125 mg twice daily for 10 days) and
such as an infraorbital abscess, intracranial abscess, or migra- prednisone (40 mg for 3 days, 20 mg for 3 days, and 10 mg for
tion of implants into the maxillary sinus or paranasal sinuses.76 3 days). FESS may be indicated to remove pathologic tissues
To put postoperative complications in perspective, a prospec- or to widen the ostium to create more favorable drainage. It
tive study of 100 consecutive patients reported postoperative would be appropriate to take a posttreatment CT to determine
loss of implants (4%), wound dehiscence (3%), graft infections if this therapy has been successful prior to initiating therapy.
(2%), postoperative maxillary sinusitis (1%), and loss of or inad-
equate graft volume (1%).70
Postoperative sinus infections
For purposes of convenience, postoperative complications
can be subdivided by time of occurrence into immediate (1 to 3 The term postoperative infection alone does not indicate the area
weeks after surgery) and late (after 3 weeks and up to months where the infection has occurred or the appropriate treatment
after surgery). pathway to be followed. Infections may occur in two locations:
within the sinus graft (sinus graft infection), which is not inside
the sinus (hence the term subantral augmentation), or in the
Postoperative infections/sinusitis
maxillary sinus proper (sinus infection). True sinus infections,
Preoperative preventive measures. Preexisting inflammatory while less common, may have more widespread consequences
sinus disease may, under less than ideal conditions, be a factor
252

Complications
a b c
Fig 13-48 (a) Hopeless molars in a panoramic view. (b) CT scan after extraction of the molars. (c) CT scan 2 months after Augmentin/prednisone
therapy.
a b
Fig 13-49 (a) Panoramic CT view of an infected graft depicting a “black hole.” (b) Cross-sectional
CT scan depicting a drainage tract. (c) Axial view depicting infected central core surrounded
by graft material.
if not appropriately managed due to the interconnectivity of the cence, and suppuration from the incision line or through a fistula.
paranasal sinus network. Increased intrasinus pressure may be a secondary factor and
Postoperative sinus infections may commonly arise from two may result in congestion due to blocked sinus drainage. The
general sources. The first is through exacerbation of a previously patient may report the discomfort to be in the antrostomy area
existing, asymptomatic, chronic sinus condition (infection or because of the localized graft infection or may report more
inflammation) by the to-be-anticipated postoperative inflamma- widespread discomfort due to the resulting sinusitis.
tory changes. The second source is via bacterial contamination If viewed in a CT scan, a graft infection often gives the appear-
through a membrane perforation with bacteria and/or infected ance of a radiolucent “black hole” within the graft space (Fig
sinus graft material entering the sinus cavity. The graft material 13-49). This is especially evident when the graft material is of
may additionally block the ostiomeatal drainage, resulting in a more radiopaque type. In late-appearing graft infections, a
congestion and sinusitis. radiopaque “halo” is sometimes seen around the radiolucent
infection, representing an undisturbed layer of consolidated
graft material.
Postoperative sinus graft infections
There are multiple causes of sinus graft infections:
Etiology and prevention. Infected sinus grafts are more com-
mon than pure sinus infections. The incidence has not been • Preexisting sinus infection via perforation (should not treat
reported separately, but one can assume an incidence of 3% to symptomatic patient)
5%. Graft infections can present early in treatment or months • Infected simultaneous lateral ridge augmentation procedures
after the procedure has been completed. The late graft infec- • Contamination of the surgical site:
tions may be preceded by vague symptoms that appear quite –– Salivary/bacterial contamination of the graft material,
benign, thus delaying corrective therapy. instruments, or membrane
Symptoms include local tenderness, localized pain in the –– Untreated periodontal disease
area over the antrostomy, swelling, fistula formation, flap dehis- –– Adjacent periapical pathology
253

Fig 13-50 CT scan view showing periapical pathology extending into Fig 13-51 Penrose drain placed in existing fistula.
the sinus.
–– Lapses in the chain of sterility be affected in a negative way by smoking; however, smoking
–– Extended surgical time alone has not been shown to be a negative factor in pure sinus
grafting procedures. In a study by Levin et al,78 onlay bone grafts
An infected sinus graft, if not properly addressed, may result had a higher complication rate in smokers than nonsmokers, but
in patient morbidity, additional therapy, increased treatment there was no such relationship present in pure sinus lift grafts.
time, and possible systemic involvement. For these reasons, A commonly overlooked source of graft contamination is the
efforts should be made to prevent these untoward outcomes. utilization of nonsterile instruments either directly in the sinus
Preventive efforts are critical, and early identification of a possi- or to manipulate the particulate graft material. Instruments that
ble graft infection should be followed by appropriate therapy. have been sterilized prior to the surgical procedure do not remain
A particularly insidious etiology is the presence of periapical sterile once they have been introduced into the oral cavity. It is
pathology close to the sinus floor. When the apices of infected a procedural error to utilize an instrument, such as a periosteal
teeth are in or close to the sinus, there is a risk of immedi- elevator, that has been utilized in the mouth to hydrate/mix the
ate bacterial contamination of the graft once the membrane is graft material or carry it to the sinus. This is an obvious break-
elevated (Fig 13-50). Localized endodontic and periodontal ther- down in sterile surgical protocol and should be avoided.
apy should be completed before sinus grafting, or the hopeless Prophylactic procedures play an important role in prevention
teeth should be extracted. of infection. Many antibiotic regimens have been recommended
Extraction of teeth with apices that extend into the sinus for this purpose. In the authors’ experience, amoxicillin/clavula-
at the time of sinus surgery can open a pathway for bacterial nate (Augmentin) is the drug of choice. The spectrum is greater
contamination of the graft. This is more of a risk when primary than that of amoxicillin or ampicillin owing to the presence of
closure is not achieved over the grafted socket. clavulanic acid, which is active against β-lactamase-producing
Cases with simultaneous ridge augmentations have more bacteria. Augmentin 875/125 mg twice daily for 7 to 10 days
commonly documented complications. A report of 124 sinus (starting the night before surgery) is an effective prophylactic
elevations, 26 with simultaneous lateral ridge augmentations, dose. Historically, clindamycin (Cleosin, Pfizer) has been recom-
showed an infection rate of 3% for the sinus graft only group mended for penicillin-allergic patients. However, many clinicians
(n = 98) and 15.4% for the group that had simultaneous ridge have observed that clindamycin is not the ideal prophylactic anti-
augmentations (n = 26). Five of the seven infections occurred biotic for use in sinus elevation surgery. In the authors’ expe-
in smokers.77 The cause of the infection in these cases and in rience over the course of more than 28 years of sinus graft-
other ridge augmentation studies has been attributed to the ing, the majority of observed or reported infections occurred in
breakdown of primary soft tissue closure over the grafted site patients taking prophylactic clindamycin or no antibiotic at all.
with exposure of the barrier membrane and subsequent graft The authors have used levofloxacin (Levaquin) or moxifloxacin
contamination. It should be noted that in a ridge augmentation (Avelox, Bayer), second- and third-generation bactericidal fluoro-
procedure the incision line is directly over the barrier membrane, quinolones, with very favorable results. However, as there have
while in a properly designed sinus graft the membrane will be been numerous reports of Achilles tendon rupture, tendonitis,
distant from all incision lines. Soft tissue healing appears to and peripheral neuropathies following the use of fluoroquino-
254

Complications
lones, especially when used in conjunction with steroids,79,80 through an incision over the window and graft site may increase
these drugs must be used with caution. Zithromax or Biaxin, the potential for an oroantral fistula. Figure 13-51 shows the
both bacteriostatic macrolides, may be an appropriate alterna- placement of a Penrose drain in an existing fistula. The drain was
tive for penicillin-allergic patients. In general, the sinus graft left in place for 3 days, and after its removal the infection resolved.
infection rate appears to be higher in penicillin-allergic patients. Should there be no response to the above, more aggressive
An unrelated study reported an infection rate 3.3 times higher therapy is indicated. Debridement of the infected graft material
after immediate implant placement in cases where amoxicillin becomes the appropriate means of infection control. All graft
could not be used owing to a history of allergy.81 material should be removed, followed by a thorough flushing
of the subantral space. Re-grafting at the time of debridement
Treatment. Treatment of sinus graft infections should begin is considered by some clinicians; however, the risk of reinfec-
immediately after symptoms are recognized. The most com- tion is considerable. It is generally appropriate to wait for the
mon symptom is swelling over the lateral window site. Other cessation of symptoms prior to retreatment.
symptoms may include localized pain and/or tenderness, fistula In cases of late infections, an alternative therapy of partial
formation, flap dehiscence, and suppuration. graft debridement may be considered. Attempting to remove
Sinus graft infections usually are seen within 2 weeks after the dense “halo” surrounding the infected central portion of
therapy. Late infections (1 to 6 months) occur less frequently. In the graft most likely will result in destruction of the integrity of
general, infections are quite evident; however, sometimes the the sinus membrane. To avoid this negative outcome, it may be
symptoms are less evident, with drainage occurring through a advisable to leave the halo intact following thorough debride-
small fistula in the area of the lateral window. On other occa- ment and irrigation of the infected central portion of the graft.
sions, the symptoms are so mild (nonspecific mild discomfort) Successful results using the Urban protocol have been reported
that the diagnosis is delayed for up to 1 month or more. in eight cases. In this protocol, the collagen membrane and
Early treatment is essential as delay may result in the partial the discolored, infected graft materials are removed, and the
or total loss of the graft. Other negative outcomes include the cavity is rinsed with saline, treated with a doxycycline putty for
occurrence of an oroantral fistula or the possible development 2 minutes, rinsed again, and closed without additional grafting
of sinusitis due to loss of graft containment. or membrane placement82 (Fig 13-52). Implant placement and
There are four protocols to follow sequentially, each more re-grafting of the central portion of the graft can usually be
invasive than the previous one, until the infection resolves. The performed with only minor changes to the original timetable as
waiting time between protocols should not exceed 7 to 10 days the retained portion of the graft matures and allows for implant
at a maximum, as positive effects should be noted by that time. placement and stability. Histology showing vital bone in this
The four protocols are as follows: nongrafted repair location has been shown in another study.83
1. Reinstitution and/or change of antibiotic therapy

Postoperative sinusitis
2. Insertion of drain along with antibiotic therapy
3. Partial or complete debridement of the graft material Common conditions that lead to acute sinusitis are blockage of
4. Total debridement of the graft and sinus cavity by oral the OMC by inflammatory changes resulting from tooth-related
approach and/or FESS problems (endodontic or periodontal) and seasonal allergic reac-
tions. The most common causes of sinusitis following sinus ele-
Without a microbiologic assay, immediate therapy is directed vation procedures are likely to be infection/inflammation relating
toward the most common pathogens and the common resis- to inadequately contained sinus grafts that have contaminated
tant strains of bacteria. The antibiotics chosen should be able the sinus proper through recognized or unrecognized perfora-
to achieve high tissue concentrations and have the broadest tions or blockage of drainage by the elevation of mucous reten-
possible spectrum. tion cysts or severely thickened sinus membranes.
If signs of infection are noted, it may be appropriate to change
from the antibiotic used in prophylaxis to one with a wider spec- Etiology and prevention. Many clinicians have noticed that
trum (Augmentin or Levaquin). Metronidazole, a member of the patients who presented with a history of low-grade chronic sinus-
nitroimidazole group, may be included for its bactericidal effect itis before sinus elevation surgery were less susceptible to this
against gram-positive and gram-negative anaerobic bacteria. It condition after that surgery was performed. This is due to both
must be used with an additional antibiotic (Augmentin or Leva- the decreased overall volume of the sinus after grafting and the
quin) that is effective against aerobic bacteria. fact that the new sinus floor is now closer to the ostium, the
A culture can be taken to obtain information in case the infec- point of drainage. This, however, assumes that a proper mem-
tion is resistant to the chosen antibiotic. In many instances, brane elevation has been performed. For purposes of supplying
however, it is difficult to obtain a culture that is not contaminated proper vascularity to the graft, the elevation should extend up
by oral bacteria or to obtain results in a reasonable amount of time. the medial wall to a horizontal position. The new sinus floor will
If a Penrose drain is placed, it is best, if possible, to place it then be horizontal as opposed to creating a narrow, difficult to
in a location that is not directly over the graft. Placing the drain drain, crestal extension of the sinus floor against the medial wall.
255

b c
a d e
f g
Fig 13-52 (a) Preoperative CBCT. (b) Sinus graft with delayed implant placement. (c and d) Drainage around middle implant. (e) Implant and sur-
rounding graft removed. (f) Panoramic CT view following removal. (g) Definitive restoration at healed site.
Resolution of
Resolution of all symptoms
all symptoms and signs Resolution of
Graft
and signs after all symptoms
Maxillary contained Second regimen
3 weeks No and signs
sinus under of antibiotics Partial graft/
the sinus resolution of Monitor the
elevation implants
No resolution of membrane symptoms patient
Graft/implants removal No
symptoms and and signs
CBCT removal via resolution of Total graft
signs after 3 symptoms removal
Graft not intraoral approach
weeks and signs
contained with or without
under interanasal
the sinus approach (FESS)
membrane
Fig 13-53 Algorithm for treatment of sinus graft infections, sinus infections, and postoperative sinusitis.
256

Complications
Following sinus elevation, there will usually be a short-term Treatment. As a precautionary measure, some clinicians rou-
increase in membrane thickness due to a postsurgical inflam- tinely prescribe decongestants such as oxymetazoline (Afrin,
matory response. The temporary nature of this phenomenon Bayer) for postoperative use. The incidence of cases requiring
has been shown by a follow-up evaluation of 24 sinus grafts that this therapy is low; therefore, many clinicians do not include
revealed that 12 membranes decreased in size, 11 remained this in their usual postoperative protocol but prescribe it on
the same, and only one increased in size.84 an as-needed basis. Nasal lavage with sterile saline rinses can
The incidence of sinusitis after elevation surgery has a be used as adjunctive therapy.
reported range of 3% to 20%.82 It is usually mild in severity Treatment is dependent upon the severity and presumptive
with symptoms including mild discomfort, stuffiness, and diffi- etiology of the sinusitis. A mild sinusitis may respond to decon-
culty in breathing. A moderate to severe postoperative sinusitis gestants. If the etiology is a combination of inflammation and
is most likely due to blockage of osteomeatal drainage owing infection, combined antibiotic and anti-inflammatory therapy
to inflammation and/or sinus infection. may be effective. If there is no resolution, and the situation
The possible etiology of postoperative sinusitis may be the involves infection in both the graft and the sinus, therapy may
following: involve a surgical approach orally and/or via endoscopic surgery.
Best clinical practice includes two therapeutic protocols to
• Postsurgical inflammatory changes be considered87:
• Bleeding into the sinus after membrane perforation
• Bacterial contamination/infection after membrane perforation 1. If the graft is well contained, but signs and symptoms still
• Blockage of the ostiomeatal complex due to: persist after an additional pharmacologic regimen (usually 7
–– Intrasinus bleeding additional days), partial or total removal of the bone graft by
–– Graft material lost through a perforation oral access combined with additional pharmacologic therapy
–– Elevation of large cysts or thickened membranes to the is recommended.
level of the ostium 2. If the graft is not contained under the sinus membrane, loss
of graft material into the sinus is present (as seen on CT scan),
Prevention of postoperative sinusitis begins with a proper and symptoms still persist after extended antibiotic therapy
presurgical evaluation of the patient’s medical history. Patients (usually 7 additional days), a multidisciplinary approach to
with a previous history of inflammatory sinus disease have manage the complication is mandatory.
been shown to be more likely to have a postoperative sinusitis
than patients with a negative history.85,86 Preoperative sinus The above information can be used to create an algorithm
pathology should be detected and evaluated by CT analysis, for the treatment of sinus graft infections, sinus infections,
and potential problems should possibly be addressed before and postoperative sinusitis (Fig 13-53). It should be noted that
sinus elevation surgery. The proper presurgical protocol thus in the algorithm if symptoms occur early or are still present
may include the following: after a 3-week interval, a CBCT must be taken for diagnostic
purposes. The results of the scan will describe the pathway for
• Three-dimensional treatment planning to discover preexist- treatment to be taken that is directed by the containment or
ing pathology lack of containment of the graft material. If the graft material is
• Prior treatment of inflammatory disease by antibiotic and not contained, graft removal by an intraoral approach, with or
anti-inflammatory medications without FESS, is usually required. If the implants do not have
• Resolution of certain pathologies by FESS sufficient bone support following loss of the graft, they will
also be removed.
One experienced dental surgical team working with an ENT3 In cases where the graft material is contained (sinus graft
recommends that all preexisting reversible sinus conditions be infection), the therapeutic course is determined by the patient’s
addressed prior to sinus elevation surgery. If the problem is due response to a series of increasingly invasive attempts to resolve
to potential or actual blocked drainage, positive therapy might the infection. In order, they consist of a second round of anti-
involve endoscopic marsupialization of a mucous retention cyst, biotics, partial removal of graft/implants, and complete graft
removal of polyps or thickened membranes, or surgical widen- removal if there is no resolution.
ing of the ostium via FESS. Infections of the maxillary sinus can have quite severe adverse
If perforation of the sinus membrane occurs during elevation outcomes well beyond loss of the graft material. Pansinusitis,
surgery, it must be repaired in such a manner that the repair intraorbital abscesses with possible loss of sight, and intracra-
membrane is stable and prevents the loss of the particulate nial abscesses have been reported in the literature. The greatest
graft material into the sinus cavity, as this may form a nidus for errors that one can make in these cases are waiting too long to
inflammatory changes, infection, or blockage of the ostium. begin therapy, waiting too long before changing an ineffective
As will be seen, treatment for sinus infections becomes more therapy, and not taking advantage of the knowledge and skills
complex if the integrity of the sinus membrane is lost. of other surgical specialists (eg, ENT physicians) by referral.
257

Fig 13-54 Cross-sectional (a) and axial (b) CT

views of displaced graft material following in-
trasinus bleeding.
a b
a b c
Fig 13-55 (a and b) Collagen barrier membrane being placed internally to prevent lifting with subsequent loss of graft particles. (c) Membrane in place.
Fig 13-56 Migration of an implant into the sinus cavity.
Other postoperative complications conform to the shape of the lateral wall. An alternate method of
stabilizing the repair membrane is to place it immediately within
Loss of graft material through the window. An increase in the sinus window, over the graft, extending approximately 2 mm
intrasinus pressure, caused by either postoperative inflamma- in each direction for stabilization56 (Fig 13-55).
tion or bleeding from within the sinus, can result in extravasation
of graft material through the window (Fig 13-54). This is likely to Migration of implants into the sinus graft. This complication
occur if a membrane was not placed over the window or if the was more common when cylindrical implants were used in the
membrane was not properly stabilized. The displaced graft mate- posterior maxilla.88 It is still seen with screw-form implants when
rial is likely to either cause an elevation in the buccal mucosa or biologic boundaries are pushed to or beyond the limit (Fig 13-56).
result in sequestration. The displaced material can be removed The problem is usually due to an initially inadequate or early loss
with a small flap entry (not over the window or membrane) or of primary stability. It can also be caused by the loss of support-
left in place and addressed at the time of implant placement. ing bone owing to infection. Most clinicians reserve simultane-
Some clinicians stabilize bioabsorbable barrier membranes with ous implant placement for those cases that have a minimum of
resorbable tacks or a mattress suture. The incidence of this 4 to 5 mm of crestal bone. While simultaneous placement has
complication is quite low, making routine mechanical membrane been reported to be successful in 1 to 2 mm of crestal bone,89
stabilization unnecessary. It would be appropriate, however, to the potential risk must be considered. If an implant is placed in
choose a membrane that is flexible when wet so that it may 1 to 3 mm of crestal bone and primary closure is not achieved
258

References
BOX 13-7 Clinical recommendations to limit intraoperative and postoperative complications
1. Careful assessment of the patient’s medical history.

2. Preoperative CT scan to evaluate sinus anatomy and identify preexisting pathology.
3. Proper patient selection, with an emphasis on a healthy maxillary sinus.
4. A smoking cessation protocol is always recommended, especially in cases of heavy smokers (≥ 15 cigarettes a day).
5. Presurgical resolution of periodontal and endodontic disease.
6. Proper antibiotic prophylaxis.
7. Full-mouth plaque score and full mouth bleeding score < 15%. In case of provisional crowns, it is advisable to remove them and
disinfect the abutments with antiseptic solution.
8. Preoperative disinfection of the skin with an antiseptic solution and mouthrinses with chlorhexidine.
9. Use of sterile draping and infection-control protocol.
10. Keep incisions distant from the antrostomy and overlying membrane.
11. Prevent salivary contamination of bone graft and/or other biomaterials.
12. Intra- and postoperative hemostasis.
13. Use of two separate sets of surgical instruments: one for use in the oral cavity; one for membrane elevation and grafting.
14. Rinse the surgical field with sterile saline solution.
15. Keep surgical time as short as possible.
16. Postoperative chlorhexidine rinses.
17. Correct postoperative pharmacologic therapy.
18. Preplanned checkups: weekly for the first month, monthly for following 3 months.
and maintained, the early formation of the biologic width may augmentation procedures. Successful outcomes are depen-
result in the loss of more than half of the supporting bone well dent upon proper diagnostic procedures and proper clinical
before the graft has matured and become supportive. management. Both are maximized through the utilization of
Box 13-7 presents precautions recommended to reduce the properly formatted three-dimensional imaging. This imaging
incidence of complications. must include visualization of the full sinus, the OMC, and the
paranasal sinuses. Most experienced clinicians feel that the
information obtained relative to sinus health and sinus anatomy
is a key factor in achieving successful outcomes.
CONCLUSIONS
The maxillary sinus elevation procedure using a lateral window
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2013;84:1087–1093. of the outcomes and complications associated with maxillary sinus
59. Ardekian L, Oved-Peleg E, Mactei EE, Peled M. The clinical signif- augmentation. Int J Oral Maxillofac Implants 2006;21:81–85.
icance of sinus membrane perforation during augmentation of the 78. Levin L, Herzberg R, Dolev E, Schwartz-Arad D. Smoking and
maxillary sinus. J Oral Maxillofac Surg 2006;64:277–282. complications of onlay bone grafts and sinus lift operations. Int J
60. Schwartz-Arad D, Herzberg R, Dolev E. The prevalence of surgical Oral Maxillofac Implants 2004;19:369–373.
complications of the sinus graft procedure and their impact on 79. Parmar C, Meda KP. Achilles tendon rupture associated with combi-
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61. Testori T, Wallace SS, Del Fabbro M, et al. Repair of large sinus review of the literature. Foot Ankle Int 2007;28:1287–1289.
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62. Hernández-Alfaro F, Torradeflot MM, Marti C. Prevalence and 81. Wagenberg B, Froum SJ. A retrospective of 1925 consecutively
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63. de Almeida Ferreira CE, Martinelli CB, Novaes AB Jr, et al. Effect 82. Urban I, Nagursky H, Church C, Lozada JL. Incidence, diagnosis,
of maxillary sinus membrane perforation on implant survival rate: and treatment of sinus graft infection after sinus floor elevation:
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401–407.
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maxillary sinus graft following debridement without re-grafting: A Clinical consensus and recommendations. Int J Dent 2012;2012:
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723–729. 88. Regev E, Smith RA, Perrott DH, Pogrel MA. Maxillary sinus compli-
84. Peleg M, Garg AK, Mazur Z. Predictability of simultaneous implant cations related to endosseous implants. Int J Oral Maxillofac
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85. Som M, Brandwein M. Sinonasal cavities: Infammatory diseases, tudinal experience study of 2132 implants placed into 731 human
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HD (eds). Head and Neck Imaging, ed 3. St Louis: Mosby, 1996: 90. Timmenga NM, Raghoebar GM, Boering G, van Weissenbruch R.
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262

14 HOM-LAY WANG • ANN DECKER • TIZIANO TESTORI
Maxillary Transcrestal
Sinus Floor Elevation
Procedures
Anatomical Structures
Techniques
Postsurgical Considerations
Complications: Prevention and Management
263

14 | Maxillary Transcrestal Sinus Floor Elevation Procedures
M
axillary sinus bone augmentation was introduced Bone quality
in 1980 by Boyne and James, who used the
Cardwell-Luc method to overcome vertical ridge Bone quality is a key contributor to the decision-making process
deficiency in the posterior maxillary alveolus due for simultaneous placement of an implant with primary stability.
to pneumatization/expansion of the sinus.1 The transcrestal, or A gradient of four classes of bone density has been developed
indirect, approach involves sinus floor elevation through the alve- in which type 1 refers to dense cortical bone, and type 4 indi-
olar crest and simultaneous implant placement. The maxillary cates porous cancellous bone.20 This system has since been
transcrestal sinus floor elevation (tSFE) approach was introduced expanded to include location, composition, and density reported
in the 1980s and later modified by Summers2–5 as an alterna- by computed tomography (CT).21 In this classification system, the
tive to the more invasive lateral window sinus floor elevation. posterior maxilla is considered D3 or D4 (porous bone), charac-
The tSFE technique may be applied to sites with residual bone terized by a thin layer of cortical bone surrounding a core of fine
height of ≥ 6 mm and sufficient bone width6; however, as implant trabecular bone.21 Moreover, bone volume is low in the maxillary
technology advances, these values are subject to modification molar areas: 23.4% for men and 17.1% for women, with a pos-
(see the following section). The tSFE procedure uses infracture itive correlation between bone volume and bone height.22,23 To
of the sinus floor by preparation of the implant bed with osteo- address this problem, the density of type 3 and 4 bone can be
tomes of increasing diameters.5 It allows for condensation of improved using osteotomes of increasing diameters.
the trabecular alveolar bone to increase bone density around
the implant,7 which has been demonstrated to positively influ-
ence primary implant stability.8,9 This chapter presents important Sinus membrane
anatomical considerations, tSFE techniques and modifications,
postsurgical considerations, and complications along with their The sinus membrane is comprised of two main components: (1)
management strategies. pseudostratified, ciliated, columnar epithelium (ie, respiratory
mucosa) and (2) underlying connective tissue (ie, mucoperios-
teal tissue) that binds the sinus membrane to the bone. Sinus
membrane thickness has been reported via histology and cone
ANATOMICAL STRUCTURES beam CT (CBCT). Assessment of cadaver specimens using his-
tology reported a mean membrane thickness of 0.4 mm, with
Residual alveolar bone dimensions thickening in inflamed areas.24,25 However, mean membrane
thickness measured with CBCT was reported to be 1.8 mm.26
The posterior maxilla undergoes remodeling upon tooth loss, Comparatively, CBCT measurements of membrane thickness
and in combination with sinus pneumatization, often results in were found to be 2.6 times greater than the histologic exam-
deficient vertical height.10,11 This vertical deficit in alveolar bone ination.24,25 Interestingly, one study has positively correlated
in the posterior maxilla creates a major challenge for placement sinus membrane thickness with gingival architecture, suggest-
of implants and implant-supported restorations. A novel classifi- ing that thick gingival architecture might suggest thicker sinus
cation system is often used to reliably plan implant treatment in membrane measurements.27
the posterior maxilla based on residual bone height (Table 14-1).6 Histologically, basal cells, goblet cells, and ciliated cells are
According to the ABC sinus augmentation classification, tSFE the main cellular components of the sinus membrane.25 Osteo-
is often used in class B (barely sufficient group), where the progenitor cells may be associated with pericytes located within
residual bone height is 6 to 9 mm, based on the placement of the microvascular walls or in the bone marrow.28 As such, these
an implant with a minimum length of 10 mm. However, predict- progenitor cells (isolated from human sinus membrane) may
able osseointegration can be reliably achieved using 8-mm-long have significant osteogenic potential if cultured under the correct
implants with surface coating technology.12–14 These data, cou- conditions in vitro.
pled with the average reliable bone augmentation distance of
5 mm,15,16 allows the residual bone limits of the osteotome
technique to be 5 mm (after subtraction of 2 mm for postoper- Sinus floor morphology
ative remodeling) with placement of an 8-mm implant.16–19 The
authors have modified the ABC classification with extended Sinus floor morphology can influence the likelihood of mem-
osteotome parameters to 5 to 8 mm with the understanding brane perforation during surgery29; therefore, clinicians should
that 8-mm implants may be selected depending on appropriate check the presurgical two- or three-dimensional images with
case selection (Table 14-2). care. Three-dimensional images are extremely important for this
type of procedure since they provide a more precise anatomi-
cal diagram of the surgical location and volume. The osteotome
technique, rather than a reamer or balloon approach, is gener-
ally recommended when the sinus floor is curved to minimize
the potential for perforation. It has been demonstrated that an
264

Techniques
TABLE 14-1 Original ABC residual alveolar height classification for sinus augmentation procedures,6 based on
the placement of an implant with a minimum length of 10 mm
Classification Residual bone height (mm) Proposed treatment
A: Adequate ≥ 10 Implant placement without intervention

B: Barely sufficient 6 to 9 Osteotome/lateral window + simultaneous or delayed implant placement
C: Compromised ≤5 Lateral window + delayed implant placement
TABLE 14-2 Current modification of the ABC residual alveolar height classification for sinus augmentation
procedures,6 based on the placement of an implant with a minimum length of 8 mm
Classification Residual bone height (mm) Proposed treatment
A: Adequate ≥ 10 Implant placement without intervention

B: Barely sufficient 5 to 9a Osteotome/lateral window + simultaneous or delayed implant placement
a
C: Compromised ≤4 Lateral window + delayed implant placement
a
Modification from the original classification given in Table 14-1.
average of 2 mm of bone reduction/shrinkage occurred after of the antral septa. The proposed treatment options include a
sinus elevation.30 One study examined the influence of the sinus combination of multiple lateral window procedures or a combi-
floor configuration on grafted bone height dimensional stability nation of transcrestal and lateral window procedures in areas
after tSFE.31 The authors classified the sinus floor configuration anterior or posterior to zygomatic septa larger than 6 mm.35
into concave, angle, and flat according to the sinus floor profile
at the implant site. A flat sinus floor had a greater reduction
in grafted bone height than the corresponding concave mor-
phology. All graft materials placed in the maxillary sinus after TECHNIQUES
tSFE underwent remodeling and shrinkage (mean: 2.4 mm)31;
however, the outcome of the procedure was more predictable Osteotome tools used in tSFE have a variety of shapes and as
in sinuses with a concave floor.32–34 This implies that if tSFE is a result different indications for use (Table 14-3). Firm resistance
going to be performed in a flat sinus floor, 1 to 2 mm of addi- during osteotome use requires the use of a drill to widen the
tional bone graft may be needed when compared with that cortex; most resistance is caused by a cortical ring that pre-
needed for tSFE in a concave sinus floor. vents passage of the osteotome.41 It has been demonstrated that
regardless of the approach, sinus augmentation procedures are
safe and predictable, although some complications might occur.
Septa Excessive use of force while using the osteotomes may lead to a
labyrinthine concussion or other side effects such as benign parox-
Septa are intrasinus bony variations that divide the sinus into ysmal positional vertigo (BPPV).42 Most clinical studies43–47 report
multiple compartments. The incidence of antral septa varies mean sinus elevation between 4 and 6 mm with this approach.16
between 20% and 67%,35 with higher prevalence in atrophic/ Clinical methods include the Summers osteotome technique,
edentulous segments compared with dentate segments.36 Pri- reamer approach, balloon technique, and hydraulic pressure
mary septa are embryologic features of the maxilla, whereas approach (using piezoelectric instruments or saline pressure).
secondary septa arise from pneumatization of the sinus floor The authors have consolidated these approaches into the three
following tooth loss.37–39 broad technique-based categories described in the following
Frequency, morphology, and locations of maxillary sinus septa sections and summarized in Table 14-4.1,5,48–54 Each tSFE tech-
can be evaluated using CBCT.40 Incidence of septa was found in nique has benefits and limitations. Importantly, the patient’s
66.5% of patients and 56.5% of sinuses.40 The most common anatomy, medical history, and requirements should be evalu-
orientation of the septa was coronal (61.8%), and most were ated to discern the appropriate technique to be used for optimal
located on the floor of the maxillary sinus (58.6%) in the region outcome and predictability.
of the first and second molars (60.7%).40
A classification for the management of antral septa during
maxillary sinus augmentation has been proposed to minimize Summers osteotomy technique5
sinus perforations in septa cases.35 The proposed classification
consists of three categories—easy (E), moderate (M), and diffi- The most common tSFE method is the Summers osteotome
cult (D)—based on the number, orientation, size, and location technique3,5 (Fig 14-1). This technique is modified from the orig-
265

TABLE 14-3 Osteotome shape and function

Shape Description
Round (convex) Bone compression; used at the beginning of crestal sinus floor elevation in the presence of narrow ridges and soft bone
Bladed Cut cortex; split the cortices apart at the segment of a narrow crest
Pointed end Advances or widens the osteotomy in less dense bone; osteotomy must be made wide enough to accommodate the osteotome without resistance
Concave Collects and compresses bone at the apical end of the osteotomy
Flat-ended Compress bone for increasing bone density; used in the anterior maxilla
TABLE 14-4 tSFE technique benefits and limitations

Technique Benefits Limitations Sources
Osteotome technique Minimally invasive compared with lateral window • Significant force used Boyne and James (1980)1
• Pressure points/high risk of perforation Summers (1994)5
• Patient discomfort
• Risk of vertigo
Drill/osteotome technique Drill used to approach sinus (1 to 2 mm) to • Significant force used Davarpanah et al (2001)50
minimize mallet force • Pressure points/high risk of perforation
• Patient discomfort
• Risk of vertigo
• Loss of alveolar bone during drill sequence
Trephine/osteotome • Trephine used to approach sinus (1 to 2 mm) to • Significant force used Fugazzotto et al (1999, 2002)51,52
combination minimize tapping force • Pressure points/high risk of perforation
• Bone block preserved and apically positioned • Patient discomfort
for graft • Risk of vertigo
Balloon technique • Minimized risk of perforation • Many parts involved Soltan and Smiler (2005)49
• Distributed force • Small parts could be lost in the sinus
Hydraulic technique Minimal risk of perforations • Significant complications reported Sotirakis and Gonshor (2005)48
• Small parts could be lost in the sinus
Crestal bone impacted trap • Multiple implant placement simultaneously • Invasive Soardi and Wang (2012)53
• Horizontal bone augmentation simultaneously • Primary stability can be unpredictable if site is
not prepared correctly
Reamer approach • Minimized risk of perforation Many steps Chan et al (2013)54
• No excessive force used with mallet
• Low risk of complications
a b c d
Fig 14-1 Illustration of the Summers osteotome technique. (a) Round bur used to create the osteotomy. (b) Osteotomes selected to upfracture
the sinus. (c) Residual bone used as a graft to create space between the implant and the sinus. (d) Implant can be placed.
inal Tatum technique. Summers used a series of conical osteo- perforation. These maneuvers specifically avoid the use of drills
tomes for two reasons: (1) to increase the density of the max- to preserve bone and increase the lateral bone density. Orig-
illary soft bone (type 3 and 4) through lateral condensation, inally this technique was indicated for 5 to 6 mm of residual
resulting in bone compression stiffness and achieving a better bone height and low-density bone.
primary stability of implants, and (2) to elevate the sinus to the The following is a brief description of the Summers tech-
proper height (approximately 10 mm) without sinus membrane nique (Fig 14-2):
266

Techniques
a b c
d e f
g h i
Fig 14-2 Clinical case depicting the tSFE tech-

nique using osteotomes. (a) Preoperative radio-
graph depicting minimal residual ridge height.
(b) Initial osteotomy drilled to a diameter of 2.3
mm. (c) Bone graft is added to the osteotomy.
(d and e) Progressively increased diameters
of osteotomes used to laterally condense the
preparation to a diameter of 3.4 mm. (f) Implants
with a 3.7-mm diameter are placed. (g) Radio-
graph after implant placement. (h and i) Clinical
j k
and radiographic views at the time of implant
restoration. (j and k) Three-year follow-up. (l and
m) Seven-year follow-up. (n and o) Thirteen-year
follow-up.
l m
n o
267

a b c d
Fig 14-3 Illustration of the Michigan

reamer tSFE technique. (a) Round
bur used to create the initial osteoto-
my through the cortical bone. (b) Drill
sequence using the drill guide sleeve
to limit vertical ascent to within 0.5 to
1 mm of the sinus floor. (c) Remain-
ing distance to the sinus is prepared
using the non–end cutting reamer.
(d) Osteotome used to elevate the
bone graft and create vertical sinus
e f g elevation. (e) Bone spreader used to
create horizontal release of the sinus
membrane. (f) The osteotomy can be
increased in diameter with a subse-
quent drill series. (g) Implant place-
ment with primary stability can be
achieved during the same procedure.
1. A midcrestal incision is made with full-thickness flap to the sinus membrane (Fig 14-3). One of the unique features of
reflection. this approach is the use of reamers, which only cut bone with-
2. Implant sites are marked with a 2.0-mm round bur drill and out soft tissue laceration. Reamers are used when the osteot-
prepared to a depth of 0.5 to 1.5 mm from the sinus floor. omy approaches the sinus membrane, thereby eliminating the
3. Osteotomes are used to expand the diameter and vertical harsh percussion present in the original tSFE approach. To this
extent of the preparation, achieving sinus upfracture, but end, a precise analysis of available remaining bone height is
the osteotome itself should never enter the sinus. required. Presurgical planning using CBCT technology is needed
4. Sinus elevation should be delayed until the osteotome with to accurately calculate the residual ridge height, drill sequence
the final apical diameter is used at the desired working depth. approach, and sinus floor morphology. Following is a concise
Once the largest osteotome has expanded the implant site, description of the technique (Fig 14-4):
the sinus floor is fractured with the final osteotome.
5. Expansion of the osteotomy is completed by concave-tipped 1. A midcrestal incision is made with full-thickness flap reflec-
osteotomes with increasing diameters. tion. Then sutures are used to assist flap reflection on both
6. Greenstick fracture is achieved by adding 2 to 3 mm of bone. the buccal and palatal sides.
7. The osteotome should advance 1 mm with each mallet tap. 2. Implant sites are marked with a 2.0-mm round bur drill and
If the osteotome does not advance, the surgeon should go prepared to a depth of 1.0 mm from the sinus floor with
back to a smaller osteotome or use a drill. first two osteotome drills (up to 2.8-mm wide).
3. A 2.8-mm reamer (SCA kit) is inserted with different stop-
In additional modifications to the technique the osteotome pers until fracture of the sinus membrane wall is felt.
is used for future site development, as a bone plug is created 4. After the sinus membrane wall is fractured, a gauge is
with a trephine bur, and the bone is displaced superiorly with applied to ensure that the membrane is circumferentially
the use of a broad osteotome.2,5 lifted.
5. Subsequently, bone graft (small-particle [250 to 850 µm]
human allograft or xenograft) is inserted into the osteotome
Reamer approach sites and then slowly tapped into the sinus floor by either
a bone inserter/spreader (SCA kit) or an osteotome instru-
A sinus crest augmentation kit (SCA kit, Neobiotech) was devel- ment using a mallet. It is important to remember that these
oped to facilitate osteotomies and avoid trauma or perforation instruments should not enter the sinus cavity.
268

Techniques
a b c
d e f
g h i
j k l
m n o
Fig 14-4 Clinical case depicting the Michigan reamer tSFE technique at a maxillary right first premolar site. (a to c) Initial clinical and radiographic
presentation. (d) Crestal incisions are made to expose the underlying alveolar bone. (e and f) Initial drill sequence taken to 1 mm from the sinus. (g
and h) Osteotomy preparation is checked to be within 1 mm of the sinus floor. (i) Non–end cutting reamer. (j) Use of the reamer with the stopper
sleeve. (k and l) Following extravasation of the remaining alveolar bone up to the sinus, a sinus depth gauge can be used to ensure the membrane
is circumferentially lifted. (m) Osteotome and bone spreader used with bone graft to elevate the sinus floor. (n and o) Orientation and diameter of
the osteotomy was checked prior to implant placement.
6. Generally, the sinus floor should be elevated at least 2 mm 7. Implant osteotome drills are used to drill the osteotome
higher than the desired implant length due to bone shrink- site to the final diameter, according to the manufacturer’s
age that may occur after healing.30 guidelines, but only to the level of the remaining bone height.
269

p q r
s t u
Fig 14-4 (cont) (p and q) Implant placed. (r and s) Clinical and radiographic views at 4 week follow-up. (t and u) Five-month follow-up.
Again, the instruments should not enter the sinus cavity to 4. The bone graft is then added to retain dimension of the
avoid any potential perforation. sinus membrane elevation.
8. The implant is inserted in the prepared osteotomy. 5. The osteotomy is then widened using a manufacturer-
9. If the implant is stable, a healing abutment can be placed. designated implant drill.
10. If the clinician feels that the implant needs more protec- 6. More bone graft is added with a wider condenser.
tion (eg, in patients who smoke or have osteoporosis or in 7. The osteotomy is then completed to the appropriate diam-
type 3 or 4 bone quality), then a healing cap is placed with eter for implant placement.
primary wound closure. 8. The implant is placed. (It is recommended to use implants
11. The implant is loaded after 5 to 6 months of healing depend- with close threads for better engagement.)
ing on the bone density.
The Physiolift device (Mectron) was developed based on a
similar principle, using piezoelectric handpieces and a specially
designed tip. After site preparation, a controlled 3-mL saline
Hydraulic pressure technique syringe is used to elevate the membrane using hydrodynamic
pressure. Later on, the Intralift (Satelec) technique56 was devel-
This modification of the original Summers technique includes oped as a minimally invasive technique for lifting the maxillary
the use of saline, which is injected under hydraulic pressure48,55 sinus floor using piezoelectric surgery with a specific set of tips
with a fitted gauge beneath the membrane to achieve sinus for the application of ultrasound. In the associated experimen-
elevation (Fig 14-5). This procedure is briefly described below: tal study, the authors compared results of pneumatic pressure
and hydraulic pressure applied to elevate the sinus during sinus
1. Diamond burs are used to create an osteotomy 1 mm from elevation procedures in sheep.56 Using the hydraulic technique,
the floor of the sinus. 19.8 millibars of pressure was used at a flow of 60 mL/minute,
2. The surgeon should downsize to a 2-mm sinus bur for creating 5.58 mL of volumetric increase and no rupture of the
the purpose of creating a conical shape at the end of the sinus membrane.56 The authors concluded that hydrodynamic
osteotomy. ultrasound could be used as an alternative method for sinus floor
3. Hydraulic pressure is introduced to the surgical site at elevation with 3-mm-diameter transcrestal access.56
this stage, providing enough force to begin atraumatically
dissecting the membrane from the sinus floor. The water
pressure should be allowed to enter the pinhole slowly Other technique modifications
before the bur is tapped all the way through. A delicate
touch should be used to safeguard against membrane The field of tSFE is quickly growing. There are many more mod-
perforation. ifications to these basic techniques to lift the sinus transcrest
270

Techniques
a b c d
Fig 14-5 Illustration of the Michigan hydraulic tSFE Technique. (a) Initial preparation made with a
round bur to within 1 mm of the sinus. (b) Smaller round bur used to make the final preparation
to the sinus. (c) The shape of the osteotomy is essential to creating the pressure needed from
the hydraulic syringe. Pressure is created, and the sinus is lifted using a number of different
methods described in the text. (d) Bone graft is added to maintain the sinus elevation through
the use of the osteotome technique (previously described). (e) Simultaneous implant placement
can be achieved.
ally, such as the use of balloon catheters49; drill sequences Grafting materials used during sinus
with the use of bone graft50; and the crestal bone impacted
augmentation procedures
trap technique, which uses a rectangular-shaped osteotomy57
(Fig 14-6). These techniques are modifications of the three broad A variety of regenerative materials have been used in sinus
categories of techniques. One of the modified techniques that augmentation to fill the elevated space created after lifting the
applies tSFE at the time of maxillary molar extraction51,52 is sinus membrane. Autogenous bone has been considered to be
briefly described below. the gold standard; however, it is not commonly used in maxillary
Fugazzotto et al51,52 described a technique for accomplishing sinus augmentation because of limited intraoral harvest site and
both localized tSFE and guided bone regeneration at the time donor site morbidity. Other osteogenic materials are available.
of maxillary molar extraction through the following procedure: Autogenous particulate bone grafts are prone to volumetric
changes over time, with a decrease of 23% at 6 months and
1. Complete an atraumatic maxillary molar tooth extraction, 39.2% at 6 years when the Intralift hydraulic sinus elevation
leaving interradicular bone. was used.58 Autogenous bone blocks performed better, with
2. Choose a trephine bur with an internal diameter that will 21.5% reduction after 6 years. When autogenous particulate
encompass both the interradicular septum and approxi- bone graft was mixed with hydroxyapatite in a 20:80 ratio, the
mately 50% of the extraction sockets. volume reduction was 25.8%.59
3. Use the trephine bur to within 1 mm of the sinus. If the bone To increase the stability of the graft over time, demineralized
core comes out inside the trephine bur, carefully pull it out of bovine bone (Bio-Oss, Geistlich) was added to platelet-rich fibrin
the trephine and replace it in the alveolar bone preparation. in a ratio of 60:40, which showed a 1.4-fold increase in new bone
4. Select and use an osteotome according to the diameter of formation.60 This result was attributed to patient-dependent
the trephine preparation. factors (eg, number of teeth, anatomy).
5. If performing guided bone regeneration, fill the residual Some clinicians advocate use of blood clots in place of bone
socket with bone graft and place a membrane over the substitutes in sinus floor elevation. In a review of 22 clinical
socket. studies (864 implants) that used a graft-free sinus elevation
6. If placing an immediate implant, use a bone tap at the crestal technique, a mean residual bone height of 5.7 ± 1.7 mm was
one-third, and place the implant. reported.61 Mean implant survival was 97.9%.61 Interestingly, the
marginal bone loss measured at these sites was 0.9 mm after
271

a b c d
e f g h
i j k
Fig 14-6 Sinus crestal window tSFE Approach. (a) CBCT of the site. (b) Incision made palatally to ensure primary closure of the site away from the
crestal window borders. (c) Round bur and piezoelectric tip used together to complete the tSFE. (d and e) Once the sinus is elevated circumfer-
entially from the access window, bone graft is placed to maintain the elevation, followed by membrane placement. (f) Sutures placed to maintain
primary closure on a tension-free flap. (g) Six-month follow-up CBCT depicts successful tSFE. (h and i) After single-stage implant placement and
seating of healing abutments. (j and k) Follow-up with definitive restoration. (Reprinted from Soardi and Wang53 with permission.)
a b c
Fig 14-7 (a) Initial radiograph of the maxillary right lateral incisor and canine sites, depicting the need for sinus elevation. (b) Sinus elevation with
implant placement completed. (c) Two-year follow-up radiograph depicting graft shrinkage (1 to 2 mm) to the apical extent of the implants.
272

Fig 14-8 (a) Radiograph of a maxillary right first

premolar site the day of implant placement.
(b) Two-year follow-up depicting 1 to 2 mm of
bone graft remodeling to the apical extent of
the implant.
a b
0.1 mL 0.3 mL (0.1 mL) (0.2 mL) (0.3 mL)

EH: 3.7 EH: 4.95 EH: 5.84
BP: 6.51 BP: 8.2 BP: 9.54
MD: 6.25 MD: 7.77 MD: 9.74
c
Fig 14-9 Graft volume relates to elevation height.64 (a) Bone graft of
0.1 mL corresponded to a vertical gain of 3.7 mm. (b) Bone graft of 0.3
mL corresponded to a vertical gain of 5.84 mm. (c) Depiction of graft
volume and corresponding dimensions of tSFE. EH, elevation height; BP,
a b buccopalatal dimension increase; MD, mesiodistal dimension increase.
a follow-up of 41.9 months, which was lower than that reported POSTSURGICAL CONSIDERATIONS
around implants placed in grafted sites and pristine maxillary
posterior sites.61 Another systematic review/meta-analysis Following the procedure, patients should be instructed to take
reported no statistically significant difference between the antibiotics for 10 days. Chlorhexidine mouthwash (2 times daily
reported survival of implants (follow-up time of 1 year) placed for 30 seconds) for 10 days can be prescribed to minimize the
using tSFE with versus without grafting.62 Membrane perfo- oral bacterial load. Dexamethasone (8 mg 1 hour prior to sur-
ration rates ranged from 0% to 10.8%.62 The literature on this gery, 4 mg on days 2 and 3, and 2 mg total on day 4) can also
topic includes significant heterogeneity, and the vertical bone be given to decrease the inflammatory burden of the site. The
dimension is often reported using different measurement tech- patient is provided with instructions to avoid physical stress
niques (panoramic and periapical radiographs). Despite reported and blowing the nose or sneezing with the mouth closed for
limitations of this emerging technique, graft-free sinus elevation 2 weeks. A postoperative appointment is scheduled 2 weeks
with simultaneous implant placement may achieve a satisfac- following the procedure to evaluate healing and suture removal.
tory mean survival outcome. Monthly postoperative appointments should be scheduled until
It is the authors’ experience that a bone graft should be placed the final restorative appointment.
if > 2 mm of elevation is required since the physical properties
of space maintenance are needed for bone growth, according
to the requirements of the PASS (primary wound closure, angio-
genesis, space maintenance/creation, stability of wound and COMPLICATIONS: PREVENTION
implant) principles63 (Figs 14-7 and 14-8). If only a minor eleva- AND MANAGEMENT
tion is required, then a blood clot may be sufficient.
Outside of the discussion of the type of bone graft, another All of the previously described techniques have been shown
question remains: How much bone graft should be added to the to be safe and predictably increase vertical bone height with
site? One study evaluated 34 patients (16 female, 18 male) with 61 limited complications. Despite the high success rate of this pro-
crestal sinus elevation sites to discern the relationship between cedure, some associated complications have occurred.65 Other
bone volume used during tSFE and vertical sinus elevation.64 complications include but are not limited to benign paroxysmal
Bone graft in the amount of 0.1 mL corresponded with a vertical positional vertigo due to extensive malleting,46,68 postoperative
elevation of 3.5 mm, while 0.2 mL resulted in 5 mm of eleva- hemorrhage (low incidence but can occur), infection, implant
tion, and 0.3 mL corresponded to 6 mm of elevation64 (Fig 14-9). migration,69–71 lack of primary implant stability (due to lack of
To avoid sinus perforation, the ratio of vertical sinus elevation to initial bone height, poor bone quality, overpreparation, and pre-
mesiodistal or buccopalatal increase should be kept under 0.8.64 mature loading), loosening of cover screws, and migration of
273

TABLE 14-5 tSFE complications

Complication Etiology Prevention Management
Perforation of the Surgical complication Cautious/low-force approach, know Microlesion (< 2 mm): Collagen plug/membrane or PRF placed. If
sinus membrane local anatomy previous elevation was sufficient, implant (or shorter implant) may be
placed. Patient should refrain from blowing nose and take systemic
antibiotics + antihistamine.
Macrolesion (> 2 mm/poor access): Either (1) revert to a lateral window
osteotomy to repair the perforation, graft the sinus, and possibly place
the implant OR (2) abort and repeat the procedure after 3 months.
Infection Graft contamination, residual Define and eliminate pathology Systemic antibiotics. If infection persists for more than 4 weeks,
pathology (ie, sinusitis, endodontic prior to surgery remove graft and attempt again in 3 to 6 months.
infection)
Incision opening, Tension-free primary closure not Achieve tension-free closure, soft Antibiotics, re-suture if needed.
mucosal achieved tissue grafting prior to surgery
dehiscence
Sinusitis, cystic Microbial infection Define pathology Antibiotics/surgical intervention.
formation
Loss of bone graft Primary closure not achieved Achieve tenstion-free closure, use Do nothing, allow to heal and evaluate in 3 months.
particles of CTG/membrane
Rotational Poor osteotomy diameter control Determine bone quality during (1) Prolonged (4 to 5 months) submerged healing if the implant stability
instability of the pilot drill; underprepare type 3 and quotient is < 65 or insertion torque is < 25 Ncm. (2) Wider implant may
implant 4 sites be considered, leaving > 1 mm buccopalatal bone to maintain crestal
bone. (3) Remove implant, graft, and bioabsorbable membrane; reenter
at 4 to 6 months.
Implant migration Poor primary stability (< 15 Ncm Ensure primary stability Remove implant, graft, and bioabsorbable membrane, and reenter at 4
into the sinus insertion torque) to 6 months.
Benign Canalith displacement Avoid significant malleting Epley maneuver to reposition canaliths or prescription of
paroxysmal benzodiazepines and antihistamines can reduce motion sickness
positional vertigo symptoms.
PRF, platelet-rich fibrin; CTG, connective tissue graft.
dental implants into the sinus (Table 14-5). The patient’s medical repair must be completed through access of a lateral window.
history should be assessed and considered during treatment If the perforation occurs before any grafting material is placed,
planning in terms of potential complications to this procedure. the procedure should be aborted; a second attempt can be
performed 6 to 9 months later.71
Undoubtedly, the incidence of sinus membrane perfora-
Sinus membrane perforation tion during tSFE will impact the overall intra- and postopera-
tive complication rate of surgery. This will not only significantly
Sinus membrane perforation is the most commonly encoun- reduce implant survival rate but also trigger many related compli-
tered intraoperative complication and can cause termination of cations, such as graft infection and/or failure, reduced bone
the augmentation surgery. The membrane perforation rate with formation,72 and sinus infection/sinusitis.73 Hence, clinicians
transalveolar techniques has been reported to be on average should learn how to protect the sinus membrane integrity during
3.8% to 56%.70 tSFE to avoid potential complications.74
However, due to the limited accessibility for assessment
of membrane integrity, this rate could be underestimating the
actual rate of occurrence. In an attempt to address this short- Sinusitis and postoperative infection
coming, endoscopic studies have been performed and reported
that the sinus floor could be elevated up to 5 mm without perfo- Postoperative infection is another complication reported with
ration of the membrane.15,16 Risk of sinus membrane perforation transalveolar sinus elevation. On average postoperative infection
is heightened with the presence of maxillary sinus septa and is 0.8%, with a range from 0% to 2.5%.70 When performing
root apices penetrating into the sinus. Small perforations may tSFE, the clinician should be mindful to minimize bacterial bur-
be closed through the transalveolar preparation using fibrin glue. den preoperatively, intraoperatively, and postoperatively. Prior to
If a perforation does occur and repair of the sinus membrane the date of the sinus augmentation procedure, patients should
cannot be achieved through the osteotomy created during the be screened/treated for active endodontic infections, periodontal
transalveolar procedure, the procedure must be aborted, or disease, and sinus diseases. Patients with a history of chronic
274

sinus disease should be free of active symptoms and have that also provides primary stability. Osteotomes and bone con-
established sinus health before the tSFE procedure to minimize densation are also techniques that can be used to increase the
postsurgical complications or compromised results.75,76 Post- bone density at the site of preparation.
surgical sinus infection can result in ostium obstruction, which Residual bone height has also been used as a valuable predic-
can be alleviated by referral to an otolaryngologist and subse- tor of primary stability. Earlier studies on tSFE emphasized
quent endoscopy. Risk of obstruction is more common (74%) in the requirement of ≥ 5 mm of residual bone height prior to
patients who present with a flat or semi-aspherical membrane surgery.43,87 Less than 5 mm of residual bone height resulted in
thickening of > 10 mm.77 The sinus membrane status, mor- a 5% to 20% reduction in the success rate.43,87 Although some
phology, and thickness can be evaluated by CBCT prior to tSFE. tSFE technique publications have demonstrated success with
To minimize bacterial infection during bone grafting or implant < 5 mm of residual bone height,88–91 the prognosis for implant
placement during tSFE, all debris should be removed, and good success is still more favorable when residual ridge height is
oral hygiene should be established. In addition, the patient can ≥ 5 mm.92 If < 5 mm of residual bone height is observed prior
rinse with chlorhexidine for 30 seconds prior to surgical inci- to surgery, a staged transcrestal approach using the reamer
sions. If infection occurs, the first line of treatment is prescrip- technique or lateral window may be employed.
tion of a bactericidal antibiotic such as amoxicillin/clavulanic acid If primary stability is not achieved after placement, implant
(875/125 mg oral two times per day for 7 days).78 If the patient displacement into the maxillary sinus can become a serious
fails to respond, the bone graft might be compromised and postoperative complication and occurs at a rate of 3.8% to
require removal, which might entail lateral access or removal 6.28%.92 Implant displacement can occur as an intraoperative
of the implant. event or in the days following the surgical procedure.67,68 Severe
displacement of the implant into the maxillary sinus can occur
if there is a combination of osseointegration failure, membrane
Incision opening/mucosal dehiscence perforation, and intrusive forces on the implant toward the
sinus.93–95 In the event an implant migrates into the sinus, a
Soft tissue management guidelines are essential to the success lateral window may be completed to extract the implant body.67,68
of tSFE procedures. Healing of an augmented sinus follows the
temporal sequence of hemostasis, inflammation, proliferation,
and maturation/remodeling.79 Fundamentals described in the Benign paroxysmal positional vertigo
aforementioned PASS principle of guided bone regeneration are
required to promote this healing sequence: primary wound clo- BPPV is the most common form of vertigo, characterized by brief
sure, angiogenesis, space maintenance, and wound stability.63 spinning sensations with or without nausea following a change
Space and wound stability are crucial for mesenchymal stem in head position, and lasts less than 1 minute. The lifetime prev-
cell and osteoprogenitor populations to undergo proliferation/ alence of BPPV in the general population not associated with
differentiation in the sinus and surrounding the implant post- dental treatment is 2.4%.96 The peak onset is between 50 to
operatively.80 Furthermore, flap stability and primary wound 60 years of age, and the female to male ratio is 2:1 to 3:1.97,98 It
closure is guided by tension-free flap design and releasing inci- is diagnosed on the basis of nystagmus trending in an upward
sions.25,81–83 If these tenets are not followed, incision opening or and torsional direction, as observed when the patient is lying
mucosal dehiscence can result, exposing the underlying graft/ on one side during the Dix-Hallpike maneuver.99 Treatment to
implant site. As such, antibiotics can be prescribed to mini- reposition a canalith can be completed using the Epley maneu-
mize infection outcomes, or re-suturing can be completed if ver, which involves a number of head positions held for a min-
the exposure is severe. imum of 30 seconds until the nystagmus and vertigo resolve.
Each head position in the Epley maneuver aims to move the
otolithic debris closer to the common crus and eventually cause
Rotational instability/implant migration the debris to fall into the vestibule through the common crus,
eliminating the etiology of BPPV.99
Primary stability is essential for predictable success in tSFE with The complication of BPPV and/or headaches can occur follow-
simultaneous implant placement. Inability to achieve primary ing use of osteotomes for sinus augmentation procedures.41,88,100
stability in this procedure could result in osseointegration failure, The incidence of postoperative BPPV was reported in the litera-
fibrous encapsulation, or implant migration into the sinus post- ture to be 2.97%.101 These complications can arise due to exces-
operatively.84 To prevent implant rotational instability, undersized sive force used in malleting during this procedure.41,88,100 This
drilling should be considered primarily in softer posterior trabec- outcome can be minimized through the use of drills to within
ular bone (type 3 and 4) to maximize bone-implant contact.85,86 a working distance from the sinus of 0.5 to 1 mm or use of
Using the reamer approach, the clinician can underprepare the the reamer technique, in which a non–end cutting drill series
tSFE site diameter prior to the osteotome/sinus augmentation is used to complete the final millimeter of the osteotomy. The
steps. Following sinus elevation and addition of the bone graft, osteotome technique is generally used preferentially to increase
the site can then be further prepared to an adequate diameter primary stability in type 3 and 4 bone; however, this technique
275

was not superior to use of conventional drill sequences after 3 5. Summers RB. A new concept in maxillary implant surgery: The
months of follow-up.102 If an osteotome technique is selected osteotome technique. Compendium 1994;15:152–158.
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rated sinus membrane with a resorbable collagen membrane: A cal instrument. Clin Implant Dent Relat Res 2012;14:585–594.
human study. Int J Oral Maxillofac Implants 2004;19:413–420. 92. Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S.
73. Ding X, Zhu XH, Wang HM, Zhang XH. Effect of sinus membrane Implant survival rates after osteotome‐mediated maxillary sinus
perforation on the survival of implants placed in combination with augmentation: A systematic review. Clin Implant Dent Relat Res
osteotome sinus floor elevation. J Craniofac Surg 2013;24: 2012;14(suppl 1):e159–e168.
e102–e104. 93. Kluppel LE, Santos SE, Olate S, Freire Filho FWV, Moreira RWF,
74. Schwartz-Arad D, Levin L, Sigal L. Surgical success of intraoral de Moraes M. Implant migration into maxillary sinus: Description
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tation. Implant Dent 2005;14:131–138. 63–66.
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Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:34–38. when performing staged sinus floor elevation procedures. Int J
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Manson WL, Vissink A. Effects of maxillary sinus floor elevation 95. Iida S, Tanaka N, Kogo M, Matsuya T. Migration of a dental implant
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Influence of space‐filling materials in subantral bone augmenta- 37:371–378.
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278

15 JAMES CHOW • GLEN LIDDELOW
The Use of Zygomatic

Implants for Maxillary
Edentulous Patients
Brånemark Protocol for Zygomatic Implants
Sinus Elevation Versus Zygomatic Implants
Diagnostic Imaging and Treatment Planning
Zygoma Anatomy Guided Approach
Extra-maxillary Zygomatic Implants
Extended Sinus Elevation
Quad Zygoma
Immediate Loading
Prosthetically Driven Approach
Maintenance
279

15 | The Use of Zygomatic Implants for Maxillary Edentulous Patients
Intrasinus path
a b c
Fig 15-1 Oroantral communication in a patient who presented with left maxillary sinusitis 5 years after receiving bilateral zygomatic implants
placement according to the original Brånemark protocol. (a) The red circle indicates that there was no bone surrounding the neck of the zygo-
matic implant installed according to the original Brånemark protocol with an intrasinus path. (b) An oroantral communication was clearly shown
radiographically in association with complete opacification of the left maxillary sinus. (c) On surgical exploration, it was obvious that the zygomatic
implant was installed with an intrasinus path (right arrow). There was no bone surrounding the coronal part of the zygomatic implant.
Z
ygomatic implants were developed by Professor P-I with zygomatic implants.11,12 It was believed that the etiology
Brånemark and his coworkers to rehabilitate the defec- of maxillary sinusitis after zygomatic implant treatment was
tive or atrophic maxilla.1 The zygomatic implant is used multifactorial. Risk factors including preexisting sinus pathology,
when there is insufficient bone volume in the posterior intrasinus path, and the development of oroantral communica-
maxillary region for adequate bone anchorage of conventional tion have been discussed (Fig 15-1).
implants. Since P-I Brånemark and his team published the first Zygomatic implant surgery was considered a complex proce-
study on zygomatic implants in 28 patients, zygomatic implants dure because of the difficult surgical access, which was due to
have gradually become a proven technique of oral rehabilitation the remote site of bone anchorage and the inconvenience of
in patients with a severely resorbed edentulous maxilla. In their instrumentation with long drills. In order to overcome these chal-
first study, Brånemark et al reported an overall survival rate of lenges, different techniques have been developed. For example,
94% for zygomatic implants. Since zygomatic implants are long the sinus slot technique, extra-maxillary technique, extrasinus
and tilted, the Brånemark protocol stated that it was important technique, and extended sinus elevation technique were intro-
to control their entrance and exit. The entrance was usually duced to simplify the surgical procedure and improve the treat-
located in the second premolar area, while the exit site should ment outcomes.13–16 However, before going into detail regarding
be inside the zygoma to ensure maximum bone anchorage. The these modifications and innovations, it is worth explaining the
trajectory of the path was usually intrasinus, and there was no step-by-step procedure of the original Brånemark protocol for
intention to keep the sinus membrane intact. zygomatic implants.1
To investigate any negative effect of the exposed implant
body on sinus health, a sinuscopy study in conjunction with
the above-mentioned study was carried out.2 The endoscopic
findings did not show any inflammation of the sinus mucosa BRÅNEMARK PROTOCOL FOR
in contact with the exposed titanium surface. Despite the ZYGOMATIC IMPLANTS
favorable endoscopic findings, amongst the 28 patients in the
above-mentioned Brånemark study, there were four patients Brånemark zygomatic implants have eight different
who were diagnosed with recurrent sinusitis after receiving lengths, from 30 to 52.5 mm. The zygomatic implant is
zygomatic implants.1 These four patients were successfully a regular-platform, machined-surface implant with an exter-
treated by antrostomy at the inferior meatus for drainage. There nal hex. The implant head has a 45-degree angle. The head
were another four asymptomatic patients who presented with of this machined-surface zygomatic implant is perforated to
radiographic features of maxillary sinusitis. accommodate the abutment screw of the conventional multi-
In the literature, there have been many publications reporting unit abutment. Currently, Brånemark zygomatic implants with
high survival rates of zygomatic implants, regardless of whether a TiUnite (Nobel Biocare) surface and nonperforated head are
these implants were submerged for healing or exposed for also available. The coronal part of the zygomatic implants is 4.5
immediate loading.3–10 However, it was found that maxillary mm in diameter, while the apical part is 4.0 mm in diameter.
sinusitis was the most common biologic complication in patients The original protocol is a two-stage procedure, with stage-one
280

Brånemark Protocol for Zygomatic Implants
2.9 mm ø round bur 2.9 mm ø twist drill
3.5 mm ø pilot drill 3.5 mm ø twist drill
Fig 15-2 Drill set for zygomatic implant osteotomy. Fig 15-3 The first drill is a 2.9-mm-diameter round bur, which prepares
the entrance at the crest and marks the entry site at the base of the
zygoma bone during zygomatic implant osteotomy.
Fig 15-4 The second drill is a 2.9-mm-diameter twist drill, which pre- Fig 15-5 The third drill is a 3.5-mm-diameter pilot drill, which widens
pares the zygomatic implant osteotomy. the osteotomy while maintaining the same direction.
Fig 15-6 The final drill is a 3.5-mm-diameter twist drill, which is used Fig 15-7 The length of the zygomatic implant is verified using the an-
to complete the osteotomy. gled depth gauge.
surgery being performed under general anesthesia. The flap 2.9-mm twist drill to prepare the osteotomy from the ridge to
design employs the Le Fort I osteotomy vestibular incision the zygoma bone. The zygoma bone is usually perforated to
to expose the maxillary bone. The entrance of the zygomatic maximize the bone-implant contact (Fig 15-4). The osteotomy
implant osteotomy is usually located on the palatal side of the is continued with the 3.5-mm-diameter pilot drill and completed
residual ridge in the premolar region. For the zygomatic implant by the 3.5-mm-diameter final twist drill (Figs 15-5 and 15-6). The
osteotomy, a set of drills consisting of a 2.9-mm-diameter round purpose of the 3.5-mm-diameter pilot drill is to enlarge the oste-
bur and twist drill as well as a 3.5-mm-diameter pilot drill and otomy from a diameter of 2.9 mm to 3.5 mm for the final twist
twist drill is available (Fig 15-2). The round bur is used first to drill. After that, the length of the zygomatic implant is measured
mark the entrance at the ridge and the entrance at the base of by the angled depth gauge (Fig 15-7). Once its length is con-
the zygoma bone (Fig 15-3). The round bur is followed by the firmed, the zygomatic implant is usually placed using a manual
281

Fig 15-8 The zygomatic implant is placed using the manual driver. Fig 15-9 Close-up view of the location of the entrance, which is usu-
ally situated in the second premolar region, and the location and size
of the sinus window according to the original Brånemark protocol for
zygomatic implant placement.
Fig 15-10 (a and b) Patients

usually receive monitored
anesthetic care for zygo-
matic implant surgery. (c)
Patients are continuously
monitored for vital signs and
depth of anesthesia.
a b c
Fig 15-11 A crestal

incision is made (a),
and a three-sided
mucoperiosteal flap
is elevated (b) to
adequately expose
the surgical field for
zygomatic implant
placement.
a b
driver (Fig 15-8). During the osteotomy, a complete antrostomy Nowadays, zygomatic implant surgery is frequently performed
about 5 × 10 mm in size is opened on the uppermost lateral under intravenous sedation (Fig 15-10). Instead of making a
aspect of the maxillary sinus (Fig 15-9). This window allows Le Fort I osteotomy vestibular incision, a crestal incision is
direct visualization of the drills when preparing the zygomatic preferred (Fig 15-11). Very often, zygomatic implants are immedi-
implant osteotomy. It is not necessary to keep the integrity ately loaded with a screw-retained fixed provisional prosthesis,
of the sinus membrane during zygomatic implant osteotomy. which can be made by converting an existing complete denture
Once placed, the zygomatic implants are submerged for undis- chairside or by making a working impression immediately after
turbed healing for 4 to 6 months. During stage-two surgery, surgery for laboratory fabrication. Similar to placing conventional
the zygomatic implants and the anterior maxillary implants are implants, it is important to achieve optimal positioning of the
exposed, and these implants should be splinted immediately zygomatic implants in order to fulfill the biologic and biome-
or as soon as possible since it is not advisable to load a single chanical requirements for long-term successful osseointegra-
zygomatic implant. tion. The optimal positioning of zygomatic implants is achieved
282

Diagnostic Imaging and Treatment Planning
Fig 15-12 Because the zygomatic implant is tilted, it is important to control

the entrance and exit locations as well as the trajectory of the path of
insertion in order to fulfill the biologic and biomechanical requirements
for osseointegration and immediate loading.
through precise control of the entrance, exit, and trajectory of matic implants for immediate loading, whereas the remaining
the implant (Fig 15-12). The entry point should be prosthetically 36 patients underwent a staged approach, with sinus augmen-
driven, whereas the exit location is selected for adequate bone tation being performed 6 months prior to dental implant place-
anchorage. Moreover, it is better to keep the zygomatic implant ment. The preliminary short-term results based on the 4-month
body external to the maxillary sinus. The external path may post-loading data showed that zygomatic implants had better
eliminate the risk of maxillary sinusitis after zygomatic implant clinical outcomes than sinus grafting with fewer prosthetic
treatment. There are several publications reporting on the anat- complications and implant failures.
omy of the zygoma bone, and these studies have confirmed
that the thickness of the zygoma bone is sufficient to support
from one to three zygomatic implants.17–20
DIAGNOSTIC IMAGING AND
TREATMENT PLANNING
SINUS ELEVATION VERSUS For any kind of oral rehabilitation, correct patient selection and
ZYGOMATIC IMPLANTS optimal treatment planning are essential to achieving a suc-
cessful outcome. When a patient presents with an atrophic
In a severely atrophic maxilla, the conventional method for edentulous maxilla, the selection criteria for zygomatic implants
reconstruction before the introduction of zygomatic implants include an assessment of the residual bone volume in the eden-
was ridge augmentation. Amongst the various augmentation tulous ridge. Bedrossian proposed a classification for dental
techniques, sinus elevation grafting is the mainstream method implant treatment planning in the edentulous maxilla by dividing
to augment a deficient posterior maxilla. Bilateral sinus eleva- the maxilla into three radiographic zones (zones I, II, and III).25
tion is a major grafting procedure that is usually performed with When there is inadequate bone volume in zone II (premolar
a staged approach and a prolonged healing period. Patients region) and zone III (molar region), either a bone augmentation
who have undergone bilateral sinus elevation may have to go procedure such as open sinus elevation grafting or zygomatic
without a denture for a few weeks to a few months to avoid implants should be considered. In an extreme situation, when
wound dehiscence that may compromise graft healing. Accord- there is not enough bone in all three zones, more major bone
ing to the Sinus Consensus Conference in 1996, the medium- augmentation such as an onlay block graft or quad zygoma is indi-
to long-term survival rates of implants placed in a grafted sinus cated. The main advantages of performing zygomatic implants
site are around 90%.21 Meanwhile, zygomatic implant treatment as compared to a major grafting procedure include: (1) a single
is a graftless solution. The current concept of zygomatic implants surgery, (2) a shorter treatment period, and (3) the possibility
is single-stage surgery for immediate loading. The survival rate of performing immediate loading.
of zygomatic implants is as high as 95% to 98%.22,23 To assess the residual bone volume in the three different zones
There was a recently published randomized study comparing of the maxilla, it is necessary to perform radiologic examination.
sinus augmentation with zygomatic implants.24 In this prospec- Currently, the most effective method is the cone beam computed
tive three-center study, there were 71 patients with severely tomography (CBCT) examination. If zygomatic implants are indi-
resorbed edentulous maxillae. Thirty-five of them received zygo- cated, it is necessary to scan the whole maxilla up to the zygoma
283

a b
Fig 15-13 The CBCT image shows Fig 15-14 A patient with a known case of chronic rhinosinusitis. (a) A CBCT image reveals radiographic
the volume of the residual ridge, the sign of pansinusitis. (b) Clinically the congested nasal polyp can be seen. Otorhinolaryngologic referral
status of the sinus, and the condition is recommended.
of the zygoma bone.
Fig 15-15 3D reconstruction of an atrophic edentulous maxilla by seg- Fig 15-16 Prosthetically driven planning can be conducted virtually after
mentation of the DICOM files. superimposing the 3D reconstructed radiographic guide on the maxilla.
bone level. The purposes of taking a CBCT scan include: (1) to 15-17 and 15-18). When postoperative CBCT is performed, it is
evaluate the status of the paranasal sinuses, particularly the maxil- also possible to evaluate the accuracy of the guided surgery
lary sinuses; (2) to assess the residual bone volume from zones I by comparing the actual position with the planned position of
to III; and (3) to export the Digital Imaging and Communications the implants.
in Medicine (DICOM) files for segmentation and simulation. When a patient is prepared for guided surgery, a radiographic
From the CBCT images, the extent of pneumatization of guide should be fabricated before conducting the CBCT exam-
the maxillary sinuses can be seen. In addition, the maxillary ination. The radiographic guide should be prepared according to
sinus could be evaluated for mucosal thickening and patency the specific requirements of the planning software.
of the osteomeatal complex (Fig 15-13). If the ostium is found
to be obstructed in a symptomatic patient, otorhinolaryngologic
consultation should be arranged to exclude any existing sinus
pathology (Fig 15-14). ZYGOMA ANATOMY GUIDED
With dental implant planning software, the DICOM files can APPROACH
be segmented for three-dimensional (3D) reconstruction (Fig
15-15). Furthermore, implant surgery can be simulated, and the In 2011, Carlos Aparicio published the zygoma anatomy guided
zygomatic implants can be placed and positioned according to approach (ZAGA) classification for zygomatic implant treat-
a prosthetically driven approach (Fig 15-16). In suitable cases, ment planning.26 ZAGA classification (Fig 15-19) takes into
surgical guides can be generated by the software, and subse- consideration the prosthetically driven implant positioning and
quently these surgical guides can be produced by 3D printing the degree of buccal concavity of the anterior maxillary wall
for pilot drilling or even for fully guided implant placement (Figs (Figs 15-20 and 15-21). According to the ZAGA classification,
284

Zygoma Anatomy Guided Approach
Z/UP
X/RT
Y/LG
Fig 15-17 After surgical simulation, a surgical guide can be generated Fig 15-18 A 3D model and a surgical guide can be produced
by the software. by additive manufacturing.
a b c d e
Fig 15-19 (a to e) ZAGA classification proposed by Aparicio. (Courtesy of Dr Carlos Aparicio, Barcelona, Spain.)
Fig 15-20 3D model of a patient with a convex maxilla. Fig 15-21 3D model of a patient with a concave maxilla.
five different situations in relation to the trajectory of the zygo- of ZAGA classification, the path of the zygomatic implant body
matic implants can be identified: 0: intrasinus path, 1: com- will vary from completely intrasinus to totally extrasinus. In
bined intra-extrasinus path, 2: combined extra-intrasinus path, addition, ZAGA is a one-stage procedure for immediate loading.
3: extrasinus path, 4: extra-maxillary path. Aparicio et al have published another study to compare the
According to the ZAGA classification, the zygomatic implant treatment outcomes of zygomatic implants placed by the orig-
osteotomy is guided by the anatomy of the zygomatic buttress– inal Brånemark protocol versus the ZAGA protocol.27 In terms
alveolar crest complex. It is not necessary to create a buccal of survival rates, there is no significant difference between the
slot or open a sinus window on the lateral wall of the maxillary two groups of patients. However, there are significant differ-
sinus when preparing the osteotomy. Depending on the type ences in the following aspects: (1) zygomatic implants placed
285

by ZAGA are closer to the crest; (2) zygomatic implants placed implants in their study and reported that there was no adverse
by ZAGA are more stable based on Periotest (Medizintechnik soft tissue response to the extra-maxillary implants.
Gulden) values; and (3) zygomatic implants placed by ZAGA are Wen et al carried out a finite element analysis comparing
associated with reduced incidence of sinus pathology. the Brånemark protocol with extrasinus and extra-maxillary
techniques.30 Nine finite element analysis models were recon-
structed based on the number and the position of the zygomatic
implants and the anterior implants. Stress and deformation
EXTRA-MAXILLARY ZYGOMATIC around the supporting bone for the zygomatic implants under
IMPLANTS vertical and lateral loading were investigated. This study showed
that all these models with the zygomatic implants were effective
In 2008, Maló and coworkers introduced the extra-maxillary sur- in supporting a maxillary reconstruction. However, the stress
gical technique together with a novel design of the zygomatic and deformation were minimal when an extrasinus technique
implant.14 The new design eliminates threads on the coronal was employed with bilateral zygomatic implants and two ante-
aspect, increases the diameter of the apical portion, and adds rior implants located at the lateral incisor regions.
a zero-degree head in addition to the 45-degree head. Maló et
al believed that the combination of software and hardware inno-
vations could result in a synergistic effect on zygomatic implant
treatment outcomes. EXTENDED SINUS ELEVATION
The zygomatic implant osteotomy of the extra-maxillary
technique starts with an entrance buccal to the residual crest. When Aparicio proposed the ZAGA classification, he found that
Then a buccal groove is cut along the lateral sinus wall. During the zygomatic implants took an intrasinus path in 69% of his
implant osteotomy, the underlying maxillary membrane may be patients.26 Among this group of patients, it is possible to keep
exposed, depending on the degree of the buccal wall concav- the body of the zygomatic implants external to the maxillary
ity. Attention should be paid to avoid laceration of the sinus sinuses by performing an open sinus elevation before carrying
membrane. The essence of the extra-maxillary technique is out implant osteotomy. Chow et al reported on 16 patients who
keeping the zygomatic implant external to the maxillary sinus underwent an extended sinus lift prior to the placement of zygo-
regardless of the anatomy, with the threadless coronal aspect matic implants.16 The purpose of the extended sinus elevation
of the zygomatic implants never penetrating the crestal ridge. was to ensure that the zygomatic implant body would always
According to Maló et al, the extra-maxillary surgical protocol be kept outside the maxillary sinus even though it might take an
has many advantages over the original Brånemark protocol. It intrasinus trajectory. Cutting an extended window from the floor
provides good visualization of the zygomatic implant osteotomy to the roof of the maxillary sinus improved the visibility for the
and allows easy positioning of the implant head buccal to the zygomatic implant osteotomy and facilitated optimal position-
crest. As a result, the zygomatic implant position will be located ing of the zygomatic implants (Fig 15-22). The short-term treat-
underneath the occlusal surface of the crown or just slightly ment outcomes for these 16 patients were promising, and there
palatal to the crown. This prosthetically driven implant position was no failure nor sinus infection reported during the period of
will reduce the bulk of the implant-supported prosthesis. The investigation. There was an interesting radiologic finding that de
slimmer prosthesis can enhance oral hygiene maintenance and novo formation of mineralized tissue seemed to occur around
prevent speech problems as compared with a bulky prosthesis the implant body, below the lifted sinus membrane (Fig 15-23).
associated with palatally placed zygomatic implants. Although this was an observation in some patients only, it was
Maló et al published several follow-up studies on their patients considered a potential benefit due to increased bone support
who had undergone the extra-maxillary technique for zygomatic to the entirety of the zygomatic implants.
implant placement and reported high implant survival rates simi- In another study on extended sinus elevation for zygomatic
lar to the other studies using different approaches.28,29 Despite implants, published in 2013 by Hinze et al, the authors used
the fact that an extra-maxillary technique was employed, 7% a similar technique to Chow et al, but they had emphasized
of their patients developed maxillary sinusitis during the period the importance of grafting the sinus immediately after zygo-
of investigation. The authors stated that 7% was considered a matic implant placement.31 The benefits of grafting included: (1)
low incidence compared with the other studies on zygomatic increased bone support to the zygomatic implant and (2) a thicker
implants. More importantly, they did not exclude patients with bony barrier to separate the antral cavity from the oral cavity.
preexisting sinus pathology. Further study will be necessary to evaluate the long-term
With the extra-maxillary technique, the coronal part of the clinical outcomes of the extended sinus elevation technique
zygomatic implants is only covered by soft tissue; therefore, and to investigate the significance of simultaneous grafting.
there is a concern of mucosal recession that may result in implant There are finite element analyses that have shown that the load
exposure. However, Maló and his coworkers had evaluated distribution on zygomatic implants was more favorable when
the peri-implant soft tissue parameters of the extra-maxillary there was alveolar bone support.32,33
286

Quad Zygoma
a b c
d e f
Fig 15-22 (a) Extended sinus elevation for zygomatic implant placement in a ZAGA type 0 patient. The extended sinus window is cut from the floor
to the roof of the maxillary sinus. (b) The bony wall is left attached to the underlying sinus membrane, and the bone and membrane are elevated
together and pushed inward and medially. (c) Zygomatic implant osteotomy with the 2.9-mm-diameter round bur. (d) Zygomatic implant osteotomy
with the 2.9-mm-diameter twist drill. (e) Zygomatic implant osteotomy is completed with the 3.5-mm-diameter twist drill. (f) Placement of the
zygomatic implant with a TiUnite surface. The implant is external to the maxillary sinus in spite of an intrasinus trajectory.
a b
Fig 15-23 (a) CBCT image of a patient before receiving zygomatic implants with the extended sinus elevation technique. (b) CBCT image of the
same patient 2 years after surgery. Mineralized tissue is noted radiographically along the entire length of the zygomatic implants even though no
graft material has been used.
QUAD ZYGOMA implant to the lateral orbital rim. Davó and Pons conducted a
prospective study on the treatment outcome of immediate
Zygomatic implants are usually placed together with anterior loading with quad zygoma and reported the 5-year results on
maxillary implants. Brånemark et al showed in a mathematical 14 patients.35 Although half of these patients presented with
model that a minimum of two anterior implants in combination biologic and mechanical complications such as penetration of
with a single zygomatic implant on each side was sufficient to the orbital cavity, fistula formation, maxillary sinusitis, fractured
support a full-arch fixed restoration.1 When the residual bone abutment screws, and fractured prostheses, all these compli-
volume is also limited in the anterior maxillary region, dou- cations were successfully managed without compromising the
ble zygomatic implants can be placed on each side to replace clinical success. Wang et al carried out a systematic review on
the anterior implants. In 2007, Duarte et al published a proto- quad zygoma based on three published studies, including the
col to rehabilitate the atrophic maxilla using four zygomatic abovementioned, and found that maxillary rehabilitation with
implants (quad zygoma) for immediate loading.34 When there four zygomatic implants was reliable, with a high implant survival
was inadequate thickness of the zygoma bone to support two rate of 96.7% to 100% in association with very few surgical
zygomatic implants, they would carefully insert one zygomatic and prosthetic complications even when there was no anterior
287

Fig 15-24 A 4-mm-diameter titanium reinforcement bar is Fig 15-25 The provisional prosthesis
laser-welded to the titanium temporary copings to provide rigid should have a polished convex tissue
cross-arch stabilization and support for the acrylic “wraparound” surface with minimal contact and provide
provisional prosthesis. space for home plaque control aids.
implant support.36 Since the most significant complication in The construction of the immediate prosthesis is critical for
this group of patients was implant perforation into the orbital the success of a zygomatic implant rehabilitation. Due to the
cavity, the importance of sound knowledge of the local anatomy inherent flexion of long implants, the provisional prosthesis
cannot be overemphasized. Recently, Hung et al conducted an should be rigid to allow osseointegration. This can be achieved
anatomical study to locate the optimal position of double zygo- by conversion of a denture at the time of surgery or construc-
matic implants in the zygoma bone of Chinese patients.37 They tion of a new prosthesis after impressions and jaw relations. A
divided the zygoma bone into 12 areas at the superior, middle, rigid framework or bar is recommended to provide support for
and inferior regions and reported that the central portion and acrylic and enhance rigidity (Fig 15-24).
the posterosuperior aspect of the zygoma bone were the most In a finite element analysis, Wen et al reported lower stress
suitable sites for maximum bone anchorage and at the same on bone and implant with the exteriorized technique of zygo-
time had a lower risk of intrusion into the infratemporal fossa matic implant placement. The addition of an axial implant ante-
when performing a quad zygoma procedure. riorly, if possible, dramatically reduces load on the system.30
Most load is transmitted to the palatal bone; therefore, flexion
of the implant can create a pumping effect, leading to bone
resorption and an oroantral communication. A sinus infection
IMMEDIATE LOADING may then ensue.38
Rigid cross-arch stabilization is therefore imperative to reduce
According to the original Brånemark protocol, the zygomatic the risk of palatal bone resorption. In addition, the induction of
implants are submerged for healing. In 2006, there were two bone along the length of the implant when using an intrasinus
publications on immediate loading of the zygomatic implants, or an exteriorized approach requires stability.
and both studies reported favorable results. Since then, imme- From a patient perspective, immediate loading has signifi-
diate loading of the zygomatic implants is becoming more com- cant benefits with respect to earlier return to work and social
mon. In the literature, there is evidence suggesting that imme- life, fewer surgical procedures, less pain and swelling, reduced
diate loading is equally successful as the traditional two-stage chair time, and improved quality of life. However, the inherent
approach.7,9 In addition, it seems that immediate loading may risk to loading non-osseointegrated implants cannot be under-
reduce the incidence of maxillary sinus infection compared estimated. Patients should be counseled to maintain a soft
with delayed loading.11 diet for 3 months postsurgery to reduce the functional load.
From a patient’s perspective, immediate loading is a dramatic Carefully customized home care measures should be initiated
improvement because it negates the need for an initial period immediately, with frequent follow-up appointments to ensure
of time without a prosthesis and the subsequent months with a adequate plaque control. The prosthesis should have a polished
prosthesis that has been adjusted and relined with soft material convex tissue surface with adequate space for home hygiene
to reduce pressure on the healing tissue. The clinician has less aids (Fig 15-25).
concern regarding denture-induced pressure causing exposure
of the implants and possible infection.
288

a b
Fig 15-26 (a and b) Quad zygoma implants have been placed with additional anterior axial implants to minimize encroachment of the tongue
space, thus providing a slim prosthesis that enables easier adaptation.
Osseoperception PROSTHETICALLY DRIVEN

Osseoperception is defined as the mechanosensitivity associ- APPROACH
ated with implant rehabilitation. The patient perceives a sensa-
tion arising from stimulation of mechanoreceptors in muscle, The current concept of implant prosthodontics emphasizes the
joint, mucosal, cutaneous, and periosteal tissues together with importance of a prosthetically driven treatment plan. The position
a change in central neural processing to maintain sensorimo- of the implants should be optimal to enhance osseointegration
tor function.39,40 Endosseous and periosteal receptors provide and achieve long-term oral function. Ideally for a screw-retained
most of the perception; however, the resultant active threshold prosthesis, the screw access and space for abutments should
for implants after adaptation is reported to be around six times be within the confines of the ideal dentition.
higher for implants compared with teeth. Tactile sensibility of a If the zygomatic implants are placed in a more traditional pala-
prosthesis depends on material selection. Studies report occlu- tal position, there is a need for increased thickness of the palatal
sal perception for acrylic teeth to be around 400 microns com- contour to accommodate the components, thus encroaching
pared to ceramometal reconstructions at around 20 microns.41,42 on tongue space and hampering plaque control (Fig 15-26).
Osseoperception develops over time with peripheral and Collaert et al evaluated the speech effects from the contour
central neuroplastic adaptation. The central dental-specific of maxillary prostheses, finding that reduction of the palatal
changes depend on neuroplastic change within the M1 and S1 volume in the premolar regions improved speech adaptation
face sensorimotor cortex. Adaptation is influenced by environ- significantly.44 As the zygomatic implant typically exits in the
mental aspects such as disease and psychosocial profile, genetic premolar region, implants should be planned with the defin-
factors, intrinsic processes, and the masticatory components.43 itive prosthesis in mind so that the head of the implant exits
This change is highly variable, with estimates of duration from the occlusal table of the planned tooth rather than being in the
3 months to 2 years and differing levels of sensibility. More traditional palatal position.
extensive interventions, such as complete maxillary rehabilita-
tions, require more time and generally an incomplete return to
dentate functioning. Determining tooth position and prosthesis
The lack of perception in the early phases of a treatment contour
plan can result in jaw movement incoordination or parafunction,
placing significant load on an immediate prosthesis. Therefore, Zygomatic implants have revolutionized the treatment of the
the immediate prosthesis should be as robust as possible to severely atrophic maxilla, creating the possibility of imme-
provide rigidity and resistance to fracture. Despite this, it is not diate loading with minimal or no bone grafting. The conse-
uncommon for stress fractures to occur in the first year after quences of severe bone loss dictate the need for prosthetic
provisionalization, particularly when the mandibular arch is also replacement of not only the teeth but also the missing basal
simultaneously treated with implants, thereby increasing the and alveolar bone to restore facial esthetics, phonetics, and
adaptive burden. masticatory function.
289

Fig 15-27 Various trial prostheses to assess lip support with (from left to right) no ridge reduction and a prosthesis with good hygiene access, 8
mm of ridge reduction, and acceptable lip support.
Fig 15-28 Anthropometric mask technology to quan- Fig 15-29 In this case, 6 mm of bone exists below the nasal cavity. Therefore, the
titatively compare a trial prosthesis with no flange ability to remove bone for prosthetic emergence and greater lip support is limited. If
with an acceptable lip-supporting denture. The great- the residual ridge was visible or there was a requirement for a large degree of pros-
est discrepancy (highlighted in red) is in the nasolabial thetic support in this case, there may be a need for a removal flange or overdenture.
region, as expected.
The position of the teeth is dependent on many factors, reduction to place the transition line above the smile line. The
including the opposing dentition, lip support, and esthetic deter- amount of bone reduction possible is limited by the nasal floor
minants from the standpoint of both the clinician and the patient. and sinus cavities (Fig 15-29).
Changing views regarding smile and facial esthetics have pushed Once the prosthesis design is acceptable, this can be scanned
for a fuller, more youthful appearance as opposed to one that along with the patient using either CT or CBCT scanning for
may be more age appropriate. Traditional complete denture prosthetically directed implant surgical planning in programs
conventions placed incisors closer to the residual ridge to reduce such as NobelClinician (Nobel Biocare). The results of planning
leverage forces that act to dislodge the tissue-supported pros- will dictate the surgical approach and highlight any difficulties
thesis. Residual resorption is directed palatally; therefore, over with implant placement in the correct position.
time the incisors would also move palatally, detrimentally affect-
ing lip support. Implant anchorage enables placement of teeth in
any desired position. A long-standing denture patient therefore Guided surgery
may be able to undergo a dramatic change in facial appearance.
Digital Smile Design may help with initial planning of tooth size Optimal positioning of a tilted implant such as a zygomatic
and proportion for an individual; however, it is limited in terms of implant requires precise control of the entry and exit locations
the effects of facial support, especially in the atrophic maxilla.45 and the trajectory of the implant placement to provide adequate
Consequently, it is important to test the changes by providing bone anchorage.
a trial prosthesis for acceptance by the patient prior to surgery In the digital age, dental implant treatment is powered by
(Figs 15-27 and 15-28). CBCT diagnostic imaging, computer simulation, and additive
The trial prosthesis should mimic the contours of the defin- manufacturing. CBCT images provide accurate information
itive partial denture, with hygiene access and anticipated bone regarding the jaw anatomy for diagnosis, and computer-based
290

Fig 15-30 The junction between the implant abutment and the pros- Fig 15-31 A verification index consists of an acrylic or composite arch
thetic tooth determines the phonetic surface and should be made as that is constructed on the master cast, supported by temporary cylin-
similar to the natural state as possible to facilitate adaptation. ders, and luted together in the mouth with acrylic or composite. The
luted index can then be tried back on the master cast to verify the
accuracy of the cast prior to construction of the prosthetic framework.
segmentation and virtual surgery allow clinicians to select the to esthetics, hygiene access, phonetics, occlusion, and function
optimal position of the implant. Subsequently, the use of addi- prior to embarking on construction of the definitive prosthesis.
tive manufacturing can produce surgical guides for executing Multiple studies have reported speech disturbance due to
the treatment plan. Although computer-based template-guided maxillary reconstructions, whether removable or fixed, and
surgery is feasible, it is not yet common practice in zygomatic generally the amount of speech disturbance increases with
implant treatment. This is because the current template-guided the size of the intervention. Time, minimal contour of the pros-
protocol is associated with several well-known limitations. First, thesis, correct vertical dimension, and practice are the key requi-
surgical access is more difficult when a surgical guide is in posi- sites for speech adaptation. The presence of interdental spaces
tion, which is more critical when the long zygomatic implant is beneath the tissue surface of the prosthesis and the residual
located more distally. Second, there is no effective mechanism ridge has not been shown to hamper speech intelligibility in
in current template-guided surgery to control the path and exit two papers.49,50 Therefore, the prosthesis should be designed
location of the zygomatic implant.46,47 for hygiene access foremost rather than limiting “airflow” in an
Chow published an article on a novel device called the zygoma attempt to improve phonetics (Fig 15-30).
drill guide, a mechanism to locate the exit point and control the Lip and facial support will change over time with adaptation
trajectory of the zygomatic implant osteotomy.48 However, there to the tooth position and contour of the provisional prosthe-
is no published clinical data on this device. sis as well as with resolution of residual swelling, which, as
In addition to static guided surgery with surgical guides, it is mentioned, may take months. The provisional prosthesis may
possible to perform a zygomatic implant osteotomy by real-time need to be adjusted for these biologic processes, especially
navigation. However, there are very few publications reporting where the change is dramatic. Once patients have adjusted to
on this, and the effectiveness of real-time navigation for place- their new situation, they will often desire to be more involved
ment of zygomatic implants is unknown. with the nuances of construction of the definitive prosthesis.
Changes can be trialed in the provisional and then replicated in
the definitive restoration if accepted.
Provisional prosthesis
As discussed previously, the provisional prosthesis is usually Definitive prosthesis

placed immediately or within a few days to facilitate patient adap-
tation and a return to normal activities. A laboratory-constructed Once the provisional prosthesis has been accepted by the
prosthesis with reinforcement is favored over the conversion of patient, the definitive prosthesis can be essentially copied from
a denture for purposes of rigidity and limiting flexion of the long it. Impressions and jaw relations of the existing provisional pros-
implants. Significant swelling can occur postoperatively, which thesis, opposing arch, and implants are recorded. The provisional
will subside over the course of a few months, usually stabilizing prosthesis can be used to cross-mount the casts and provide
at 6 months; however, it may take longer. Therefore, a robust matrices for the laboratory technician to follow. A verification
provisional prosthesis is necessary. The provisional phase of index to check the master cast is invaluable for the reduction
treatment allows the clinician to make adjustments with respect of errors and possible remakes (Fig 15-31).
291

a b
Fig 15-32 (a) Tooth position, form, and shade as well as lip support have been determined in the provisional prosthesis. (b) The definitive prosthesis
merely fine-tunes the provisional prosthesis, providing esthetic character for this older individual.
Fig 15-33 Zygoma treatment of an atrophic maxilla often entails Fig 15-34 Individualized ceramic crowns on a CAD/CAM-milled titanium frame-
considerable prosthetic replacement of the lost supporting tis- work with composite gingival replacement opposes acrylic denture teeth in a
sues and alveolus. CAD/CAM-milled frameworks from less expen- hybrid acrylic CAD/CAM-milled titanium framework. The acrylic teeth in the
sive materials, in this case CoCr alloy with porcelain veneering, mandible will wear rather than fracture or abrade the maxillary arch.
can reduce the cost while ensuring accuracy of fit and strength.
A trial tooth setup is usually done to verify acceptance with The timing of definitive prosthesis placement should be after
the patient, and then the definitive prosthesis is delivered, know- the soft tissues have stabilized following surgery. Reduction of
ing that any issues with the maxillary reconstruction have been the alveolar ridge to create more room for the emergence profile
rectified in the provisional prosthesis (Fig 15-32). and the placement of implants can result in an excess of tissue
The options for the materials as well as the manufacturing that will take some time to remodel. In addition, the placement
process for the definitive prosthesis are plentiful today. Cast of zygomatic implants is a relatively invasive procedure that will
frameworks are rarely used in favor of computer-aided design/ result in postoperative swelling. The effects of the prosthesis on
computer-assisted manufacture (CAD/CAM) construction for a facial support may only be truly appreciated around 6 months
greater uniformity of material and improved fit.51 Zygoma recon- after implant placement; therefore, the definitive prosthesis
structions often have a large volume to restore due to atrophy should be delayed at least this amount of time.
of the maxilla, so the use of cheaper materials such as titanium, Commonly, a zygomatic reconstruction opposes a mandibular
cobalt chrome (CoCr), and zirconia helps to reduce the overall implant reconstruction. The choice of material for each arch is
cost of the prosthesis (Fig 15-33). up for debate since there is little evidence to support a partic-
A framework may be layered with porcelain, acrylic, and ular option.52 The preference of the authors is for a ceramic
composite, and individual crowns may be made from various reconstruction for stability and individualized esthetics in the
materials and combinations depending on the preference of maxilla and an acrylic/titanium reconstruction for the mandible.
the clinician and technician. Replacement of the lost soft tissue This philosophy minimizes staining and fracture of the maxillary
component can be achieved with pink acrylic, composite, or prosthesis (Fig 15-34). Reported “clicking” by patients as well as
ceramic. Generally, more esthetic results can be obtained with small fractures are minimized by the inherent resiliency of the
acrylic or composite; however, layered porcelain has greater acrylic teeth. Cost is also reduced. Patients need to be aware
longevity and is less prone to staining. As with all procedures, that the mandibular teeth will wear over time and usually need
the skill of the technician has a greater influence than the choice replacement every 5 to 7 years.
of material per se.
292

References
MAINTENANCE should be emphasized that while the success and survival rates
of zygomatic implants reported are very impressive, they have
All patients require maintenance, and the recall frequency should been reported by highly experienced, well-trained teams. As with
be tailored to the needs of the individual. Zygoma patients usually all clinical procedures, training, patient selection, skill in delivery,
have lost their teeth as a result of periodontal disease and there- and attention to detail are key to a successful treatment outcome.
fore will need more assistance from their dental professional.
In addition, zygoma reconstructions have some unique issues.
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294

16 STEPHEN M. PAREL • PAULO MALÓ •
MIGUEL DE ARAÚJO NOBRE
Treatment of the
Edentulous Patient
Using All-on-Four
and the Zygoma Implant
All-on-Four Approach
The Three-Implant Fixed Partial Denture
The Zygoma Implant and All-on-Four
The Extra-maxillary Implant
295

16 | Treatment of the Edentulous Patient Using All-on-Four and the Zygoma Implant
a b
Fig 16-1 (a) Severe mandibular atrophy as a result of long-term denture wear. In a previous era, this patient would have been a candidate for an
extensive block bone graft procedure. (b) Using the all-on-four concept, tilted implants provided a stable base for a fixed prosthesis with cantilever
extension to the first molars.
ALL-ON-FOUR APPROACH implant surgery. This would include those with varying degrees
N
of atrophy, with the exception of patients with severe maxillary
o one knows for sure when it happened, but a atrophy or sinus pneumatization who wish to avoid a graft proce-
paradigm shift occurred in the early 1990s with dure. These individuals might more realistically be candidates for
regard to full-arch implant restoration. A concept zygoma therapy, which is covered in the second section of this
for placing implants at previously unacceptable chapter. Conversely, patients with a severely atrophic mandible
angles, usually in posterior sites, was introduced through the can avoid a very difficult graft procedure when the all-on-four
work and publications of Maló and others.1,2 It was an approach, concept is used because of the benefit of tilting some or all of
eventually known as the all-on-four, which was not immediately the implants to gain length and minimize inferior cortical plate
accepted or understood in an era when the more traditional penetration (Fig 16-1).
vertical implant was known to work very effectively for the An ever-increasing indication for the all-on-four approach is
treatment of edentulism.3–5 the patient with a failing dentition. Nearly all demographic stud-
The advantages this concept offered in treatment planning for ies of the United States conclude that the aging population is
patients who are edentulous or have a failing dentition eventu- living longer and retaining dentition to a far greater degree than
ally began to expand its acceptance. By increasing the antero- ever before. Baby boomers are turning 65 at a rate of 10,000
posterior spread of the implant array, distal cantilevers could per day and will continue to do so well into the next decade.6
be shortened, minimizing implant and restoration stress in the Concurrently, this demographic is also taking an increasing array
molar region. Angling the posterior implant up to 40 degrees of medications, many of which create increasing challenges to
anterior to the maxillary sinus or mandibular nerve canal allowed the health of the residual dentition. Among them, xerostomia
a longer implant to be placed compared to the vertical approach is probably the most prevalent and the most common cause
in either arch. Since implant forces on full-arch distal implants of caries-related failure of the senior adult dentition (Fig 16-2).
may be as much as 10 times higher than those on the ante- The implied definition of edentulism is changing: Yesterday’s
rior implants, an increase in strength was theoretically created denture is today’s removable partial denture. With this shift
with the increased length. The potential for using as few as four comes a growing population of entirely new candidates for
implants universally had clinical advantages in terms of both cost full-arch implant restoration.
and duration of treatment, especially as the corresponding era
of immediate loading became routine.
Even though the term all-on-four is generic, the use of the Expanded applications
number 4 in the trademarked designation is a matter of concern.
This is only a concept, an alternative means of improving resto- Simply stated, the use of implants angled both distally and ante-
ration stability through the angling of implants, which may or riorly has allowed full-arch treatment planning to be expanded
may not require four implants in every patient. To consider the to categories of patients who previously might not have been
four-implant approach as inviolate is to misunderstand the concept. candidates for immediate placement or loading. The need, for
example, for sinus grafting to create posterior implant sites is
now less common. Moderately to severely atrophic jaws that
Clinical considerations might have required large bone grafts in the past can now be
treated with implant lengths that allow immediate loading in
Indications for the use of this technique include essentially any selected clinical situations. Some examples follow.
edentulous patient who presents as a suitable candidate for
296

Fig 16-2 The extensive caries in this 78-year-old patient is presently a

more common finding as a result of teeth being retained longer and
increased use of medications with xerostomic side effects. This patient
with a failing dentition is a representative example of what has become
an integral part of the edentulous clinical picture.
Bone volume deficiencies often the most prudent approach because it will allow conven-
tional integration to occur and will have greater potential for
For years, the only reliable means of evaluating bone volume was long-term implant survival (Fig 16-6).
the panoramic plain film study, which is strictly two-dimensional.
Surgical misadventures could occasionally occur as a result of
Skeletal malocclusion
anatomical anomalies that appeared normal on the panoramic
film. Perhaps the most important advancement in the modern The goal of achieving a Class I occlusal relationship in Class II or
era for treatment planning the full-arch patient has been the III malocclusions with full-arch implant restorations is a challenge
proliferation of cone beam computed tomography (CBCT). The using a vertical implant approach. By angling distal implants
depth of patient information discernible with this mode of film via the all-on-four concept, posterior cantilevers for the patient
study allows the clinician to determine well in advance of sur- with a Class III malocclusion are more adequately supported
gery the potential for implant success as well as the staging of (Fig 16-7). The extended anterior cantilever in the patient with
the ensuing clinical procedures. a Class II malocclusion is also more effectively managed with
In the maxilla, a panoramic film alone may show adequate center implants tilted forward and angled abutments direction-
bone for implant placement, but this can be a misleading find- ally positioned (Fig 16-8). Being able to manage these require-
ing (Fig 16-3). Correspondingly, anatomical undercuts in either ments for implant and abutment position greatly facilitates the
jaw, especially the mandible, may be equally undetectable and creation of a Class I occlusion without the need for significant
even more consequential (Fig 16-4). Prior to CBCT, discovery orthognathic surgical intervention.
of these anomalies at the time of surgery usually led to aban- The patient with a Class II malocclusion almost always has
donment of or unanticipated significant changes in the treat- more translational capability than the other classifications and
ment plan. With the diagnostic capabilities the CBCT provides may therefore require more careful presurgical evaluation with
and the versatility of implant positioning using the all-on-four regard to occlusal scheme. Occasionally those who present
concept, many of these patients can provide realistic informed with a deep anterior overbite on opposing soft tissue only, with
consent and be treated conventionally with same-day resto- no posterior contacts, will not have a repeatable centric occlu-
rations in either jaw. sion. These individuals may struggle to find a centric position for
extended postoperative periods and will require more clinical
visits than other patients to manage their occlusion. Occasion-
Soft bone
ally, it is necessary to reestablish a Class II occlusal scheme.
The absence of suitable bone density can be easily evaluated
in relative terms prior to surgical intervention using bone den-
Age
sity calibrations in the CBCT software (Fig 16-5). Low bone
density measurements have been shown to correlate with low One of the most valuable aspects of the all-on-four concept is
insertion torque, a significant preoperative finding for informed the ability to routinely provide a sufficiently strong implant base
consent, planning for immediate loading, and interim prosthe- for immediate loading considerations. Applying this principle to
sis selection.7–11 aging patients, many of whom were previously thought to be
In patients with soft bone, who are often active or previous contraindicated for any implant therapy, has created a new and
long-term smokers, the decision for immediate loading is usually highly appreciative prospective implant patient population, some
modified to the traditional approach of delayed loading. This is of whom are in their second century (Fig 16-9).12
297

a b
c d
Fig 16-3 (a) The panoramic radiograph shows what appears to be adequate maxillary bone for implant placement. (b) However, the CBCT study
reveals that horizontal atrophy has resulted in a knife-edge ridge in critical areas for implant placement, a finding that was not evident on the
two-dimensional film evaluation. (c) Using the all-on-four approach, implants can be placed palatal to the ridge crest at angles that allow more os-
seous contact and greater implant length. Exposed threads on the palatal aspect are common and acceptable with this approach. (d) An immediate
loading protocol was used, and this 6.5-year follow-up shows no adverse effects of angled implant placement in a horizontally bone-deficient maxilla.
a b c
Fig 16-4 (a) Mandibular anatomy may be similarly masked in a pan-

oramic film study only, which in some cases may have an even
more profound effect on treatment planning. The hourglass shape
of this mandible was only evident on the CBCT evaluation. (b and c)
Vertical resection of the residual alveolar bone would have result-
ed in a severely atrophic residual mandible. Angling the implants
through the top and bottom levels of adequate osseous structure,
as shown in both tomographic and solid model views, allowed for
enough stability to immediately load the provisional restoration. (d)
This panoramic follow-up of more than 7 years shows no adverse
effects of the implants, which are not fully surrounded in bone but
are anchored crestally and apically.
298

a b
Fig 16-5 (a) CBCT cuts show abundant bone for implant placement, which, considered alone, can be misleading. The Hounsfield measurements
show lower than average readings in the medullary spaces. These findings are dependent on the individual CBCT unit and may not be similar on
units from different manufacturers. (b) The solid bone model shows dramatic differences between maxillary and mandibular bone calcification
and density levels in this long-term smoker. This is not only an indication that soft bone exists in the maxilla but is also a valuable, nonintimidating
patient education tool.
Fig 16-6 (a) Insertion torque values on

the maxillary implants were half or less
than half of the anticipated torque values
recommended by the manufacturer. A
maxillary immediate denture was placed
over the protective healing caps. The
decision for delayed loading was made
at the time of surgery, but the patient
was informed of this possibility based
on density measurements prior to any
intervention. (b) Definitive restorations
were completed after a suitable unload-
ed integration period. This is an 8-year, a b
4-month follow-up photograph.
Fig 16-7 The patient with a Class III maloc-

clusion who is edentulous or has a failing
dentition can be converted to a Class I occlu-
sion with distally inclined anterior implants
and angled abutments. (a) Aiming the screw
channels at the center of the opposing ridge
crest will generally leave room for position-
ing the anterior teeth. (b) The final occlusion
was in a Class I relationship.
a b
a b c
Fig 16-8 (a) The patient with a Class II malocclusion presents with cantilever management considerations opposite to those of the individual with
a Class III occlusion. The extended anterior cantilever may require anterior implants that are tilted labially with corresponding angled abutments to
minimize the unsupported extension. (b) Even with the extensive repositioning of the access sites, there may still be a larger than normal anterior
cantilever. Patients generally adapt easily to this configuration. (c) A Class I occlusion is a possibility with these patients, but careful management
of the adaptation to this new position is necessary.
299

a b c
Fig 16-9 (a) This patient’s residual dentition was nonrestorable conventionally. She was 102 years old at initial presentation and in good general
health. (b) The final radiograph after immediate loading with provisional restorations. (c) The patient survived to age 108 years, with the definitive
restorations, shown here, functioning perfectly.
a b c
Fig 16-10 (a) Illustration of a classic pattern of implant failure. The thin line of fibrous tissue indicates a loss of nearly all of the osseointegrated
surface. (b) After simple implant removal, a larger-diameter rescue implant is placed in the site at the same surgery. It can usually be loaded im-
mediately using the existing prosthesis as indicated by the temporary cylinder splinted to the adjacent implants. (c) Radiograph taken after the
definitive restoration had been in function for 3 years and 10 months. No additional bone loss was evident.
a b c
Fig 16-11 (a) It may be more difficult to immediately load the failed maxillary distal implant (shown here being removed) with the existing provisional
restoration because of the potential instability of the remaining implants. (b) Placing a rescue implant and reducing the provisional cantilever so un-
loaded healing can occur is generally recommended. (c) Eventual reconnection to the provisional or definitive restoration can occur after integration.
Complications the original provisional prosthesis with uninterrupted definitive

healing (Fig 16-10).
Enhanced diagnostic capabilities, predominantly related to the Placement of rescue implants in the maxilla is a much less
CBCT, have minimized the complication rate for full-arch res- predictable process, usually requiring a prosthetic approach
torations. Factors related to immediate loading such as higher different from that in the mandible. This is especially the case in
implant insertion torque and increased anteroposterior spread a distal implant site since adjacent implants may not be strong
for improved cross-arch stabilization have made this option far enough to allow healing with immediate loading of a provi-
more viable. Aside from not creating enough vertical space for sional restoration with a full cantilever extension. To avoid what
prostheses, there are relatively few complications to consider may then become a catastrophic event, it is often necessary
other than implant failure. to reduce the distal cantilever to allow unloaded healing on the
When failures do occur, they are usually at the site of the rescue implant (Fig 16-11).13
most stressed immediately loaded implant, ie, the most distal As stated previously, the designation of four implants is not
implant, and usually during the provisional restoration heal- a requirement. In fact, it is only a numerical starting point in
ing period. This complication is usually easier to manage in the treatment planning process, which after a complete health
the mandible and can often be addressed with a procedure history and CBCT analysis may change dramatically. A number
allowing immediate reincorporation of the rescue implant in of factors may influence this decision, most of which were
300

The Three-Implant Fixed Partial Denture
a b
Fig 16-12 (a) The at-risk patient may often require more than four implants.
The thin bone illustrated here is an example of findings that would indicate that
the patient may need additional implant support. (b) Numerous implants were
placed as an alternative to a bone-grafting procedure, which was declined by
the patient. Vomer implants were among the angled components. (c) In this
delayed loading situation, only one implant was lost at the time of integration
evaluation. The definitive restoration is supported by the remaining implants
and has functioned well for more than 5 years.
Fig 16-13 The Novum system was Professor Brånemark’s final Fig 16-14 The Novum was reintroduced in 2012 by Dr Kenji Higuchi as the
contribution to implant dentistry. It remains today as the only Trefoil mandibular fixed partial denture. It has much improved fit and mechanical
viable definitive restoration at the time of surgery. components, and maintains the immediate load capability.
elaborated in a publication by Parel and Phillips regarding risk the principles of immediate loading in its application.3,16 It was
assessment for full-arch implant cases.14 Factors such as bone also Professor Brånemark’s last major contribution to the dental
density, patient sex, opposing dentition, and bruxism, among profession and implant dentistry in particular (Fig 16-13).
others, may be critical to the decision regarding how many It was based on a one-size-fits-all principle, with a prefabri-
implants to place. Planning to avoid failure, especially in at-risk cated bar structure resting on precisely placed implants. The
patients who may require more than four implants, is an inte- Novum was anticipated to be a cost-effective alternative to the
gral part of the all-on-four approach (Fig 16-12).15 conventional mandibular fixed partial denture supported by four
or more implants, and it remains today as the only effective
definitive mandibular implant restoration with the potential for
same-day delivery. Unfortunately, the passivity of fit was incon-
THE THREE-IMPLANT FIXED sistent, causing the concept to fall out of favor a few years later.
PARTIAL DENTURE In 2012, the Novum was reintroduced by Dr Kenji Higuchi as
the Trefoil (Nobel Biocare). With vastly improved mechanical
A unique implant concept was introduced in 1999 by Profes- components and a significantly controlled study protocol, it is
sor P-I Brånemark. Called the Novum system (Nobel Biocare), now a viable consideration for immediate loading in the mandi-
it was a mechanically guided surgical approach that included ble (Fig 16-14).17,18
301

Fig 16-15 The original zygoma implant was made of Fig 16-16 The 45-degree angulation of the hex head
medical grade titanium, with a turned surface and a made this implant much easier to use in conventional
straight hex external connection. It was used from applications.
1987 until 1997 primarily for cancer-related defect
restoration.
THE ZYGOMA IMPLANT AND zygoma concept in concert with conventional implants can often
provide a previously unattainable and predictable level of support
ALL-ON-FOUR and retention for even the most compromised patients with
maxillary deficiency (Fig 16-17).20–22 Maximizing engagement of
Extraoral anchorage with an osseointegrated approach was first the available peripheral defect bone with implant combinations
visualized and ultimately created in 1987 by Professor Brånemark will often result in positional implant combinations emerging at
as a means of providing prosthetic support for patients with significantly divergent angles. This may require an imaginative
maxillary defects. The implant initially used a straight hexagonal approach to prosthesis design, bar configuration, and incorpo-
connection (Fig 16-15) but was modified in 1997 with the intro- ration of retentive devices, all of which falls easily within the
duction of a pre-angled 45-degree platform and a roughened realm of maxillofacial prosthetics. The potential for creating a
surface for improved clinical performance and convenience peripheral seal and functional stability with the addition of the
(Fig 16-16).19 As perhaps the first implant ever designed exclu- zygoma option has created a life-altering opportunity for a patient
sively for angled placement, it conceptually falls within the defi- population that was previously considered treatable with only
nition of the all-on-four approach. marginal improvement in esthetics, function, and self-esteem
(Fig 16-18).23,24
Patients with maxillary defects Trauma

Ablation defects
Patients in this category are similar in the challenges they may
Providing any degree of retention, stability, or functional seal present but are more likely to have significant or unrecogniz-
for patients with maxillary open defects has been one of the able displacement of anatomical osseous structures as a result
most challenging aspects of maxillofacial prosthetics for gener- of their injuries, often in both jaws. Again, the placement of
ations. Dependence on the remaining dentition for the support implants in available bone can result in angular projections
necessary to stabilize the obturating prosthesis is most often a that require an imaginative approach to prosthesis design.
significant challenge to long-term maintenance of periodontal These challenges are usually unique to each individual patient
status because of the excessive cantilever forces generated. (Figs 16-19).
If teeth are subsequently lost or were never present, the chal- Commonly considered an implant designed for the maxilla
lenges for stability are magnified, often beyond any reasonable exclusively, there may be indications for the zygoma implant in
expectation for a functional result. mandibular discontinuity defects as well. Guerrero has used this
Utilizing the approximately 13 mm of dense bone in the zygo- modification for reconstruction and prosthesis support, avoid-
matic buttress, along with maxillary bone where available, the ing the need for block grafting to the defect area (Fig 16-20).25
302

Fig 16-17 (a) This defect was created by

removal of an aggressive, nonmalignant tu-
mor in a 26-year-old patient. Only five molars
remained for prosthesis retention. (b) A cast
precious metal framework was created for
housing two powerful magnet retainers.
The implant positions required two-piece
construction with a center tube and screw
connection.
a b
a b c
Fig 16-18 (a) Opposing magnets in the obturator bulb provided vertical stability in both directions, with a bone-sparing effect on the residual
dentition. (b) The final removable partial denture obturator was constructed with light anterior stresses from occlusion. (c) The frontal plain film
radiograph shows the position of three zygoma implants and additional conventional implants around the periphery of the defect site.
a b
c d e
Fig 16-19 (a) Massive maxillary and mandibular destruction and positional disruption resulting from a self-inflicted gunshot wound. (b) Following
more than 20 months of surgical reconstruction, the patient presented for implant planning and placement. (c) The angulation issues are represen-
tative of implant placement in patients with trauma of this nature. (d) Bilateral zygoma implants provided posterior support in areas where bone
availability was limited. These are augmented by standard interim fixtures in the anterior maxillary area. (e) The occlusion was idealized as much as
possible given the implant positions and intraoral access restrictions. A unilateral crossbite was the only viable option in the right posterior quadrant.
Fig 16-20 Zygoma implants placed in the resected segments of a mandibular

discontinuity defect provided the required support for the eventual prosthesis.
(Courtesy of Dr Cesar Guerrero, Houston, Texas.)
303

a b c
Fig 16-21 (a) An adult patient with ectodermal dysplasia had been using an overdenture prosthesis until the residual dentition was no longer
serviceable. The mandibular arch had been restored with implants 3 years previously. (b) Zygoma implants were used in the posterior areas that
were underdeveloped from the syndrome effect. Additional anterior and hamular sites created a full-arch base of implants for restoration support.
(c) The definitive maxillary fixed prosthesis is anchored with seven prosthetic screws with desirable cross-arch stabilization.
Fig 16-22 (a) This intraoral presentation for an

adult with cleidocranial dysostosis shows virtually
no usable erupted dentition. (b) The radiograph-
ic presentation shows multiple supernumerary
and unerupted tooth formations in both jaws.
(c) Even with several surgical procedures, it was
impossible to remove all of the impacted denti-
tion, especially in the maxilla, without adversely
affecting the already compromised residual bone.
a b Zygoma implants were selected because of their
ability to anchor in unaffected remote bone sites.
(d) Definitive restorations were ceramic in the
maxilla and resin in the mandible.
c d
Patients with bone-related syndromes implant more universal in treatment planning, especially for, but
not limited to, the following patient presentations.
While not generally as challenging as the obturator patient,
there are challenges associated with treating patients who have
Anterior maxillary sinus intrusion
insufficient residual bone volume for reconstruction without
additional support from an extra-maxillary site. Patients with As the size of the maxillary sinus increases with age, the avail-
cleft palate or those with altered dentition and eruption patterns able bone in the anterior maxilla may be limited to the point
such as ectodermal dysplasia or cleidocranial dysostosis are where the resultant anteroposterior spread is ineffective. This
examples of opportunities for zygoma-assisted implant rehabil- will result in poor cross-arch stabilization, a shortened dental
itation where growth patterns have resulted in less than ideal arch, or the necessity to graft the sinus space extensively to
bone availability (Figs 16-21 and 16-22). get the needed posterior implant support for molar occlusion
(Figs 16-23a and 16-23b).26–32 The use of distal zygoma implants
with conventional anterior implants can restore the arch curva-
Indications unrelated to defects ture to the point where grafting is unnecessary, and immediate
loading can often be considered (Figs 16-23c and 16-23d).33–39
As the benefits of a strong distal implant component have
become more appreciated, the range of applications in con-
Severe atrophy
ventional full-arch patients has expanded in kind. Prospects for
a graftless surgery, combined with the convenience of imme- For decades, the treatment of choice for severe maxillary bone
diate loading when possible, has made the use of the zygoma loss was autogenous block grafting from the iliac crest, a lengthy
304

a b c
Fig 16-23 (a) Horizontal views from the CBCT study show extensive sinus intrusion into the
area of the canines bilaterally. Anterior implant placement alone would not allow for distal
cantilevers beyond the premolar region. The patient refused any grafting options. (b) Posterior
zygomas with anterior standard implants allowed for immediate load and created a desirable
anteroposterior spread. (c) The provisional restoration was supported in the molar region by
implant exit points very close to the extent of the distal dentition. Cantilevers were minimal.
(d) The definitive restoration is consistent with the all-on-four concept and was accomplished
without the need for sinus grafting.
a b
c d
Fig 16-24 (a) This patient had been unable to effectively wear a maxillary denture for several years. Retention and stability were entirely based on
adhesion. (b) The panoramic film confirms the almost total absence of available maxillary bone for implant placement. The opposing natural dentition
is a causative factor and a significant treatment planning consideration. (c) Bilateral pairs of implants, known as the quad zygoma approach, provided
adequate support and spread for this definitive prosthesis. Immediate load was not employed. (d) The definitive prosthesis with this approach will
generally have a greater cantilever in the anterior compared with the posterior region. Light anterior occlusion is recommended.
procedure with numerous potential complications. Aside from The original protocol for the quad zygoma approach in the
usually requiring general anesthesia, the procedure was often maxilla was designed around a delayed period of loading for
associated with donor site discomfort, an extended healing implant integration. More recent literature, however, would
period, unpredictable implant success rates, and difficulty wear- seem to support the immediate loading approach as a viable
ing a provisional denture prosthesis. The use of two implants alternative with no significant reduction in reported implant
bilaterally, known as the “quad” approach, eliminated most if success rates.44–47 A guided approach with CBCT validation can
not all of the limitations associated with block graft options further enhance the placement and predictability of the zygoma
(Fig 16-24).38,40–43 implant in severely atrophic patients.48–50
305

a b
Fig 16-25 (a) Classical failure of a distal all-on-four implant in very soft and compromised maxillary bone. Replacement with a standard rescue
implant was considered but was ruled out due to high risk of a repeat event. (b) A zygoma implant was used as a rescue alternative and was
deemed strong enough for immediate loading. (Courtesy of Dr Edmund Bedrossian, San Francisco, California.)
Rescue implants In order to potentiate the features of the extra-maxillary

surgical technique, several developments were needed in both
The almost universal popularity of the all-on-four concept as a implants and abutments. The zygomatic fixture (NobelZygoma
means of graftless reconstruction has resulted in a refocus on 0º TiUnite, Nobel Biocare) features a 5-mm-diameter, 4-mm
the indications for the zygoma implant. The all-on-four approach regular-platform implant with external hexagon connection and
addresses many of the same treatment planning issues with a narrow tip with engaging threads extending to the apex of the
a less invasive surgery. It is ironic, however, that the loss of a implant (NobelSpeedy tip, Nobel Biocare) to enable high primary
distal all-on-four implant has become a very favorable indication stability for immediate function; moreover, the fact that there are
for the use of a zygoma implant in a rescue role.51 Provisional no threads in the coronal third of the implant aims to provide a
prosthesis use can be continuous or reinstated with modifica- stable connection with the soft tissue; and third, the absence of
tions, and immediate load is a realistic possibility (Fig 16-25). angulation on the implant head provides more prosthetic flexibil-
ity for the connection of standard multi-unit angulated abutments
of 45 and 60 degrees (Multi-unit Abutments, Nobel Biocare).
This approach may be relevant for patients with insufficient
THE EXTRA-MAXILLARY IMPLANT bone posteriorly due to pneumatized sinus cavities but without
the classic signs of severe atrophy. An expressed desire from
The implant-supported rehabilitation of edentulous patients the patient to avoid bone grafting will also influence this treat-
with reabsorbed jaws, especially atrophic maxillae, represents ment plan. Surgery involves the placement of four implants in
a challenge for dentists due to anatomical limitations.52 The a combination of one to three zygomatic implants (placed exter-
placement of zygomatic anchored implants through the stan- nally to the maxilla through a channel created to accommodate
dard technique often causes the implant head to emerge too the implant and anchored only in the zygomatic bone covered
palatally for an optimal prosthetic solution (especially in cases by soft tissue) and one to three standard implants anchored
of extreme atrophy), as the bone ridge retracts palatally when it in the anterior maxillary bone (All-on-4 Hybrid, Nobel Biocare;
atrophies.53 The extra-maxillary surgical technique aims to elim- Figs 16-26 to 16-30).
inate these difficulties by placing zygomatic implants external To rehabilitate the severely atrophic maxilla, the zygoma
to the sinus, anchored in the zygomatic bone only and covered all-on-four extra-maxillary technique54–56 has been proven to be
by soft tissue after emerging from the bone. This procedure a valid concept. In these situations, the CBCT evaluation is criti-
aims for the implant head to be positioned in a more favor- cal to preoperatively evaluate the amount of bone available and
able location from the prosthetic point of view. The implants to confirm the diagnosis of severe atrophy (Fig 16-31).
emerge in sites on the crest between the lateral incisor and The surgical approach involves the use of four zygomatic
the first molar, at the ideal prosthetic position, with the pre- implants placed externally to the maxilla, anchored in the zygo-
planned prosthetic screw exits located on the occlusal surfaces matic bone, and covered by soft tissue when the residual bone
of the prosthetic teeth or on the internal wall of the prosthesis crest is insufficient to allow standard maxillary implant place-
through the false gingiva. ment proximal to the midline (Figs 16-32 to 16-35).44
306

The Extra-maxillary Implant
Fig 16-26 NobelZygoma 0º implant featuring TiUnite surface, 5-mm Fig 16-27 Intraoral intraoperative view of an All-on-4 Hybrid rehabilita-
diameter, regular platform, no angulation of the implant head, and a tion, featuring two zygomatic implants inserted using the extra-maxillary
smooth transition zone in the area to be in contact with soft tissue. The surgical technique and two standard implants inserted in the anterior
absence of an angulated implant head is compensated by the multi-unit region of the maxilla. Note the channel created to accommodate the
angulated abutments of 45 and 60 degrees. zygomatic implant anchored only on the zygomatic bone, with no max-
illary anchorage.
Fig 16-28 An All-on-4 Hybrid definitive prosthesis: acrylic partial denture Fig 16-29 Patient smiling after rehabilitation using the All-on-4 Hybrid
(Malo Clinic), featuring a titanium framework and acrylic resin crowns. and an acrylic partial denture (Malo Clinic).
Note the exit of the prosthetic screws (less palatal) in the posterior
region and the reduction of the prosthesis thickness provided by the
extra-maxillary surgical technique.
Fig 16-30 Panoramic radiograph of an All-on-4 Hy-

brid maxillary rehabilitation featuring two zygomatic
implants inserted through the extra-maxillary surgical
technique and two standard implants. In the mandible,
an All-on-4 standard rehabilitation was performed with
the insertion of four standard implants (two anterior
implants with an axial orientation and two posterior
implants tilted distally). The definitive prosthesis in both
jaws consisted of an acrylic partial denture (Malo Clinic)
featuring a titanium framework and acrylic resin crowns.
307

a b
Fig 16-31 (a) The CBCT scan, panoramic view, demonstrates a severely atrophic maxilla with minimal residual anterior maxillary bone for implant
placement. The sinus cavities bilaterally are significantly expanded. (b) The sagittal views confirm the lack of posterior bone for implant placement
and the minimal amount of bone below the sinus floors. This is a typical presentation of a severely atrophic maxilla.
Fig 16-32 An All-on-4 extra-maxillary configuration, with the insertion of Fig 16-33 Intraoral photograph of an All-on-4 extra-maxillary rehabil-
four zygomatic implants through the extra-maxillary surgical technique. itation with the definitive prosthesis, an acrylic partial denture (Malo
The zygomatic implants have only zygomatic anchorage (no maxillary Clinic) featuring a titanium framework and acrylic resin crowns. Note
anchorage). the exit of the prosthetic screws (less palatal) and the reduction of the
prosthesis thickness provided by the extra-maxillary surgical technique.
Fig 16-34 Intraoral photograph (frontal view) of an All-on-4 Fig 16-35 Panoramic radiograph of a maxillary All-on-4 extra-maxillary rehabilita-
extra-maxillary rehabilitation (maxilla) and an All-on-4 stan- tion featuring four zygomatic implants inserted through the extra-maxillary surgical
dard rehabilitation (mandible) with the definitive prosthesis, technique. The mandible has been treated with an All-on-4 standard rehabilitation
an acrylic partial denture (Malo Clinic) featuring a titanium with the insertion of four standard implants (two anterior implants with an axial
framework and acrylic resin crowns. orientation and two posterior implants tilted distally). The definitive prosthesis in
both jaws consisted of an acrylic partial denture (Malo Clinic) featuring a titanium
framework and acrylic resin crowns.
308

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310

17 MARCO RONDA • MASSIMO SIMION •
FORTUNATO ALFONSI
Horizontal Bone
Augmentation Procedures:
A GBR Approach
Classification of Bone Defects
GBR with Nonresorbable Membranes
Surgical Technique
Soft Tissue Management
Clinical Cases
311

17 | Horizontal Bone Augmentation Procedures: A GBR Approach
I
mplant therapy is a predictable strategy to restore CLASSIFICATION OF BONE
esthetic conditions and natural function in edentulous
patients.1 DEFECTS
The key factors are the following:
The process of atrophy is not standardized, and clinical situa-
• Systemic clinical condition of the patient tions can be extremely variable in terms of shape, extension,
• Specific factors related to the surgical technique and type of defect. Different classifications of bone atrophy have
• Materials indicated for prosthetic rehabilitation been proposed to improve the comparison between various
• Esthetic requests made by the patient cases and to associate an appropriate therapeutic plan to dif-
ferent anatomical situations. Some classifications have focused
The progress of scientific knowledge, the evolution of bioma- on the parameter of bone architecture and the quality/density
terials, and the enhancements of modern technologies advanced of tissues. On the other hand, some authors have favored the
the ability to treat increasingly complex cases, converting implan- description of the morphologic aspect.5
tology into a rehabilitative science. Changes in living conditions The most highly regarded classification in literature is that of
and increased expectations for quality of life expand the field Cawood and Howell.7 These authors examined 300 dry crani-
of application to an active aging population in need of adequate ums, analyzing the reabsorption process after tooth loss using
esthetic appearance and function in advanced stages of life. defined and reproducible reference points. Chiapasco et al
Therefore, in daily clinical practice the authors recommend a described a classification of atrophy of the maxilla that takes
comprehensive multidisciplinary approach linked to strict eval- into account the height and thickness of the residual ridges
uation criteria, proper surgical protocols, and an individualized and the distance between the dental arches, giving indications
treatment plan.2 on the reconstructive surgical approach to follow.8 A recent
The authors suggest the following steps: classification of Chiapasco and Casentini details the horizontal
defect based on a prosthetic diagnostic protocol and the possi-
1. Know: Anamnesis and clinical, radiographic, and laboratory ble surgical options, giving it a clinical perspective that makes it
data collection applicable to daily practice.2 There are four classes:
2. Plan: Data processing and development of the treatment
plan • Class 1: Absence of discrepancy among the ideal implant
3. Evaluate: Assessment of the degree of surgical and pros- position, ideal prosthetic position, and alveolar bone volume.
thetic complexity • Class 2: Presence of a moderate horizontal defect. In this
4. Do: Clinical procedures and assessment of outcomes, clinical condition, the procedures of horizontal bone augmen-
including any complications tation are indicated to place the implant in a prosthetically
correct position. The correction of bone volumes can be
Step 3 is a great challenge and requires multidisciplinary inter- combined with the increase of soft tissues by way of connec-
action among the surgeon, prosthodontist or restorative dentist, tive tissue grafts.
and technician. In particular, in anterior sites the esthetic goals • Class 3: Presence of a significant horizontal deficit, and
are more important because the integration of the prosthe- the residual bone anatomy does not allow placement of
sis with the adjacent teeth and achievement of biomimesis is the implant in an ideal prosthetic position while achieving
required. The correct architecture of hard tissues, the harmony primary stability. After the correction of the horizontal defect,
and the integration of soft tissues, and proper implant placement an adequate healing period should be allowed (from 4 to 9
are the prerequisites for achieving correct esthetic, biologic, months, depending on the selected techniques and graft
and functional integration.3 The result depends on the balanc- material) prior to implant placement (a two-stage surgical
ing of available volumetric areas and the ideal esthetic design procedure). The following surgical techniques can be used
of the restoration. for the correction of advanced horizontal defects:
In many cases, the rehabilitative choice is to compensate for –– GBR
the missing volumes through the use of implant-supported pros- –– Autogenous bone block grafts (onlays) taken from intra-
theses with pink ceramic, and thanks to modern computer-aided oral or extraoral donor sites or nonautogenous grafts
design/computer-assisted manufacture technologies, extraordi- • Class 4: Presence of combined horizontal and vertical
nary results are achievable with this approach. In other cases, it defects. The augmentation of vertical defects increases the
is preferable and recommended to restore the missing volumes complexity of the treatment and requires the use of more
using additive/reconstructive surgical techniques. The scientific demanding surgical techniques, which are associated with
literature has provided a large amount of data on the surgical greater and more frequent complications.
techniques of bone augmentation and soft tissue management.4,5
This chapter analyzes the use of the guided bone regenera-
tion (GBR) technique in the treatment of horizontal defects in
the esthetic area.6
312

Surgical Technique
a b c
d e f
Fig 17-1 (a to c) Horizontal bone re-

generation with a two-stage approach:
A titanium-reinforced nonresorbable
membrane is used as a barrier and
covered by the flaps for 6 to 9 months.
(d to h) Once the bone regeneration is
complete, the membrane is removed,
and two implants are placed.
g h
GBR WITH NONRESORBABLE implant placement is recommended at 6 to 9 months depending

on the biomaterial used.9 The suggested procedure is, there-
MEMBRANES fore, a two-stage technique, with removal of the membrane
in the second phase and subsequent implant placement (Fig
The use of nonresorbable membranes is linked to their greater 17-1). The technique also includes steps dedicated to correct
rigidity, which assures greater stability for as long as necessary, management of soft tissues.
contributing considerably to the biologic regeneration process.6
These membranes are used in major defects, whether hori-
zontal, vertical, or combined. The main nonresorbable mem-
branes are made of polytetrafluoroethylene (PTFE) material SURGICAL TECHNIQUE
and are classified into two types: dense (d-PTFE) and expanded
(e-PTFE). GBR with nonresorbable membranes is particularly Flap design
recommended in Chiapasco and Casentini2 class 3 and 4 cases
of partially edentulous patients with horizontal and/or vertical Horizontal bone regeneration in the anterior region is often
defects, particularly in the maxillary esthetic area.4 The tech- required in an intercalated space affected by atrophy pursuant
nique is most useful when the deficit has an irregular shape to bone loss or periodontally compromised teeth. This technique
and the adaptation of a bone block is more complicated.3 The demands a rigid protocol based on specific biologic principles and
GBR technique with nonresorbable membranes involves strict calls for adequate flap design with a precise suture technique.2
surgical protocols, from patient selection to perfect and metic- The flap design is determined by the fact that the palatal
ulous management of soft tissues.4 flap cannot be advanced coronally and that the tissue dimen-
In this technique, the use of a combination of biomaterials sions necessary to cover the new augmented volume must
consisting of autogenous particulate bone and a bone substitute be accomplished exclusively by the coronal positioning of the
is recommended. The technique has specific surgical timing, and buccal flap. This is why the crestal incision will be carried out
313

pel with a perpendicular brushing movement to the length of

the flap within the connective tissue region exposed following
the periosteal incision.10 The procedure allows separation of the
muscle component, located deep in the flap, from the submu-
cosa layer appearing on the surface. This type of procedure
notably reduces vascular lesions and muscle damage, limiting
bleeding and postsurgical edema. The application of this passive
procedure yields another significant coronal advancement of
the flap, measuring on average another 15 to 20 mm. The two
a b passivation procedures together ensure between 30 and 35
Fig 17-2 (a) View of the passivated periostal incision. (b) Coronal dis-
mm of coronal advancement of the buccal flap3,4,10,11 (Fig 17-2b).
placement of the flap and measurement with a periodontal probe.
Timing of the surgical procedure
in the paracrestal buccal area, respecting the thickness of the The clinical success of a regenerative procedure in the esthetic
adherent gingiva. The change of position of the crestal incision zone depends on precise protocols, which are the outcome of
(4 to 5 mm more buccally versus the top of the crest) presents a series of biologic events guided by a combination of techni-
a vertical increase in the palatal flap when it is raised to full cal factors, procedural execution, and operational timing.4 The
thickness.8 The incision described continues on the palatal side preparation phases of the site to be regenerated, the biomaterial
in the intrasulcular space one to two teeth distant on each side graft selection, the shaping and stabilization of the nonresorb-
so as to raise the flap adequately and allow effective adapting able membranes, the suture techniques, and their timing are all
and fixing maneuvers of the membrane. On the buccal side, linked to rigid operational criteria.6 Particular attention should be
the incision proceeds intrasulcularly around the first two teeth paid to soft tissue management procedures, even in the initial
on both sides, completing with two releasing incisions (hockey stages, prior to the volumetric reconstruction of hard tissues.
stick technique), rising vertically to the point of the fornix depth. Post-GBR soft tissue management is related to two distinct
procedures4:
Flap passivation 1. Coronal increase of tissue thickness justified by the need

to support the height of the interimplant papillae
In the maxilla, the coronal displacement of the flaps is limited 2. Restoration of the morphology and quality of the peri-implant
to advancing, with the passivation technique, the buccal flap soft tissues, often altered by the use of a passive buccal
only. The palatal flap consists of fibromucosa, is inelastic, and flap technique
given its structural characteristics, cannot be passivated. Con-
versely, the buccal flap presents significant elasticity but only The whole surgical procedure must, therefore, bear in mind
by way of the detailed and precise employment of dedicated several aspects, preparatory to achieving precise esthetic and
surgical techniques.3 functional results.12 The regenerative potential of the GBR tech-
The first passivation technique requires the use of the nique is such that three-dimensional bone reconstruction may
well-known periosteal incision, the main inelastic component be planned and performed in the height, thickness, and width
of the flap. A single incision—the exact thickness of the peri- available. This leads to the creation of ideal conditions for implant
osteum, targeted in the space immediately above the fornix, positioning that will restore the missing teeth with congruous
and extending from one releasing incision to the other—allows profiles and shapes.
interruption of the periosteum and an average coronal displace- In the procedures of horizontal volumetric increase, the
ment of the flap of around 1 cm. The coronal passivation of the authors recommend the two-stage technique.6 The bone volume
buccal flap created by the periosteal incision is accompanied by is rebuilt by the use of a barrier in the first surgical stage. The
further coronal movement of the flap due to its full-thickness choice of barrier is subject to multiple factors. The most signif-
detachment, measuring about 5 mm. Overall, this initial proce- icant defects and sites requiring a highly predictable result are
dure allows the buccal flap to advance coronally about 15 mm10 treated with titanium-reinforced, nonresorbable membranes.
(Fig 17-2a). The resorbable membranes do not have a space-making effect
The second technique that can be employed allows the clini- and their role as a barrier is not particularly stable over time.
cian to displace the flap coronally (called the brushing technique) This is not a modifiable barrier effect but is related to the type
and is considered both selective and dissective. This procedure of defect. If resorbable membranes are used for more complex
accomplishes the coronal displacement of the flap by way of defects, their barrier effect could prove to be insufficient before
dividing the inner muscle component from the submucosa of the osteogenic processes complete the defect regeneration.4
the flap itself.10 The technique is executed using a no. 15 scal- The time for keeping the membrane in situ to obtain new bone
314

Soft Tissue Management
formation is on average 6 to 8 months.11 This depends mainly SOFT TISSUE MANAGEMENT

on two factors: defect dimension and biomaterial type.
The combination of large defects and the use of nonresorb- The third surgical phase is performed about 4 months after the
able materials slows the bone regeneration processes. Neovas- second phase and comprises implant loading and soft tissue
cularization of a large area and the biology of the bone neofor- management. The periosteum is now adherent to the new bone
mation require a longer period of time, and consequently the surface, increasing its maturation and promoting corticalization;
barrier must remain in situ for a prolonged period. When the the implants are now osseointegrated.3 In this final phase, the
barrier is removed, along with any space-making screws, the management of soft tissue is needed to create optimal quality
implants may be placed.4 of the peri-implant tissues and restore the presurgical gingival
Implant positioning always requires respect for specific condition lost during the bone regeneration surgery. A site that
factors that allow their correct function and healthy mainte- receives bone regeneration surgical therapy may demonstrate
nance. In esthetic areas, there is little margin for error in terms incongruous dislocation of the buccal tissue and loss of a con-
of the intrabony position of the implant.13 Implants positioned spicuous quantity of keratinized gingiva. The inability to move
incorrectly may negatively influence the final esthetic outcome. the palatal flap requires the buccal flap to be moved coronally
More buccal positioning, as opposed to the ideal position, may and palatally in order to achieve palatal flap immobilization in
create symmetry in the scalloped gingival line and the length of the maxilla.10
prosthetic crowns. Adjacent implants that do not have adequate Summing up, soft tissue management during the third surgi-
distance between them are often characterized by the absence cal stage aims to do the following:
of an interdental papilla, and implants placed too palatally limit
the execution of a correct and harmonious prosthetic result.1,5– 1. Restore the fornix depth
8,12–22
It follows that the insertion of implants, even in the pres- 2. Increase the peri-implant keratinized tissue lost during
ence of a sizeable volume of regenerated bone, requires the surgery
use of surgical guidance.16 This phase may be completed with 3. Restore the alignment of the mucogingival line
a connective tissue graft to the crestal base if necessary. 4. Restore the vermillion symmetry distrupted by coronal
Summing up, the second surgical step entails the following4: displacement of the buccal flap during the passivation
techniques
1. Removal of the membrane and its stabilizing elements
2. Insertion of the implants guided by a surgical stent Once soft tissue maturation is complete, the tissues may be
3. Possible crestal connective tissue graft conditioned by progressive modification of the gingival portion
4. Mandatory primary intention healing of the gingival flaps of screw-retained provisional crowns.9
Primary intention closure is required for two precise reasons:

Connective tissue grafting
1. Any connective tissue graft without suprabony vascular
support (ie, a full-thickness flap, rather than a partial-thickness In esthetic areas that require the replacement of more than one
flap, was raised in order to remove the membrane) will tooth and for which esthetic rehabilitation is mandatory, a con-
receive vascular support solely from the crestal flap; conse- nective tissue graft is always suggested. Well-executed bone
quently, an incomplete primary intention closure of the flaps regeneration, whether for a vertical or a horizontal defect, is not
might partially or totally compromise the vascularization sufficient to create ideal support for an interimplant papilla with
of the connective tissue graft and expose it to the risk of dimensions similar to the interdental papillae of the adjacent
necrosis. teeth. Bone volume alone cannot support a papilla; this can hap-
2. At the time of membrane removal (irrespective of the pen only after volumetric increase of the soft tissue.3 The new
connective tissue graft), the regenerated bone is not mature. thickness is shaped into a pseudo-papilla through changes to
The presence of a nonresorbable membrane has isolated the provisional prosthesis, with the aim of obtaining the classi-
the periosteum from the bone volume to be regenerated; cal scalloped gingival margin.
bone regeneration has had only the benefit of osteogenic The implant surface must be placed 3 to 4 mm apical to the
mechanisms of endosteal origin. The regenerated bone does cementoenamel junction of the adjacent teeth (the ideal line
not boast an external cortical cover and is not prepared to linking the buccal profile of bone to healthy teeth), and the
function. It possesses a histomorphometry that cannot be extent of the interdental papilla should be located about 5 mm
superimposed onto the native bone and thus has to be coronally. It follows that the distance between the periodontal
protected. The contact the periosteum reestablishes with bone profile and the tip of papilla is about 8 to 9 mm.10 Indeed,
the regenerated bone surface allows osteogenic processes the GBR technique has great potential to provide the clinician
of periosteal origin to improve bone maturation and obtain with the ability to regenerate bone coronal to the implants and
initial external corticalization as witnessed in our radiologic to create an interimplant bone peak; however, this cannot be
result. preserved, and progressive physiologic remodeling will reduce
315

this volume to create a flat bone morphology.10 This is why a adherent gingiva of a modest thickness (Fig 17-3). The increase
papilla cannot be obtained without an increase in the soft tissue. in keratinized tissue is needed both to ensure peri-implant health
In any case, it is difficult to ensure a papilla with the same and to obtain esthetic tissue integration around the prosthetic
vertical dimension as an interdental papilla, which is known crowns in the maxilla. The probability of the necessity for soft
to be sustained by an interdental bone septum and periodon- tissue surgery is very high in the maxilla because the new bone
tal attachment. Interimplant papillae will always have a lower volume can be covered only by the buccal flap since the pala-
height when compared to natural interdental papillae, despite tal flap cannot be moved buccally.6 The residual keratinized tis-
combined hard tissue and soft tissue increases.3 sue band present at the time of surgery tends to be dislocated
In terms of the timing of connective tissue graft, there are palatally and contracts consequent to the cicatricial effects of
two possibilities4: conventional horizontal mattress sutures performed at the end
of GBR procedure.3
1. At the time of membrane removal and implant insertion During this surgical step, the surgeon has to uncover the
2. Three months after membrane removal and implant insertion implant as well as restore several soft tissue–related anatomi-
cal conditions modified during the GBR surgical protocol.3 The
The first solution has both advantages and disadvantages. The surgical phases may be listed as follows:
main advantage is a reduction of morbidity since it implies one
fewer surgery. At the time of membrane removal, the first step 1. Restoration of the fornix depth
of soft tissue management can be refined with the stabilization 2. Realignment of the mucogingival line
of connective tissue on the top of the crest in the regenerated 3. Implant activation
bone. There are two possible disadvantages. The first is the 4. Increase of the keratinized tissue zone
lack of vascularity of the connective tissue above the immature 5. Restoration of the symmetry of the lip topography if needed
regenerated bone at this juncture; the connective tissue must
be protected and sealed with perfect flap closure for primary This final surgical phase is performed with partial-thickness
intention healing. There is no room for error. With imperfect flap elevation. A flap involving only the alveolar mucosa is
cicatrization of the flap, the exposed tissue graft would certainly elevated from the mucogingival line. Mucosal detachment
necrotize, and without periosteum protection, the immature continues until the hypothetical fornix is reached, a zone where
bone might be absorbed.9 The second disadvantage is hypo- the alveolar mucosa is stabilized to the periosteum with a resorb-
thetical because no randomized trials have been carried out able 6-0 suture.6 Thus prepared, the vascular bed has to be
to demonstrate that a connective tissue graft on bone alone protected by a scaffold on or through which epithelial cells can
is less effective than a graft placed on a periosteal bed. By the be differentiated. Different surgical solutions for increasing the
rules of logic, it should be true, but to date differences are still soft tissues have been proposed by various authors, but no
to be evaluated. ideal protocol can predictably satisfy the surgical and esthetic
The second solution requires different timing: The connective requirements.
tissue graft is performed 3 months after membrane removal and A keratinized tissue graft to replace the missing band of
implant insertion.3 Three months is the amount of time needed adherent tissue is likely the most widely adopted surgical solu-
for the periosteum to perfectly adhere to regenerated bone tion.10 The advantage is that it creates good tissue thickness. Its
and promote its early maturation. This second solution should survival can be ensured by adequate preparation of the recipi-
be more effective. The opportunity to elevate a split-thickness ent site and by a suture technique performed with compressive
flap and create a double vascular bed for hematic tropism of cross sutures, better known as compressive graft stabilization.
the grafted connective tissue should increase its integration. In the case of large grafts, the disadvantage lies in the donor
Furthermore, the presence of periosteum adherent to regen- area morbidity, even though new tissue-harvesting techniques
erated bone is an effective form of protection should there be have considerably reduced morbidity. A second disadvantage
imperfect closure of the flap with consequent secondary inten- concerns the chromaticity of the new graft, which after its
tion healing. An underestimated disadvantage is that with this integration often is more white in color if compared with the
timing, patients undergo supplementary surgery.4 keratinized tissue of the adjacent teeth. This drawback can be
overcome by performing a gingival graft that covers the gingi-
val profile of all of the patient’s teeth, camouflaging the differ-
Gingival grafting ence in color and ensuring a homogenous appearance without
scars and disharmony in morphology. The graft has to cover
The last surgical step of regenerative therapy is in effect a simul- the area where the keratinized tissue is missing as well as the
taneous approach: implant loading and placement of a gingival residual keratinized tissue at the tooth margins after its initial
graft.9 Normally, the tissue graft is required in all regenerated de-epithelialization.6 The limitation of this kind of approach is the
sites because keratinized gingival tissue is lost during the surgical graft dimension: Several centimeters in length and a minimum
phases, and even before surgery, atrophic ridges generally have height of approximately 10 to 12 mm is required.6
316

Clinical Cases
a b
c d e
f g h
Fig 17-3 (a and b) Initial situation. (c) Suture after GBR showing how the buccal flap translates to the palatal area. (d) Connective graft in the
esthetic area to ensure the soft tissue ridge volume will achieve verticality of the papilla.(e and f) Peri-implant autogenous tissue graft to obtain a
good thickness of keratinized mucosa. (g and h) Healing after GBR showing loss of keratinized tissue due to the surgical approach.
A valid alternative to autogenous tissue grafting is the use CLINICAL CASES

of a dermal or collagen matrix, either of which can be a good
alternative to harvesting palatal tissue. With this procedure Case 1: Horizontal bone regeneration
there are no limitations in the quantity and size of the graft
because it does not depend on palatal tissue availability. Another The case was treated with the two-stage surgical approach.
positive aspect is related to perfect chromatic integration. The The first step was GBR with a titanium-reinforced nonresorb-
area where the keratinized tissue has formed, passing over and able membrane (Fig 17-4). Six months later, the membrane was
through the grafted matrix, has a similar color to the residual removed, and the implant was placed. During the same surgical
keratinized tissue around adjacent teeth.8 This technique is, phase, a connective tissue graft was stabilized on top of the
however, limited in esthetic cases for two reasons12: ridge (Fig 17-5). Four months later, the implant was uncovered,
and a gingival graft of significant size was placed to restore the
1. The amount of adherent tissue obtained with this procedure, depth of the fornix (Fig 17-6). A screw-retained provisional crown
consequent to healing by second intention, is often very thin. was placed and progressively modified in its contour in order
This is an esthetic limitation because its thickness should to create the ideal scalloped margin and esthetic integration
contribute to the volume of the pseudo-papilla. (Fig 17-7). Figure 17-8 shows cone beam computed tomography
2. Sometimes the regenerated band of keratinized tissue does (CBCT) images taken throughout treatment.
not possess the desired width because the alveolar mucosa
takes a portion of its space. This is in relation to the process
of secondary intention healing, which is slower and therefore
allows the mucosal tissue to gain more space.
317

a b
c d e
f g h
i j k
l m n
Fig 17-4 Case 1: First surgical stage. (a to d) Frontal and occlusal views with and without the existing prosthesis at the beginning of surgical
treatment. (e) Radiograph taken at the beginning of treatment. (f) The flap design involved two teeth on each side of the site and was completed
with two vertical hockey stick releasing incisions. (g) After the periosteal incision, the muscle was isolated from the submucosal layer. These two
tissue layers were separated with a brushing technique. With this minimally invasive approach, bleeding and swelling were drastically reduced.
(h) The buccal flap was totally released and moved coronally. (i) After exposure of the bone defect, a previously shaped nonresorbable membrane
was fixed palatally with two self-tapping screws. (j) The biomaterial graft was stabilized around the defect and shaped to match the contours of
the membrane. (k) The membrane was fixed on the buccal side with self-tapping screws and tacks. It was adapted to the residual bone in order to
achieve closed contact. The membrane should be 1.5 to 2 mm away from the root profile in order to ensure biologic attachment. (l) The nonresorb-
able membrane was covered with PRF fibrin membranes to improve soft tissue healing and sealing of the wound. (m and n) A 4-0 d-PTFE suture
was used for both horizontal mattress and interrupted sutures. A 6-0 resorbable multifilament suture was applied to the vertical releasing incisions.
318

Clinical Cases
o p
Fig 17-4 (cont) (o and p) The sutures were removed 12 to 15 days after surgery. At this stage, the tissues
were no longer swollen, and the horizontal mattress sutures could be removed easily. (q) Radiograph taken
after membrane placement.
a b c
d e f
g h i
Fig 17-5 Case 1: Second surgical stage. (a and b) Soft tissue health and new bone profile at membrane removal, 6 months after GBR. (c) The
flap design was limited to the crestal incision and one vertical releasing incision. With this design the surgeon could remove the fixing screws
and the membrane while also stabilizing the connective tissue graft. Alternatively, the design could be limited to only a crestal incision. (d to f)
After full-thickness flap elevation, the membrane was found in the same position as during GBR surgery, and after its removal complete bone
regeneration could be appreciated. (g and h) With the help of a surgical guide, the osteotomy was prepared in the regenerated bone, and the
implant was placed. (i) Because of the esthetic importance of the site, a connective tissue graft was necessary at the time of implant placement.
An epithelial-connective tissue graft was harvested from the palatal area, and the epithelial layer was removed with a blade.
319

j k l
Fig 17-5 (cont) (j) Collagen material was adapted in the donor area and stabilized with interrupted
cross sutures, with closure around the teeth on buccal side. (k) The connective tissue graft was
positioned on top of the newly regenerated bone and anchored with thin sutures (6-0 resorbable
sutures) to the palatal flap and to the periosteum on the buccal flap. (l and m) The flaps were
perfectly adapted to the connective tissue graft in order to allow vascularization.
a b c
d e f
g h
Fig 17-6 Case 1: Epithelial-connective tissue graft. (a and b) Four months after placement of the implant and connective tissue graft, the quality,
quantity, and health of the soft tissue is ideal for esthetic prosthetic restoration. (c) A half-thickness flap was elevated. The incision line started
from the modified mucogingival margin, and the buccal flap was lifted until it reached the ideal depth of the fornix. The alveolar mucosa was an-
chored to the periosteum to the depth of the new fornix. (d) The epithelium was removed from the profile of the residual keratinized tissue with
a diamond ball bur. This limits the invagination of the epithelium during graft integration. (e and f) The alveolar mucosa was sutured apically on the
ideal line of the new fornix. The vascular bed was prepared for the keratinized tissue graft, and the implant was uncovered. (g and h) A template
that reproduced the shape of the recipient area was placed on the palatal area in order to perfectly design the dimension and form of the graft.
The donor area was filled with collagen material, which was stabilized with compressive cross sutures.
320

Clinical Cases
i j
Fig 17-6 (cont) (i and j) The keratinized tissue band was stabilized with two different types of sutures:
On the margins, a thin thread (absorbable multifilament 6-0) was used to define the correct spatial
position, and compressive sutures, which are ideal for improving the contact between the graft and
periosteal bed, allowed completion of graft stabilization. (k) Radiograph taken after membrane removal,
implant insertion, and connective tissue grafting.
a b c
d e f
Fig 17-7 Case 1: Prosthetic restoration. (a and b) Soft tissue healing 2 months after the epithelial-connective tissue graft. (c and d) A provisional
screw-retained crown was placed and progressively modified in order to condition the gingival scallop. (e and f) Six months later, the preliminary
crown was placed. Its length was similar to that of the adjacent tooth, and the gingival scallop was in harmony and mature.
Fig 17-8 Case 1: CBCT images. (a)

Before surgery. (b) At membrane
removal. (c) At the time of implant
placement.
a b c
321

a b c
d e f
g h i
j k l
Fig 17-9 Case 2: First surgical stage. (a to d) Clinical situation before treatment. (e and f) Soft tissue healing was
complete about 3 months after tooth extraction. The extraction sites were not filled with biomaterial, nor were they
closed with advanced flaps. (g) Radiograph taken at the beginning of the treatment. (h) The flaps were elevated with
a full-thickness approach involving two teeth anterior to the defect and reaching the maxillary tuberosity posteriorly. (i) m
Some spacer screws were placed in order to define the regeneration profile vertically and horizontally. (j) Two dental
probes were placed for defect measurement: 11 mm vertically and 8 mm horizontally. (k) Allograft material was placed
around the defect in correspondence with the shape of the membrane. (l) The graft was compacted in order to eliminate
spaces and allow intimate contact with the membrane. The membrane was extended over the material and fixed on
the buccal side. (m) A double suture line was performed in order to guarantee perfect closure and seal of the wound.
Case 2: Vertical and horizontal bone tissue graft was placed in order to restore the keratinized gin-
giva and ensure better implant prognosis.
regeneration
GBR was carried out with the application of a titanium-reinforced
The patient presented with severe bone loss in the right max- nonresorbable membrane to guarantee biomaterial stabilization
illa together with soft tissue recession. Due to the extensive and defect site isolation conditions required for bone regener-
area involved, the case was treated with a three-step surgical ation. Four spacer screws were inserted into the native bone
approach. In the first phase the patient underwent the GBR pro- to create a scaffold for biomaterial placement (Fig 17-9). After 9
cedure; in the second phase the membrane was removed, and months, the titanium-reinforced membrane was removed, and
implants were placed. In the third phase an epithelial-connective four implants were inserted into the new bone with the help of a
322

Clinical Cases
b c d
a e f
g h i
Fig 17-10 Case 2: Second surgical stage. (a and b) The tissue quality was good, and the new ridge profile corresponded with that of the adjacent teeth.
(c and d) Radiographs taken at the time of membrane removal. (e and f) The membrane was removed 9 months after GBR. Note how the shape of the
newly regenerated bone corresponded to the shape of the membrane. (g and h) A surgical guide was used for implant placement, precisely following
the plan developed at the time of GBR. The new bone corresponded with ideal positioning of the implants. (i) Closure of the flap after membrane
removal and implant placement was necessary in order for bone maturation to complete through periosteal contact over the following 4 months.
a b c
d e f
Fig 17-11 Case 2: Third surgical stage. (a) A half-thickness flap was elevated in order to prepare the periosteal bed for keratinized tissue grafting.
The alveolar mucosa was anchored apically to the level of hypothetical new fornix. The implants were uncovered. (b) Graft template. (c and d) The
template was divided into two pieces and adapted on both sides of the palate. (e and f) A very thin graft was harvested from bilateral palatal sites
in order to remove only dense connective tissue, leaving the soft connective and adipose tissue.
surgical guide (Fig 17-10). Once osseointegration was achieved, implants were activated simultaneously (Fig 17-11). Figure 17-12
the epithelial-connective tissue graft was performed, and the shows CBCT images taken throughout treatment.
323

g h i
j k l m
Fig 17-11 (cont) (g) The two graft pieces were sutured in the middle and then, after the coronal profile was shaped around the healing abutments,
tested to confirm correspondence with the form defined by the template. (h and i) The keratinized tissue graft was stabilized with two different
types of sutures: On all margins, 6-0 resorbable thread was used to define the precise position of the graft, and several 5-0 compressive cross
sutures were used to ensure intimate contact between the graft and the periosteal bed. (j) After 10 days, the sutures were removed. The graft
was perfectly integrated, approaching maturation, and the fornix was completely restored with its original depth. (k) One month after connective
tissue grafting, the implants were activated, and a provisional screw-retained partial denture replaced the missing teeth. (l and m) Radiographs
taken after membrane removal, implant insertion, and connective tissue grafting.
a b c d
e f g h
i j k l
Fig 17-12 Case 2: CBCT images of the maxillary right second molar and premolar, canine, and central incisor sites,
respectively. (a to d) Bone situation at the time of surgery. (e to h) Nine months after GBR, at the time of membrane
removal and implant placement. (i to l) Six months after implant placement, at the time of uncovering.
324

Clinical Cases
a b c
d e f
g h i
j k l
Fig 17-13 Case 3. (a and b) Clinical views of the patient before treatment,
showing horizontal soft and hard tissue loss. (c) Three-dimensional CBCT
demonstrating a large vertical and horizontal bone defect extending to the nasal
cavity and the sinus. (d) A full-thickness flap was elevated, and a 20-mm-deep
vertical bone defect was exposed. Periodontal attachment loss is evident at the
level of the central incisor and first premolar. (e) A titanium-reinforced e-PTFE
membrane was fixed to the palatal aspect of the defect, and two tenting screws
were placed in the mesial and distal walls of the defect. (f) The defect was
filled with a mixture of 70% autogenous bone chips and 30% deproteinized
bovine bone, and the membrane was fixed buccally with two tacks. (g) A
periosteal partial-thickness flap has been elevated and sutured to the palatal m
flap. (h) The buccal flap has been sutured to the palatal flap with horizontal
mattress and interrupted sutures. (i) Healing was uneventful and complete
after 15 days. (j) Panoramic radiograph taken after the surgery. (k) Stage-two
surgery after 8 months demonstrating complete bone fill of the defect. Two
implants have been placed at the level of the lateral incisor and the canine. (l)
Panoramic radiograph showing the two implants placed in regenerated bone.
(m) After 6 months of submerged healing, the implants were connected with
the abutments, and a definitive all-ceramic prosthetic rehabilitation replaced
the provisional restoration that had been in function for 4 months.
Case 3: Vertical bone regeneration

Figure 17-13 shows the treatment of a 34-year-old female patient the right maxilla. The lateral incisor and the canine had been
who had undergone resective surgery for a benign tumor in extracted.
325

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relationship on esthetics. Int J Periodontics Restorative Dent
2005;25:113–119.
1. Nevins M. Implant dentistry: A continuing evolution. Int J Peri- 14. Sicilia A, Quirynen M, Fontolliet A, et al. Long-term stability of peri-
odontics Restorative Dent 2014;34(suppl 3):s7. implant tissues after bone or soft tissue augmentation. Effect of
2. Chiapasco M, Casentini P. Horizontal bone augmentation proce- zirconia or titanium abutments on peri-implant soft tissues.
dures in implant dentistry: Prosthetically guided regeneration. Summary and consensus statements. The 4th EAO Consensus
Periodontol 2000 2018;77:213–240. Conference 2015. Clin Oral Implants Res 2015;26(suppl 11):
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ment of the buccal flap. Int J Periodontics Restorative Dent 15. Fontana F, Santoro F, Maiorana C, Iezzi G, Piattelli A, Simion M.
2015;35:795–801. Clinical and histologic evaluation of allogeneic bone matrix versus
4. Ronda M, Rebaudi A, Torelli L, Stacchi C. Expanded vs. dense autogenous bone chips associated with titanium-reinforced e-PTFE
polytetrafluoroethylene membranes in vertical ridge augmentation membrane for vertical ridge augmentation: A prospective pilot
around dental implants: A prospective randomized controlled clin- study. Int J Oral Maxillofac Implants 2008;23:1003–1012.
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5. Aghaloo TL, Moy PK. Which hard tissue augmentation techniques Germano AR. Block allograft for reconstruction of alveolar bone
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Int J Oral Maxillofac Surg 1988;17:232–236. resorbed (Class VI) maxilla. A two-step procedure. Int J Oral Maxil-
8. Chiapasco M, Casentini P, Zaniboni M. Bone augmentation proce- lofac Surg 1994;23:219–225.
dures in implant dentistry. Int J Oral Maxillofac Implants 2009; 19. Chiapasco M, Brusati R, Ronchi P. Le Fort I osteotomy with inter-
24(suppl):237–259. positional bone grafts and delayed oral implants for the rehabilita-
9. Rocchietta I, Ferrantino L, Simion M. Vertical ridge augmentation tion of extremely atrophied maxillae: A 1–9-year clinical follow-up
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10. Ronda M, Stacchi C. Management of a coronally advanced lingual 20. Chiapasco M, Casentini P. Implant-supported dental restorations
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326

18 ISTVAN URBAN
Vertical Bone
Augmentation with
Advanced Flap Design
Posterior Mandibular Vertical Ridge Augmentation
Anterior Mandibular Vertical Augmentation
Posterior Maxillary Vertical Ridge Augmentation
327

18 | Vertical Bone Augmentation with Advanced Flap Design
S
upracrestal or vertical bone augmentation presents coronoid process of the mandible. A vertical incision is placed
one of the greatest challenges for bone regeneration in mesiobuccally at least one, and preferably two, teeth away from
implant dentistry.1 This is primarily due to the difficulty of the surgical site. Mesiolingually, a short, 3- to 4-mm incision is
the surgical procedure and its potential complications. placed at the mesiolingual line angle of the most distal tooth
Supracrestal augmentation aims to achieve bone regeneration that is mesial to the defect.
in a direction that lacks bony walls to support the stability of the After the primary incisions, periosteal elevators are used to
bone graft. It is biologically demanding because bone regenera- reflect a full-thickness flap beyond the mucogingival junction
tion and angiogenesis have to reach a significant distance from and at least 5 mm beyond the bone defect. The lingual flap is
the existing bone. In addition, the soft tissue has to be advanced elevated to the mylohyoid line, where the attachment of the
to provide a closed healing environment for the increased dimen- mylohyoid muscle fibers is identified.
sion of the healing bone graft. Several treatment modalities have
been developed for vertical bone growth, including distraction
osteogenesis, onlay bone grafting, and vertical guided bone Preparation of the recipient site
regeneration (GBR). This chapter reviews the different tech-
niques available for vertical bone augmentation with GBR. The exposed bone is cleaned of all soft tissue remnants with
Based on the literature, it can be concluded that vertical GBR chisels (eg, back-action chisels). The recipient bone bed is pre-
can be achieved using stable, titanium-reinforced expanded pared with multiple decortication screw holes using a small
polytetrafluoroethylene (e-PTFE) or dense PTFE (d-PTFE) round bur. If a tenting screw is preferred to precisely determine
membranes. Alternatively, titanium osteosynthesis plates or the desired vertical position, it should be placed at this time.
titanium mesh covered with a resorbable membrane can also
be used.
Membrane adaptation
An appropriately sized membrane is selected and trimmed so

POSTERIOR MANDIBULAR that it totally covers the volume of the graft and the edges will
not be in contact with the natural teeth (note that this is critical
VERTICAL RIDGE
if a nonresorbable membrane is used). The membrane should
AUGMENTATION rest on at least 2 mm of the adjacent bone. Membrane fixation
is a critical aspect of this procedure since immobilization of the
Vertical ridge augmentation in the posterior mandible remains graft must be maintained for graft incorporation. The membrane
a technique-sensitive procedure associated with increased is stabilized first on the lingual/palatal sides using titanium pins
risk of damaging key anatomical structures, such as the lingual or short (3-mm) titanium screws at two or more points.
nerve, the sublingual artery, and the Wharton duct.2–5
Management of the soft tissue is a critical aspect of posterior
mandibular surgery. The flap design should account for the fact Modified lingual flap advancement
that primary tension-free closure will need to be achieved over
an increased dimension after the bone graft has been applied In order to properly achieve primary closure to minimize the
to the defect. occurrence of complications and maximize long-term regener-
ative outcomes, adequate flap release of both the buccal and
the lingual flap is required.6,7 In recent years, different lingual
Flap design flap management techniques for bone augmentation in the
posterior mandible have been proposed in the literature. How-
In general, a flap that is too small is very difficult to manage ever, the level of evidence is limited to technical descriptions
and is often responsible for early membrane or graft exposure. and case series studies.8,9 Additionally, these “classic” tech-
The safety flap should be used in this procedure, a design that niques present limitations associated with complete8 or par-
consists of both crestal and vertical releasing incisions. This tial9 detachment of the mandibular insertion of the mylohyoid
flap design was described previously as the remote flap.2,3 The muscle, which may lead to serious postoperative complications.
rationale behind the flap design is to have enough soft tissue Hence, a more conservative and predictable approach, consist-
to accommodate the increased dimension of the grafted ridge. ing of the advancement of the lingual flap via blunt preparation
With this design, the clinician can anticipate that free flap clo- in three different anteroposterior zones while preserving the
sure with primary tension will be achievable. A full-thickness, entire mylohyoid muscle attachment, was developed and inves-
midcrestal incision is typically used in the keratinized gingiva tigated in a comparative split-mouth cadaver study in addition to
with a no. 15 surgical scalpel. The distal extension of the crestal the author’s years of clinical experience . This technique, called
incision ends within 2 mm of the retromolar pad. For surgical the modified lingual flap advancement technique, involves three
access, a distal oblique vertical incision is made toward the distinct zones (Fig 18-1):
328

Fig 18-1 Illustration (a)

and cadaver specimen (b)
depicting the anatomy of Zone I
the typical insertion of the Zone II
Zone III
mylohyoid muscle on the
internal aspect of the man-
dibular body and the location
of zones I, II, and III.
Mylohyoid line
Mylohyoid muscle
a Hyoid bone b
a b c
Fig 18-2 (a) Elevation of the retromolar pad (zone I). (b) Careful elevation of the soft tissue
located above the superior fibers of the mylohyoid muscle using a blunt instrument (zone
II). (c) Semi-blunt periosteal release using the back end of a no. 15c blade on the anterior
area of the flap (zone III). (d) Demonstration of vertical flap release (~20 mm).
• Zone I: Tunneling and lifting of the retromolar pad. Following deeply in the mandible, flap reflection should be no deeper
a straight supracrestal incision within keratinized mucosa, than in zone II. A semi-blunt periosteal incision is performed
the facial and lingual flaps are carefully elevated. A periosteal with a no. 15 blade in a rotated perpendicular angle using
instrument is used to gently reflect the retromolar pad from a sweeping motion (zone III) into the middle zone (zone II).
the bone and then pull it up in a coronal direction. Since this This maneuver provides flexibility to zone III and helps to
tissue tends to be very elastic and resistant, it is relatively prevent postoperative wound dehiscences, which typically
easy to perform this step. This allows for the incorporation occur if flap management is not adequate (Fig 18-2c). If
of the retromolar pad into the lingual flap (Fig 18-2a), which adequately performed, this technique typically allows for
contributes to maximal flap release and reduces the risk of sufficient flap release to achieve passive primary closure
perforation when working in zones II and III. (Fig 18-2d).
• Zone II: Flap separation with mylohyoid muscle preservation.
After visual identification of the mylohyoid muscle inser- When this technique was objectively compared with the clas-
tion, the soft tissue superior to the muscle is gently pushed sic lingual flap technique, the mean increase in the amount
with blunt instruments in a lingual direction (Fig 18-2b). This of vertical flap release in the test (modified technique) versus
allows the flap to be separated from the superior fibers of the control (classic technique) group in zone I (retromolar pad
the muscle in a minimally invasive fashion, without detach- area), zone II (middle area), and zone III (premolar area) was
ment of the muscular insertion. 8.273 mm (standard deviation [SD]: 1.794; standard error of
• Zone III: Anterior, semi-blunt periosteal release. At the the mean [SEM]: 0.5409), 10.09 mm (SD: 2.948; SEM: 0.8889),
premolar region, where the mylohyoid muscle is attached and 10.273 mm (SD: 2.936; SEM: 0.8851), respectively, reach-
329

Fig 18-3 Force gauge connected to straight mosquito forceps to pull the released
flap in a perpendicular direction respective to the floor of the mouth. Notice the
applied force of ~1.1 N.
Fig 18-4 Measurement of the amount of vertical flap

release using a calibrated probe.
Zone I Zone II Zone III

12 20 16
18
10 14
16
12
Flap release (mm)
Flap release (mm)
14
Flap release (mm)

8
12 10
6 10 8
8
4 6
6
4
2 4
2 2
0 0 0
Mean and SEM Mean and SEM Mean and SEM
Fig 18-5 Bar graphs illustrating the amount of vertical flap release (mean and SEM) for green test (modified tech-
nique) and blue control (classic technique) groups in zones I, II, and III.
ing very strong statistical significance (P < .0001) in all zones Step 2: Cutting the subperiosteal bundles
(Figs 18-3 to 18-5).
Since most patients have periosteal “cross bundles,” the flap
cannot be advanced as necessary once the periosteal incision
Advancement of the buccal flap: has been completed. These dense fibers are gently cut with
Periosteo-elastic technique sweeping incisions, using the blade first in a 45-degree and
then a 90-degree angle. It is important that the blade is no lon-
Careful advancement of the buccal flap and the protection of ger used for flap advancement.
the mental nerve are essential parts of the surgery. The tech-
nique the author’s team developed for this is mostly bladeless
Step 3: Separation of the elastic fibers
and involves three steps.
Once this is completed, a blunt periosteal instrument, such as
a Prichard periosteal or Mini Me (Hu-Friedy) should be used in a
Step 1: Gentle periosteal incision and the
coronal pushing motion to separate the elastic fibers (Fig 18-6).
protection of the mental nerve
This will ensure that the flap will be significantly advanced with
The periosteum should be cut very carefully in the line con- less chance of causing injury to vital anatomical structures.
necting the two vertical incisions. The cut should only be made
through the periosteum and not into the fibers below it. This
incision is just an entrance into the more flexible elastic fibers Clinical cases
that can be further expanded.
The strategy of the clinician should be to minimize any nerve A representative case of bilateral posterior mandibular ridge
injury and even temporary paresthesia of the mental nerve. deficiency treated using the techniques described in this sec-
Around the nerve, the blade should be used very carefully in tion is shown in Fig 18-7.
a backward motion to ensure that no accidental injury occurs. Using the modified lingual flap and the periosteo-elastic tech-
This incision is superficial, and the clinician should make certain nique for lingual and buccal flap advancement can predictably
that only the periosteum is cut and that no incision is made close the flap even in very severe vertical defects in the poste-
deeper into the tissue. rior mandible (Fig 18-8).
330

Fig 18-6 Elastic separation. A blunt instrument is used in a coronal motion to

separate the fibers and advance the flap.
a b c
d e f
g h i
j k
Fig 18-7 (a and b) Labial views of the vertically deficient ridges. (c and d) Labial views of the defects after flap elevation. (e and f) Placement of
particulated anorganic bovine bone combined with autogenous graft (1:1 ratio). (g and h) Labial views of the fixed membranes. Note that on the
left side the anterior part of the defect was regenerated with a resorbable membrane. (i to k) Sutures after flap closure at surgery (i) and after 2
weeks (j) and 9 months (k) of healing.
331

l m n
o p q
r s t
u v w
x y z
Fig 18-7 (cont) (l to o) Labial views of the regenerated bone after 9 months of healing. Three implants with an internal connection were placed on
both sides. (p and q) Occlusal views of the soft tissue dimensions after implant placement. Note the minimal amount of keratinized tissue. (r and
s) Labial views of the strip gingival grafts used to augment keratinized tissue. (t to v) Labial and occlusal views of the soft tissue dimensions after
abutment connection. Note the good quality and quantity of soft tissue dimensions on both the buccal and lingual sides. (w and x) Labial views
of the definitive restorations. (y and z) Periapical radiographs of the crestal bone after 3 years of loading.
332

a b c
d e f
g h i
j k l
m n o
p q r
Fig 18-8 (a and b) Oblique and anterior views of a patient seeking treatment of a severe vertical defect in the right mandible. (c) Panoramic ra-
diograph revealing that the defect involves the entire alveolar bone close to the alveolar nerve. (d) Note that the mylohyoid muscle was attached
on the crest. This part of the flap was advanced without disturbing the muscle attachment. (e) Autogenous bone was harvested from the ramus
using trephines and then particulated in a bone mill. (f) Autogenous bone mixed with anorganic bovine bone matrix (ABBM). (g) A perforated
titanium-reinforced d-PTFE membrane was fixed lingually. (h) Labial view of composite graft (1:1 ratio of autograft mixed with ABBM) in place. (i
and j) Labial and anterior views of the fixed membrane immobilizing the graft. Note that no tenting screws were needed. (k) Oblique view of the
advanced lingual flap. Note that the flap is several centimeters higher than the membrane, which is more than a centimeter higher then the ridge.
(l) The flap was advanced on the buccal aspect using protective steps for the mental nerve. (m) A native collagen membrane was used to cover the
perforated PTFE membrane. This membrane was selected for allowing additional vascularization of the bone graft. (n) Tension-free, double-layer
closure was achieved using 3-0 PTFE and 6-0 monofilament sutures. (o) Occlusal view of uneventful healing after 9 months. (p) Labial view of the
PTFE membrane in place after flap elevation. (q) Labial view of the regenerated bone. Note the excellent vertical bone gain. (r) Occlusal view of
implants placed into the regenerated bone.
333

a b c
d e f
g h i
j k l
Fig 18-9 (a) Labial view of a patient presenting with an anterior mandibular vertical defect after a
trauma. (b) At the lateral incisors the lingual bone was missing, and external resorption was noted;
therefore, the two lateral incisors were extracted. (c) Labial view of the periosteal incision exposing
the dense connective tissue. (d) Labial view of the advancement of the flap with a microsurgical
periosteal instrument (Mini Me). (e) Labial view of the lingual flap advancement. (f and g) Lingual
view of fixing a perforated d-PTFE membrane using two titanium screws and a titanium tack. (h)
Labial view of autogenous particulated bone mixed with anorganic bovine bone matrix. (i) Labial
view of the stabilized membrane. (j) A collagen membrane was used to cover the PTFE membrane.
(k and l) Labial view of the tension-free flap closure at surgery (k) and after 2 weeks of healing (l).
(m) Labial view of the regenerated anterior mandible after 9 months of uneventful healing.
m
ANTERIOR MANDIBULAR pulling on this flap frequently result in the suture line opening
and early membrane exposure. Therefore, it is imperative that
VERTICAL AUGMENTATION lingual flap management be practiced safely and effectively in
this region as well.
Reconstruction of the anterior mandible requires mobilization A representative case of anterior mandibular vertical augmen-
of both the buccal and lingual flaps. Performing only buccal flap tation is shown in Fig 18-9.
mobilization usually results in poor clinical outcomes; the forces
334

Posterior Maxillary Vertical Ridge Augmentation
a b c
d e f
g h i
Fig 18-10 (a) Labial view of a long-span, 10-mm vertical defect in the posterior maxilla of a healthy,
60-year-old male patient. (b) Labial view of an e-PTFE titanium-reinforced membrane fixed on the
palate after sinus augmentation has been performed. (c) Labial view of the sinus graft and vertical
bone graft, composed of a 1:1 ratio of ABBM and autogenous bone. (d) Labial view of the e-PTFE
membrane fixed and the sinus window covered with a collagen membrane. (e) Labial view of the
soft tissues after 9 months of uneventful healing. (f and g) Labial view of the e-PTFE membrane in
place and during its removal, demonstrating vascularized bone. (h to j) Labial and occlusal views
of the regenerated bone demonstrating more than 10 mm of vertical and horizontal bone gain.
POSTERIOR MAXILLARY remodeling or implant success rates between simultaneous

sinus, horizontal, and vertical augmentation cases compared
VERTICAL RIDGE with vertical ridge augmentations performed in other regions
AUGMENTATION of the mouth.11–13 These results are encouraging, and the author
strongly recommends that the clinician should perform the sinus
Sinus augmentation is a well-documented, frequently per- and ridge augmentation simultaneously.
formed, and predictable procedure with established methods A “safety flap” should be designed with a mesial vertical
and a low rate of complications.6–8 However, in about 30% of the releasing incision one or two teeth mesial to the defect. On the
cases9,10 there is a combination of a ridge defect and sinus prox- distal side, no vertical incision is made; instead, the midcrestal
imity. Most of these combination defects are horizontal defects; incision is continued into the mucosa. A palatal vertical releas-
however, typically in patients with previous severe periodontal ing incision is performed at the mesiolingual line angle of the
disease, a vertical ridge deficiency also exists. In these cases, most distal tooth mesial to the defect.
a simultaneous sinus and ridge augmentation is necessary. A representative case requiring posterior maxillary vertical
The author has demonstrated in a retrospective study that and sinus augmentation is shown in Fig 18-10.
there were no statistically significant differences in crestal bone
335

Fig 18-10 (cont) (k) Occlusal view of the im-

plants placed into the newly formed ridge. (l)
Periapical radiograph demonstrating stable
crestal bone after 10 years of loading. (m and
n) Panoramic and cross-sectional views of the
implant after 10 years of loading.
k l
m n
CONCLUSION 6. Urban IA, Monje A, Lozada JL, Wang HL. Long-term evaluation of
peri-implant bone level after reconstruction of severely atrophic
edentulous maxilla via vertical and horizontal guided bone regen-
Based on the literature and the author’s clinical experience, it eration in combination with sinus augmentation: A case series
can be concluded that vertical GBR can be achieved using form- with 1 to 15 years of loading. Clin Implant Dent Relat Res 2017;
stable, titanium-reinforced e-PTFE or d-PTFE membranes. 19:46–55.
7. Pikos MA. Atrophic posterior maxilla and mandible: Alveolar ridge
Alternatively, titanium osteosynthesis plates or titanium mesh reconstruction with mandibular block autografts. Alpha Omegan
covered with a resorbable membrane can also be used. 2005;98:34–45.
8. Ronda M, Stacchi C. Management of a coronally advanced lingual
flap in regenerative osseous surgery: A case series introducing a
novel technique. Int J Periodontics Restorative Dent 2011;31:
505–513.
REFERENCES 9. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus
Consensus Conference of 1996. Int J Oral Maxillofac Implants
1. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a 1998;13(suppl):11–45.
membrane technique associated with osseointegrated implants. 10. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on
Int J Periodontics Restorative Dent 1994;14:496–511. the survival of endosseous dental implants. A systematic review.
2. Tinti C, Parma-Benfenati S. Vertical ridge augmentation: Surgical Ann Periodontol 2003;8:328–343.
protocol and retrospective evaluation of 48 consecutively inserted 11. Urban IA, Nagursky H, Lozada JL. Horizontal ridge augmentation
implants. Int J Periodontics Restorative Dent 1998;18:434–443. with a resorbable membrane and particulated autogenous bone
3. Urban IA, Lozada JL, Jovanovic SA, Nagursky H, Nagy K. Vertical with or without anorganic bovine bone-derived mineral: A prospec-
ridge augmentation with titanium-reinforced, dense-PTFE tive case series in 22 patients. Int J Oral Maxillofac Implants
membranes and a combination of particulated autogenous bone 2011;26:404–414.
and anorganic bovine bone-derived mineral: A prospective case 12. Urban IA, Nagursky H, Lozada JL, Nagy K. Horizontal ridge augmen-
series in 19 patients. Int J Oral Maxillofac Implants 2014;29: tation with a collagen membrane and a combination of particulated
185–193. autogenous bone and anorganic bovine bone-derived mineral: A
4. Urban IA, Lozada JL, Wessing B, Suárez-López del Amo F, Wang prospective case series in 25 patients. Int J Periodontics Restor-
HL. Vertical bone grafting and periosteal vertical mattress suture ative Dent 2013;33:299–307.
for the fixation of resorbable membranes and stabilization of partic- 13. Urban IA, Jovanovic S, Lozada JL. Vertical ridge augmentation
ulate grafts in horizontal guided bone regeneration to achieve more using guided bone regeneration (GBR) in three clinical scenarios
predictable results: A technical report. Int J Periodontics Restor- prior to implant placement: A retrospective study of 35 patients
ative Dent 2016;36:153–159. 12 to 72 months after loading. Int J Oral Maxillofac Implants
5. Simion M, Fontana F, Rasperini G, Maiorana C. Vertical ridge 2009;24:502–510.
augmentation by expanded-polytetrafluoroethylene membrane
and a combination of intraoral autogenous bone graft and depro-
teinized anorganic bovine bone (Bio Oss). Clin Oral Implants Res
2007;18:620–629.
336

19 MARC L. NEVINS • WILLIAM V. GIANNOBILE •
YOUNG-DAN CHO • CHIN-WEI WANG
Growth Factors:
Clinical Development
for Periodontal and
Implant Applications
Biology and Clinical Development of Growth
Factors
Clinical Applications
Tissue Engineering for Periodontal Tissue
Regeneration
Future Directions and Conclusion
337

19 | Growth Factors: Clinical Development for Periodontal and Implant Applications
TABLE 19-1 Growth factor biologics and dental clinical applications

Molecule Source Mechanism Product (manufacturer) FDA approval in dental application
BMP-2 Bone morphogenetic Increased osteoblast differentiation Infuse Bone Graft (Medtronic) Sinus augmentation
proteins Bone mineralization Socket preservation
PDGF-BB Blood platelets Increased blood vessel formation GEM 21S (Lynch Biologics) Intrabony defect
Cellular proliferation Furcation treatment
Wound healing Gingival recession
FGF-2 Basic fibroblast growth Increased angiogenesis REGROTH (Kaken Under development
factors Cell proliferation and differentiation Pharmaceutical) (Japanese domestic approval only)
Wound healing
ECM synthesis
GDF-5 Growth and differentiation Increased PDL cell proliferation Ongoing development by Under development
factors Osteoblast differentiation Medtronic and Scil Technology
ECM synthesis
Teriparatide Parathyroid hormone’s first Increased bone anabolic effect FORTEO (Eli Lilly) None
34 amino acids Osteoblast activation
FGF-2, fibroblast growth factor 2; ECM, extracellular matrix; GDF-5, growth differentiation factor 5; PDL, periodontal ligament.
A
dvances in biomedicine continue to evolve toward cloning,2 and FDA approval has been obtained, allowing human
minimally invasive procedures with faster healing clinical applications (Table 19-1).
using biomimetic approaches and improvements
in patients’ quality of life. The use of biotechnology
and growth factors has advanced the field of dentistry by allow- Bone morphogenetic proteins (BMP-2
ing clinicians to regenerate periodontal and supporting alveolar
bone tissues around teeth and dental implants. While the US
and BMP-7)
Food and Drug Administration (FDA) approvals for growth factors Biology
for oral surgical and periodontal treatment are rather limited, the
combination of preclinical and clinical research advances over the BMPs were first isolated by Urist in 1965.3 They are a group of
past 30 years has made significant advances to dental surgical growth factors that are members of the transforming growth
care beyond these limitations, often including “off-label” utili- factor beta (TGF-β) superfamily.4 BMP-2, a well-known regula-
zation for expanded indications. In this chapter, an overview is tor of bone formation, is a hydrophobic glycoprotein, classified
presented for the most studied growth factors, including clinical as a morphogen.5 This unique biologic activity has allowed its
applications for those that are FDA approved and commercially application as a therapeutic agent for bone-related reconstruc-
available for human use. These growth factors are recombinant tions and has made it an important molecule impacting the
human bone morphogenetic protein-2 (rhBMP-2) and recom- development of skeletal tissues in general. As a developmental
binant human platelet-derived growth factor BB (rhPDGF-BB). regulator, it interacts with other signaling pathways to promote
The authors have not included comparison with platelet gel skeletal development. The BMP signaling pathway is mediated
products, mesenchymal stem cell concentrates, nor amelo- by a heteromeric complex of type I and type II transmembrane
genins, given the limited information available on comparisons serine/threonine kinase receptors.4 Subsequent SMAD signal-
with these approaches. ing transduction cascades stimulate osteoblast differentiation
and bone mineralization6 (Fig 19-1).
Development and clinical applications

BIOLOGY AND CLINICAL
With progress in the understanding of the important roles of
DEVELOPMENT OF GROWTH
BMPs, tissue engineering trials for regenerative therapy have
FACTORS focused on osseous wound healing, beginning with early pre-
clinical repair of nonunion fractures as well as sinus graft-
Cells and tissues contain naturally occurring bioactive proteins, ing and socket preservation for buccal wall extraction socket
which are termed morphogens or growth factors.1 These mol- defects.7,8 The first BMPs commercially available and approved
ecules have received considerable attention in the tissue engi- by the FDA were Infuse Bone Graft (Medtronic; rhBMP-2) and
neering fields. Advances in recombinant biotechnology have Osigraft and OP-1 Implant (Stryker Biotech; rhBMP-7) for clin-
enabled the mass production of growth factors by molecular ical use, including spinal lumbar fusion and tibial nonunion.8
338

Biology and Clinical Development of Growth Factors
BMP PDGF FGF
BMPRII
BMPRI
PDGFR
PDGFR
FGFR
FGFR
P P
P Ras
PI3K RAS PLC
R-Smad R-Smad
Raf
Co-Smad
AKT MAPK PKC
MEK 1/2
Erk
Transcription
Cell proliferation Angiogenesis

Cell adhesion Cell survival
Cell differentiation
Fig 19-1 Summary of BMP, PDGF, and fibroblast growth factor 2 (FGF-2) cellular signaling pathways. Erk, extra-cellular signal-regulated kinases;
MAPK, mitogen-activated protein kinases; MEK1/2, mitogen-activated protein kinase kinase 1 and/or 2; PKB, protein kinase B; PKC, protein kinase
C; Pl3K, phosphatidylinositide 3-kinases; PLCγ, phospholipase C gamma.
Although FDA-approved usage is permitted for bone-related isoform and has the highest affinity with PDGFR-β. Upon acti-
treatments, it is currently limited to a specific carrier (acellu- vation by PDGF, two receptors are dimerized, turning on sig-
lar collagen sponge, ACS), which is a non-space-making scaf- nal transduction by autophosphorylation of the tyrosine-kinase
fold matrix.9 Therefore, a large number of clinical applications receptors (see Fig 19-1). The action of rhPDGF is dual; it acts
have been off-label,10 and the results, while overall impressive directly on the bone and periodontium-forming cells by increas-
in terms of bone healing, showed limitations such as ectopic ing the neovascularization of the wound through its indirect
bone formation, antibody formation, inflammation, and edema.11 effects of upregulation of vascular endothelial cell growth fac-
Despite controversy about the effectiveness of rhBMP, its clin- tor.21 Although the majority of the applied growth factor remains
ical use has been widespread in the orthopedic area. Since detectable in wounds for less than 48 hours, its effects are
FDA approval of rhBMP-2 (INFUSE Bone Graft) for sinus floor long standing, lasting more than 8 weeks due to a biologic
augmentation and localized alveolar ridge augmentation, many “cascade” effect. This has been established by wound fluid
studies have demonstrated its strong osteogenic potential for evaluation during a periodontal clinical trial documenting the
alveolar bone regeneration.12–15 presence of elevated levels of interstitial collagen telopeptide,
which is a bone-specific collagen in the gingival crevicular fluid
samples of rhPDGF-treated sites.22
Platelet-derived growth factor BB
Biology Development and clinical applications
PDGF was one of the first growth factors characterized16 and is Many in vitro studies have demonstrated the biologic effect
the most-studied growth factor developed clinically in the den- and molecular mechanisms of rhPDGF-BB activity.23 The initial
tal arena.17 PDGF is naturally sequestered in bone matrix and preclinical studies demonstrating the regenerative potential of
is secreted by platelets during the wound healing process.18 growth factors for periodontal regeneration were published in
The PDGF signaling network consists of five biologically active the late 1980s.24 These preclinical studies demonstrated the
ligands (four homodimers: PDGF-AA, PDGF-BB, PDGF-CC, ability of rhPDGF-BB, alone or in combination with insulin-like
and PDGF-DD and one heterodimer: PDGF-AB) and three dimeric growth factor 1 (IGF-1), to induce periodontal regeneration in
combinations (PDGFR-aα, PDGFR-bβ, and PDGFR-aβ) of two naturally occurring and surgically created periodontal alveolar
receptors (PDGFR-α and PDGFR-β).19 PDGF acts as a potent bone defects. The next decade led to multicenter clinical trials
mitogen to regulate cell growth and division and also has a crit- combining IGF-1 with PDGF to treat intrabony and furcation
ical role in angiogenesis.20 PDGF-BB is the prevalent circulating defects.25 The initial studies demonstrated the power of growth
339

PDL
NC
NB
a b c
Fig 19-2 (a) Advanced periodontal bone loss evident after placement of a calculus notch and scaling and root planing. (b and c) Histologic evidence
of periodontal regeneration on the previously diseased root surface with new cementum (NC), periodontal ligament (PDL), and alveolar bone (NB).
factors to heal large Class II furcations and interproximal bone significant increase in the extent of LBG (P < .01), %BF (P <
defects. The control furcation sites treated with a methylcellu- .004), and CAL gain (P < .01) when compared with the control
lose gel displayed minimal bone gain (0.1 mm) versus the IGF/ group (β-TCP only).
PDGF-treated site, which demonstrated 2.9 mm of bone fill on
reentry. The result was a broad continual effort in translational
science to present the biologic rationale for PDGF-BB as an Fibroblast growth factor 2
important periodontal therapeutic.24
Biology
Human histologic studies Fibroblast growth factor (FGF) was first discovered in 1974 from
The earlier studies led to a human histologic study demon- cow pituitary gland.28 In the 1980s, two proteins—acidic FGF
strating the ability of rhPDGF-BB, combined with demineral- (aFGF, FGF-1) and basic FGF (bFGF, FGF-2)—were identified,29
ized freeze-dried bone allograft, to induce periodontal regenera- and complementary DNA (cDNA) of human FGF-2 was cloned.30
tion for intrabony and Class II furcation defects (Fig 19-2).26 The Since then, more FGFs have been isolated and identified, with
histology presented clear evidence of new cementum at and 23 members now included in the FGF family. FGF receptor
coronal to the calculus notches placed prior to surgical cleaning (FGFR) comprises four types (FGFRs1 through FGFRs4) and
of the root surface and adjacent healthy and vascular periodontal has extracellular immunoglobulin-like domains, transmembrane
ligament and new alveolar bone. The regenerative response was regions including tyrosine kinase, and C-terminal domains.31
documented for both intrabony and Class II furcation defects. FGFs are widely expressed in cells and tissues and regulate a
wide range of cellular functions: cell proliferation, migration, dif-
Phase III human clinical trials ferentiation, angiogenesis, and wound healing.32,33 FGF-2 binds
A randomized, controlled clinical trial was designed as an FDA to the extracellular domain of FGFRs and then induces the phos-
pivotal trial for approval of a commercial product, GEM 21S phorylation of the intracellular domain of FGFRs.31 Activation
(Lynch Biologics). This study tested two doses of rhPDGF-BB of tyrosine kinase induces phosphorylation on various tyrosine
(0.3 mg/mL and 1.0 mg/mL) combined with beta tricalcium phos- residues; then the activated FGFRs recruit target proteins to
phate (β-TCP) versus the control of β-TCP alone in the treatment its cytoplasmic tail and phosphorylate these proteins, trans-
of intrabony periodontal defects.27 In the radiographic analysis, ducing the intracellular downstream signaling pathways, such
both doses showed significant increases: linear bone growth as mitogen-activated protein kinase, phosphoinositide 3-kinase/
(LBG) of 2.88 versus 1.42 mm and percent bone fill (%BF) of Akt, and protein kinase C pathways34 (see Fig 19-1). The criti-
60.5% versus 32.6% at 12 months (P ≤ .001), and LBG of 3.32 cal effects on mesenchymal cells within the periodontal liga-
versus 1.81 mm and %BF of 68.3% versus 41.5% at 24 months ment have been reported to be effective in periodontal tissue
(P ≤ .001). In the clinical examination, the 0.3-mg/mL PDGF-BB regeneration.31,35,36
treatment group showed the greatest improvement in clinical
attachment level (CAL) gain and probing depth (PD) reduction
Development and clinical application
throughout the 36-month study. In the composite outcome
analysis of CAL and LBG, 0.3-mg/mL PDGF stimulated peri- Compared to BMPs and PDGF-BB, FGF-2 has been limited by
odontal regeneration. In the follow-up clinical trial,17 only one the fact that it has yet to gain FDA approval. In 2001, rhFGF-2
dose (0.3-mg/mL) of rhPDGF-BB was used with β-TCP in the was first used as a medication for chronic skin ulcers in the clin-
intraosseous defect in the test group. The test group showed ical field (Fiblast spray, Kaken Pharmaceutical), and its clinical
340

Biology and Clinical Development of Growth Factors
effect has been demonstrated.37 FGF-2 has important effects a phase IIa clinical study, comparable safety of rhGDF-5 was eval-
on periodontal tissue regeneration, and the results of a mul- uated in the patients’ blood samples,49 and periodontal wound
ticenter, randomized clinical trial demonstrated the effective- healing/regeneration were evaluated clinically and histologi-
ness and safety of rhFGF-2 for enhancing periodontal tissue cally in an intrabony defect. The results showed PD reduction,
regeneration.36,38,39 In one multicenter clinical trial in the United CAL gain, and significant bone regeneration at the site receiv-
States,38 three doses (0.1%, 0.3%, and 0.4%) of rhFGF-2 were ing rhGDF-5/β-TCP compared with control.50 In a multicenter
applied with β-TCP, and β-TCP alone was used as the control, in clinical study,51 sinus augmentation with rhGDF-5/β-TCP resulted
vertical intrabony periodontal defects. Significant improvement in a comparable amount and similar quality of new bone com-
of clinical attachment and %BF was observed in the 0.3% and pared with β-TCP/autogenous bone graft. Based on this scien-
0.4% rhFGF-2/β-TCP groups over control and 0.1% rhFGF-2/β- tific and clinical evidence, Medtronic and Scil Technology have
TCP groups. Moreover, the success rate at 6 months was 71% established a partnership for the commercial usage of rhGDF-5,
in the 0.3% and 0.4% rhFGF-2/β-TCP groups, as compared with and development of a therapeutic agent is underway.
45% in the control and 0.1% rhFGF-2/β-TCP groups. In a mul-
ticenter clinical trial in Japan,39 control (vehicle only) and 0.2%,
0.3%, and 0.4% rhFGF-2 were tested in two- or three-walled Teriparatide
vertical bone defects. In this study, a gel-like formulation was
Biology
used to improve drug administration. Although there were no
significant differences among groups, percentage bone fill Teriparatide (FORTEO, Eli Lilly) is a recombinant protein form
showed significant superiority for each dose of rhFGF-2 at 36 of parathyroid hormone (PTH) and is the first FDA-approved
weeks after administration. Based on these results, rhFGF-2 has anabolic agent for the treatment of osteoporosis.52 This syn-
recently been commercialized in Japan as REGROTH (Kaken thetic peptide mimics the action of PTH on bone, inducing the
Pharmaceutical) under a domestic approval for dental surgery. increase of osteoblast number and activity and a decrease
of osteoblast apoptosis.53,54 Teriparatide involves the mecha-
nism of the WNT signaling pathway, which stimulates bone
Growth differentiation factor 5 formation, and downregulating sclerostin, which is an inhib-
itor of the WNT-LRP5/6 signaling pathway.55 Many pharma-
Biology
cologic agents, such as anti-proteinases, anti-inflammatory
Growth differentiation factors (GDFs) are a subfamily of drugs, bone-sparing agents, and bone-forming drugs, have been
the TGF-β superfamily that are dominantly expressed during studied for host modulatory therapy for periodontal treatment.
the developmental stage.40 Among the GDFs, GDF-5, also Among them, PTH represents a recent research field, and many
known as cartilage-derived morphogenetic protein-1, is mainly clinical trials have proven that PTH induces bone formation. The
expressed in the central nervous system during development binding of teriparatide to the receptors induces a signaling cas-
of the joints and skeleton.41 Although GDF-5 has a close struc- cade, which activates protein kinase 1, cyclic adenosine mono-
tural relationship to BMPs, which have been studied in bone phosphate, and protein kinase C.56 In addition to the exclusive
formation, GDF-5 mainly has been studied in chondrogenesis.42,43 effect of teriparatide, it acts synergistically with FGF-2; research
Similar to BMPs, GDF-5 binding leads to hetero-oligomerization demonstrates that FGF-2 is upregulated in teriparatide-treated
of membrane serine/threonine kinase receptors and follows the patients.57 Although the clinical effect of teriparatide has been
SMAD signaling pathways.43,44 In addition to its role in chondro- well confirmed, inconvenient usage with a daily subcutane-
genesis, GDF-5 stimulates the expression of genes related to ous injection and the potential risk of osteosarcoma makes the
preosteoblasts or osteoblasts like alkaline phosphatase (ALP), search for new candidate drugs, such as sclerostin antibody,58
bone sialoprotein (BSP), and osteopontin (OP).45 In other exper- necessary.
iments, GDF-5 gene expression was shown during tooth for-
mation,46 and recombinant human GDF-5 (rhGDF-5) treatment
enhanced human periodontal ligament (PDL) cell proliferation
but decreased ALP activity.47 Collectively, these various studies In the dental field, various preclinical studies have indicated that
support that GDF-5 could be a candidate therapeutic agent for osseous defects in the oral cavity could be a therapeutic target
periodontal tissue regeneration. for the anabolic effect of teriparatide.59–61 In addition, clinical stud-
ies suggested that systemic administration of teriparatide for
oral reconstruction, including periodontal regeneration, resulted
in successful outcomes, showing a significant increase of alveo-
Numerous preclinical and clinical studies indicated that GDF-5 lar bone formation.62,63 In one clinical study, patients with severe
also plays important roles in periodontal wound healing and periodontitis received teriparatide (20 mg) or placebo through
regeneration.43,48 GDF-5 has been studied in randomized clini- a self-administered daily subcutaneous injection. Radiographic
cal trials for use in periodontal tissue regeneration,49,50 maxillary linear resolution data showed that osseous defects were signifi-
sinus floor augmentation,51 and alveolar bone augmentation.48 In cantly greater in the teriparatide group than the placebo group
341

TABLE 19-2 Clinical trials using growth factors

Growth factors Periodontal application Implant-based application Alveolar ridge construction/sinus augmentation
BMP-2 Off-label indications only Peri-implant bone regeneration 12

Sinus augmentation13,68–70
Extraction socket augmentation14,15,64–67,71
Alveolar ridge reconstruction72,73
PDGF-BB Periodontal osseous defect17,22,25–27,74 Off-label indications only Alveolar bone reconstruction77–79
Soft tissue augmentation75,76 Maxillary sinus floor augmentation80
Ridge preservation81,82
FGF-2 Periodontal osseous defect38,39 Off-label indications only Off-label indications only
GDF-5 Periodontal wound healing49,50 Off-label indications only Maxillary sinus floor augmentation51
Teriparatide Osseous periodontal defect62,63 Osseointegration Off-label indications only
beginning at 6 months, with a mean linear gain in bone at 1 ing augmentation procedures revealed normal bone histology,
year of 29% as compared with 3% (P < .001). Clinical improve- and an rhBMP-2–enhanced grafted site also provided improved
ment was greater in the teriparatide group than in the placebo osseointegration and supported functional loading of the dental
group, with a reduction in periodontal PD of 33% versus 20% implants for at least 3 years with stable results.14
(2.42 versus 1.32 mm) and a gain in CAL of 22% versus 7% In a trial using rhBMP-2 and ACS for human maxillary sinus
(1.58 versus 0.42 mm) in target lesions after 1 year (P = .02 for floor augmentation, the effects of bone induction were well
both comparisons).62 A case report regarding a patient who was tolerated by the patients. Most studies have reported similar
diagnosed with severe chronic periodontitis and took teriparatide clinical and histologic results with the addition of rhBMP-2 after a
daily for 6 weeks showed successful radiographic and clinical 6- to 9-month healing period; however, there was a trend favoring
results over 4 years after open-flap debridement surgery.63 How- the control groups, some of which were using autogenous bone
ever, the daily systemic administration of teriparatide delivery as a gold standard control.7,70 One study reported significant
also makes clinical application challenging in the dental arena. negative effects of rhBMP-2 when combined with the use of a
Emerging developments in clinical pharmacology for the use of xenograft,83 which may indicate the need for the evaluation of
oral PTH delivery are promising; however, since the studies by other carrier agents for clinical use. Another recent clinical trial
Bashutski et al,62,63 there has not been significant development demonstrated that simultaneous implant placement and maxil-
of this technology for periodontal or dental implant applications. lary sinus elevation procedures using rhBMP2-loaded calcium
phosphate was possible and showed comparable and stable clin-
ical and radiographic results for up to 5 years.84 When compared
with harvesting of autogenous bone, the use of rhBMP-2 may
CLINICAL APPLICATIONS reduce patient morbidities, but a cost-benefit analysis needs to
be performed since such economic evidence is lacking. More
Periodontal and dental implant long-term, well-controlled clinical studies with different carriers
applications for rhBMP-2 or delivery methods are still needed to investigate whether the
application of rhBMP-2 for sinus augmentation can be optimized.
Evidence The development of clinical applications for rhBMP-2 has
been challenging for multiple reasons. Given that the product
The well-documented anabolic effects of rhBMP-2 have enabled is commercially available to be delivered on an ACS, there is the
its use for therapeutic purposes. The effect of rhBMP-2 has challenge that this material has minimal mechanical strength
been evaluated in randomized clinical trials for extraction socket as compared with ceramic or polymeric biomaterials. Multiple
wound healing of buccal plate defects14,15,64–67 and sinus floor clinicians have published case reports utilizing various scaf-
augmentation13,68–70 (Table 19-2).12,17,22,25–27,38,39,49–51,62,63,71–81 folds to increase the mechanical stability with various scaf-
Its efficacy for bone induction in the extraction socket was folds for regenerative surgery.85–88 These include the use of
evaluated using two concentrations of rhBMP-2 (0.75 mg/mL titanium mesh, polytetrafluoroethylene (PTFE) membranes,
or 1.50 mg/mL), delivered on a bioabsorbable collagen sponge tenting screws, and various particulate bone products such as
(ACS), compared to placebo (ACS alone) and no treatment. The freeze-dried bone allograft (FDBA) or anorganic bovine bone
results in the extraction socket indicated that patients treated matrix. The heterogenous nature of these reports makes it diffi-
with 1.50 mg/mL rhBMP-2/ACS had significantly greater bone cult for the dental surgeon to determine the appropriate path-
augmentation compared with controls. The results from this way to expand the use of BMP-2 beyond the currently approved
randomized, masked, placebo-controlled clinical study with a clinical indications. The adoption of BMP-2 in clinical practice
higher dosage (1.5 mg/mL) of rhBMP-2 were very promising for has most likely been limited to those surgeons gaining exten-
extraction socket augmentation.15 Human bone biopsy follow- sive experience to move past learning curves and develop their
342

a b c
d e f
Fig 19-3 (a and b) Cone beam CT scan and clinical photograph revealed a combined vertical and horizontal defect in the mandibular right quadrant.
(c) The site was grafted with rhPDGF-BB combined with autogenous bone and ABBG and protected by a dense PTFE membrane. (d to f) Healing
after 12 months revealed adequate volume of type 1 bone for implant placement.
personal techniques and applications according to economic In short, clinical applications for rhBMP-2 in implant-related
models of reimbursement for the costs associated with recom- bone augmentation procedures, including socket grafting and
binant molecules. alveolar ridge augmentation, are promising.90–92 Surface modi-
A number of randomized clinical trials have been criti- fication of dental implants to release BMP-2, enhanced deliv-
cally assessed in several recent systematic reviews and ery, and immobilization methods are still under preclinical
meta-analyses.7,70,88 In general, there is a significant positive development.93 Numerous randomized controlled clinical trials
effect on ridge augmentation procedures, but there seem to be have proven that rhBMP-2 applications in ridge preservation
more limited effects or even negative effects in a few studies on or augmentation for implant therapy are effective and promis-
sinus augmentation surgeries.7,70,83 Some adverse events associ- ing15,73,90 (see Table 19-2).
ated with the natural course of healing have also been reported,
including oral and facial edema, mouth pain, and erythema.
Although most clinicians observed more swelling and edema Periodontal and dental implant
during healing after rhBMP-2 application, they may not be consis- applications for rhPDGF-BB
tently reported in the published studies as adverse events, and
no statistically significant issue was found. More information After its approval in 2005, rhPDGF-BB became commercially
regarding its safety is available on the FDA report.89 available as the product GEM 21S, which is marketed as a 0.5-
mm syringe of liquid rhPDGF-BB and a separate vial of particu-
late β-TCP. The product is specifically approved for regeneration
Alveolar ridge augmentation
of bone and gingival tissues around natural teeth. Any clinical
For most of the included randomized clinical trials on ridge therapy for extraction socket treatment or alveolar ridge regen-
augmentation procedures, 5 out of 6 studies favored the use eration is currently considered as “off-label” use.
of rhBMP-2.7 Augmentation of extraction sockets with severe Figure 19-3 presents treatment of an existing alveolar defect
dehiscences72 was also included in the systematic reviews and with a combination of rhPDGF, autogenous bone, and anorganic
demonstrated that BMP can assist in regenerating lost buccal bovine bone graft (ABBG) protected by a titanium-reinforced,
bone for ridge augmentation. All studies used computed tomogra- dense PTFE membrane (Osteogenics). The membrane was
phy (CT) to measure clinical outcome in terms of the bone height stabilized with fixation tacks/screws, and the flaps were
and alveolar ridge width between the 3- to 6-month follow-ups. advanced for primary closure (Figs 19-3a to 19-3c). After 12
The only study that showed similar results for the test and con- months of healing, reentry surgery revealed type 1 bone at the
trol groups used autogenous bone as the control.72 time of implant placement (Figs 19-3d to 19-3f).
343

Fig 19-4 (a) Recession is evident with no at-

tached gingiva at the mandibular right canine.
(b) Postoperative result with root coverage and
ideal gingival contours after a connective tissue
graft with application of rhPDGF-BB.
a b
Clinical experience has shown the potential benefit of using Vertical ridge augmentation
rhPDGF-BB as an adjunctive biologic for root coverage proce-
dures combined with a connective tissue graft.76 PDGF not only Simion et al98 investigated the ability of anorganic bovine bone
induces periodontal regeneration but maximizes the overall blocks soaked in rhPDGF to induce vertical bone augmentation.
healing potential and may allow for optimal root coverage since There were three groups: two test (T) and one control (C): T1,
clinical trials demonstrate a decrease in gingival recession using ABBG + rhPDGF; T2, ABBG + rhPDGF + collagen membrane; C,
local application. Growth factors and other biologics, includ- ABBG + collagen membrane. The T1 group had robust new bone
ing amelogenins and platelet gels, seem to induce improved formation and resorption and replacement of much of the bovine
general wound healing with the benefit of decreased wound bone mineral at 4 months postsurgery. For the rhPDGF combined
dehiscence.94,95 In addition, the effect on early tissue remodel- with membrane group (T2), there was significantly less new bone
ing results in excellent soft tissue contours with minimal signs formation. The authors concluded that the results suggested the
of surgical intervention after completion of the healing process importance of the periosteum as a source of osteoprogenitor
(Fig 19-4). cells in regenerative procedures involving growth factors and
Due to its biologic effects, rhPDGF-BB may result in more that while a very thin layer of new bone in continuity with the
dense bone at earlier time points, and the scaffold/graft delivery basal bone was found in the control site, no regenerated bone
biomaterials may have a greater amount of contact with host was found in the entirety of the bovine block area.98
bone and earlier remodeling. This has been documented through This study demonstrated the ability of rhPDGF-BB soaked
various preclinical24,96–98 and clinical studies27,74,77,99,100 as well as onto a solid xenogenic bone block to induce significant vertical
case reports/examples.78,81 For example, Nevins et al100 evaluated bone gain combined with osseointegration of the implants used
short-term healing of buccal wall extraction defects treated with to stabilize the block. Challenges exist, however, as the bioma-
mineral collagen bone substitute (Bio-Oss collagen, Geistlich), terial bone block is fragile, and if the block breaks upon place-
and upon 4-month reentry, the defect was clinically healed with ment of the implants after already being soaked in rhPDGF-BB,
apparent new bone formation covering the graft particulate there is a significant economic consideration that needs to be
(Figs 19-5a to 19-5c). Micro-CT scans showed the intense new examined by either the treating doctor, the patient, or both.
bone trabeculate interspersed among the graft particulate (Fig Moreover, performing the implant placement to stabilize the
19-5d). This was confirmed with histologic evaluation, demon- block may compromise the ability to have restoratively driven
strating new bone covering most of the bovine graft particles implant positioning.
(Figs 19-5e and 19-5f). Additional histologic observation revealed A second study replicated this preclinical work with the
the presence of reversal lines and multinucleated giant cells use of an equine mineral/collagen bone block that is some-
on the ABBG after 4 months of healing (Figs 19-5g and 19-5h). what pliable, which reduces the risk of fracture on placement,
A follow-up study99 comparing mineral collagen bone substi- without a varrier membrane.101 The blocks were stabilized
tute (MCBS) with and without growth factor identified signifi- with bone fixation screws rather than with dental implants.
cant variance in wound healing as observed clinically and histo- This proof-of-principle study demonstrated the ability of this
logically. The control defects healed with a clinically observable technique to induce vertical ridge augmentation with dense,
persistent concavity (Fig 19-6), whereas the rhPDGF-BB–treated well-vascularized bone; high bone-implant contact; and accel-
sites healed with a convex bone contour (Fig 19-7). The histology erated replacement of graft particles with new bone.
found that the control sites healed with osteoconductive bone Clinical case reports78 have demonstrated the applicability of
ingrowth from the lateral alveolar walls (Fig 19-8a), whereas this technique in patients requiring lateral augmentation with
the rhPDGF-treated sites had inductive healing with new bone a minimal vertical component. The inability to have a commer-
growth throughout the defect (Fig 19-8b). cial bone product consistent with the mineral-collagen equine
344

a b c
ABBG
ABBG
e f
ABBG
d g h
Fig 19-5 (a) Buccal wall extraction socket defect is evident. (b) Grafting with growth factor–enhanced bone matrix combining mineral collagen bone
substitute with rhPDGF-BB. (c) Four-month reentry surgery demonstrates significant bone regeneration. (d) Reformatted micro-CT three-dimensional
(3D) image of trephine core biopsy, demonstrating bone (red) and graft biomaterial (white). (e and f) Histologic assessment reveals an ABBG particle
covered with new bone (NB) on its surface (yellow arrows). (g and h) At 4 months postoperatively, there were signs of resorption and remodeling
of the xenograft particulate graft with the presence of multinucleated giant cells (MN-GC).
a b c
Fig 19-6 (a) Buccal wall extraction site defect. (b) Preservation grafting with MCBS alone without adding growth factor. (c) Five-month reentry
revealed a residual defect in the edentulous site.
a b c
Fig 19-7 (a) Buccal wall extraction site defect. (b and c) Five-month reentry after grafting with growth factor–enhanced bone matrix, combining
MCBS with rhPDGF-BB. Note the regenerated bone volume and clinical quality.
345

Coronal ABBG Apical

Coronal ABBG Apical
a b
Fig 19-8 (a) Histologic (top) and scanning electron microscopy (SEM; bottom) of the MCBS-treated control site. Note the ingrowth of bone from
the bone margins, demonstrating osteoconduction. NB, new bone; LB, lamellar bone; BM, bone marrow; D, debris. (b) Histologic (top) and SEM
analysis (bottom) of rhPDGF-treated site, demonstrating new bone throughout the entire defect as an example of osteoinductive healing induced
via the growth factor–enhanced bone graft.
a b c
d e f g
h i
Fig 19-9 (a and b) Maxillary right lateral incisor, presenting with clinical recession and 8-mm buccal pocket depth, associated with the loss of buccal
plate. (c and d) Periapical radiographs before and immediately after extraction. Note the thin bone remaining mesial to the canine and distal to the
central incisor. (e) Clinical photograph after minimally invasive socket management and grafting with FDBA combined with rhPDGF-BB, covered by
a collagen membrane stabilized with medical-grade cyanoacrylate. (f) 3D reconstruction of the 4-month postoperative CT scan reveals adequate
bone for implant placement. (g and h) Postoperative radiograph and clinical photo after implant placement and soft tissue grafting. (i) Two-year
postoperative clinical photograph.
block used in the preclinical research has slowed progress of series of work supports moving forward with a large-scale clin-
this clinical strategy for vertical augmentation. The preclinical ical trial in the future.
346

b c
a d e
Fig 19-10 (a) A maxillary left canine with a split root, 11-mm periodontal pocket, and extensive bone loss was extracted and treated with ridge
preservation, similar to the case shown in Fig 19-9. (b and c) Histologic evaluation at 5 months reveals robust new bone formation with new bone
(NB) on the surface of most of the allogeneic bone graft particles. (d and e) Higher magnification reveals vital new bone located geometrically
within the graft particulate at 5 months after treatment.
The concept of when and how to use membranes with surgical correction. Nevins et al present case reports, including
growth factors is a complex topic. When using particulate bone histology and clinical documentation, with flapless procedures
grafts, there is a need for an adequate scaffold to stabilize the treated with rhPDGF-BB combined with FDBA protected by a
graft in the desired position. This can be achieved in multiple collagen membrane (Bio-Gide, Geistlich) and stabilized with
ways, including tenting screws, absorbable or nonabsorbable medical-grade cyanoacrylate (PeriAcryl, GluStitch) (Figs 19-9
membranes, titanium microplates,102 and titanium mesh. In and 19-10).104
addition, Nevins et al103 evaluated a tunnel procedure in which Fagan et al79 presented the concept of rhPDGF-BB–induced
no membranes were used and the graft was stabilized by the healing to enhance combination procedures for hard and soft
periosteum. This demonstrated proof of principle of periosteal tissue healing during dental implant regenerative procedures.
healing for particulate grafts; however, the ability to clinically The ability of rhPDGF-BB to improve primary wound healing as
gain the ideal contour of the edentulous site at the most coro- described previously via neovascularization and direct osteoblas-
nal aspect of the ridge is questionable. The histology demon- tic effects is pivotal to its benefit for these procedures. A clini-
strated the best bony ingrowth for the particulate xenograft with cal case example of combined treatment is shown in Fig 19-11.
this technique compared with mineral collagen bone substitute The patient presented after two infections following extraction
and mineralized bone allograft. It is possible that the mineral of the maxillary right canine. A fractured buccal plate was not
collagen bone substitute experienced micromovement that diagnosed during the extraction, which resulted in a bony dehis-
decreased bone gain. cence and a subsequent ridge defect with esthetic deformity.
Various case reports have demonstrated the benefit of growth Clinical intervention involved rhPDGF-BB soaked onto a mineral-
factors for flapless socket preservation.66,104 The ability to induce ized bone allograft scaffold protected by a collagen membrane.
bone preservation for an intact extraction socket or better regen- A connective tissue graft was then stabilized with absorbable
eration when there is a damaged plate of bone without the need sutures, and a modified double pedicle technique was used
to raise a flap is of clinical significance. It allows for a minimally to close the clefting of the gingival tissues prior to advancing
invasive procedure to achieve the clinical goal of bone preserva- the flap for primary closure. Remarkably, the final fixed partial
tion and regeneration without invasive procedures. Flap proce- denture was delivered only 4 months after the surgery, meet-
dures that require advancement for closure may result in loss ing the patient’s esthetic and functional demands. The 3-year
of vestibular space and keratinized tissue, necessitating further follow-up demonstrated postoperative stability.
347

a b c
d e f
g h i
j k l
j k l
Fig 19-11 (a and b) Significant esthetic ridge defect as a sequela of an infection following extraction of the maxillary right canine and loss of the
buccal bone and soft tissue. (c) Significant bone loss is evident on the periapical radiograph. (d) The extent of the clinical defect is easily visualized.
(e) Growth factor–enhanced bone matrix (FDBA and rhPDGF-BB) condensed into the defect. (f) After placing a collagen membrane over the bone
particulate, a connective tissue graft is stabilized with mattress sutures. Note that the clefting of the primary flap has been repaired with modified
double pedicle sutures. (g) Primary closure has been achieved after periosteal release with mattress and interrupted sutures. (h) Six-week postop-
erative radiograph. (i) Four-month postoperative radiograph. (j) Four months postoperatively, the esthetic goals have been achieved with surgical
and prosthetic therapy. (k and l) Three-year postoperative clinical and radiographic follow-up.
348

Tissue Engineering for Periodontal Tissue Regeneration
Cell source Type of signaling molecule Delivery approach

Protein Gene
Hydrogel
MSC Cementoblast
PDGFs Plasmid
Solid scaffold
Periodontal
iPSC ligament cell
Retrovirus Micro-/Nanosphere
BMPs
Osteoblast Adenovirus Polymer
FGFs
Endothelial cell
AAV Liposome
Gingival fibroblast 3D bioprinting

GDFs Baculovirus
Fig 19-12 Cells, proteins, genes, and delivery approaches for periodontal tissue engineering. MSC, mesenchymal stem cell; iPSC, induced plu-
ripotent stem cell; AAV, adeno-associated virus.
TISSUE ENGINEERING FOR cellular matrix (ECM) and promote periodontal regeneration.105
However, there are some limitations, such as a low potential
PERIODONTAL TISSUE of differentiation and lack of self-renewal capacity, that make
REGENERATION it necessary to search for another strategy. The isolation and
identification of stem cells has brought great hope into tissue
As a combined technology of cells, signaling factors, and bioengineering.106,107 The term stem cell is defined as an uncom-
materials, tissue engineering requires optimal interaction and mitted progenitor cell having two properties, self-renewal and
integration with cells or tissue through the application of scaf- differentiation potential, and can be isolated from embryonic or
folds with appropriate carriers to deliver the cellular signals postnatal (adult) tissues.108 Mesenchymal stem cells (MSCs), a
(Fig 19-12). The scientific developments with stem cells, bioma- type of adult stem cell, were first isolated from bone marrow and
terials, and growth factors have made the impossible possible: further isolated from diverse tissues, including muscle, tendon,
to regenerate cells and tissues from bench to bedside. Among peripheral blood, adipose, umbilical cord, oral mucosa, gingiva,
the many challenges was the need for a precise application to dental pulp, periodontal ligament, and alveolar bone.107–111 This
make a biomimetic environment, for which three-dimensional differentiation potential of MSCs into multiple specialized cell
(3D) printing technology represented a turning point. Follow- types has made them a target for periodontal tissue regener-
ing are some examples of different technologies that can be ation.108 In addition, reprogramming technology using somatic
used either for growth factor delivery or to stimulate locally cells such as induced pluripotent stem cells (iPSCs) or direct
applied stem cells to produce growth factors for periodontal conversion have been recently developed.112–115 The iPSCs, which
and peri-implant bone regeneration. are derived from adult cells through transcription factor (OCT4,
SOX2, MYC, and KLF4)-based reprogramming, are considered
to be a candidate for regenerative medicine.113 However, the
Cell source
generation of iPSCs is time consuming, labor intensive, and
For cell-based regenerative therapy, stem cells and mature associated with a risk of dedifferentiation into the original cell
somatic cells have received a great amount of attention for state because of their epigenetic memory.116 Therefore, trans-
their regenerative ability.105 In periodontal tissue regeneration, differentiation, another approach to cell reprogramming, has
somatic cells such as cementoblasts, PDL fibroblasts, and dental been focused on making the optimal cells that can enhance the
follicle cells also demonstrated the ability to mineralize the extra- likelihood of developing personalized cell therapies.117
349

Gene therapy Based on these material sources, recent advances in 3D print-

ing technology have taken a leap ahead for personalized clinical
Gene therapy is a therapeutic delivery of nucleic acid into the application with well-suited biomaterials at the defect site.119
cells. Because of the limitations of using recombinant growth
factors in vivo, high dosage due to short half-life, and difficulty
in controlling the release of proteins, gene delivery has received
great attention.118 This delivery method is divided into two large FUTURE DIRECTIONS AND
groups: one is a viral method using vectors, and the other is a CONCLUSION
nonviral method using naked DNA.119 In the viral method, a num-
ber of viruses—retroviruses, adenoviruses, or adeno-associated There has been significant advancement over the past several
viruses—have been used, and these vectors introduce their decades in the introduction of growth factors into the clinical den-
genetic materials into the host cell and use the host’s cellular tal arena. The commercial development of PDGF and BMPs for
machinery to replicate themselves and produce the proteins. periodontal and alveolar bone regeneration around teeth and for
They could be a permanent part of host’s genome or degraded implant site development has changed treatment planning options
naturally. Because they do not have cell or tissue specificity to for clinicians.7,83,123 Furthermore, early-stage studies regarding
transduce, great care is needed to deliver the virus to the tar- expanded applications for growth factor biologics for extraction
get cells or tissues. socket repair, vertical ridge augmentation, and soft tissue graft-
ing offer more potential for patient rehabilitation.76–78,80,99 New
developments using stem cells, novel scaffold designs, and 3D
Scaffold delivery technologies for growth factor
printing have now been applied in proof-of-concept clinical stud-
delivery
ies, presenting new avenues for patient oral rehabilitation.124–127
The safe and efficient delivery of biomolecules into the body With the introduction of these new delivery approaches, growth
is very important for the success of tissue engineering. Many factor technologies may become less costly and easier to apply
pharmaceutical compounds such as peptides, proteins, anti- for the benefit of our patients seeking improved clinical care.
bodies, and genes have therapeutic potential for clinical appli-
cations; however, they need customized routes of administra-
tion to prevent enzymatic degradation or systemic circulation.
Furthermore, the controlled and sustained release of biomol- ACKNOWLEDGMENTS
ecules is also a critical factor to maintain the biologic effects
within a desired period. Administration with a high dosage due Dr Giannobile received support from NIH/NIDCR DE
to the short half-life of proteins (eg, rhBMP-2) continues to offer U24 DE026915-01, and Dr Cho was supported by the Oste-
challenges, whereby controlled drug delivery offers significant ology Foundation. The authors thank James Sugai for his help
opportunities to reduce “dose dumping” of high concentra- with the text and figures.
tions of recombinant growth factors.120 The optimal design of
biologically active scaffolds is one of the critical factors for the
success in the tissue engineering. The gene delivery carriers
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353

20 ROBERT E. MARX
The Introduction of
Tissue Engineering for
Bone Regeneration
In Situ Tissue Engineering
How Bone Forms with In Situ Tissue Engineering
Specific Clinical Applications of In Situ Tissue
Engineering
Proof of Performance
355

20 | The Introduction of Tissue Engineering for Bone Regenerations
Matrix
Cells Signal
Bioreactor
Fig 20-1 The bioreactor for ISTE is the wound space in Fig 20-2 Quality PRP should have a red coloring,
which the cells, signal, and matrix interact. indicating capture of the younger, larger platelets
that get caught up with some of the red blood cells.
I
mplantology has advanced greatly in the last 40 years, the site of a future dental implant) and at the point of care,
with the focus mostly on technologic innovations such either a dental office or an operating room. The basic principles
as advanced implant surfaces, cone beam computed of bone tissue engineering are well known and require cells
tomography scans, computer-generated guide splints, and capable of forming bone, a signal to direct these cells to form
most recently navigation-guided precision implant placement. bone, and a matrix (often referred to as a scaffold) upon which
However, implants still require bone that is of sufficient density the bone can form.2
to gain primary stability and sufficiently active to osseointegrate More recently, scientists have also recognized that this
implants and gain mineral density with functional loading. tissue engineering triad requires a suitable biochemical envi-
Today, a vast array of xenogeneic, allogeneic, and synthetic ronment to regenerate bone, termed a bioreactor (Fig 20-1).
products compete for the clinician’s attention. However, they are For the laboratory scientist, the bioreactor is a nutrient-rich
all nonviable products that are dependent upon osteoconduction culture medium. For the dental surgeon, the bioreactor is the
to regenerate bone. These have a proven track record in small inherently low pH, low O2 tension, and nutrient-rich plasma of
defects such as socket grafts with two or more remaining walls, the recipient site.2
closed and small-sized sinus elevation procedures, and local hori-
zontal ridge defects. However, when used to graft a hyperpneu-
matized sinus, a large horizontal or vertical ridge defect, a conti- Cells
nuity defect, or into a scarred and poorly vascularized tissue bed,
these materials have proven to be inadequate. Up until recently, The cells available to the clinician are adult mesenchymal stem
surgeons have looked to autogenous bone grafting from such cells (MSCs) and osteoprogenitor cells (OPCs). These are not the
donor sites as the tuberosity, ramus, symphysis, tibia, and ilium primordial omnipotent stem cells of cloning an entire organism
in these situations.1 However, the needed training and skills of or even the pluripotent stem cells capable of forming an entire
the surgeon, the added time and effort to harvest the bone, and organ. Instead, they are the undifferentiated or only partially dif-
the too-often understated morbidity and complications at the ferentiated cells capable of forming a single tissue (bone in this
donor site have given pause to this grafting. The result has been case) if guided by the appropriate signal. Clinicians can access
that certain patients are unable to benefit from dental implants MSCs and OPCs via either cellular platelet-rich plasma (PRP),3
or have to accept a less than adequate or less durable outcome. bone marrow aspirates (BMAs),2 or BMA concentrates (BMACs).2
Practical tissue engineering in the form of in situ tissue-
engineered bone regeneration can and has already proven to
regenerate implantable bone in the aforementioned defects Platelet-rich plasma
and situations without the inherent pain, swelling, morbidity,
and potential complications of bone harvesting. PRP is a centrifugation product derived from whole blood. There
are several devices available to the clinician that can provide PRP.
However, the clinician should require a capability of concentrating
1 × 106 platelets/uL or five times baseline to qualify as truly regen-
IN SITU TISSUE ENGINEERING erative PRP (Fig 20-2). PRP is known to provide a high concentra-
tion of the growth factors derived from platelets: platelet-derived
In situ tissue engineering (ISTE) refers to the regeneration of growth factor (PDGF) AA, PDGF-BB, PDGF-AB, transforming
tissue (in this case bone) within the recipient site (in this case growth factor (TGF) b1, TGF-b2, vascular endothelial growth fac-
356

In Situ Tissue Engineering
a b c d
Fig 20-3 (a) Heparin-coated trocar inserted into the marrow space. (b) At each 360-degree rotation, 5 mL of bone marrow is aspirated as the
cannula is advanced 5 mm. (c) After three full turns 15 mL of BMA is obtained per puncture site. (d) After centrifugation of 60 mL of BMA, 10 mL
of BMAC is obtained.
TABLE 20-1 TNCs, CD34+, and CD117+ cells in Marrow Cellution aspirates compared with harvested BMAC
Marrow Cellution aspirator Harvest system (BMAC)
TNCs/mL CD34+/mL CD117+/mL TNCs/mL CD34+/mL CD117+/mL

Patient × 106 × 103 × 10 3 × 10 6 × 103 × 103
1 23.1 235 348 15.7 91.2 89.7

2 15.3 135 84.4 28.3 164 76.5
3 16.4 177 193 44.8 125 89.6
4 44.1 423 450 55.8 447 463
5 22.1 315 282 53.7 258 183
Mean ± SD 24.2 ± 11.6 257 ± 115 272 ± 141 39.7 ± 17.2 217 ± 143 180 ± 164
tor (VEGF), and stromal-derived activation factor 1a.3,4 Quality the trocar advanced 5 mm after each draw (Fig 20-3c). In this
PRP must also contain a nutrient-rich plasma fraction with the manner, a greater number of the MSCs and OPCs, which are
cell adhesion molecules fibrin, fibronectin, and vitronectin. It is adherent to the mineral surface of the bone, is obtained while
worth noting that while the fibronectin and fibrin are within the reducing the amount of bone marrow blood. The four 15-mL
plasma at native levels, vitronectin is derived from the platelets site draws will yield 60 mL of BMA, which, after a double spin
and is at higher than baseline levels.5 centrifugation, will yield 10 mL of BMAC useful for any dental/
oral surgical applications (Fig 20-3d). For some large continuity
defects 30 mL BMA can be drawn from each puncture site,
Bone marrow aspirate concentrates yielding 120 mL of BMA that will in turn yield 20 mL of BMAC.
The resultant BMAC has been shown to yield cluster of differ-
BMACs are currently the most commonly used system to entiation (CD)34+, CD44+, CD90+, CD105+, and CD271+ MSCs/
access MSCs and OPCs at the point of care. They also provide OPCs, of which the CD34+ cells have been shown to be most
the nutrient-rich bone marrow plasma. One can conceptualize this closely related to the regeneration of a high volume of bone.6
product as the PRP of bone marrow, where MSCs and OPCs are To eliminate the manipulation of the BMA into BMAC as
harvested and concentrated along with bone marrow platelets. well as to eliminate the centrifuge and its related expense, a
The technique requires four needle/trocar punctures, two in new design of bone marrow aspirators has been developed by
each side of either the anterior or posterior ilium. A heparin-coated Marrow Cellution. These aspirators have been shown to meet
trocar is worked through the cortex of the iliac crest into the and even exceed the viable yield of MSCs/OPCs over BMAC.
bone marrow (Fig 20-3a). A 15-mL syringe with the inner surface Levels of total nucleated cells (TNCs), CD34+, and CD117+ in
coated with the same heparin solution of 2,000 units/mL is then Marrow Cellution aspirates and harvested BMAC taken from
attached to the trocar at its luer lock end. With the trocar inserted contralateral iliac crest draws in the same patient indicate
approximately 3 cm into the ilium, bone marrow is aspirated 5 improved MSC and OPC cell counts from Marrow Cellution’s
mL at a time while rotating the trocar handle 360 degrees (Fig device with a minimal 10-mL BMA and without centrifugation
20-3b). This maneuver is repeated for each 5-mL draw, with (Table 20-1).
357

Fig 20-5 (a) A threaded lock and screw system

controls the repositioning of the cannula in the
Fig 20-4 The controlled sequential repositioning of the Marrow Cellution
Marrow Cellution MSC/OPC harvester. (b) Au-
cannula will yield a greater number of MSCs/OPCs with only a 20-mL
togenous bone core harvested by the Marrow
marrow draw and without centrifugation.
Cellution system.
The concept of this system is to draw the trocar aspirator port tion of 1.5 mg/mL is constant. The dissolved liquid preparation
3 mm, aspirating only 1 mL of BMA from each new position is then dripped onto the ACS. It is allowed to loosely bind to
in the bone marrow (Fig 20-4). Therefore, the adherent MSCs/ the collagen of the ACS over 15 minutes, gaining 93% to 95%
OPCs are preferentially drawn off the trabecular bone surfaces, binding. It is cautioned not to substitute any solvent other than
reducing the dilution from blood. the prescribed amount of sterile water to avoid changing the
These systems use a similar trocar to enter the marrow space pH of the rhBMP-2 protein to a less active growth factor and
as is used to develop BMAC. However, a threaded lock and making it more hypertonic, resulting in greater edema at the
screw system is used to reposition the aspirator tip 3 mm toward surgical site.10 The best use of the rhBMP-2/ACS is to cut up the
the initial entry point with each full 360-degree turn (Fig 20-5a). rhBMP-2–loaded ACS and evenly mix it into the other compo-
These systems can also yield a core of autogenous marrow prior nents (Figs 20-6 and 20-7). In this manner many foci of osteoin-
to aspirating BMA without adding any morbidity (Fig 20-5b). duction are carried out throughout the graft volume.
Signal Matrix
The signal for in situ tissue-engineered bone regeneration is The matrix for a tissue-engineered graft of this construction is
recombinant human bone morphogenetic protein 2/acellular composed of cancellous allogeneic bone and the cell adhesion
collagen sponge (rhBMP-2/ACS). Cleared by the US Food and molecules of fibrin, fibronectin, and vitronectin found in PRP,
Drug Administration in 2003 for orthopedic lumbar fusions7 and BMA, and BMAC. Cancellous allogeneic bone is preferred over
in 2005 for fresh tibia fractures,8 it was then cleared for dental/ cortical allogeneic bone powder and cortical particles because
oral surgery ridge preservation and sinus augmentations in of its greater surface area and its microscopically textured sur-
2007, using high doses as a single preparation.9 Since then, its face, which more readily binds the cell adhesion molecules.
practical clinical use has been ISTE combined with PRP, BMAC,
or BMA and allogeneic bone at greatly reduced doses. While
this use of rhBMP-2/ACS as well as its use in other indications Bioreactor
such as ridge grafting, cleft grafting, cystic defects, and continu-
ity defects is considered “off label,” its track record of success The bioreactor for ISTE is the environment within the wound
in these indications has made it the preferred graft material. space of the recipient site. While laboratory tissue engineering
rhBMP-2/ACS is provided as a dry lyophilized white powder attempts to duplicate or enhance this cellular niche, the natural
in a vial. It is commercially available in doses of 1.05, 2.1, 4.2, wound space itself has been perfected over millions of years
8.4, and 12.0 mg. Its directions require a precise amount of of evolution and remains the best supportive environment for
sterile water to be added so that for each dose the concentra- cell replication, differentiation, and osteoid synthesis (Fig 20-8).
358

How Bone Forms with ISTE
Fibrin strands
Fig 20-6 Acellular collagen sponges to which rhBMP-2 was

allowed to bind for 15 minutes or more, cut into pieces to
be mixed into the graft composite.
Platelets
Fig 20-7 Graft composite of rhBMP-2/ACS, BMA (Marrow Fig 20-8 The wound space of a sinus augmentation can be conceptu-
Cellution), and cancellous allogeneic bone. alized as an example of a bioreactor.
a b
Fig 20-9 (a) Representation of sinus augmentation with allogeneic bone particles connected by cell Fig 20-10 Bone regeneration with
adhesion molecules and osteoid migrating up from the sinus floor. (b) Representation of sinus augmen- ISTE.
tation with bone trabeculae interconnecting and thickening as the graft matures.
HOW BONE FORMS WITH ISTE to the wound space and continue the modulation of wound
healing and bone regeneration via their own growth factors
The resultant composite graft contains the MSCs and OPCs once the platelets have been exhausted (3 to 7 days). Capil-
that become adherent to the surface of the allogeneic bone lary ingrowth is complete between days 17 and 21, at which
particles and the cell adhesion proteins, which in turn con- time osteoid has begun to be laid down upon the surface of
nect the allogeneic bone particles to each other (Fig 20-9a). the allogeneic bone and along the strands of the cell adhesion
The rhBMP-2–loaded ACS is evenly distributed within this coag- molecules13 (Fig 20-9b). Thus, the first 3 weeks of the graft
ulum and begins a slow release of rhBMP-2 over 21 days.11 involves growth factor, stimulated cell replication, cell differ-
The rhBMP-2 adheres to the cell membranes of the MSCs entiation, and capillary ingrowth. In this time period, the graft
and OPCs, which signals their proliferation and differentiation, is fragile and susceptible to instability and infections. Between
followed by osteoid synthesis.12 The growth factors from the 3 weeks and 6 months is a time of osteoid synthesis. After 6
platelets, particularly VEGF and TGF-b1, signal a capillary bud- months, the graft undergoes osteoclast-mediated resorption
ding and ingrowth into the graft. The naturally low pH and low and replacement to a more mineralized and mature bone. It
O2 environment of the wound signals macrophages to migrate is at this time that dental implants can be placed (Fig 20-10).
359

Fig 20-11 (a) Molar socket ISTE graft using 0.5 mg rhBMP-2/
ACS. (b) Membrane coverage can be used over ISTE grafts. (c)
Excellent bone regeneration of the graft at the time of implant
placement. (d) Implant placed in ideal position for molar crown
placement due to the appropriate height and width of the graft.
a b
c d
Fig 20-12 (a) Titanium mesh used to contain an ISTE graft for
horizontal and vertical ridge augmentation. (b) Bone regener-
ated by ISTE graft within the titanium mesh.
a b
SPECIFIC CLINICAL resulting in thread exposures outside the bone. In such cases,
the author uses one of two equally successful approaches:
APPLICATIONS OF ISTE
1. A particulate graft of rhBMP-2/ACS evenly distributed with
Socket grafting cancellous allogeneic bone and either 3 or 7 mL of clotted
PRP, as per the ridge length requiring horizontal augmenta-
Although an ISTE graft may be used in any extraction socket, tion, is first prepared. This graft composite requires contain-
its strongest indication is one where the buccal wall has been ment with titanium mesh or a reinforced membrane. The
lost. In such cases, it is best to use just enough cancellous allograft coagulum is then compacted within the pre-shaped
geneic bone mixed together with 3 mL of clotted PRP and 1.05 containment much like impression material in an impres-
mg of rhBMP-2/ACS. The 1.05-mg dose of rhBMP-2 is the small- sion tray and fixed to the native ridge with 1.5-mm mono-
est dose available. As a general rule, half of this dose (0.5 mg) cortical screws (Fig 20-12a). Because titanium mesh and
is sufficient per every single-tooth socket grafted (Fig 20-11a). titanium-reinforced membranes recoil somewhat, it is
The socket is best closed with a membrane (Fig 20-11b) but advised to fix it on the lingual/palatal side if possible. If a
may also be left open with a collagen plug at the crest. Mature gain in vertical height is also required, one should shape
implantable bone will develop over 6 months (Figs 20-11c the titanium mesh or reinforced membrane to obtain the
and 20-11d). desired vertical gain (Fig 20-12b). Additionally, due to the
gain in ridge width and/or ridge height one should score
the periosteum and undermine the flap so as to gain an
Horizontal ridge augmentation absolutely tension-free closure.
2. Another approach uses an allogeneic cortical cancellous
Patients with adequate vertical height may have a horizontally block graft carved to intimately conform to the buccal surface
deficient ridge, making dental implant placement impossible or of the thin ridge and achieve the desired gain in ridge width.
360

Specific Clinical Applications of ISTE
a b c
Fig 20-13 (a) Allogeneic block graft procedure in which an rhBMP-2/ACS sponge has
been placed between the graft and the maxilla, and both have been fixed with screw
retention. (b) Horizontal and vertical ridge augmentation with an allogeneic block graft
acting as a containment for an ISTE particulate graft. (c) Robust bone regeneration is
observed with an allogeneic block graft enhanced by ISTE. (d) Implants placed into a
wide alveolar ridge.
Fig 20-14 (a) ISTE graft placed into an augmented

sinus with implants. (b) Mature bone and implant
without thread dehiscence within the graft.
a b
This bone block should be soaked in clotted PRP for several Maxillary sinus augmentation
minutes so that the cancellous marrow side is thoroughly
penetrated. An rhBMP-2/ACS sponge is then laid over the Closed sinus elevation procedures and sinus augmentations
native bone, the bone block is fixed with the native bone where 4 mm or more of the sinus floor remains require neither
cancellous side facing the rhBMP-2 sponge, and a 1.5-mm autogenous bone grafts nor in situ tissue-engineered grafts. A
screw is placed for fixation (Fig 20-13a). Small block grafts variety of graft materials have been shown to be effective in
may only require one screw, while larger block grafts often these situations. However, the large hyperpneumatized sinus
require two screws for absolute stability. over an edentulous space of three or more teeth requires a
quantity of bone regeneration that such nonviable and noncel-
In cases where some vertical augmentation is required in lular grafts cannot achieve. In these cases, a tissue-engineered
addition to horizontal augmentation, one should select a donor graft consisting of 3 to 5 mL of allogeneic cancellous bone, 3
bone specimen that can be configured into a J shape, with the mL of PRP, and 2.1 mg of rhBMP-2/ACS compacted into a fully
curvature of the J shape ridge-lapping the deficient ridge (Fig elevated sinus floor space will provide a mature viable bone
20-13b). regenerate within 6 months that can accommodate several
The bone regeneration in this graft design is through osteoin- implants (Fig 20-14).
duction from the rhBMP-2 on the native ridge surface and the
osteoconduction through the cancellous network of the bone
block by the scaffolding of the cancellous bone assisted by Cystic defects
the growth factors and cell adhesion molecules from the PRP.
These grafts also require a 6-month period for full maturity and Although cystic defects will regenerate bone without grafting,
to predictably osseointegrate dental implants (Figs 20-13c and the resultant bony ridge is often too thin to accommodate dental
20-13d). implants. This is due to the collapse of the oral mucosa into the
defect after the cyst has been removed. In the past, the size of
361

a b c
Fig 20-15 (a) Large multilocular radiolucency from an odontogenic keratocyst. (b) Large defect
and mobile teeth due to minimal bone support after removal of the odontogenic keratocyst. (c)
ISTE graft placed into cystic defect. (d) Five-year follow up showing complete bone regeneration
and stability of teeth without external root resorption.
a b c
Fig 20-16 (a) Scarred and contracted soft tissue with a hypoplastic lateral incisor in an
adult with a residual nasoalveolar cleft. (b) ISTE graft contained within a titanium mesh
in the treatment of an adult nasoalveolar cleft. (c) Bone regeneration within the titanium
mesh. (d) Soft tissue health and contour improved by the ISTE graft.
many cystic defects and the donor site morbidity of autogenous in their late teens or older, present with retracted and scarred
bone harvest precluded the grafting of cystic defects. However, soft tissue that may even contain a hypoplastic (peg) lateral
an ISTE bone graft regenerates the full height and width of the incisor (Fig 20-16a). Tissue beds such as this that have reduced
alveolus without donor site morbidity, gaining sufficient bone vascularity and cellularity cannot be successfully grafted without
for wide and long dental implants (Fig 20-15). using autogenous bone or ISTE.
Grafts for cystic defects are constructed similarly to previously The composite graft for the nasoalveolar cleft is the same
discussed grafts, using cancellous allogeneic bone in which as previously discussed: cancellous allogeneic bone admixed
clotted PRP is added and 5 × 5–mm pieces of the rhBMP-2– with 3 mL of clotted PRP and 21 mg of rhBMP-2/ACS. However,
loaded ACS. this graft site requires closure of the mucosa on the nasal side
so as to prevent bacterial seepage into the graft, which would
result in an infection. Therefore, the nasal side closure is first
Unrepaired adult nasomaxillary alveolar accomplished, after which the graft composite is pressed into
clefts the defect between the walls of the cleft. Most nasomaxillary
clefts are sufficiently small so as to not require containment
Too many cleft lip and palate patients undergo excellent early other than a membrane. Large or bilateral clefts may require a
cleft lip and palate repair that is not followed up with bone regen- titanium mesh (Fig 20-16b). As before, the graft will regenerate
eration in the maxillary lateral incisor area. These patients, now implantable bone within 6 months (Figs 20-16c and 20-16d).
362

Specific Clinical Applications of ISTE
Fig 20-17 Continuity defect reconstructed with an ISTE graft within a titanium mesh.
Fig 20-18 (a) In this case, a PLA/PLGA re-

sorbable mesh was used but resulted in
late-term pain, swelling, and bone resorption
due to a foreign body giant cell reaction. (b)
Histology of the foreign body giant cell reac-
tion from the PLA/PLGA resorbable mesh.
Note the clear spaces, which represent frag-
mentation of the partially resorbed mesh and
the numerous giant cells and inflammatory
cells present.
a b
It should be noted that in many clefts the ISTE graft is placed recommends a delayed procedure to allow the cure or resolu-
against a root surface. In the author’s experience, external root tion of the underlying initiating disease or event.
resorption has never been observed. The recipient tissue bed is prepared by the removal of the
benign tumor; in some cases, preservation of the mandibu-
lar neurovascular bundle is also possible. In cases of delayed
Continuity defects grafting, the preparation of the recipient tissue is carried out
prior to placing the graft. Before the ISTE graft is prepared, the
Continuity defects of the mandible or maxilla are the most chal- oral mucosa must be meticulously closed using an extraoral
lenging of all and in the past certainly required autogenous approach. In patients under 40 years of age and with tissue
grafts. However, even in this most challenging graft indication, unadulterated by excess scarring from previous infections or
ISTE grafts have regenerated viable bone capable of providing radiation therapy, PRP is the author’s choice for the grafting
implant primary stability equal to autogenous grafts over the procedure. For all others, the increased number of MSCs and
same 6-month interval without the pain, gait disturbance, pro- OPCs from BMA or BMAC is required. The graft is prepared
longed hospital stay, convalescent period, and operating time using allogeneic cancellous bone in a ratio of 8 mL per 1 cm
required for autogenous grafting. of bony continuity defect, rhBMP-2/ACS in a ratio of 1 mg per
Due to the support of soft tissue healing by the upregulation 1 cm of defect, and at least a total of 10 mL of PRP, BMA,
of VEGF and by the VEGF in either PRP, BMA, or BMAC, conti- or BMAC.
nuity defects resulting from benign tumor defects are immedi- For mandibular continuity defects, a titanium reconstruction
ately reconstructed at the time of tumor removal. This is made plate reinforced with titanium mesh at the inferior border to
possible because these growth factors create a rapidly healing contain the composite graft is recommended (Fig 20-17). Resorb-
wound module, closing the mucosa so that salivary seepage and able meshes of polylactic acid (PLA)/poly(lactic-co-glycolic acid)
bacterial contamination are significantly reduced. For continuity (PLGA) are not recommended due to a painful foreign body giant
defects resulting from malignant tumors, trauma, osteoradio- cell reaction associated with the latter phases of their resorption
necrosis, drug-induced osteonecrosis, or infection, the author (Fig 20-18). The graft composite is then packed against the titat-
363

Fig 20-20 (a) Mature ISTE

continuity reconstruction with
the mandibular canal outlined
and functional dental implants
in place. (b) Screw-retained
prosthesis rehabilitating lost
dentition with an ISTE graft.
a b
Fig 20-21 ISTE graft contained in a titanium mesh for maxillary reconstruction.
a b c
Fig 20-22 (a) Upon removal of the mesh, adequate bone for eight implants was observed. (b) Mature
maxillary graft at 6 months. (c) Spark erosion swing-lock appliance fabricated for this reconstruction.
(d) The maxillary denture is stable and functional in opposition to the natural mandibular dentition.
nium mesh and plate to the full height of the tissue volume. If For similar-sized defects in the maxilla, a transoral approach
the inferior alveolar neurovascular bundle has been preserved is required. In such cases, titanium mesh is once again used
or grafted, it is best to place the neurovascular bundle in its for graft containment and stability (Fig 20-21). Alternatively,
normal anatomical location and graft around it. By 6 months, graft containment may be achieved using a crib derived from
a radiographically identifiable mandibular canal will be seen an allogeneic rib or iliac crest wedge hollowed out to receive
so as to guide implant placement (Fig 20-20). Since the first the graft composite (Fig 20-22). In defects in the maxilla, it is
3 weeks of either an ISTE graft or an autogenous cancellous important to seal the graft off from the nasal cavity, maxillary
marrow graft is the critical time for revascularization and cellu- sinus, and oral cavity. Undermining the oral mucosa sufficiently
lar activity, maxillomandibular fixation with arch bars or fixation to gain tension-free primary closure is crucial, as is repairing
screws is recommended. any tears in the nasal mucosa and placing a membrane to seal
off any perforations of the sinus mucosa.
364

References
TABLE 20-2 Maxillary vertical ridge augmentation TABLE 20-3 Patient outcome parameters following
treatment of mandibular continuity defects
Parameter ISTE Autograft P value
N 80 80 — Parameter ISTE ACM MVF
Bone regeneration 74 (92.5%) 73 (91.5%) 0.94 N 100 100 100
TBA 71% 68% 0.90 Bone graft regeneration 94 (94%) 91 (91%) 90 (90%)
Implant osseointegration 176/190 (92.6%) 179/203 (88.2%) 0.88 Donor site paina
0 100 (6/10) 100 (5/10)
Donor site None 80/80 — Dental implant function 78 (78%) 79 (79%) 23 (23%)
Average cost $5,900 $5,300 0.89 Parenthetical numbers indicate mean subjective pain score.
a
Average time of procedure 48 minutes 81 minutes 0.05

TABLE 20-4 Time and cost parameters following
TBA, trabecular bone area from bone cores.
treatment of mandibular continuity defects
Parameter ISTE ACM MVF
PROOF OF PERFORMANCE Mean hospital stay (days) 1.7 4.2 10.4

Intensive care unit (days) 0 0 2
While the forgoing six clinical applications detailed dosages Mean procedure time (hours) 3.7 5.7 9.8
of the tissue engineering triad and the technical aspects of Hospital cost (US $) $19,200 $41,300 $87,200
placement, they understate the significant advantages of bone
regeneration without harvesting autogenous bone from a donor
site. The author accomplished two studies that address the
advantages of ISTE.
placement and useful function (78% and 79% versus 23%).
ISTE grafts created no donor site pain, whereas both ACM and
Vertical ridge augmentation MVF grafts produced a variable degree of postoperative pain in
the range of 5 to 6 out of 10 on a subjective pain scale.
Our study, which included 80 patients in each arm, analyzed the The time and cost parameter data show a significant reduction
outcome of ISTE grafts compared with autogenous grafts from in hospital care time for ISTE grafts as compared with ACM and
the tibia or symphysis in a clinic setting (Table 20-2). MVF grafts, with the MVF grafts requiring 2 days of intensive
The results show nearly equal outcomes of bone regener- care unit management during an already lengthy hospital stay.
ation frequency and bone density as measured by trabecular Moreover, another significant difference between the three
bone area. They also showed an equal ability of the bone regen- graft techniques is seen in operating time. This, together with
erate to osseointegrate dental implants. However, the strong the length of hospital stay, shows a very significant difference
advantage of ISTE is apparent in the lack of a donor site and the in hospital charges: ISTE: $19,200, ACM: $41,300, and MVF:
associated morbidity in each patient as well as the time saved $87,200.
by a shorter procedure in which bone is not harvested. The time Such data strongly support ISTE as one of several current
saving also contributes to a nearly equal cost, overcoming the standard of care options for surgeons aiming to replace a
expense of the rhBMP-2/ACS. This study did not address the patient’s lost or missing bone. Moreover, they establish ISTE
time and costs involved in the postoperative management of as a method consistent with today’s trends in value analysis,
the donor site in cases of autogenous bone harvest, which are tissue/organ preservation, and cost savings.
not required with ISTE.
Continuity defects REFERENCES

In this study, 100 consecutive size-matched continuity defects 1. Marx RE, Stevens MR (eds). Atlas of Oral and Extraoral Bone
Harvesting. Chicago: Quintessence, 2010.
indicated for elective bone graft surgery were treated using ISTE,
2. Marx RE. The role of growth factors in tissue engineering. In:
autogenous cancellous marrow (ACM), or microvascular fibular Lynch SE, Genco RJ, Marx RE (eds). Tissue Engineering: Applica-
(MVF) grafts; each patient’s outcome parameters are shown in tions in Maxillofacial Surgery and Periodontics. Chicago: Quintes-
Table 20-3. Time and cost parameters are shown in Table 20-4. sence, 1999:74–80.
3. Marx RE. Platelet-rich plasma: Evidence to support its use. J Oral
The patient outcome parameters indicate nearly equal bone
Maxillofac Surg 2004;62:489–496.
regeneration across the three grafts. However, ISTE and ACM 4. Yazawa M, Ogata H, Nakajima T, Mori, T, Watanabe N, Handa M.
grafts produced greater height and width of bone than did MVF Basic studies on the clinical applications of platelet-rich plasma.
grafts and thus resulted in a better outcome related to implant Cell Transplant 2003;12:509–518.
365

20 | The Introduction of Tissue Engineering for Bone Regeneration
5. Marx RE, Garg AK. Dental and Craniofacial Applications of 10. Wang EA, Rosen V, D’Alessandro JS, et al. Recombinant human
Platelet-Rich Plasma. Chicago: Quintessence, 2005. bone morphogenetic protein induces bone formation. Proc Natl
6. Marx RE, Harrell DB. Translational research: The CD34+ cell is Acad Sci U S A 1990;87:2220–2224.
crucial for large-volume bone regeneration from the milieu of bone 11. Seeherman H. The influence of delivery vehicles and their prop-
marrow progenitor cells in craniomandibular reconstruction. Int J erties on the repair of segmental defects and fractures with osteo-
Oral Maxillofac Implants 2014;29:e201–e209. genic factors. J Bone Joint Surg Am 2001;83-A(suppl 1[Pt 2]):
7. Schimandle JH, Boden SD, Hutton WC. Experimental spinal fusion S79–S81.
with recombinant human bone morphogenetic protein-2. Spine 12. Hassel S, Schmitt S, Hartung A, et al. Initiation of Smad-dependent
(Phila Pa 1976) 1995;20:1326–1337. and Smad-independent signaling via distinct BMP-receptor
8. Swiontkowski M, Goulet J, Paiement G, et al. Safety and feasibil- complexes. J Bone Joint Surg Am 2003;85-A(suppl 3):44–51.
ity of implanting recombinant human BMP-2/absorbable collagen 13. Marx RE. Application of tissue engineering principles to clinical
sponge in patients with open tibia fractures. Presented at the practice. In: Lynch SE, Marx RE, Nevins M, Wisner-Lynch LA (eds).
Annual Meeting of the Orthopedic Trauma Association, 1997. Tissue Engineering: Applications in Oral and Maxillofacial Surgery
9. Boyne PJ, Lilly LC, Marx RE, Moy PK, Nevins M, Spagnoli DB. De and Periodontics, ed 2. Chicago: Quintessence, 2008:47–63.
novo bone induction by recombinant human bone morphogenetic
protein-2 (rhBMP-2) in maxillary sinus floor augmentations. J Oral
Maxillofac Surg 2005;63:1693–1707.
366

21 GIOVANNI ZUCCHELLI • MARTINA STEFANINI
Soft Tissue Management to

Augment Implant Success
Increasing Keratinized Mucosa and Deepening the
Vestibule After Implant Placement
Increasing Height and Thickness of Soft Tissues After
Implant Placement
Treating Soft Tissue Defects Around Submerged
Implants
Increasing Soft Tissue Height and Thickness at
Implant Placement
Soft Tissue Augmentation in Esthetic Zone at Implant
Placement
Soft Tissue Augmentation at Postextraction Implant
Placement with Immediate Provisionalization
Soft Tissue Papillae Preservation for Implant
Placement in Extraction Socket
Treating Peri-implant Soft Tissue Dehiscence with a
Prosthetic-Surgical-Prosthetic Approach
367

21 | Soft Tissue Management to Augment Implant Success
a b c
Fig 21-1 (a to c) Baseline clinical and radiographic images showing the lack of keratinized tissue and the reduced depth of the vestibular fornix.
W
hether or not keratinized mucosa (KM) is This chapter describes several soft tissue augmentation tech-
needed to maintain peri-implant health has niques for different clinical situations through the presentation
been a matter of controversy in the literature of clinical cases.
in terms of a number of parameters: (1) estab-
lishment and maintenance of soft tissue health, (2) prevention of
recession, (3) esthetics, and (4) ability to clean the prostheses.
The Third European Association for Osseointegration Consensus INCREASING KERATINIZED
Conference, which was held in 2012 and considered scientific MUCOSA AND DEEPENING THE
evidence on the need for KM around dental implants, concluded
that “there is a lack of high-quality studies evaluating the need
VESTIBULE AFTER IMPLANT
for KM around implants to maintain health and tissue stability.”1 PLACEMENT
However, soft tissue recessions around implants were more
pronounced at sites with “inadequate” KM at the short-term Ideally, the increase in KM/soft tissue thickness should be
evaluation, even if this association was less evident in long-term performed before or simultaneously with implant placement.
follow-up studies (1 to 5 years). However, in the clinical setting these techniques can also be
In a recent review paper, Wennström and Derks2 suggested performed after implant placement. After implant insertion, espe-
that although the lack of an “adequate” band of KM by itself is cially in the mandible, clinical scenarios are frequently encoun-
not harmful to peri-implant health, it may hamper the perfor- tered in which there is complete absence or a minimal quantity
mance of proper hygiene. The authors hypothesized that some of KM, many times associated with a reduced depth of the ves-
patients might experience pain and discomfort during brushing tibular fornix and coronal muscle insertion (Figs 21-1a to 21-1c).
at implant sites with inadequate amounts of KM, which could In these cases, where there are no esthetic demands, the
result in poor plaque control. main objective is to reconstruct/increase the quantity of KM and
A study comparing the level of brushing discomfort during deepen the vestibule so as to facilitate the performance of oral
oral hygiene and peri-implant clinical variables between patients hygiene by the patient and at the same time reduce the risk of
presenting with implant sites with KM ≥ 2 mm and those with soft tissue dehiscence (Fig 21-1d). The most appropriate surgi-
KM < 2 mm concluded that patients in the latter group were cal technique to obtain those results is the free gingival graft.
more prone to brushing discomfort, plaque accumulation, and The use of screw-retained implant crowns allows their
peri-implant soft tissue inflammation.3 In a 10-year prospective removal and the subsequent placement of a healing abutment
study, Roccuzzo et al4 studied the clinical conditions around (Fig 21-1e). This is done 2 months prior to surgery with the
dental implants placed in the posterior mandible of healthy or aim of obtaining an increase in and further maturation of the
moderately periodontally compromised patients in relation to peri-implant soft tissues. The surgery is easier to perform with-
the presence or absence of KM. He concluded that implants out the implant crown, which can be reused after the healing
not surrounded by KM are more prone to plaque accumulation phase to avoid increasing costs to the patient.
and recession, even in patients practicing sufficient oral hygiene
and receiving adequate supportive periodontal therapy. There-
fore, even though there is no unanimous agreement within the Surgical technique
scientific literature, most clinicians agree that there is a need
to adopt surgical techniques to increase the height of the KM The recipient bed is prepared by making a trapezoidal flap that
and/or the thickness of the peri-implant soft tissues. consists of two horizontal incisions (3 mm in length) performed
368

Increasing Keratinized Mucosa and Deepening the Vestibule After Implant Placement
d e f
g h i
Fig 21-1 (cont) (d) Demonstration of the mobility of the peri-implant soft tissues, which impairs oral hygiene. (e) Before surgery, the crown is
removed, and a healing abutment is placed. (f) Surgical procedure: trapezoidal flap design, flap elevation, and muscular insertion dissection. (g)
Free gingival graft. (h and i) Stabilization of the epithelial-connective tissue graft at the recipient bed.
distal and mesial to the implant platform, and two vertical releas- distal), and a thickness of 1.5 to 2 mm (Fig 21-1g). Hemostasis
ing incisions extended into alveolar mucosa (Fig 21-1f). It is of at the donor site is achieved with the use of either a collagen
utmost importance to try to place the horizontal incisions in matrix or fibrin sponge that is stabilized with compressive cross
keratinized tissue in order to facilitate the suture of the graft mattress sutures suspended from individual neighboring teeth.
and accomplish direct healing between the keratinized tissue The epithelial-connective tissue graft is stabilized at the recip-
of the graft and the keratinized tissue of the recipient bed; ient site with several suture techniques: simple interrupted
this will guarantee stability and better blending of the tissues. sutures at the level of the horizontal incision in keratinized tissue
Flap elevation is done entirely by deep split-thickness incision, (7-0 PGA sutures; black arrows in Figs 21-1h and 21-1i); vertical
keeping the blade parallel to the bone surface until 5 to 6 mm external mattress sutures with periosteal anchorage at the apical
of periosteum is exposed apically. mesial and distal angles (6-0 PGA sutures; white arrows in Figs
In this step, it is important to leave only the periosteum cover- 21-1h and 21-1i); and compressive horizontal mattress sutures
ing the bone, eliminating muscle insertions that could render anchored to the periosteum apical to the graft and suspended
the graft mobile. This also allows visualization of the depth of around the implant’s healing abutment (6-0 PGA sutures; yellow
the vestibular fornix. Particular attention must be paid in the arrows in Figs 21-1h and 21-1i). For the vertical external mattress
posterior mandible given the ease with which the periosteum suture with periosteal anchorage, the needle perforates the
can be stripped from the bone, making it difficult—if not impos- graft, passes beneath the vertical incision, and exits on the
sible—to adequately stabilize the gingival graft. The next step adjacent soft tissues (Fig 21-1j). Then, it reenters apical to initial
is to dissect the muscular insertions from the inner part of the exit point and passes once more beneath the vertical releasing
flap, keeping the blade parallel to the mucosal plane as when incision, this time taking periosteal anchorage and exiting apical
performing the superficial split-thickness incision in a coronally to the graft (Fig 21-1k). The suture is closed with a surgical knot
advanced flap. By doing this, the mucosa, now free from the positioned over the graft (Fig 21-1l).
muscle pull, can be sutured to the base of the recipient bed It should be stressed that the whole surgery, particularly
with simple interrupted sutures anchored to the periosteum (6-0 the flap elevation, is made easier by the absence of prosthetic
polyglycolic acid [PGA] sutures). Leaving muscle insertions on components (implant crown or even healing abutment); on the
the mucosa could cause sutures to detach as a consequence other hand, the healing abutment is essential for placing the
of the forces exerted whenever the patient pulls on the lip. suspended sutures. After suturing, lip and cheek movements
The free gingival graft taken from the palate is an must be done to ensure that these do not destabilize the grafted
epithelial-connective tissue graft with an apicocoronal dimen- tissue, since movement of the epithelial-connective tissue graft
sion of 4 to 5 mm, a mesiodistal dimension approximately 6 during the healing phase would result in failure of the surgical
mm greater than the implant diameter (3 mm mesial and 3 mm procedure.
369

j k l
Fig 21-1 (cont) (j to l) Illustrations of the

vertical external mattress sutures. (m and
n) Buccal and occlusal views after 4 months
showing the increase in keratinized tissue
and vestibular fornix depth. (o and p) Clinical
and radiographic views at the 1-year follow
up. The intraoral radiograph shows the stabili-
ty of the peri-implant bone level. (Restorative
therapy by Dr Mauro Fadda, Bologna, Italy.)
m n
o p
Postoperative protocol Super Floss [Oral-B]). No prosthetic structures, except for a tall
healing abutment, are placed during the first 4 months to allow
Sutures are removed after 2 weeks, during which time the for undisturbed soft tissue maturation (Figs 21-1m and 21-1n).
patient performs only chemical plaque control with the use of When the screw-retained crown is reseated, there will be
an antiseptic rinse with 0.12% chlorhexidine three times a day, some compression that will create ischemia of the soft tissues.
applying it locally for 1 minute. Good surgical stabilization of If this ischemia disappears within a few minutes it is not neces-
the graft is a key factor in its subsequent dimensional stabil- sary to make any adjustments to the restoration.
ity. If the graft is precisely adapted to the recipient bed, with-
out mobility and with the thickness of the coagulum between
the graft and the periosteal bed reduced to a minimum, it will Outcomes
undergo minimal postoperative contraction during the first
weeks of healing. At the 1-year postoperative follow-up, there is an evident
After the first 2 weeks, the patient begins to brush the treated increase in keratinized tissue and good tissue integration of
area with an ultra-soft toothbrush for 4 weeks and uses the the preexisting screw-retained crown (Figs 21-1o and 21-1p).
chlorhexidine-based rinse twice a day. Brushing is done with The misalignment of the mucogingival junction and different
the roll technique: The bristles are placed in contact with the color/texture of the grafted area associated with this surgical
soft tissues and rolled in an apicocoronal direction. Afterward, technique limits the indications of a free gingival graft to areas
for the next 2 months, the patient uses a soft toothbrush and of low esthetic value. The increase in the height and thickness
rinses once a day with the chlorhexidine mouthwash. Nearly of the buccal keratinized tissue is accompanied by an increase in
4 months after the surgery, the patient recommences using the vestibular depth. These conditions reduce discomfort when
the medium toothbrush, suspends chlorhexidine rinses, and brushing and therefore contribute to better hygiene maintenance
starts performing interdental hygiene (with the soft portion of and improved plaque control by the patient.
370

Increasing Height and Thickness of Soft Tissues After Implant Placement
a b
c d e
f g h
Fig 21-2 (a and b) Baseline situation showing the implant-supported crown with incorrect emergence profile. (c to e) Clinical views showing the
lack of adequate thickness of the buccal soft tissue. (f to h) Surgical procedure: 2 months after crown removal and the placement of a tall healing
abutment, a trapezoidal coronally advanced flap can be performed.
INCREASING HEIGHT AND healing abutment because this will allow an increase in the inter-
proximal space between the abutment and the adjacent teeth.
THICKNESS OF SOFT TISSUES In 2 to 3 months, this space will be filled with thick, mature soft
AFTER IMPLANT PLACEMENT tissues that can be used during the surgery for vascular supply
of the surgical papillae of the coronally advanced flap.
Most of the time soft tissue deficiencies at the buccal aspect
of implant-supported crowns are a matter of thickness rather
than height of keratinized tissue. The lack of adequate thick- Surgical technique
ness of the buccal soft tissues can lead to incorrect emergence
profiles of the prosthetic crown, which are difficult to maintain The buccal flap design is similar to the trapezoidal flap used in
from a hygienic point of view; this favors the development of mucogingival surgery for the treatment of single gingival reces-
buccal dehiscence defects and visibility of the underlying metal- sions. The horizontal incisions (approximately 3 mm long) are
lic components while also causing bothersome food retention executed apically to the vertex of the anatomical papillae at a
(Figs 21-2a to 21-2e). In these cases, the main goal of the peri- distance equivalent to the desired coronal advancement of the
odontal surgery is not to increase the height of the keratinized flap; the vertical releasing incisions are slightly divergent, reach-
tissues but to augment the thickness of the connective tissue at ing the alveolar mucosa (Figs 21-2f to 21-2h). The thickness of
the level of the peri-implant transmucosal portion. This is achieved the flap elevation varies: partial at the level of the surgical papil-
with a surgical technique that involves the use of a connective lae; full from the buccal gingival margin and past the osseous
tissue graft covered by a coronally advanced flap. In this scenario, crest, performed with a periosteal elevator; and finally partial
it is even more important to replace the implant crown with a tall again to achieve coronal flap advancement.
371

21 | Soft Tissue Management to Augment Implant Successs
i j k
Fig 21-2 (cont) (i) Ideal connective tissue graft

position (shaded box). (j to l) Connective tissue
graft derived from de-epithelialization of a pala-
tal free gingival graft. (m) De-epithelialization of
the anatomical papillae toward the palatal aspect
(arrows), which will ensure vascular supply to the
surgical papillae of the coronally advanced flap.
l m
The connective tissue graft (1 mm thick), obtained from Outcomes

the de-epithelialization of a palatal free gingival graft, must
be positioned to cover the implant shoulder and the underly- Once the soft tissues have matured, the preexisting screw-
ing periosteal bed5 (Figs 21-2i to 21-2l). It is fixed with simple retained prosthetic crown can be reused. Frequently, in the
interrupted sutures at the base of the anatomical papillae, case of apicocoronal and buccolingual increase in soft tissues,
which given their increased surface and thickness, can be at the moment of reseating the screw-retained crown there
de-epithelialized on the occlusal plane toward the palatal side will be excessive compression of the soft tissues. In these
(white arrows in Fig 21-2m). The coronally advanced flap is cases, there is no need to force the placement of the crown or
closed with interrupted sutures along the vertical releasing retouch it significantly; instead, it is advised to go through an
incisions and with a sling suture suspended along the palatal intermediate soft tissue conditioning phase by placing progres-
surface of the healing abutment at the level of the surgical sively larger healing abutments or a provisional screw-retained
papillae (Figs 21-2n and 21-2o). By positioning the flap’s surgi- resin crown. When placing the definitive crown, ischemia from
cal papillae on top of the de-epithelialized anatomical papillae, compression should disappear within a few minutes (Figs 21-2s
the marginal tissue advances coronally over the buccal surface and 21-2t).
of the healing abutment. This creates a vertical augmentation The technique of a connective tissue graft covered by a coro-
(in addition to the horizontal one) of the soft tissues buccal nally advanced flap has the following advantages with respect
to the implant. to the free gingival graft: (1) allows for a greater gain in thick-
ness (and volume) of buccal soft tissues without requiring the
harvest of very thick palatal grafts because both the thickness
Postoperative protocol of the flap and that of the graft contribute to the final result; (2)
avoids unesthetic results related to color difference, surface
Sutures are removed after 2 weeks. At this time, it is already texture, and misalignment of the mucogingival junction typical
possible to appreciate the buccolingual volume augmentation of the free gingival graft; and (3) allows for vertical augmentation
of the buccal soft tissues and the absence of apical contraction (in addition to increased thickness) of the soft tissues since the
of the marginal tissues. This can be attributed to the underlying graft, placed covering the implant shoulder, survives thanks to
connective tissue graft. The healing abutment is left in place for the vascular supply of the overlaid flap.
4 months in order to allow for soft tissue maturation free from On the other hand, the increase in height of the keratinized
prosthetic interferences (Figs 21-2p to 21-2r). tissue happens very slowly (mainly as a result of the realign-
372

Treating Soft Tissue Defects Around Submerged Implants
n o p
q r s t
Fig 21-2 (cont) (n and o) Clinical views after flap closure. (p to r) Clinical views 4 months after surgery showing the apicocoronal and buccolingual
soft tissue increase. (s and t) Clinical views at the end of the treatment showing the increase in soft tissue thickness and the correct emergence
profile of the crown. (Restorative therapy by Dr Mauro Fadda, Bologna, Italy.)
ment of the mucogingival junction) and often in lesser amounts merged. Once the site is healed, implant uncovering is done
compared with the free gingival graft. These differences make by means of the flapless technique.
the technique of the connective tissue graft covered by a coro- The following clinical case refers to a patient who, 6 months
nally advanced flap the most suitable technique for the maxilla; prior, had an implant placed with simultaneous guided bone
however, the free gingival graft still is the technique of choice regeneration on the buccal aspect and was therefore submerged.
for augmentation of keratinized tissues in the mandible, where Unfortunately, the result in terms of the amount of buccal soft
there may be muscle or frenulum insertions and the patient’s tissues was unsatisfactory, and a moderate buccolingual defect
esthetic demands are less. was present (most evident in profile view); a small fenestra-
tion at the level of the buccal keratinized tissue had formed,
exposing the platform of the implant. An intraoral radiograph
showed good implant osseointegration and absence of signs
TREATING SOFT TISSUE DEFECTS of peri-implantitis (Fig 21-3a).
AROUND SUBMERGED IMPLANTS
Stage-two surgery is a generic term used to refer to a surgical Surgical technique
intervention performed after an implant is placed and left to
heal submerged. The choice of differing the treatment in stages The surgical technique for such cases consists of a buccal flap
can be related to the clinician’s preference, but many times it similar to the one used in mucogingival surgery for the treat-
must be done because of either lack of primary implant stabil- ment of multiple recessions: Oblique paramarginal incisions
ity or simultaneous bone reconstruction at the time of implant convergent toward the implant site are performed at the level
placement. In this stage-two surgery, it is possible to improve of the papillae adjacent to the edentulous site, where a horizon-
the peri-implant soft tissue condition, which is frequently sub- tal incision, completely displaced to the buccal side, is made
optimal as a consequence of shrinkage of buccal soft tissues (Fig 21-3b). The incision of the mesial surgical papillae and the
and loss in height of the keratinized gingiva, both associated buccal flap at the edentulous site are done at partial thickness;
with submerged healing. When possible, it is preferred that the when the bone crest is reached, flap elevation is done at full
soft tissue augmentation be done in conjunction with implant thickness for 2 to 3 mm apically. Even the marginal soft tissue
uncovering, but in cases with severe soft tissue deficiencies, buccal to the teeth neighboring the edentulous area is elevated
it may be necessary to perform a stage-two surgery for man- full thickness by inserting the periosteal elevator in the sulcus.
agement of the soft tissues while still leaving the implant sub- Coronal advancement of the buccal flap is accomplished using
373

a b c
d e f
Fig 21-3 (a) Baseline radiograph. (b) Flap design. (c) Flap elevation and exposure of the implant by circular excision. (d and e) Titanium microbrushes
for decontamination of the exposed implant surface. (f) A free gingival graft is harvested from the palate and subsequently de-epithelialized extraorally.
two partial-thickness incisions: one deep, parallel to the bone 1 mm apical to the horizontal crestal incision (Figs 21-3g and
surface to detach muscle insertions from the periosteum, and 21-3h).
one superficial, to detach muscle fibers from the inner aspect To position the graft, two internal mattress sutures must
of the flap. Coronal advancement of the flap is considered suf- be performed starting (and ending) at the base of the surgical
ficient when the buccal flap more than covers the supracrestal papillae mesial and distal to the healing abutment. The needle
soft tissues at the edentulous site. Exposure of the implant enters through the external surface, perforating both the base
platform is done with circular excision of the soft tissues cov- of the surgical papilla and the graft (1 mm from the coronal
ering it (Fig 21-3c). border); then it reenters, perforating the graft and the flap from
The exposed implant surface is decontaminated mechani- the internal surface and exits horizontally to the starting point,
cally with a titanium microbrush and chemically with ethylene- where a surgical knot is made (Figs 21-3i to 21-3m).
diaminetetraacetic acid (EDTA, 24%) and chlorhexidine gel (1%); The anatomical papilla mesial to the edentulous site is
both substances are kept in place for 2 minutes each. The micro- de-epithelialized. The coronally advanced flap is first sutured
brush is used on a low-speed contra-angle handpiece with plenty at this site with a sling suture suspended around the cingulum
of irrigation with physiologic saline (Figs 21-3d and 21-3e). A of the canine. At the implant site, the buccal flap is first closed
6-mm-high healing abutment is placed on the implant, provid- with simple interrupted sutures done at the level of the surgical
ing a hard, smooth surface onto which the connective tissue papillae mesial and distal to the healing abutment; afterwards,
and the coronally advanced flap can be stabilized. The connec- a sling suture suspended from the palatal surface of the heal-
tive tissue graft is obtained from extraoral de-epithelialization ing abutment is also performed. This last suture allows for tight
of a free gingival graft harvested from the palate (Fig 21-3f). and precise adaptation between the keratinized tissue of the
The graft’s dimensions should be as follows: The mesiodistal coronally advanced flap and the convex surface of the healing
dimension must exceed the implant diameter by 6 mm (3 mm abutment (Fig 21-3n).
each mesially and distally), the apicocoronal dimension must
cover the exposed implant surface plus 4 mm (1 mm coronal
to the implant shoulder, resting on the healing abutment, and 3 Postoperative protocol
mm apical to the buccal bone crest), and the thickness should
be approximately 1 mm. The graft is sutured onto the internal Sutures are removed after 2 weeks. In this case, the buccal soft
surface of the flap in a paramarginal position, approximately tissues did not seem to have undergone any type of contraction
374

Treating Soft Tissue Defects Around Submerged Implants
g h
i j k
l m
n o p
Fig 21-3 (cont) (g and h) Connective tissue graft sutured at the inner aspect of the flap in a paramarginal position. (i to m) Illustrations of the
internal mattress suture technique to stabilize the connective tissue graft onto the internal surface of the flap. (n) Occlusal view of flap closure.
Note the tight adaptation of the gingival margin around the healing abutment. (o and p) Four months of undisturbed healing with a tall abutment
obtained an increase in soft tissues and further coronal growth.
with respect to their surgical placement. This can be attributed it is advisable to place a tall healing abutment that will allow
both to the good flap stabilization around the healing abutment this growth. This is done with the objective of obtaining, at the
and to the barrier effect of the connective tissue graft, which, end of the maturation phase, a mucosal margin buccal to the
by being in a paramarginal position, prevents apical contraction healing abutment that is more coronal in respect to the margin
of the coronally advanced flap. of the adjacent tooth (Figs 21-3o and 21-3p).
Soft tissues must be left undisturbed for about 4 months to After the maturation phase, the conditioning phase is started
allow maturation. Given that an increase in thickness is accompa- with a screw-retained provisional that has a twofold purpose:
nied by additional coronal growth of the soft tissues (creeping), give the buccal mucosal margin a curvature similar to that of its
375

q r s
t u v
w x y
z aa bb
cc dd ee
Fig 21-3 (cont) (q to s) Conditioning phase with a screw-retained provisional crown. (t and u) Clinical views at the end of the conditioning phase,
when no further papilla growth is observed. (v) Buccal view before definitive restoration. (w to y) Buccal views comparing the situation at baseline
and 1 year after crown restoration. (z to bb) Occlusal views comparing baseline and 1 year after crown restoration. (cc) Profile view 1 year after
crown restoration. (dd) The increase in soft tissues enables a good emergence profile of the implant-supported crown. (ee) Radiograph 1 year
after definitive restoration.
376

Increasing Soft Tissue Height and Thickness at Implant Placement
counterpart and promote growth of the papillae mesial and distal height of the buccal soft tissues in the same surgical phase in
to the implant crown. This last point is achieved by modifying which the implant is placed6 (Figs 21-4a to 21-4d).
the interproximal profiles of the provisional crown and progres- A prerequisite for the execution of this technique is the pres-
sively displacing the contact point coronally. The duration of the ence of a minimum of 2.5 to 3 mm of keratinized crestal tissue.
conditioning phase with the provisional crown varies from one This is due to the need for 2 mm of keratinized tissue on the
patient to another, but it is never less than 3 to 4 months (Figs lingual side, while 0.5 to 1 mm is incorporated on the buccal flap
21-3q to 21-3s). to guarantee its stability at the end of surgery. In the absence of
When no further papilla growth is observed (when papillae said quantity of keratinized crestal tissues, a free gingival graft
fail to entirely fill the interproximal space) and after making the should be done prior to implant placement. This technique is
last modifications to the provisional restoration, the conditioning particularly indicated in the presence of combined buccolingual
phase can be concluded, and the definitive restoration can be and apicocoronal soft tissue defects. An adequate height and
made (Figs 21-3t and 21-3u). The definitive crown must replicate thickness of bone should be present to allow proper placement
the shape of the last provisional at the level of the transmu- of an implant with ideal length and diameter. Minor buccal bone
cosal portion and, of course, have color and shape that match dehiscences (< 3 mm) can be treated with this surgical technique
the adjacent teeth. in association with a transmucosal dental implant. Larger osseous
Soft tissue conditioning continues even with the definitive buccal defects must be treated with guided bone regeneration.7
crown because it is made with materials that are more biocom-
patible and more readily cleaned than those of the provisional;
this favors further growth of the papillae. For this reason it is not Surgical technique
recommended to completely obliterate the interproximal spaces
when making the definitive crown, but rather to leave space for The surgical technique begins with a horizontal crestal incision
additional growth of the interproximal soft tissues (Fig 21-3v). that divides the existing keratinized tissue between the buccal
and lingual/palatal flap, preserving more keratinized tissue on the
lingual side (1.5 to 2 mm) than on the buccal side (0.5 to 1 mm).
Outcomes Once the bone is reached, the flaps are elevated at full thick-
ness with a periosteal elevator in order to expose the underlying
Comparisons between the initial situation and the follow-up 1 osseous crest for correct implant placement. Afterwards, the
year after placing the definitive restoration in this case exam- buccal flap is elevated at partial thickness, freeing it from muscle
ple (Figs 21-3w to 21-3cc) show good integration of the implant insertions and making its coronal advancement possible. Buccal
crown with the adjacent soft tissues, which have been aug- flap design and elevation at the sites neighboring the edentulous
mented in both the apicocoronal and buccolingual dimensions. area are similar to those of the envelope flap for treating multi-
The apicocoronal increase in the soft tissues allows the forma- ple gingival recessions (Figs 21-4e and 21-4f). Once the implant
tion of triangular papillae that completely fill the interproximal bed has been prepared and the implant has been placed with its
spaces, as do the anatomical papillae of the adjacent teeth. The transmucosal portion situated supracrestally, the future connec-
buccolingual increase in soft tissues enables the creation of a tive tissue graft dimensions can be calculated. Its apicocoronal
prosthetic crown with a very natural emergence profile that dimension should be sufficient to cover the transmucosal por-
resemble those of the adjacent teeth, making it easier to main- tion of the implant and 2 mm of buccal bone apically. The graft’s
tain from a hygienic point of view (Fig 21-3dd). An intraoral radio- mesiodistal dimension should be approximately 6 mm larger
graph taken 1 year after definitive crown placement shows sta- than the implant’s diameter; its thickness will vary according to
bility of the peri-implant bone level (Fig 21-3ee). This, in addition the extent of the horizontal defect but is generally around 1 mm.
to the absence of clinical signs of mucositis or peri-implantitis, The height of the healing abutment is selected based on
indicates a healthy status of the peri-implant tissues. the dimension of the transmucosal portion of the implant and
the amount of coronal advancement desired of the buccal flap.
Normally, 2- to 3-mm healing abutments are used. The connec-
tive tissue graft, obtained from the de-epithelialization of an
INCREASING SOFT TISSUE epithelial-connective tissue graft harvested from the palate, is
sutured to the internal surface of the buccal flap (1 mm apical
HEIGHT AND THICKNESS AT
to the coronal margin) by means of internal horizontal mattress
IMPLANT PLACEMENT sutures (Figs 21-4g and 21-4h). The submarginal position of the
graft will not interfere with the capacity of the keratinized tissue
In some cases, it is possible to avoid a second surgical phase by of the flap to adapt to the healing abutment, but it will limit the
improving the soft tissues at the moment of implant placement. postsurgical contraction of the flap, contributing to the treatment
The technique presented, which consists of a buccal coronally of the vertical component of the defect and to the increase in
advanced flap in conjunction with a submarginal connective tis- soft tissue thickness needed for the treatment of the horizontal
sue graft, makes it possible to increase both the thickness and component of the defect (Fig 21-4i).
377

a b c
d e f
g h i
Fig 21-4 (a to d) Clinical and radiographic views of the

edentulous area at baseline. (e and f) Flap elevation
and occlusal view after implant placement. (g and h)
Simultaneous connective tissue graft application. (i)
Connective tissue graft sutured at the inner aspect of
the flap in a paramarginal position. (j) Primary intention
closure of the flap. (k) Soft tissue maturation phase.
j k
The flap, free from muscle insertions, is coronally advanced, due to the barrier effect of the underlying connective tissue
and the marginal keratinized tissues are tightly adapted to the graft.
convex and polished surface of the healing cap placed on the Soft tissues must be left undisturbed for about 4 months to
transmucosal portion of the implant. This is achieved by a sling allow maturation. Given that an increase in thickness is accompa-
suture suspended around the lingual aspect of the healing cap. nied by additional coronal growth of the soft tissues (creeping),
It is fundamental to obtain primary closure between the lingual at the time of implant loading, the marginal keratinized tissue
and buccal flaps mesially and distally to the implant with single is even more coronal with respect to its position at the end of
interrupted sutures (Fig 21-4j). the surgery, demonstrating the improved stability provided by
the underlying connective tissue graft (Fig 21-4k).
Following soft tissue maturation and implant osseointegra-
Postoperative protocol tion, it is possible to start the conditioning phase, which is
performed by a provisional restoration. Emergence profiles are
Sutures are removed after 2 weeks, during which time only created that aid in the patient’s hygiene practices and allow
chemical plaque control (chlorhexidine 0.12%) is performed the soft tissues to adapt to the provisional crown, concluding
by the patient. No shrinkage of the buccal flap was demon- their maturation and leading to a further increase in thickness
strated in this case in the first weeks of healing. This is mainly over time.
378

Soft Tissue Augmentation in Esthetic Zone at Implant Placement
l m n
o p q
Fig 21-4 (cont) (l) Occlusal view of the clinical situation at the end of the
conditioning phase. (m to o) Buccal views at baseline and the time of definitive
restoration. (p and q) Before and after definitive crown restoration placement.
(r) Profile view at the end of treatment showing the correct crown emergence
profile. (s) Intraoral radiograph demonstrating implant osseointegration. (Re-
storative therapy by Dr Mauro Fadda, Bologna, Italy.)
r s
The definitive restoration can be done at the end of the condi- the distance between the soft tissue margin and mucogingival
tioning phase once the soft tissues are stable three-dimensionally. junction with respect to the baseline situation (see the dotted
This period is variable from patient to patient, but it is never less lines in Figs 21-4m and 21-4n).
than 3 months (Fig 21-4l). The periapical radiograph shows good osseointegration of
the transmucosal implant (Fig 21-4s). The coronal displacement
of the implant-abutment connection with respect to the osse-
Outcomes ous crest contributes to a reduction in crestal bone resorption.
Comparison of the clinical images at baseline and after place-

ment of the definitive restoration make it possible to appre-
ciate the volumetric increase in the soft tissues (Figs 21-4m SOFT TISSUE AUGMENTATION
to 21-4r). The horizontal increase allows the placement of an
IN ESTHETIC ZONE AT IMPLANT
implant crown with accurate emergence profiles and masks the
underlying implant-prosthetic structure. The vertical increase PLACEMENT
allows the clinical crown to have a height similar to that of the
neighboring natural dentition, favoring esthetics and facilitating The improvement of soft tissue at the time of implant placement
hygienic maintenance by the patient. The increase in keratinized is particularly indicated in the case of delayed implant placement
tissue height is not due to graft exposure (as with the free in esthetic areas. In the case presented here, the first premo-
gingival graft) but to the vertical soft tissue augmentation that lar was extracted due to a vertical fracture, and no alveolar
together with the realignment of the mucogingival line increases preservation procedures were performed. Six months after the
379

extraction, a residual mild to moderate horizontal bone defect minimizing errors in the final implant position. Another advan-
was present (Figs 21-5a to 21-5d). Apicocoronally, the level of the tage of computer-guided implant planning is the possibility to
edentulous bone ridge is close to the gingival margin position fabricate beforehand a provisional crown that is much more
of the adjacent premolar, which has recession, and the papil- precise with respect to the implant platform and that can easily
lae on either side of the edentulous site are rather flat. It is the be relined intraoperatively.
authors’ opinion that implant placement without simultaneous The flap is elevated with a variable thickness: split thickness
soft tissue augmentation would lead to an implant crown that at the level of the surgical papillae (including those delimiting the
is longer than the adjacent tooth and has an inadequate emer- edentulous site) until the buccal bone crest is reached, full thick-
gence profile in conjunction with further papillae contraction. ness to expose 2 to 3 mm of buccal bone, and split thickness
Augmentation of the soft tissues apicocoronally (in addition apically to free the flap from muscle insertions in the periosteum
to buccolingually) is indicated to provide the prosthodontist a (deep split-thickness incision) and from the inner aspect of the
surplus of soft tissues that can be conditioned in order to obtain flap (superficial split-thickness incisions). This last incision is the
a mucosal margin of the implant crown that resembles that of one that allows coronal advancement of the flap8 (Fig 21-5g).
the premolar and also to create longer papillae that are simi- The surgical sleeve for the first implant drill is used to trace,
lar to those of the adjacent teeth. The patient has a thin, scal- with a microblade, the exact position for implant placement.
loped biotype that has favored the formation of buccal gingival By keeping the microblade in contact with the walls of the
recessions on the neighboring teeth (second premolar, central sleeve, a circular incision is made, which allows full-thickness
incisor, lateral incisor, and canine). One of the advantages of removal of soft tissues only in the site where the implant is to
the chosen surgical approach is the possibility of treating the be placed, leaving the mesial and distal papillae intact. After
gingival recessions on adjacent teeth when designing the coro- removing the tissue, implant bed preparation is done in a guided
nally advanced envelope flap. manner. In this case, following implant placement, a small
bone dehiscence was present, as foreseen during planning
(Figs 21-5h to 21-5j).
Surgical technique The de-epithelialization of the anatomical papillae on the
teeth adjacent to the implant site is done in the vertical plane,
The design of the buccal flap is similar to the envelope flap used while de-epithelialization of the peri-implant papillae can be
for treatment of multiple recessions with a lateral approach. All done also on the horizontal plane in a palatal direction (white
interproximal incisions are oblique and paramarginal, converg- arrows in Fig 21-5k). The connective tissue graft, obtained from
ing toward an imaginary line that passes vertically through the the de-epithelialization of a free gingival graft harvested from
center of the buccal surface of the canine (center of rotation); at the palate, is fixed to the base of the anatomical papillae with
the edentulous site, the horizontal incision is done at the level simple interrupted sutures (7-0 PGA). This leaves wide and deep
of the adjacent papillae. Interproximal incisions must start from vascular beds coronal to the graft, which are necessary for the
the gingival margin of the adjacent tooth and end at a distance stabilization of the surgical papillae of the coronally advanced
from the papilla vertex that corresponds to the desired amount flap. The apicocoronal dimension of the graft should be sufficient
of coronal advancement of the marginal tissues. The advance- to cover the buccal bone dehiscence entirely plus 2 to 3 mm
ment should be greater at the teeth with deeper recessions of bone apically; its thickness must be a little more than 1 mm.
and at the implant site, where the incision is slightly curved After it has been relined, the provisional restoration is screwed
and also paramarginal so as to leave coronal soft tissue that in, making sure that there is no excessive compression on the
can be de-epithelialized occlusally toward the palate for the papillae and no occlusal contact (infraocclusion). The flap is coro-
creation of the future peri-implant papillae. nally advanced and fixed with a sling suture suspended at the
The three-dimensional radiographic study shows an adequate level of the palatal cingulum of the provisional crown and of
thickness and height of bone for prosthetically and esthetically the teeth included in the flap design (6-0 PGA, 11-mm needle).
guided placement of an implant with a length and diameter ideal Further closure of the flap’s surgical papillae onto the anatomical
for replacing a premolar (Figs 21-5e and 21-5f). In the axial view, a palatally de-epithelialized papillae is done with simple interrupted
buccolingual defect can be appreciated at the most coronal level sutures (7-0 PGA, 7-mm needle) placed mesial and distal to the
of the edentulous ridge, which doesn’t impede implant placement provisional crown (Figs 21-5l and 21-5m).
but does significantly reduce the amount of bone that will remain
buccal to the implant platform, predisposing it to the formation
of a small (< 3-mm) osseous dehiscence at the moment of or Postoperative protocol
after (during postsurgical remodeling) implant placement.
In the authors’ opinion, computer-guided implant placement Suture removal is done at 2 weeks (Fig 21-5n). During this period,
is mandatory whenever bone quantity is adequate but barely the patient performs chemical plaque control and avoids chew-
sufficient for the correct positioning of the implant. A surgical ing in the treated area. Already at suture removal, an increase
stent is obtained from the computer-guided planning; this will in buccal soft tissue thickness is evident, completely compen-
guide the use of all the drills as well as the implant insertion, sating for the preexisting horizontal defect.
380

Soft Tissue Augmentation in Esthetic Zone at Implant Placement
a b c
d e f g
h i j
k l m
Fig 21-5 (cont) (a to d) Clinical and radiographic views of the baseline situation. (e and f) Three-dimensional radiographs used for guided implant
planning. (g) Flap elevation. (h to j) Guided implant placement. (k) Connective tissue graft sutured at the base of the anatomical papillae to cover
the bone dehiscence and increase soft tissues thickness. (l) Coronally advanced flap closure with the provisional restoration. (m) Postsurgical
radiograph to check the correct implant position.
Tissues are left to mature undisturbed for 6 months. After- Outcomes

ward, prosthetic conditioning is started in order to realign the
mucosal margin with respect to the gingival margin of the adja- The horizontal increase in the soft tissues allows treatment of
cent teeth and to favor papillae regrowth (Figs 21-5o and 21-5p). the baseline buccolingual defect while also increasing buccal
At the time of definitive restoration placement, the marginal soft soft tissue thickness at the transmucosal level. In this area,
tissues at the implant site were at the same level as the gingi- soft tissue augmentation is crucial for the final esthetic result:
val margin of the adjacent premolar, which (along with those to prevent soft tissue dehiscence, to mask the underlying
of the canine and incisors) was positioned more coronally with metal implant-prosthetic structure, and to create adequate
the coverage of the gingival recessions. emergence profiles for the prosthetic crown that can be easily
381

n o p
q r s
Fig 21-5 (cont) (n) Two weeks after surgery, at the time of suture removal. (o and p) After 6 months of soft tissue maturation, the conditioning
phase is started. (q to s) Clinical and radiographic views at 1 year after definitive restoration show good esthetics and implant osseointegration.
(Restorative therapy by Dr Fabrizia Pierini, Bologna, Italy.)
maintained by the patient from a hygienic point of view. Clinical distal papillae have adequate width, height, and buccopalatal
images 1 year after definitive restoration show good esthetic thickness. Even when taking into account the ideal positioning
and functional results (Figs 21-5q to 21-5s). of the connective tissue graft, ie, approximately 1 mm coronal
to the margin of the adjacent tooth, the remaining anatomical
papillae to be de-epithelialized have sufficient width and height
to guarantee sufficient vascular support to the surgical papillae
SOFT TISSUE AUGMENTATION of the coronally advanced flap (Fig 21-6e).
AT POSTEXTRACTION IMPLANT The advantages of digital planning and computer-guided
implant placement can be summarized as (1) reduced risk of
PLACEMENT WITH IMMEDIATE implant positioning errors, (2) greater odds of obtaining primary
PROVISIONALIZATION stability for immediate provisionalization, (3) surgical template
that guides implant drilling (reducing the risk of incorrect posi-
Anterior tooth replacement with dental implants in patients tioning), (4) a precisely customized provisional restoration that
with a high smile line entails high esthetic risks. Any eventual can be easily relined to reduce surgical chair time, and (5) peace
misalignment and asymmetry of the gingival margin or metallic of mind for the clinician, who can focus on the proper manage-
translucency will be visible during smiling and therefore impair ment of the soft tissues9 (Fig 21-6f).
the esthetic appearance of the patient (Figs 21-6a to 21-6d).
In this clinical scenario, there is a very high risk of not fulfill-
ing the patient’s expectations. It is the authors’ opinion that Surgical technique
postextraction implant placement with immediate provisional-
ization represents the treatment of choice for maximizing the The soft tissue procedure consists of a coronally advanced
predictability of an esthetic outcome and for reducing both the envelope type of flap with a frontal approach similar to
number of surgical procedures and overall treatment time. Nev- the one used for the treatment of multiple gingival reces-
ertheless, this approach must comprise a surgical procedure sions. Both anatomical papillae mesial and distal to the
that includes the augmentation of the soft tissues at the time implant have a width, height, and buccopalatal thickness that
of implant placement. allows de-epithelialization palatally (white arrows in Fig 21-6g),
In spite of the difficulties associated with the esthetic zone providing a larger vascular supply for the surgical papillae of
and the high smile line, this case presents particularly favorable the coronally advanced flap.
conditions for implant placement with immediate provisionaliza- The convex surface of the provisional restoration starts
tion: The gingival margin of the tooth to be extracted is at the approximately 2 mm coronal to the cementoenamel junc-
same level as that of its homologous tooth, and both mesial and tion (1 mm coronal to the presurgical position of the gingival
382

Soft Tissue Augmentation at Postextraction Implant Placement with Immediate Provisionalization
a b c
d e f
g h
Fig 21-6 (a to d) Baseline clinical and radiographic situation in a patient with a high smile line and a failing central incisor. (e) Schematic drawings
showing the appropriate connective tissue graft position and papillae dimensions. (f) Digital implant planning. (g) Flap elevation and implant place-
ment. (h) Connective tissue graft positioned and sutured.
margin) of the matching homologous tooth, and it must have the papillae as well as a tight adaptation of the flap’s keratinized
same buccal profile as this tooth. Apically, toward the implant tissue to the convexity of the provisional crown (Figs 21-6i to
shoulder, the buccal surface of the provisional restoration is 21-6k). At the end of the surgery, it is of utmost importance
slightly concave to facilitate adaptation and suturing of the graft. to obtain adequate stability of the surgical wound; this can be
The interproximal surfaces of the provisional crown must be confirmed by the absence of blood seeping between the soft
reduced to avoid compression of the soft tissues and interfer- tissue margin and the profile of the underlying crown when the
ence with healing of the papillae. The apicocoronal dimension clinician moves the patient’s lip.
of the connective tissue graft should cover 2 to 3 mm of buccal
bone. The graft is fixed with simple interrupted sutures (7-0,
7-mm needle) to the base of the de-epithelialized anatomical Postoperative protocol
papillae (Fig 21-6h).
Good adaptation of the connective tissue graft to the provi- For the first 3 weeks after the procedure, the patient does not
sional restoration and underlying bone allows the creation of a perform mechanical oral hygiene (suture removal is done 14 days
surface upon which the buccal flap can be easily advanced and postoperatively) but instead is instructed to maintain chemical
sutured in a coronal position that embraces the convex surface plaque control by means of an antiseptic rinse with 0.12% chlor-
of the provisional restoration without tension. hexidine used three times a day for 1 minute. Afterwards, the
Suture of the coronally advanced envelope flap is performed patient can begin to brush the treated area using a toothbrush
with a series of sling sutures that are suspended on the palatal with ultra-soft bristles while continuing to use the mouthrinse
cingulum of each tooth included in the surgical area. The suture twice a day. During the first month of the healing process, it is
that should be done last is the sling suture around the palatal crucial that the patient uses atraumatic oral hygiene techniques
cingulum of the provisional; this suture allows healing by first to allow the soft tissues to adapt and mature around the provi-
intention between the surgical and anatomical de-epithelialized sional restoration. Any area of the provisional restoration that
383

i j
l m
k n o
p q
r s t
u v
Fig 21-6 (cont) (i and j) Flap closure. (k) Radiograph taken immediately after surgery to check the implant position. (l and m) Clinical images 1
month after surgery. (n and o) Tissue maturation 3 months after surgery. (p) Increase of the soft tissues at 6 months. (q) Clinical situation at the end
of conditioning phase. (r to t) Clinical pictures and intraoral radiograph 1 year after delivery of the definitive restoration. (u and v) Clinical situation
after 2 years. (Case courtesy of Drs Claudio Mazzotti of Bologna, Italy, and Tommaso Cantoni of Verona, Italy.)
384

Soft Tissue Papillae Preservation for Implant Placement in Extraction Socket
causes compression that interferes with soft tissue growth and SOFT TISSUE PAPILLAE
maturation should be reduced. For this reason, it is necessary
to have close patient follow-up (Figs 21-6l to 21-6o). PRESERVATION FOR IMPLANT
In the first months after the surgery, the grafted tissue under- PLACEMENT IN EXTRACTION
goes a maturation process that results in augmented height
and thickness of the soft tissues buccal to the implant crown.
SOCKET
The excessive apicocoronal increment allows conditioning of Many times, papillae mesial and distal to a tooth that must be
the soft tissues by the prosthodontist in order to obtain gingi- extracted are not sufficiently wide or thick to provide enough
val architecture similar to that of the contralateral homologous anchorage for either a connective tissue graft or the surgical
tooth. The increase in buccal soft tissue thickness along the papillae of a coronally advanced flap. This happens frequently
transmucosal portion is fundamental for creating the adequate around posterior teeth (premolars and molars), in which an inter-
emergence profile of the prosthetic crown, avoiding visibility dental col is present between the buccal and palatal papillae.
of the underlying prosthetic components, and preventing the Additionally, the edentulous site resulting from the extraction
development of soft tissue dehiscence. of a premolar is much more narrow mesiodistally with respect
The occlusal view of this case at 6 months shows the thick- to that of a central incisor, which is why the residual postex-
ness of the buccal wall of the transmucosal tissue (Fig 21-6p). traction papillae are rarely sufficient for anchorage of the graft
The gingival margin of the implant crown is located coronal to and its covering flap. Mainly because of this reason, it is even
that of the contralateral homologous tooth. At this point, soft more important to avoid traumatizing the papillae with the sur-
tissue conditioning can be started; its objective is to obtain a gical maneuvers and/or instruments used for tooth extraction
gingival margin in the implant crown similar in height and scal- (Figs 21-7a to 21-7d).
loping to the margin of the contralateral natural tooth.
At the end of the conditioning phase, the gingival margin
of the implant crown must be located at the same level and Surgical technique
have the same shape as the gingival margin of its homologous
tooth, with mesial and distal papillae as similar as possible It is the authors’ opinion that elevating a buccal flap makes it
to those of adjacent teeth (Fig 21-6q). Once these objectives possible to perform the extraction while almost entirely avoiding
have been achieved, the definitive restoration can be placed, contact of the instruments with the papillae and buccal kerati-
taking care to maintain the results achieved with the provi- nized tissues and allows placement of the extraction forceps in
sional restoration. a more apical position on the root, therefore improving leverage.
Buccal flap elevation permits visualization of the buccal bone
wall during the extraction and reduces mechanical trauma to it
Outcomes (Figs 21-7e and 21-7f).
The flap design is essentially the same as for the coro-
One year after placement of the definitive crown, the esthetic nally advanced envelope flap used for treatment of multiple
result fully satisfies the patient’s expectations. The radiographic gingival recessions in mucogingival surgery. In the case of
image at this point shows good osseointegration of the implant postextraction implants, the coronally advanced buccal flap
as well as absence of interproximal bone loss (Figs 21-6r helps to (1) compensate for the tendency of the soft tissues
to 21-6t). to contract, which could lead to an excessively long implant
Clinical images 2 years after treatment reveal the stability crown, (2) cover the connective tissue that must be positioned
of the obtained esthetic result and patient satisfaction. The close to the gingival margin of the adjacent tooth (or more
thickness of the soft tissues, visible in the occlusal image, coronally), and (3) have an excess of soft tissue both apico-
remains stable with respect to the 1-year follow-up (Figs 21-6u coronally and buccolingually that can later be conditioned in
and 21-6v). the provisional prosthetic phase to optimize the final esthetic
Comparison between the initial situation and the 2-year result. Computer-guided implant placement is particularly indi-
follow-up after placement of the definitive restoration makes it cated in the case of postextraction implants to (1) reduce the
possible to appreciate the obtained results, from both esthetic risk of implant positioning errors, which are very frequent in
and functional points of view. The increase in buccal soft tissue postextraction sockets; (2) increase the chances of obtaining
thickness at the implant site, together with adequate morphol- the primary stability needed for immediate provisionalization,
ogy of the prosthesis, minimizes the risk of buccal soft tissue which is essential for an esthetic final result; and (3) have
dehiscence while masking the underlying implant components a prefabricated provisional that is much more precise with
and allowing the creation of an optimal emergence profile that respect to the implant platform, which reduces the intraoper-
can be properly cleaned by the patient. ative time needed for its relining (Figs 21-7g and 21-7h). Buccal
soft tissue augmentation is done in conjunction with implant
placement through the use of a connective tissue graft obtained
from the extraoral de-epithelialization of a free gingival graft. The
385

a b c
d e f
g h i
j k l
m n o
Fig 21-7 (a to c) Baseline clinical images and radiograph showing a fractured maxillary
premolar. (d) Guided implant planning on a three-dimensional radiograph. (e and f)
Flap elevation and atraumatic tooth extraction. (g and h) Guided implant placement. (i
and j) Connective tissue graft sutured at the inner aspect of the flap in a paramarginal
position. (k and l) Flap closure through sling sutures that are tightly adapted to the
gingival margin around the provisional crown. (m and n) Soft tissue maturation with a
short provisional crown. (o and p) Occlusal view at the end of the conditioning phase.
386

Treating Peri-implant Soft Tissue Dehiscence with a Prosthetic-Surgical-Prosthetic Approach
q r s
t u v
Fig 21-7 (cont) (q to s) Clinical and radiographic views with the definitive screw-retained implanted-supported crown with a natural emergence
profile. (t to v) Clinical and radiographic views at 3 years after definitive restoration showing the stability of the esthetic results and bone levels.
(Restorative therapy by Dr Carlo Monaco, Bologna University, Italy.)
presence of mesial and distal papillae with reduced width and profile that is similar to that of the adjacent natural dentition
thickness makes it necessary to suture the connective tissue and can be easily cleaned (Figs 21-7q to 21-7s).
to the internal surface of the flap with two internal horizontal
mattress sutures (shown previously) in a paramarginal position
(Figs 21-7i and 21-7j). Due to the curved design of the buccal Outcomes
flap, the surgical papillae remain free (white arrows in Fig 21-7j),
without interference of the graft, to be positioned on top of the When soft tissue augmentation procedures are done with a
anatomical de-epithelialized papillae for primary intention inter- connective tissue graft (de-epithelialized) covered by a coronally
proximal healing. After intraoperative relining, the provisional is advanced flap, an additional increase in tissue thickness contin-
screwed onto the implant and is reduced interproximally so as ues even years after the surgery. For this reason, it is necessary
not to interfere with healing of the surgical papillae positioned to leave small free interproximal spaces to allow further papillae
over the corresponding anatomical papillae mesial and distal growth and to give the prosthetic crown an emergence profile
to the implant crown. that hampers excessive coronal growth (creeping) of the buccal
The coronally advanced flap is fixed with sling sutures soft tissues that could result in an implant crown that appears
suspended at the palatal cingulum of the provisional crown shorter than the adjacent tooth. The result at 3 years after defini-
and adjacent teeth (Figs 21-7k and 21-7l). Sutures are removed tive crown placement completely satisfies the patient’s esthetic
after 2 weeks, at which time the buccolingual and apicocor- demands (Figs 21-7t and 21-7u). The intraoral radiograph shows
onal increase in the soft tissues is already evident. The verti- stability of the peri-implant bone levels (Fig 21-7v).
cal tissue augmentation renders the implant-supported clinical
crown shorter with respect to that of the adjacent premolar
(Figs 21-7m and 21-7n).
Soft tissue is left undisturbed for 6 months to allow matura- TREATING PERI-IMPLANT SOFT
tion, after which the conditioning phase is started with a dual TISSUE DEHISCENCE WITH
purpose: provide the same height and scallop of the adjacent
natural premolar to the buccal gingival margin of the implant
A PROSTHETIC-SURGICAL-
crown and favor papillae growth. Normally, the same initial PROSTHETIC APPROACH
screw-retained provisional is used for soft tissue conditioning.
The conditioning phase lasts 3 to 4 months and ends when there The recession of the vestibular peri-implant mucosal margin is
is no further change in the soft tissues with respect to the last called soft tissue dehiscence. While in the natural dentition the
modification of the provisional. This is the moment to proceed to definition of gingival recession is universally accepted as the
definitive restoration (Figs 21-7o and 21-7p). The definitive crown apical displacement of the gingival margin with respect to the
must reproduce the exact shape of the provisional restoration cementoenamel junction, there is no consensus on the defini-
at the level of the transmucosal path and have an emergence tion of soft tissue dehiscence around implants. This is mainly
387

a b c
Fig 21-8 (a to c) Clinical images showing soft tissue dehiscences at both implant-supported crowns replacing the lateral
incisors and radiographs showing good osseointegration of the implants.
due to the lack of a fixed reference point on implants that is The treatment of buccal dehiscences at osseointegrated
equivalent to the cementoenamel junction in the natural den- implants involves a prosthetic-surgical-prosthetic approach. The
tition. On implants, some authors consider mucosal recession surgical technique, based on the placement of a connective tissue
to be the apical shift of the soft tissue margin with reference graft covered by a coronally advanced flap, is preceded by an initial
to the homologous adjacent or contralateral tooth, while oth- provisional prosthetic phase and followed by a second provisional
ers consider exposure of the gray abutment/implant surface as and then a definitive prosthetic phase. Through this approach,
mucosal recession. The lengthening of the implant-supported it is possible to cover the dehiscence in a predictable way and
crown in comparison with the homologous tooth is the primary to prevent the color of the implant-prosthetic structure from
esthetic concern from a patient’s point of view. Therefore, it being visible through the soft tissues. The absence of clinically
would be appropriate to take into account the gingival margin and radiographically documented peri-implantitis is a sine qua
of the homologous adjacent or contralateral tooth as a refer- non for the therapeutic choice of covering implant dehiscences.
ence point when detecting peri-implant soft tissue dehiscence. Possible surgical alternatives for the treatment of soft tissue
It follows that the primary outcome of treatment should be dehiscence include the free gingival graft, the partially or totally
complete soft tissue dehiscence coverage, ie, the repositioning de-epithelialized graft inserted in a buccal envelope, and the
of the soft tissue margin at the same level as the homologous coronally advanced flap + connective tissue graft. The first two
tooth.10 Moreover, in order to achieve long-term stability of the options should be excluded, as the survival of a graft covering
results, prevent recurrence, and mask implant transparency, it the avascular implant-supported crown without the vascular
is mandatory that the buccal soft tissue thickness is equal to supply provided by a full-coverage flap is highly unpredictable.
or more than 2 mm. Furthermore, the esthetic result would surely be unsatisfactory
The etiology of buccal soft tissue dehiscence is still contro- because of the keratostic aspect that results from these tech-
versial. It includes a variety of anatomical/predisposing factors, niques. For these reasons, the technique of choice is the coro-
such as a buccally positioned implant platform, bad positioning nally advanced flap + connective tissue graft. The ideal position
or angulation, osseous dehiscence or fenestration, thin gingival of the connective tissue graft depends on which implant site has
biotype, inadequate keratinized attached mucosa, high frenum, to be treated. If it is a lateral incisor, since its soft tissue margin
or muscle pull, along with pathologic/precipitating factors, such should be coronal to that of the central incisor, the connective
as recurring inflammation, overcontoured prosthesis, and tissue graft should be placed 1 mm more coronal then the
self-inflicted injury from toothbrushing or flossing trauma.11 gingival margin of the central incisor (Figs 21-8d and 21-8e). The
The presence of soft tissue dehiscence (Figs 21-8a to 21-8c) vascular supply for the coronally advanced flap is provided by
is related to different esthetic and biologic problems, such as: the anatomical papillae that, once de-epithelialized, represent
the anchorage bed for the coronally displaced surgical papillae
• Increase in the apicocoronal dimension of the implant- (red areas in Figs 21-8f and 21-8g).
supported crown with respect to the natural homologous/ However, these small and triangular papillae, which are pala-
adjacent tooth tally displaced with respect the buccally dislocated implant
• Unesthetic exposure of the metallic surface of the implant crown and are not supported by an intact bone crest (as is
or prosthetic abutment the case with anatomical papillae in Miller Class I and II gingi-
• Discoloration of the buccal soft tissues due to the visibility val recessions) would not represent, once de-epithelialized, an
of the underlying implant-prosthetic components adequate vascular bed for the stabilization of the surgical papillae
• Exposure of the implant surface, which, due to its macro- of the coronally advanced flap. In these conditions, the risk of
or microroughness, tends to accumulate bacterial plaque, early flap shrinkage with consequent exposure of the connec-
favoring further apical migration of the soft tissues and/or tive tissue graft would be very high, reducing the potential for
the onset of mucositis/peri-implantitis covering the buccal dehiscence.
388

1 mm
d e f
g h i
Fig 21-8 (cont) (d to g) Schematic draw-

ings of the ideal connective tissue graft po-
sition—1 mm coronal to the gingival margin
of the central incisors—and the inadequate
dimensions of the papillae at baseline. (h to
m) Schematic drawings showing the ratio-
nale for increasing the interdental soft tissue
width and thickness during the presurgical
prosthetic phase.
j k
l m
Presurgical prosthetic protocol sion of the de-epithelialization of the anatomical papillae on

the occlusal surface, further increasing the vascular anchorage
The presurgical prosthetic treatment allows increase of the bed for the surgical papillae, which are also trapezoidal, of the
space between the surgical abutment and the two adjacent coronally advanced flap.
teeth, enabling the interproximal soft tissues to increase in The presurgical prosthetic phase consists of the removal of
width, thickness, and volume through the removal of the implant the crowns and the replacement of the prosthetic abutments
crown and replacement of the prosthetic abutment with a “sur- with “surgical” abutments that are as narrow and thin as possi-
gical” abutment that is as narrow and thin as possible (Figs 21-8h ble. During the soft tissue maturation phase, short provisional
to 21-8m). The papillae, by occupying the space previously occu- restorations that do not interfere with the growth of the soft
pied by the crown and prosthetic abutment, will acquire a trap- tissues apical and lateral to the abutments are placed, and the
ezoidal shape with a coronal isthmus as opposed to a triangular patient performs a rolling toothbrushing technique in an apico-
vertex. The presence of this isthmus will allow palatal exten- coronal direction12,13 (Figs 21-8n to 21-8t).
389

n o p
q r s
t u v
w x y
Fig 21-8 (cont) (n to p) Baseline clinical images showing the interproximal soft tissues after crown removal at both implant sites. (q to t) Clinical
images of the “surgical” abutments and the short provisional crowns at both implant sites. (u) Clinical appearance at the end of the presurgical
prosthetic phase. (v) Flap elevation at the right lateral incisor site. (w) Connective tissue graft derived from de-epithelialization of a free gingival
graft, sutured at the base of the anatomical papillae and adapted above the abutment of the right lateral incisor implant. (x and y) Primary closure
of the flap.
The patient is recalled monthly for removal of the provisional Surgical technique
restorations, polishing of the surgical abutments with rubber
cups, and reductions on the crowns wherever they are in contact It is recommended to treat both sites during the same surgical
with the soft tissues so as not to interfere with their growth. procedure; this favors a symmetric and esthetic final result. The
When no additional growth of the soft tissues apical and lateral flap design is similar to that used for the treatment of multiple
to the abutment is observed between appointments, the surgi- recession defects. It is a lateral approach with one vertical releas-
cal procedure can be scheduled (Fig 21-8u). ing incision distal to the canine and a series of interproximal
The change in the interproximal soft tissues is evident when submarginal oblique incisions oriented toward the canine, which
images of the initial situation are compared with those taken represents the center of rotation of the flap. Said submarginal
3 months after placing the reduced abutments and the short incisions must start from the gingival margin of the adjacent
provisional crowns. At this point, the wider and thicker papil- tooth and finish at a distance from the papilla vertex that cor-
lae can be de-epithelialized toward the palate, increasing the responds to the desired coronal advancement of the marginal
surface of the vascular bed for the surgical papillae of the coro- tissues; this distance will be greater at the level of the soft tis-
nally advanced flap. sue dehiscence and lesser at the level of the adjacent teeth.
390

z aa bb
cc dd ee
Fig 21-8 (cont) (z to cc) Clinical images showing the same surgical procedure for the left lateral incisor implant. (dd) Clinical view at the completion
of the surgeries bilaterally. (ee) Tissue maturation at 1 month.
Afterwards, the flap is elevated split thickness at the level of Postoperative protocol
the surgical papillae, full thickness at the central portion in order
to adequately expose the bone crest, and again split thickness It is crucial that soft tissues are left to heal undisturbed, without
apically (deep split thickness followed by superficial split thick- prosthetic interference, during the first 4 months postsurgically.
ness) to allow its coronal advancement (Fig 21-8v). For this reason, provisional restorations should be cemented
The graft is harvested from the palate as an epithelial-connective and kept short with respect to the soft tissues. This will allow
tissue graft that is de-epithelialized extraorally. The apicocoronal the grafted connective tissue, always covered by the flap, to
dimension of the graft is measured with the probe starting 1 mm mature and reach adequate tissue stability for the subsequent
coronal to the gingival margin of the central incisor and ending 2 conditioning phase. The main disadvantage in these first few
mm apical to the buccal bone crest of the site with soft tissue months is the unesthetic appearance of the metallic abutment
dehiscence. When tailoring the graft, it is important to leave a apical to the margin of the provisional (Fig 21-8ee). For more
thicker central zone, which will be placed on top of an avascular demanding patients, this negative element can be lessened
surface (implant and abutment), while in the lateral parts of the with the use of a more esthetic zirconia prosthetic abutment.
graft the thickness can be reduced (variable thickness connec- At the end of the 4-month maturation phase, it is possible to
tive tissue graft) to facilitate suturing and improve adaptation proceed to soft tissue conditioning with a new screw-retained
of the graft to the underlying surgical abutment. The connec- provisional. The main objective is to achieve height and scallop
tive tissue graft is sutured coronally at the base of the anatom- similar to that of the gingival margin of the adjacent/contralat-
ical de-epithelialized papillae and apically to the periosteum by eral teeth; the papillae should be regenerated to completely fill
means of single interrupted sutures (7-0). The use of a thin, the interdental spaces by progressively moving the provisional
flexible graft like the one obtained from the de-epithelialization contact point in a coronal direction (Figs 21-8ff to 21-8jj).
of a free gingival graft is essential for its correct adaptation onto Tissue conditioning can be considered complete when there
the implant abutment prominence as well as to the base of the are no evident modifications to the scallop of the gingival margin
anatomical papillae and periosteal bed (Fig 21-8w). or growth of the interdental papilla between successive follow-up
The vertical releasing incision is closed first by means of single appointments. At this moment, the definitive prosthetic phase
interrupted sutures. Primary closure between the surgical and can be scheduled. The duration of tissue conditioning is variable
anatomical papillae is achieved with sling sutures (6-0, 11-mm but never less than 3 months (Figs 21-8kk and 21-8ll).
needle), each anchored around the palatal cingulum of the teeth When possible, the definitive restoration should be a
adjacent to the implant site. Once suturing is finished, it is funda- screw-retained crown; however, most of the time a cemented
mental that the flap’s marginal tissue is tightly adapted to the restoration must be used because of an implant position that
surgical abutment, not allowing blood to seep through; this clini- would require the screw access holes to be placed buccally.
cally indicates good stability of the surgical wound (Figs 21-8x and Customized zirconia abutments with finish lines that are the
21-8y). The same procedure is done for treatment of the buccal least subgingival possible facilitate cementum removal and
dehiscence of the left lateral incisor implant (Figs 21-8z to 21-8dd). patient plaque control (Fig 21-8mm).
391

ff gg hh
ii jj kk
ll mm nn
oo pp qq
rr ss tt
Fig 21-8 (cont) (ff to ii) End of soft tissue maturation. (jj) Smile showing the new screw-retained provisional crowns during the conditioning phase.
(kk and ll) End of conditioning phase. (mm) Customized zirconia abutments. (nn to qq) Comparisons between the baseline situation and after soft
tissue conditioning. (rr to tt) Clinical views of the definitive restorations.
Outcomes the formation of a new transmucosal path that is mainly buccal

and easy for the patient to clean.
The increase in height and thickness of the soft tissues buc- A comparison of the patient’s smile at baseline and 1 year
cal to the implant makes it possible to obtain a good esthetic after cementation shows the good esthetic outcome with
result, masking the underlying implant-prosthetic components complete coverage of both buccal dehiscences and good blend-
and favoring the natural appearance of the restoration within ing of the grafted area with the adjacent soft tissues. Even the
the treated area (Figs 21-8nn to 21-8tt). This technique enables gingival discoloration is masked by the increase in buccal soft
tissue thickness (Figs 21-8uu to 21-8xx).
392

uu vv ww
xx yy
zz aaa bbb
ccc ddd eee
Fig 21-8 (cont) (uu to xx) Clinical pictures 1 year after definitive restoration. (yy)
Patient’s smile 5 years after definitive restoration. (zz to eee) Intraoral views
of the clinical situation at the 5-year follow-up visit. (fff and ggg) Radiographs
demonstrating bone level stability after 5 years. (Restorative therapy by Dr Marco
Piferi, Cantu, Italy.)
fff ggg
Five years after cementation, the esthetic outcome is still minimizes the risk of buccal soft tissue dehiscence recurrence
highly satisfactory for the patient (Fig 21-8yy). Intraoral views at while simultaneously masking the underlying implant compo-
the 5-year follow-up show the stability of the obtained results nents and allowing the creation of an optimal emergence profile
in terms of dehiscence coverage, harmonization of the gingival that can be properly cleaned by the patient. The radiographs
margins, and increase of buccal soft tissue thickness (Figs 21-8zz at the 5-year follow-up show stability of the peri-implant bone
to 21-8eee). The increase in buccal soft tissue thickness at the levels and radiopacity of the osseous crest14 (Figs 21-8fff and
implant site, together with good morphology of the prosthesis, 21-8ggg).
393

REFERENCES 7. Chiapasco M, Zaniboni M. Clinical outcomes of GBR procedures

to correct peri-implant dehiscences and fenestrations: a system-
atic review. Clin Oral Implants Res 2009;20:113–123.
1. Sicilia A, Botticelli D. Computer-guided implant therapy and soft- 8. Zucchelli G, De Sanctis M. Treatment of multiple recession-type
and hard-tissue aspects. The Third EAO Consensus Conference defects in patients with esthetic demands. J Periodontol
2012. Clin Oral Implants Res 2012;23:157–161. 2000;71:1506–1514.
2. Wennström JL, Derks, J. Is there a need for keratinized mucosa 9. Joda T, Ferrari M, Gallucci GO, Wittneben JG, Brägger U. Digital
around implants to maintain health and tissue stability? Clin Oral technology in fixed implant prosthodontics. Periodontol 2000
Implants Res 2012;23:136–146. 2017;73:178–192.
3. Souza AB, Tormena M, Matarazzo F, Araújo MG. The influence of 10. Mazzotti C, Stefanini M, Felice P, Bentivogli V, Mounssif I, Zucchelli
peri-implant keratinized mucosa on brushing discomfort and G. Soft-tissue dehiscence coverage at peri-implant sites. Periodon-
peri-implant tissue health. Clin Oral Impl Res 2016;27:650–655. tol 2000 2018;77:256–272.
4. Roccuzzo M, Grasso G, Dalmasso P. Keratinized mucosa around 11. Fu JH, Su CY, Wang HL. Esthetic soft tissue management for
implants in partially edentulous posterior mandible: 10-year results teeth and implants. J Evid Based Dent Pract 2012;12:129–142.
of a prospective comparative study. Clin Oral Implants Res 12. Zucchelli G, Mazzotti C, Mounssif I, Mele M, Stefanini M, Monte-
2016;27:491–496. bugnoli L. A novel surgical-prosthetic approach for soft tissue
5. Zucchelli G, Mele M, Stefanini M, et al. Patient morbidity and root dehiscence coverage around single implant. Clin Oral Implants
coverage outcome after subepithelial connective tissue and Res 2013;24:957–962.
de-epithelialized grafts: a comparative randomized-controlled clin- 13. Zucchelli G, Mazzotti C, Mounssif I, Marzadori M, Stefanini M.
ical trial. J Clin Periodontol 2010;37:728–738. Esthetic treatment of peri-implant soft tissue defects: A case report
6. Stefanini M, Felice P, Mazzotti C, Marzadori M, Gherlone EF, of a modified surgical-prosthetic approach. Int J Periodontics
Zucchelli G. Transmucosal implant placement with submarginal Restorative Dent 2013;33:327–335.
connective tissue graft in area of shallow buccal bone dehiscence: 14. Zucchelli G, Felice P, Mazotti C, Marzadori M, Mounssif I, Monaco
A three-year follow-up case series. Int J Periodontics Restorative C, Stefanini M. 5-year outcomes after coverage of soft tissue
Dent 2016;36:621–630. dehiscence around single implant: A prospective cohort study.
Eur J Oral Implantol 2018;11:1–10.
394

22 LUIGI CANULLO
Implant-Abutment
Junction: A Crestal
Bone and Soft Tissue
Determinant
Biologic Processes Involved in Crestal Bone
Remodeling
Platform-Switching Concept
One Abutment, One Time Concept
395

22 | Implant-Abutment Junction: A Crestal Bone and Soft Tissue Determinant
M
any clinical studies have demonstrated that The morphology and structure of the connective tissue barrier
implant integration can be achieved and main- has also been investigated in animals.17 The connective tissue
tained in various areas of the mouth on a immediately next to the implant surface is characterized by an
long-term basis. In these studies, two basic absence of blood vessels and the presence of abundant fibro-
approaches to the placement of dental implants emerged: blasts, interposed between thin collagen fibers. The connective
submerged (two-stage1) and nonsubmerged (single-stage2). tissue away from the implant contains more abundant collagen
In the submerged approach, the implant is placed at or below fibers, which may run in a variety of directions, including circular,
the bone crest level underneath the soft tissues and allowed parallel, and perpendicular. Therefore, this implant–soft tissue
to heal, typically for 3 to 6 months. A stage-two surgery is then interface may be interpreted as a scarlike response to implant
required to uncover the implant and place the abutment on the surgery, formed to keep bone protected from the contaminated
top of the implant. The restoration is then located on the abut- intraoral environment. After the placement of an abutment (both
ment. This procedure results in two gaps, one located at the in single- and two-stage implant surgical protocols), the circular
crestal level and one slightly above the soft tissue margin. In the and perpendicular fibers play a key role in soft tissue healing and,
nonsubmerged approach, the implants extend above the alve- therefore, in the histomorphogenesis of the biologic width.18
olar crest, and there is only one microgap, which is below the On the natural tooth, Sharpey fibers are firmly inserted into
gingival margin. According to the literature, surgical placement cementum and bone. They are perpendicularly or obliquely
of two-piece implants using a submerged, non-loaded healing oriented to the tooth surface, serving as a barrier to epithe-
protocol resulted in crestal bone levels 1.5 to 2 mm apical to lial migration and bacterial invasion.10 In contrast, there is no
the implant-abutment junction (IAJ) after 1 year of loading.3,4 cementum on implant surfaces: The orientation of the connec-
This chapter discusses the biologic processes associated with tive fibers in the supracrestal soft tissue compartment is parallel
crestal bone remodeling at the IAJ and treatment concepts that to the implant surface, providing no effective connection to the
aim to minimize this phenomenon. implant.19 Because the connective tissue attachment is consid-
ered of paramount importance in supporting the epithelium
and blocking its apical migration, its absence around implants
represents a weak area in the peri-implant defense mechanism.
BIOLOGIC PROCESSES INVOLVED Tearing the connective tissue–implant interface could induce,
IN CRESTAL BONE REMODELING due to lack of soft tissue stability, apical migration of the junc-
tional epithelium. From a clinical point of view, this could lead
Several factors may affect this post-restorative biologic pro- to gingival recession or pocket formation and bone resorption.
cess. Although position of the implant platform,5 biomechanical The morphogenesis of biologic width, 10 as previously
stress,6 or framework misfit7 have been shown to be related to mentioned, is basically the same in the two different clinical
this process, peri-implant bone resorption seems to be a physio- situations routinely adopted: single-stage implant surgery and
logic response of the bone to surgical trauma and the following stage-two surgery for exposure of a previously placed implant.20
bacterial invasion of the IAJ.8 This biologic reaction leads to the According to Berglundh et al20 and Tomasi et al,21 immedi-
reestablishment of the so-called biologic width, similar to the ately following stage-two surgery, a blood clot fills the space
one described for teeth by Gargiulo et al9,10 and now referred between the mucosa and the implant, and the platelets release
to as supracrestal soft tissue attachment. chemotactic and growth factors. After 4 to 7 days, the blood clot
Focusing on the interaction of bacteria with soft and hard is infiltrated by several polymorphonuclear leukocytes (PMNLs)
tissues, several investigators have suggested that crestal bone entangled in a dense fibrin network; this starts the formation of
remodeling could be the result of localized inflammation within an initial seal at this early stage of healing. However, the protec-
the soft tissue located close to the IAJ due to either the soft tive function of soft tissues is still incomplete; therefore, during
tissue reestablishing the biologic width or the presence of a the first week after single-stage implant surgery, bacteria are
septic reservoir at the implant-abutment interface.11–13 allowed to accumulate around the abutment-implant connec-
Several studies in human and canine models have exam- tion: The result is an inflammatory response in the surround-
ined and described the anatomy of the biologic width. It is ing tissues. Bacteria may cause peri-implant tissues damage
now accepted that the biologic seal around implants consists directly (by releasing exotoxins and endotoxins) and indirectly
of two principal layers, regardless of the surgical protocol that (by activating systemic and local immune responses through
was used (single- or two-stage): the epithelial attachment and PMNLs and macrophages).
the underlying connective tissue barrier. Approximately 2 weeks later, initial epithelial growth can be
The epithelial component of the implant-mucosa interface has observed. These cells extend from the basal epithelium toward
been demonstrated to form a cufflike barrier that adheres to the the smooth surface of the abutment, which is already contam-
surface of titanium abutments.14 Histologic studies suggest that inated. The smooth surface does not offer a stable attachment
peri-implant epithelium is directly attached to the titanium via and causes initial apical migration.
hemidesmosomes.15 However, recent investigations showed After 2 weeks, according to one widely used restorative
that epithelium cannot firmly attach to the titanium abutment.16 protocol, the healing abutment is removed, and an implant-level
396

Platform-Switching Concept
impression is made. There is histologic evidence that this proce-

dure produces additional apical migration of the epithelium.
At the third and fourth week, following the combined effects
of bacterial response, bone resorption can be observed. Bone
remodels in an apical direction and is replaced by a circumfer-
ential band of connective tissue with abundant inflammatory
cells.22 At this stage, additional insertions and removals of heal-
ing abutments for prosthetic procedures typically occur.
At the fifth and sixth weeks, connective tissue attaches
to a horizontal surface (the first thread of a Brånemark-type
implant23). Ingrowth (maturation and growth) of the connective
tissue onto the rough surface inhibits epithelial downgrowth and
permits its attachment to the lateral surface of the implant.17
At the 8th to 12th week, when the abutment and crown are
placed on the implant, morphogenesis of the biologic width
is concluded. Definitive establishment of the biologic width
takes the form of a 1.5-mm band of supra-alveolar connective Fig 22-1 Histologic image of a platform-switching restoration. Connective
tissue can be detected over the implant platform not covered by the abut-
tissue that provides support and nutrition to the epithelium. ment (original magnification ×100). (Courtesy of Dr Daniele Botticelli.)
The connective tissue cells are dispersed in a dense extracel-
lular matrix. Connection of this tissue to the implant surface
depends on the extracellular matrix. Fibroblasts and the extra- the outer edge of the implant-abutment interface was horizon-
cellular matrix tend to interdigitate into the rough surfaces of tally repositioned inward (toward the screw) and away from the
the implant.17 outer edge of the implant platform. This prosthetic arrangement
Earlier research demonstrated connective tissue fibers paral- was defined as platform switching (Fig 22-1).
lel to the implant surface in the coronalmost portion. In the A long-term study 27 demonstrated with radiographic
apicalmost region, the fibers tend to be arranged in circular and follow-up that wide-diameter dental implants restored with this
parallel directions.24,25 Phase-contrast microscopy revealed that platform-switching technique resulted in a smaller than expected
the collagen bundles were not randomly oriented but rather vertical change in crestal bone height around implants compared
organized into three major systems: longitudinal, circular, and with traditionally restored implants. This study introduced the
obliquely oriented fibers.26 According to these studies, it can be concept and described the clinical rationale and radiographic
concluded that reestablishment of the biologic width is respon- findings for this technique retrospectively.
sible for early crestal bone resorption around endosseous dental Several theories were adopted to explain the positive
implants. Controversially, any change in the macroscopic design outcomes associated with the platform-switching concept. Both
of the prosthetic restoration could influence peri-implant soft histomorphometric studies and three-dimensional finite element
and hard tissue rearrangement. models have shown the potential role of the platform-switching
configuration to limit peri-implant marginal bone resorption, opti-
mizing space for the components of biologic width,28 medializing
the implant abutment microgap and inflammatory cell infiltrate,29
PLATFORM-SWITCHING and shifting the area of maximum biomechanical stress toward
CONCEPT the central axis of the implant.30,31
Prospective controlled clinical trials confirmed reduced bone
The unavoidability of peri-implant bone remodeling was shown remodeling values around implants restored with this innova-
to be questionable by a study from Lazzara and Porter,27 in tive prosthetic concept compared with those restored using
which it was demonstrated that an abutment with a diame- the standard approach32,33 (Fig 22-2).
ter that did not match that of the implant could lead to a more Horizontal inward repositioning (medialization) of the IAJ could
favorable rearrangement of soft and hard tissue. During the lead to two different results:
past decade, wide-diameter (5.0 and 6.0 mm) implants were
available, partly as rescue implants for failed standard 4.1-mm- 1. The overall effect of the inflammatory cell infiltrate on the
diameter implants, but also intentionally used in wide eden- surrounding tissue may be reduced. An inflammatory infil-
tulous ridges. Originally, these larger-diameter implants were trate in the connective tissue has been described as local-
restored with abutments with standard dimensions (having the ized over the entire surface of the implant platform and
same connection as the original 4.1-mm-diameter implants); approximately 0.35 mm coronal to the IAJ. This has been
the net result was that a circumferential horizontal difference reported along healing abutments. A possible reason for bone
could be observed between the implant seating surface and preservation around a platform-switched implant, in fact, is
the seating surface of the restorative component. In this way, supposed to be related to the horizontal (medial) shift of the
397

a b
c d e
f g h
Fig 22-2 (a) Implant inserted with a flapless surgery. (b) After 3 months of submerged healing, an impression was taken. (c) A definitive abutment
was inserted and tightened at 30 Ncm. (d and e) Clinical and radiographic images after 1 year of loading. (f to h) Clinical and radiographic images
at 10-year follow-up.
inflammatory connective tissue zone at the IAJ. Medializa- While a variety of clinical studies reported favorable outcomes
tion of the biologic width is thought to reduce its injurious with respect to preservation of crestal bone,37–40 histologic
effect on alveolar bone adjacent to endosseous implants.29 evidence relative to platform switching remains sparse and
2. The platform surface not covered by the abutment increases controversial. In fact, only two case reports with human histol-
the surface on which connective tissue can stabilize. In fact, ogy confirmed minimal crestal bone loss after a short period of
it was observed that the horizontal mismatch promotes loading (1 to 6 months).28,29 Several preclinical histologic stud-
perpendicular fibers to the abutment and prevents the apical ies on animal models have been published. For example, in a
downgrowth of the junctional epithelium.34 study by Cochran et al,41 60 implants with mismatched platform
designs were placed in submerged or nonsubmerged modalities
However, analysis of several studies focusing on bone levels and compared with traditional implants. After 6 months, crestal
around implants restored using platform switching reveals a bone loss was significantly reduced (five- to sixfold) at sites with
high variance of marginal bone level changes, suggesting that mismatched IAJs placed at the bone crest when compared with
the positive outcomes not only are the result of the mentioned matched implant-abutment components. Similar conclusions
prosthetic concept but also may be related to an individual bone were reported by Weng et al.42 On the contrary, Becker et al43,44
response or inflammatory pattern, as already highlighted in did not find any statistically significant differences in buccal and
the field of periodontology.35 At the same time, since several palatal crestal resorption when comparing traditionally restored
implant systems with different implant-abutment mismatches implants with those restored using a platform-switching concept
were involved in the previously mentioned studies, the high vari- after 4 to 24 weeks.
ance in the reported bone level changes might suggest also that The controversial aspects of the results mentioned so far
there are biologic rules behind the platform-switching concept. might be explained by the fact that different study designs
Following this hypothesis, investigation has shown that bone were adopted. For example, in the study by Becker et al,43,44 the
loss seems to be related to implant-abutment mismatch in an authors used implants inserted supracrestally, which obviously
inverse linear relationship.36 minimizes the advantages of platform switching. In the study by
398

Baffone et al45 different planes were used for histologic analysis tions and reconnections of implant abutments were demon-
(ie, the buccolingual bone dimension was analyzed; since it is strated to result in soft tissue disruption, allowing for epithe-
narrower than the mesiodistal aspect, it could be more prone lial downgrowth. This shortcoming could be amplified in the
to amplify the resorptive effect of flap elevation and osteotomy platform-switching configuration by the connective tissue
site preparation). located just over the platform directly adhering to the abut-
Positive clinical outcomes of platform switching were ment. It should be noted that the results of this study20 were
confirmed by systematic reviews with meta-analysis.37–40,46–48 obtained in an animal model, and for this reason linear values of
The authors confirmed that this prosthetic approach appeared to the peri-implant soft tissues should be considered with caution
be useful in limiting bone resorption. Nevertheless, these data and not compared with human values. However, the propor-
should be interpreted cautiously because significant heteroge- tional distribution of the peri-implant tissues in the study may
neity and possible publication bias were noted. provide reference values applicable to humans. All this data
At the same time, all data expressing bone level changes can be used to better analyze hard and soft tissue reactions to
around platform-switched implants in the mentioned studies platform-switched implants and may yield additional informa-
are referred to as mean values, very often with a high standard tion to clinicians to optimize implant placement, manipulate soft
deviation. This might suggest that an individual bone pattern tissue, and achieve better esthetic results.
could influence the dimension of biologic width reestablished
and, thus, bone level changes in the long run, as confirmed by
immunohistochemical studies.49,50
To understand how platform switching minimizes bone ONE ABUTMENT, ONE TIME
remodeling, the first step is to analyze the arrangement of CONCEPT
the soft tissues around platform-switched implants. Histo-
logic analysis showed51 different arrangements of supracrestal From a clinical point of view, platform switching with immediate
soft tissue attachment around traditionally restored versus use of a definitive abutment (ie, the one abutment, one time
platform-switched implants. If implants were positioned at the concept, which avoids traumatizing the connective tissues once
level of the alveolar bony crest, the platform-switching concept the abutment is positioned) seems to be a strategy to further
may have a minor impact on the length of the epithelial attach- minimize peri-implant crestal bone resorption, as demonstrated
ment (0.84 versus 1.91 mm), while the connective tissue adap- in clinical studies.36,54 This appears even more clinically relevant
tation compartment remains relatively unaffected. This initial in cases with a thin soft tissue biotype (Fig 22-3).
data might better explain esthetic outcomes reported in the But together with biologic reasons, there seems to be a
literature.33,52,53 Changing observation points and focusing just microbiologic/biomechanical rationale behind the one abutment,
on the connective component, however, the most clinically rele- one time protocol: It might minimize the connection and screw
vant data of this study can be highlighted: The position of the deformation.55–57 At the same time, it might prevent microbio-
connective component was dramatically different in test and logic growth in the inner part of the connection during the pros-
control groups. Using IAJ as reference, histologic data confirmed thetic workflow. To reinforce the clinical relevance of the supra-
that while traditionally restored implants present a connective crestal connective tissue attachment to the abutment, several
component below the IAJ, platform-switched implants allow a efforts were made to longitudinally stabilize this connection. For
more coronal positioning of connective tissues. In fact, while this purpose, enhancement of the abutment surface micropo-
the control group connective tissue was adapted below the rosity using laser-ablated microgrooves was demonstrated to
IAJ, the platform-switching connective tissue was medialized allow connective tissue stability and a perpendicular rearrange-
to the abutment, especially over the implant platform in direct ment of the connective components with junctional epithelium
connection with the prosthetic components. ending at the coronalmost position of the laser-microgrooved
However, although platform switching presents encouraging zone.58 As a clinical consequence, this seems to lead to a signif-
results in terms of bone preservation, in accordance with the icant improvement in peri-implant hard and soft tissue healing
histomorphogenesis of traditionally restored implants,20,21 when compared with traditional smooth titanium abutments, both in
platform-switched implants are exposed to the oral environment, preclinical16,59 and clinical longitudinal studies.60,61
bacteria colonize the microgap. Within the first week, implant At the same time, connective tissue–titanium surface proxim-
exposure to the oral cavity promotes peri-implant inflammation ity suggests the need to investigate the abutment surface prop-
with apical migration; at 2 weeks, initial epithelial growth is erties. Several studies analyzed soft and hard tissue response
found.26 These results are amplified by prosthetic procedures, to different abutment materials, suggesting that tissue reac-
during which the implant abutment is disconnected several tion depends on materials properties, despite controversial
times: at impression taking, provisional abutment insertion, outcomes.14,62,63 However, it must be noted that the chemical
and definitive abutment placement.22 composition of the bulk material is often significantly different
These clinical procedures could in fact jeopardize hard tissue from what the surface expresses at the living tissues inter-
stability due to the unconventional disposition of the biologic face. This could explain the controversial results expressed in
width. According to Berglundh et al20 continuous disconnec- literature.10,18
399

a b c
d e f
g h i
Fig 22-3 (a and b) Preoperative buccal and occlusal views. Recession on the left central incisor and hopeless lateral incisors can be noted. (c)
Occlusal perspective after tooth extractions. (d) Implant placement after mini-flap elevation. (e) Impression taken intraoperatively using the surgical
stent. (f to h) During the submerged healing phase, the technician prepared a definitive cast using the intrasurgical index and the preoperative
cast. (i) This allowed the preparation of a definitive abutment.
Decontamination of customized abutments screw level could negatively affect pre-loading and connection
stability.70 The cumulative effect of all these drawbacks was
Since most prosthetic components are customized by lab tech- to initiate the peri-implant bone resorption process. For this
nicians, analyzing tissue response to the external surface of the reason, removal of chemical and microbiologic pollutants from
abutment is mandatory. Although technical procedure allows the prosthetic components is obligatory, thus approaching the
for decontamination by steaming, which might be sufficient for prosthetic phase similarly to the sterile surgical phase.
contaminant removal, the workflow (packing, transport, handling Several procedures have been tested for this goal, with cold
by an assistant) introduces additional contaminants on the pros- plasma of argon being one technology proven to remove pollut-
thetic components. For this reason, an in vitro study was per- ants and simultaneously decontaminate.71 This process works
formed comparing new abutments to customized abutments. through the activation of the electronic mantle of materials by
Starting with a contaminated situation at the time of abutment electrified argon under pressure and at room temperature. As
removal from the plastic bag, by the end of the study, the authors demonstrated, plasma of argon allows attainment of a nearly
found a dramatic increase of contamination during customiza- sterile prosthetic phase,72,73 allowing better longitudinal stability of
tion phases. Contamination can be recognized as microparticles the implant-abutment complex.74 However, in addition to remov-
of titanium and remnants of lubricant and facultative anaerobic ing debris and bacteria, activation of the electronic mantle of the
bacteria. Pollutants and bacteria were found on the entire abut- materials increases the wettability of the surface, which in turn
ment, external surface, connection, and screw.64 It is possible allows faster and stronger fibroblast adhesion to the abutment.72,73
that titanium wear microparticles could activate osteoclasto- To test this hypothesis, an in vitro study was undertaken to
genesis.65 The anaerobic environment at the connection level test a sterile abutment in culture with fibroblasts; it showed the
could create a potential reservoir for microflora and peri-implant attachment of many cells.75 The same treatment was carried out
disease,66–69 and the presence of pollutants at the connection/ on an abutment cleaned with plasma. Even macroscopically it
400

j k l
m n
o p q r
Fig 22-3 (cont) (j and k) Clinical and radiographic images of the definitive abutment, which was inserted immediately after the second surgery
and never disconnected. (l) Provisional restoration inserted after a shoulderless preparation on the natural tooth abutments. Minimal recession
still can be seen on the left central incisor. (m and n) Radiographic and clinical images of the definitive restoration after 1 year. (o to r) Clinical and
radiographic images at the 8-year follow-up. The soft tissue contour is stable, and no bone loss can be detected.
could be observed that the time of reaction cells and titanium randomized controlled trial (RCT) demonstrated that smooth tita-
decreased under the activation of the plasma, allowing a quan- nium abutments treated with plasma of argon allowed fibroblast
titative increase of cells. But at the same time, a qualitative adhesion, while untreated abutments resulted in lack of contact
improvement of the adherence or adhesion could be observed. with cells. At the same time, histologic analysis demonstrated a
The fibroblasts normally come into the closest proximity possi- denser connective tissue with an oblique fiber orientation with
ble with the titanium in a globular form and then relax. Scan- bio-activated abutments.77
ning electron micrographs (SEMs) showed that on the surfaces From a theoretical point of view, the mentioned positive
treated by plasma, the first step (globular) is skipped, and the cell outcomes have a cumulative effect of eliminating etiologic
flattens out as soon as it comes into contact with the metal.75,76 cofactors leading to bone level changes, thereby minimizing
From a histologic point of view, this allows better layering of prosthetic cofactors inducing bone resorption in both periodon-
the cells. From a clinical point of view, the importance of the tally healthy patients and those with a history of periodontal
mentioned qualitative and quantitative increment of the cell disease, as demonstrated in several RCTs66,67,72,73,75,76 (Fig 22-4).
adhesion is that it seems to allow faster soft tissue healing,
which is already clinically and histologically advanced 3 days
after surgery. Analyzed by SEM, fibroblast adhesion appears Microgvrooved implant collars
stronger even in the initial stages of the treatment, as the pres-
ence of pseudopodia demonstrates. Similarly, following a human histologic study that demonstrated
The use of a cleansed abutment ensures minimal contam- direct connective tissue attachment to microgrooves on the
ination of the implant connection over the long term, and all implant collar,78 such a configuration was proved to provide a direct
this would allow a more coronal and resistant adaptation of soft fibrocollagenous attachment when used at the abutment level.16
tissues on the abutment. Additionally, a recent human histologic These microgrooves were confirmed, in fact, to guide and stabilize
401

a b c
d e f
g h i j
Fig 22-4 (a) Hopeless right incisor. (b) After tooth extraction, consistent horizontal tissue shrinkage can be detected. (c)
Flapless implant placement. (d) Immediate impression taking. (e) After 3 months of submerged healing, a bio-activated
definitive titanium abutment was inserted at the time of the stage-two surgery, according to the one abutment, one
time concept. (f) Provisional restoration cemented. (g and h) Clinical and radiographic images of the definitive restoration
at the time of cementation. (i to k) Radiographic and clinical images at the 8-year follow-up.
a b c d
Fig 22-5 (a) Shoulderless abutment presents the absence of a margin circumferentially. (b) Restoration is shaped for soft tissue contouring. (c)
Hybrid abutment presents the absence of a margin only on the buccal aspect. (d) This allows for a perfect fit of the crown on the palatal aspect
without jeopardizing esthetics.
fibroblasts.79 From a histologic point of view, laser-ablated micro- Abutment shape

grooves were demonstrated to produce functionally oriented, per-
pendicularly directed connective tissue fibers.16 This connective The proximity of the supracrestal connective tissue to the
tissue was intimately juxtaposed against the entire band of the prosthetic components could depend on the abutment shape
microchannels.60 From a clinical point of view, as previously dis- and its interference with connective tissue compression and
cussed for bio-activated abutments, this might potentially limit the myofibroblasts. This might suggest that a thinner, convergent
apical epithelial migration. In fact, in a recent multicenter study, abutment enhances space for connective tissue, resulting
direct connective tissue attachment to the abutment surface in coronal displacement of myofibroblasts during healing.
was shown to reduce peri-implant crestal bone loss61 (Fig 22-5). Convergent abutments have been shown to enhance space
402

Fig 22-6 Histologic images demonstrating native and new bone

(darker stain) on the implant surface. (a) Although it is likely the
result of the correction of drilling disparity, it is evidenced that the
laser-ablated microgrooves on the abutment allowed supracrestal
connective tissue fiber attachment. This prohibited apical migration
of the epithelium, allowing the bone to respond in an aseptic envi-
ronment. (b) Laser-ablated microgrooves on the abutment demon-
strated perpendicularly oriented connective tissue fibers against
the entire surface of the Laser-Lok (BioHorizons) grooved area.
a b
a b c
d e f
g h i
Fig 22-7 (a) Zirconium definitive abutment. (b) Blue resin caps for secondary tissue impression. (c) After the stage-two surgery, definitive abutment
was tightened at 30 Ncm. (d) Soft tissue maturation was guided by the provisional restoration. (e) Once the soft tissues had matured, resin caps
were used to transfer the soft tissue contour and abutment position to the laboratory. (f and g) Definitive restorations. (h and i) Radiographic and
clinical appearance after 7 years of loading.
for the connective compartment of the supracrestal tissue the correct margin, which is an almost impossible task when
attachment.80,81 an open-flap impression is taken (Fig 22-7).
A shoulderless configuration may promote extra soft tissue.82 However, to prevent IAJ contamination, the only clinically
This approach eliminates the emergence profile of the abutment available option remaining is a tissue-level implant. While the
and allows creation of a prosthetic crown without any anatom- traditional configuration of soft tissue–level implants, ie, with a
ical limit. This is because the emergence profile is transferred divergent collar, might represent a valid option in the posterior
from the abutment (classic geometry) to the crown (Fig 22-6). area, it is more likely to present problems in the esthetic area.
Using the one-abutment, one-time approach, this abutment Recently developed implants with a convergent collar might
design provides for an ideal prosthetic workflow. It prevents represent a valuable option in esthetic cases (Fig 22-8).
the technician and the clinicians from needing to determine
403

a b c
d e f
g h i j
Fig 22-8 (a and b) Implant insertion in healed site after mini-flap elevation. The convergent collar of the soft tissue
implant can be seen. (c) Technical overview of the implant/abutment/crown complex: Alternation of convergence
and divergence can be detected. (d and e) Once osseointegrated, the soft tissue–level implant was restored using a
zirconia abutment. A provisional restoration was used to guide soft tissue maturation. (f and g) Clinical and radiographic
images of the definitive restoration. (h to k) Clinical and radiographic images at the 5-year follow-up.
In a recently published case series,80 it was observed that the 2. Weber HP, Buser D, Fiorellini JP, Williams RC. Radiographic eval-
absence of an IAJ at bone level minimizes the chronic inflam- uation of crestal bone levels adjacent to nonsubmerged titanium
implants. Clin Oral Implants Res 1992;3:181–188.
matory infiltrate and the associated crestal bone loss. At the
3. Hermann JS, Schoolfield JD, Schenk RK, Buser D, Cochran DL.
same time, a convergent collar shape, which allows more soft Influence of the size of the microgap on crestal bone changes
tissue space, and use of a delayed approach might allow implant around titanium implants. A histometric evaluation of unloaded
placement in a more proper midcrestal position, even in the non-submerged implants in the canine mandible. J Periodontol
2001;72:1372–1383.
anterior area.
4. Manz MC. Factors associated with radiographic vertical bone loss
around implants placed in a clinical study. Ann Periodontol
2000;5:137–151.
5. Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-implant
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406

23 YOSHIHIRO ONO • TAKESHI SASAKI • MITSUHIRO IWATA •
SACHIKO MAEDA • TOKOU MATSUI • KIMIO NAKAMURA •
KIYONOBU SABURI • SATOKO ONO RUBIN
Effective Application
of Orthodontics with
Implant Therapy
for Periodontally
Compromised Patients
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
407

23 | Effective Application of Orthodontics with Implant Therapy for Periodontally Compromised Patients
C
ontemporary implant therapy was introduced to the ment to achieve long-term coexistence of natural teeth and
routine clinical practice of dentistry in 1984 in Toronto, implants in periodontally compromised patients.
Canada.1 Numerous basic and clinical implant stud- The following six cases exhibit posterior bite collapse due to
ies have been published and have demonstrated a advanced periodontal disease. Treatment was established with
high degree of predictability. Implant treatment contributes interdisciplinary therapy, including periodontics, orthodontics,
to patients’ function and self-esteem when teeth are lost to implants, and prosthodontics.
advanced periodontitis and trauma, whether patients are fully
edentulous or partially dentate. Implant treatment also contrib-
utes to the stabilization of any remaining teeth experiencing
secondary occlusal trauma, mitigating some of the force they CASE 1
must bear. There are, however, issues associated with implant
treatment, including peri-implantitis, mechanical problems, and An 18-year-old woman presented with a chief complaint of
effects on craniofacial development. These problems challenge missing maxillary canines (Fig 23-1a). The molar relationships
both function and esthetics and can interfere with the full benefit were Angle Class I malocclusion bilaterally. Overjet and overbite
of implant therapy. Peri-implantitis has become a global problem were both 2.5 mm. The patient had seven congenitally missing
as the number of implants placed continues to grow. teeth: maxillary canines, a mandibular incisor, and all second
Periodontally compromised patients have a demonstrated premolars (Fig 23-1b). The primary maxillary left canine and all
susceptibility to inflammation. They require the establishment primary second molars were present at the initial visit. She also
of periodontal health prior to implant placement and a strong had a distally rotated maxillary right first premolar and a mesi-
individual maintenance program after implants are placed.2 Many ally rotated maxillary left first premolar (Figs 23-1c and 23-1d).
reports demonstrate that periodontally compromised patients According to the conventional treatment plan, the primary
can have the same positive outcomes from implant therapy as teeth would be extracted, and the teeth would be moved into
healthy periodontal patients.3 position so that the implants could be placed appropriately.
Patients with advanced periodontal disease often exhibit However, she had only three mandibular incisors; therefore,
malocclusion due to missing teeth and reduced supporting the midline would deviate, and the molar and canine relation-
structure. The remaining teeth tend to migrate, resulting in func- ships would not be Class I. A treatment plan was developed
tional and esthetic problems such as diastemata, extrusions, and in which the teeth would be moved (arrows in Fig 23-1e) after
rotation, which may collectively lead to posterior bite collapse.4 the primary teeth were extracted. The spaces from the primary
Malocclusion associated with pathologic migration is considered second molars would be closed, and space was to be made in
a risk factor that exacerbates periodontitis.5–7 Teeth that have which to place a mandibular left lateral incisor implant. Implants
drifted following the loss of adjacent teeth and supporting bone would replace the maxillary canines. This treatment plan resulted
frequently exhibit secondary occlusal trauma.8 Patients who in the establishment of the maxillary and mandibular midlines
have malocclusion (such as an open bite or migration of teeth) in a Class I canine relationship.
present complications for restorative rehabilitation. Proper ortho- The primary second molars were extracted, and pre-adjusted
dontic alignment of teeth results in better hygiene access and edgewise appliances were placed for both arches. After leveling
helps prepare the mouth for prosthetic treatment.9,10 Orthodon- and alignment with nickel-titanium archwires, space was gained
tic treatment can improve the position of abutment teeth and for the mandibular left lateral incisor, and correction of the midline
establish a proper occlusal plane with anterior guidance. Optimi- began with a stainless steel archwire. After midline correction, a
zation of the occlusion after orthodontic treatment contributes miniscrew was placed distal to the mandibular right first premo-
to the maintenance of periodontal health with an appropriate lar, and molar mesialization began with elastomeric chains (Figs
occlusal interrelationship.11 23-1f and 23-1g). After alignment of the maxillary dentition, a
The inflammation and mobility of remaining periodontally dental implant was placed at the site of the maxillary right canine
compromised teeth can be better controlled with optimal distri- in combination with horizontal guided bone regeneration (GBR).
bution of occlusal force on both remaining teeth and implants, The left canine space required a sinus elevation procedure with
obtained with a multidisciplinary approach to treatment. Implants simultaneous horizontal GBR. Subepithelial connective tissue
will then be able to articulate and be in harmony with the resid- grafts were performed on the labial aspects of both maxillary
ual natural teeth. If additional implants are required after the implants 6 months after placement. Screw-retained provisional
extraction of malpositioned teeth, it is necessary to align the crowns were delivered the following month. Mesial movement of
rehabilitation of tooth position and angulation with the implants. the maxillary right molars began, using the implant as anchorage.
In order to achieve long-term stability of natural teeth and The mandibular left lateral incisor implant was placed with GBR,
implants in periodontally compromised patients, an interdisci- and a provisional restoration was screwed into the fixture before
plinary approach to managing periodontal inflammation, tooth removing the orthodontic components. Wraparound retainers
mobility, and tooth position is indispensable. Through the were placed on both arches following the removal of the edge-
presentation of clinical case examples, this chapter discusses wise appliances. During the retention period, definitive zirconia
the importance of the effective application of orthodontic treat- abutments and crowns were placed.
408

Case 1
a b c
d e
f g h
i j k
Fig 23-1 (a) Pretreatment intraoral photograph. The patient’s chief complaint was missing maxillary canines. The maxillary dental midline almost
coincided with the facial midline; however, the mandibular dental midline was deviated 3.0 mm to the left. (b and c) Pretreatment intraoral pho-
tographs (occlusal views). Wide spaces were found in both arches because of the seven congenitally missing teeth, and the primary maxillary
left canine and all primary second molars showed prolonged retention. (d) Pretreatment panoramic radiograph. Root resorption was observed in
the primary maxillary left canine and primary mandibular molars. (e) Both the maxillary and mandibular molars would be mesialized to reduce the
spaces for the prosthetic restorations. Implants would replace the maxillary canines and the mandibular left lateral incisor. This procedure would
bring the arches into a Class I occlusion. (f and g) Space gaining for the left lateral incisor and correction of the deviated midline began in the man-
dibular arch. After the midline correction, a miniscrew was inserted distal to the alveolus of the mandibular right first premolar (arrow), and molar
mesialization was initiated with elastomeric chains. (h) Posttreatment intraoral photograph. Definitive restorations, zirconia abutments and crowns,
were delivered. The dental arches were well aligned, and an esthetic outcome was achieved. (i and j) Posttreatment lateral intraoral photographs.
The occlusion was much more stable, and acceptable intercuspation of the teeth was achieved with a Class I canine and molar relationship. (k)
Posttreatment panoramic radiograph. Three dental implants and proper root paralleling are shown. The maxillary molars were completely mesialized,
although their roots appear closer to the sinuses.
The dental arches were well aligned, and an esthetic outcome radiograph (Fig 23-1k). The maxillary molars were completely
was achieved (Fig 23-1h). The occlusion was stable, with a Class mesialized, although their roots appear closer to the sinuses.
I canine and molar relationship (Fig 23-1i and 23-1j). Three dental At the 3-year follow-up, the occlusion remained stable, and
implants with proper root position are evident in the panoramic the excellent esthetic result was maintained.
409

a b
c d e
f g
Fig 23-2 (a) A 35-year-old woman with a chief complaint of mastication difficulties. Tooth malposition, malocclusion, and significant disturbance
of the occlusal plane were observed. (b) A full-mouth radiographic survey at the initial examination showed generalized horizontal bone loss and
vertical bone loss for multiple teeth. (c) A diagnostic wax-up was fabricated to help plan the final treatment goals. (d) Orthodontic treatment was
conducted to correct tooth positions and adjust the gingival margin. The maxillary left lateral incisor was extruded to facilitate the regeneration and
elimination of the mesial bone defect. (e) Orthodontic treatment to optimize the tooth axes allowed for pulpal preservation during abutment tooth
preparation procedures. (f) The definitive prosthesis was delivered. Function and esthetics were successfully provided. (g) Posttreatment full-mouth
radiographic survey showed tooth and pulp preservation was successfully achieved. Tissue continuity was also accomplished.
CASE 2 also decreased, which in turn contributes to disease progres-

sion. Proper tooth position needs to be restored to achieve
A 35-year-old woman presented with a chief complaint of mobile hygiene access, stable periodontal tissues, and optimum distri-
mandibular teeth. The intraoral examination revealed tooth mal- bution of occlusal force. A diagnostic wax-up was fabricated
position, malocclusion, and disturbance of the occlusal plane to plan the treatment goals from the prosthetic perspective
(Fig 23-2a). Although her oral hygiene was fair and gingival (Fig 23-2c). The prosthetically driven treatment goals were to
inflammation was mild, she had periodontal pockets of up to establish tissue continuity and stability, fabricate precise resto-
12 mm. A full-mouth radiographic survey at the initial examina- rations with appropriate crown length, and achieve a stable
tion demonstrated generalized horizontal bone loss, and vertical occlusion supported by stable teeth. Orthodontic treatment was
bone loss was seen for multiple teeth (Fig 23-2b). Some teeth required to achieve these treatment goals. Surgical planning
were hopeless and nonrestorable. Bacterial testing revealed included extraction of teeth with poor prognosis and preserva-
that 20% of the total bacterial count was Porphyromonas gin- tion of teeth with more favorable periodontal prognosis. Pulpal
givalis, suggesting high periodontal disease activity. She was vitality was to be preserved where possible. The key maxil-
diagnosed with aggressive periodontitis based on age, family lary teeth (right second molar, left lateral incisor, and left first
history, and bacterial profile as well as the distribution and nature molar) would be treated with periodontal regeneration. Exten-
of the bone defects. sive implant-supported restorations would be needed if peri-
In a healthy periodontium, bone, gingiva, and teeth are in odontal regeneration did not successfully retain the teeth. An
harmony. In contrast, for this patient, periodontal disease had optimal treatment plan needed to be made from both the pros-
resulted in bone loss, tooth loss, and tooth malposition. Not only thetic and the surgical perspectives. The treatment sequence
are function and esthetics compromised, but hygiene access is was planned as follows:
410

Case 3
1. Initial treatment (scaling and root planing, extractions, CASE 3

antibiotic therapy)
2. Periodontal regenerative therapy A 57-year-old man had masticatory disturbance due to peri-
3. Implant surgery odontitis. An intraoral examination showed the occlusal verti-
4. Orthodontic treatment cal dimension and anterior guidance were almost lost. Poste-
5. Definitive periodontal surgery (resective therapy) rior teeth were inclined mesially, and the anterior teeth were
6. Periodontal prosthesis and implant prosthesis pathologically flared. As a result, the occlusal vertical dimen-
7. Maintenance procedures (periodontal, prosthetic, sion was reduced, and bite collapse occurred. The continuity
orthodontic) of the bone, occlusal plane, and gingival margin was disrupted
(Fig 23-3a). The full-mouth radiographic survey showed severe
It is essential to define distinct treatment goals and to make bone loss (Fig 23-3b).
a detailed plan with sequenced treatments in order to achieve The decision was made to extract the hopeless maxillary
a successful outcome. right first premolar and left first molar as well as the mandibular
Gingival inflammation was decreased, and mastication left first molar during the initial preparation. After healing of the
improved during initial preparation. P gingivalis was controlled in extraction sites, an implant was placed at the site of the maxil-
combination with antimicrobial treatment (numbers decreased lary left second premolar, and sinus elevation was performed
from 220,000 to 400 [from 20% to 0.07%]). Periodontal regen- for the left side. While waiting for the healing of the left sinus,
erative procedures were then performed for the maxillary right simultaneous implant placements with sinus elevation for the
second molar and second premolar as well as the left lateral right posterior segments were conducted. Ten months after heal-
incisor. Excellent bone regeneration was achieved. Then, ortho- ing on the left side, two maxillary molar implants were placed.
dontic treatment was conducted to correct tooth positions, Six months after implant placement, free gingival grafts were
improve the occlusal plane, and adjust the gingival margin from placed at the time of stage-two implant surgeries. Augment-
the prosthetic viewpoint. At the same time, the maxillary left ing the amount of keratinized gingiva around implants not only
lateral incisor was extruded to facilitate the regeneration and facilitates plaque control but also promotes long-term stability
elimination of the mesial bone defect (Fig 23-2d). of the tissue. Simultaneously, soft tissue ridge augmentation
Six months after orthodontic treatment, definitive periodontal was performed in the future pontic area of the maxillary right
surgery was performed to eliminate pockets and increase the lateral incisor site. This was done to correct the ridge deformity
attached gingiva. Six months after surgery, the abutment teeth as well as to facilitate plaque control.
were prepared with caution taken to preserve the pulp (Fig Once the occlusal vertical dimension was established, upright-
23-2e). The definitive prosthesis was delivered (Fig 23-2f). Good ing of the mesially tilted posterior teeth could be undertaken
hygiene access to the periodontal tissue was established, and (Fig 23-3c). Periodontally accelerated osteogenic orthodontics
accurate prosthetic treatment was completed. Stable intercus- (PAOO) was performed for the right posterior segments. After
pal and condylar positions were achieved by eliminating occlusal a full-thickness flap was elevated, vertical slits were made into
plane disturbances. Mastication and esthetics were success- the interdental alveolar bone as decortications (Fig 23-3d). Miner-
fully recovered along with continuity of the gingival margin and alized freeze-dried bone allograft was then applied to the bone
dentition. After treatment, radiographs showed that tooth and surface, and the flap was sutured with primary closure. The ortho-
pulp preservation was successful and that a stable periodontal dontic appliance was replaced immediately after the surgery.
prosthesis had been achieved while placing only four implants The advantages of PAOO are as follows12:
in the posterior mandible (Fig 23-2g). In this case, many teeth,
as well as their vital pulps, were preserved with an effective 1. Increasing the thickness of the alveolar bone
application of periodontal regenerative therapy and orthodontic 2. Shortening the treatment duration
treatment. The orthodontic therapy resulted in the natural teeth 3. Prevention of possible root resorption
being in the proper position to receive the definitive prosthe- 4. Reduction of pain during orthodontic treatment
sis. Therefore, it was possible to preserve the vitality of all the 5. Avoidance of postoperative relapse
teeth. Strategic teeth responded successfully to the periodontal
regeneration procedures, and continuity of the bone level was PAOO was then conducted in the left posterior regions in
achieved. If problems occur in the future, the tissue continuity the aforementioned manner. After uprighting in the posterior
that was achieved with this course of treatment will facilitate segments was completed (Fig 23-3e), the anterior segments
retreatment involving implant therapy. With effective control of were ready for uprighting. PAOO, for both maxillary and mandib-
inflammation and force, periodontal health has been maintained ular anterior segments, was again carried out in the same way
with a stable occlusion for 5 years. (Fig 23-3f). At this point, the uprighting of all segments was
completed (Fig 23-3g).
Orthodontic treatment was then completed with correc-
tion of the malposition of the teeth and the disturbance of the
occlusal plane. A final implant was placed in the mandibular
411

a b
c d e
f g h
i j k
l m
Fig 23-3 (a) A 57-year-old man with a chief complaint of masticatory disturbance. The posterior teeth had inclined mesially, and the anterior teeth
had pathologically flared. As a result, bite collapse occurred. (b) The full-mouth radiographic survey showed severe bone loss. (c) The occlusal
vertical dimension was established with eight implants placed in posterior regions. (d) PAOO was performed. (e) Uprighting was completed in
the posterior segments. Note the space between the maxillary right canine and lateral incisor. (f) PAOO was also carried out for both maxillary
and mandibular anterior segments in the same way. (g) The uprighting at all segments was completed. Orthodontics were in place to correct the
malposition of the teeth and the disturbance of the occlusal plane. (h to j) The definitive restoration was fabricated. The continuity of the dentition
and occlusal plane has been improved successfully. (k) Six years after treatment. Stable occlusion was maintained without postoperative relapse. (l)
Panoramic radiograph right after the treatment. (m) Panoramic radiograph taken 6 years later. The continuity of the bone level has been maintained.
412

Case 4
a b
c d e
Fig 23-4 (a) Pretreatment intraoral photograph. All teeth, including molars, had mesial inclination and showed advanced pathologic tooth migration.
Both the mandibular and maxillary anterior teeth were flaring out without anterior guidance. Many deep periodontal pockets of up to 10 mm were
observed with bleeding on probing and purulent exudate. (b) Periapical radiographs at baseline. Significant alveolar bone loss was observed for
the maxillary anterior teeth, and almost all teeth had intrabony defects. (c and d) Six months after regenerative therapy, orthodontic therapy was
initiated. Leveling, alignment, and uprighting of all teeth were performed using anchor screws (arrows) placed in the molar region. (e) The definitive
restorations were delivered with a stable occlusal relationship and appropriate anterior guidance, reducing occlusal trauma. (f) Periapical radio-
graphs 2 years after treatment. Probing depths were 3 mm or less in almost all regions. All teeth were stable and received individual restorations.
left lateral incisor position at this time. Then all the definitive CASE 4
restorations were delivered (Fig 23-3h to 23-3k). The entire
maxillary right second premolar to left second premolar denti- A 63-year-old woman presented with a chief complaint of max-
tion was splinted with a fixed restoration to prevent postoper- illary anterior tooth mobility (Fig 23-4a). Many teeth, including
ative relapse and to provide a functional rehabilitation. At this molars, had significant tooth mobility, deep periodontal pockets,
point, the continuity of the dentition and occlusal plane had and intrabony defects (Fig 23-4b). All teeth, including molars,
been achieved successfully. had mesial inclination and showed pathologic tooth migration.
The occlusal vertical dimension was reconstructed, and appro- After initial periodontal therapy, periodontal regenerative therapy
priate anterior guidance was established by effectively applying was performed in all molar regions. Comprehensive orthodontic
the distal retraction of mesially inclined teeth in combination treatment using anchor screws was subsequently carried out to
with PAOO and implant therapy. In order to achieve long-term upright all of the teeth (Figs 23-4c and 23-4d). After completing
coexistence of natural teeth and implants, a stable occlusion orthodontic therapy, staged GBR was applied to achieve ridge
with an appropriate mandibular position is indispensable (Fig augmentation, allowing two implants to be placed in the max-
23-3k). Two panoramic radiographs are presented: one right illary anterior region. Periodontal surgeries were performed
after treatment in 2011 (see Fig 23-3h) and the most recent in for the molar regions. Periodontal intrabony defects were first
2018 (Fig 23-3m). Nothing has changed over that period, and treated with periodontal regeneration surgery. Six months later,
the continuity of the bone level has been maintained. A favor- the second surgery was done to achieve physiologic bone mor-
able long-term prognosis can be expected. phology and shallow gingival sulci. Then, definitive surgeries
were performed for the molar regions before placing the defini-
413

a b c
d e
f g h
Fig 23-5 (a to c) Frontal and lateral views from the first exam-
ination. (d) Full-mouth radiographic survey from the first exam-
ination. (e) Frontal view during orthodontic treatment. Two TADs
were placed in the anterior mandible. (f) Full-mouth radiographic
survey with the definitive restorations in place. (g to i) Definitive
restorations after 6 years.
tive prosthesis. These treatments improved alveolar bone levels advanced periodontitis, and there was severe malocclusion
and established an environment that the patient and hygienist with an extreme anterior deep overbite (Figs 23-5a to 23-5d).
can maintain. A stable occlusion was established with anterior When examining the frontal and lateral views from the initial
guidance. A favorable periodontal condition has been maintained examination (see Figs 23-5a to 23-5c), it can be seen that the
postoperatively (Figs 23-4e and 23-4f). occlusal vertical dimension was markedly decreased. Because
of the severely deep bite, the occlusal vertical dimension was
opened about 3 mm in the anterior area using the provisional
partial dentures. It was difficult to initiate orthodontic treatment
CASE 5 when anchorage was limited for significant numbers of teeth.
After initial therapy, scaling and root planing along with the
A 63-year-old man requested fixed restorative dentistry treat- extraction of the hopeless teeth (maxillary lateral incisors and
ment utilizing fixed partial dentures and implants. The results left third molar and mandibular right premolars and first molar).
of the patient’s first examination showed that there was severe Then, periodontal surgery was performed to eliminate peri-
malocclusion in the entire mouth caused by the missing man- odontal pockets. After completion of the periodontal surgery,
dibular right and left first premolars and first molars and the orthodontic treatment began.
hopeless maxillary lateral incisors and left third molar and man- Two anchor screws (temporary anchorage devices [TADs])
dibular right premolars and first molar. Many residual teeth had were placed buccally and apically to the mandibular lateral inci-
414

Case 6
a b
Fig 23-6 (a) Initial intraoral view of a 49-year-old woman with a chief complaint of tooth mobility. The maxillary
left first and second molars and mandibular left first premolar were extracted 3 months before the initial
visit. Abnormalities in dentition were seen throughout the arches. (b) The full-mouth radiographic survey
demonstrated advanced bone loss for both maxillary right premolars. The clinical roots of the maxillary
anterior teeth were short. The mandibular left first molar had furcation involvement and angular bone loss.
There was also a marked alveolar ridge bone defect in the site of the missing mandibular left first premolar.
(c) Orthodontic treatment was provided to correct the flaring of the maxillary anterior teeth and to facilitate
lip closure.
sors, allowing anchorage for intrusion of the mandibular anterior was present for the maxillary right premolars and mandibular left
teeth (Fig 23-5e). first molar (Fig 23-6b). The occlusal relationship was an Angle
Because of the malposition of the remaining natural teeth, Class II malocclusion with an incisal vertical overbite of 2 mm
proper implant position was only obtainable by performing ortho- and overjet of 7 mm (Fig 23-6c). The maxillary lip protruded, and
dontic treatment. Implants were placed in the mandibular first the patient had difficulty closing her lips.
premolar and first molar areas bilaterally. Titanium screws were Periodontal treatment began with initial debridement and
used as supports for resorbable membranes required for guided oral hygiene education. The maxillary right second premolar
tissue regeneration during implant placement. A decision was was extracted, and guided tissue regeneration was performed.
made to correct the morphology of the anterior six teeth using A provisional fixed prosthesis was placed from the maxillary
restorative techniques. Due to severe alveolar bone loss and left canine to the second premolar. It was used as anchorage
the absence of both maxillary lateral incisors, it was impossible for orthodontic treatment of the maxillary anterior region. This
to solve the problem with orthodontics. This patient continued began by setting the orthodontic brackets from the maxillary
maintenance therapy for 6 years after the definitive restorations first premolar to the canine. Mesial and distal reduction of the
were placed. During this time, no major problems occurred, and maxillary central and lateral incisors and mesial reduction of the
he was satisfied with the esthetic and functional results of the maxillary right canine of approximately 1 mm per tooth provided
treatment (Figs 23-5f to 23-5i). the space required for the correction of the crowding. The active
orthodontic phase of treatment was completed after about 6
months, after which a free gingival graft was placed from the
maxillary left canine to the premolar. When the orthodontic
CASE 6 treatment was completed after 9 months, periodontal surgery,
including osseous contouring with a partial-thickness apically
A 47-year-old woman presented with a chief complaint of mobil- positioned flap was performed for pocket elimination. Tooth
ity of her maxillary teeth. Clinical examination revealed gingival preparation resulted in the appropriate interdental space for the
inflammation, poor restorations, tooth malposition, and maloc- prosthesis and hygiene access. Twenty-three months later, a free
clusion (Fig 23-6a). Periodontal examination revealed a general- gingival graft and apically positioned flap were performed on
ized lack of attached gingiva with 8-mm periodontal pockets on the provisional partial denture site of the right maxilla. A sinus
the distal surfaces of the maxillary right first and second pre- elevation was performed in the maxillary left molar region using
molars and mandibular left first molar. The radiographic survey autogenous bone harvested from the chin. Fifteen months after
revealed moderate bone loss for other teeth. Vertical bone loss
415

d e
f g
i j
Fig 23-6 (cont) (d) Orthodontic treatment was performed bilaterally in the mandible to reposition the premolars and molars with plans to fab-
ricate partial dentures. Anterior crowding was also relieved at the same time. (e) The definitive restoration has been placed. The protrusion and
dentition abnormalities have been corrected with an esthetically pleasing outcome. (f) Pretreatment profile. (g) The improved posttreatment pro-
file. Achievement of lip closure also eliminated her dry mouth syndrome. (h) A full-mouth radiographic survey. Eleven years after the delivery of
the definitive prosthesis, the mandibular left second molar was extracted because of tooth fracture and replaced with implants. (i) The maxillary
anterior definitive restoration. (j) A panoramic radiograph revealed that the bone level had been stable for 14 years after the definitive restorations
were placed, except for the area around the more recent left mandibular molar implants.
the sinus floor elevation, three implants were placed at the site, in the right and left premolar regions (Fig 23-6d). Orthodontic
followed by a stage-two surgery 10 months later. treatment was completed, and a free gingival graft procedure
Mandibular orthodontic treatment was initiated after was performed in the region between the mandibular left canine
extraction of the right second premolar and left first molar. A and the second molar. Similarly to in the maxilla, 10 months
lingual archwire was fitted between the mandibular right first after the completion of the orthodontic phase, a free gingival
molar and left second molar, augmenting the anchorage while graft was placed between the mandibular right first and second
corrections were made to the anterior crowding and tipping premolars.
416

References
The provisional restorations were then adjusted and evalu- contributes greatly toward achieving hygiene access, establish-
ated for function, hygiene access, and esthetics. The definitive ing a functionally stable occlusion with improved tooth position,
restorations were then fabricated (Fig 23-6e), and a nightguard and facilitating the regeneration of tissues around teeth and in
was provided for maintenance. There was a dramatic change in anticipation of implants. Periodontally compromised patients
her appearance, and her dry mouth was eliminated because she can benefit greatly from the close and effective collaboration
was able to close her lips (Figs 23-6f and 23-6g). A full-mouth of orthodontic, implant, and periodontal therapies.
radiographic survey revealed that the bone had become level
and there was no further bone loss (Figs 23-6h and 23-6i). Later,
the mandibular left second molar was extracted due to tooth
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for patients with periodontal disease, orthodontic treatment
417

24 LEANDRO VELASCO
The Interaction Between

Implantology and
Orthognathic Surgery
Classical and Ideal Cases
Classical and Not Ideal Cases
Atypical Cases
Extreme Cases
419

24 | The Interaction Between Implantology and Orthognathic Surgery
O
rthognathic surgery almost automatically brings to Fundamentally, the designation of a case as ideal or not is
mind young people, fully dentate with malocclu- based on whether the patient presents with deformities that
sions due to dentofacial deformities. When consid- are related to the position and not the shape of the arches.
ering treatment, such cases are immediately asso- That is, a harmonic result can be obtained with only the repo-
ciated with orthodontics and long treatments that are rarely sitioning of the maxillomandibular complex, without any other
concluded in less than 18 to 24 months. This is the stereotype concern regarding the morphology of the jaws. It is also worth
of orthognathic surgery, and those who practice it still carry mentioning that the greatest guarantee of long-term stability
stigmas today, more than 20 years after the development of in orthognathic surgery cases is a small compliment of teeth
internal rigid fixation, which eliminated the need for postopera- and the appropriate occlusal balance at the conclusion of treat-
tive maxillomandibular fixation. Patients still question how long ment. Once this balance is achieved, the chances of stability
it will be necessary to have a “tied mouth” after the surgery. are much better.
This happens because there is a long history of comorbidities Note that so far nothing has been mentioned relating to the
associated with this surgical procedure. There was not a signif- type of deformity, because this issue is overvalued by some
icant technical evolution associated with surgical practice, and professionals and is of secondary relevance. It does not matter
the procedure was performed in an archaic way. This caused if we are considering a case of prognathism, retrognathism,
significant postoperative suffering. Only patients with extreme laterognathism, or vertical excess with a broad gummy smile,
deformities considered the possibility of treatment. since there is no deformation in the shape of the jaws and good
The fact is that these outdated concepts are not exclu- occlusal stability. The type of deformity will only impact the type
sive to patients. Many dentists continue to view orthognathic of movement that will be performed and the possible surgical
surgery with many caveats and do not consider the procedure technique to be employed. If properly planned and executed, the
a preferred therapeutic option. They reserve the indication of type of deformity has no great effect on the treatment success
this technique only for cases where they do not see any other or the final stability.
possibility of resolution. In so doing, they deprive many patients It is important to note that certain deformities are associated
of the possibility of better results that are not achievable using with higher or lower rates of complications and relapses. For
conventional techniques. example, a brachycephalic patient with a prognathic pattern in
With this vision the author has retrospectively classified cases general presents much lower odds of idiopathic condylar resorp-
into four large groups: tion than a case with a long face and a retrognathic pattern.
However, the rate of relapse or sequelae associated with orthog-
1. Classical and ideal cases nathic surgery is quite low. The data varies according to differ-
2. Classical and not ideal cases ent authors, but it can be said with confidence that more than
3. Atypical cases 90% of patients do not experience major complications from
4. Extreme cases treatment.1–3
Figures 24-1 to 24-3 present a case that is representative of
This chapter explores each of these groups, outlining the main this group of patients. The patient is a 22-year-old woman with
aspects that should be taken into consideration when choosing a critical dentofacial deformity that includes a laterognathism
orthognathic surgery as therapy for patients. associated with a mandibular prognathism. As a result of this
deformity, the patient presents a significant deviation of the
mandibular midline with severe functional masticatory impli-
cations. However, it can be observed that although the arches
CLASSICAL AND IDEAL CASES have a substantially altered positioning, there is no significant
deformation in the jaws’ shape, the patient has all of her teeth
It may sound strange to speak of “ideal” cases when referring present, and there has been adequate orthodontic preparation.
to orthognathic surgery. This surgery is recognized as treatment This is in fact a classical and ideal case for orthognathic
of dentofacial deformities that orthodontic treatment cannot surgery. There is no doubt about its indication. There is no other
resolve. However, if one moves beyond the indication phase treatment capable of satisfactorily resolving the clinical condi-
to a stage of evaluating the case itself, it is clear that if a case tion, and a case with ideal characteristics should have ideal
presents a bone deformity, orthognathic surgery is an obvi- results regarding facial harmony, adequate breathing function,
ous option for treatment. From there, one can verify if the ele- and occlusal stability.
ments that this case presents make a procedure within ideal
standards possible.
420

a b c
d e
f g h
i j
Fig 24-1 Case 1: First visit. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radiograph. (e) Three-dimensional
(3D) reconstruction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal
view of mandible.
421

a b c
e f g
h i
Fig 24-2 Case 1: End of orthodontic preparation. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radio-
graph. (e) Intraoral right lateral view. (f) Intraoral frontal view. (g) Intraoral left lateral view. (h) Occlusal view of maxilla. (i) Occlusal view of mandible.
422

a b c
d e
f g h
i j
Fig 24-3 Case 1: End of treatment. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radiograph. (e)
3D reconstruction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal view
of mandible.
423

CLASSICAL AND NOT IDEAL conclusion. In fact, even the patient understands that once the
orthodontic treatment is over it will be necessary to undergo
CASES implant and/or prosthodontic treatment.
The problem usually occurs when the patient does not begin
Following in the same line of reasoning, the second group with the orthodontist or the maxillofacial surgeon but with the
includes those cases with a classical indication of orthognathic restorative dentist. It is very frequent that professionals have a
surgery but non-ideal conditions. These are cases with position- viewpoint that is limited to their own area of expertise and do
ing problems and/or shape deformation of the jaws and dental not properly identify dentofacial deformities or are not able to
stability that is less than ideal. adequately determine the treatment for such problems. In these
When shape deformations are present, one must consider situations, the clinician prescribes oral rehabilitation only and the
not only the simple repositioning of the arches but also bone final outcome often falls short of the patient’s expectations. When
remodeling. This can usually be done in three ways. The first this occurs the results are unstable and often associated with
and easiest is through the shaving of regions that have more prosthetic complications such as fractured screws and cemen-
volume, aiming at a dimensional decrease. The second is by tation failure, and the patient becomes a “chronic” patient. The
filling regions of decreased volume with juxta-bone prostheses fact is that in most of these situations, adequate repositioning
or grafts in order to obtain a dimensional increase. The third is of the jaws would provide ideal occlusal stability to construct the
through atypical repositioning or removal of bone to accomplish prosthesis, and none of this would be likely to happen.
balance in the morphologic changes. Figures 24-4 to 24-6 present the case of a 50-year-old woman
Although deformations in the shape of the arches are often with slight dental crowding, mandibular retrusion, sharp curva-
not simple to resolve, they usually require only the technical ture of the occlusion plane, absence of both mandibular first
ability of the surgeon to plan and execute the surgical proce- molars and the mandibular right second molar, and a complaint
dure to obtain an adequate resolution. The cases that in practice of snoring. This patient did not have a large deformity, but due
bring the greatest consequences are those that do not have to retrognathism and the high curvature of the occlusal plane,
ideal dental stability. the overload of the posterior teeth is significantly increased.
In most of these cases, more than orthodontics and surgery This makes her a strong candidate for having a higher than
will be needed for adequate clinical resolution. Usually pros- expected failure rate of oral rehabilitation if a surgical proce-
thetic interventions for occlusal correction are required in order dure to correct her malocclusion and improve her respiratory
to establish long-term stability. function is not performed.
With this group of patients it is generally necessary to have A maxillomandibular advancement surgery was performed,
interdisciplinary interaction between orthognathic surgery, correcting the occlusal plane, and posterior oral rehabilitation
implant treatment, and prosthodontics. It is precisely here that was carried out through placement of osseointegrated implants
one begins to see more critical cases that are often accompa- in the region of both mandibular first molars. The region of the
nied by more lengthy clinical histories. mandibular right first and second molars was orthodontically
This is because in general when a patient with a facial or reduced to a single-tooth dental space. With this plan, mandib-
dental complaint presents at an orthodontist’s office for treat- ular retrusion was reduced, achieving adequate occlusal stabi-
ment, once the diagnosis is established the rehabilitation treat- lization and increase of the pharyngeal airway, which cured the
ment is somewhat obvious. The missing teeth will need to be snoring. Therefore, treatment eliminated not only the problem
replaced; it is not necessary to be a specialist to reach this of tooth loss but all the complaints presented by the patient.
424

a b c
d e
f g h
i j
Fig 24-4 Case 2: First visit. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radiograph. (e) 3D recon-
struction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal view of mandible.
425

a b c
e f g
h i
Fig 24-5 Case 2: End of orthodontic preparation. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radio-
graph. (e) Intraoral right lateral view. (f) Intraoral frontal view. (g) Intraoral left lateral view. (h) Occlusal view of maxilla. (i) Occlusal view of mandible.
426

a b c
d e
f g h
i j
3D reconstruction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal view
of mandible.
427

a b c
d e
f g h
i j k
Fig 24-7 Case 3: First visit. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radiograph. (e) 3D re-
construction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal view of
mandible. (k) Intraoral frontal view without the removable prosthesis.
428

Atypical Cases
a b c
d e
3D reconstruction.
ATYPICAL CASES that in many of these cases, if the search for a receptor bed for
anchorage of implants is combined with an effort to adequately
Surely all professionals who provide oral rehabilitation have position the arches, significantly superior results in terms of a
faced challenging cases. These cases go beyond the normal prosthetic rehabilitation that is esthetic and durable are possible.
demand for atypical procedures and require an effort to seek Figures 24-7 and 24-8 present the case of a 56-year-old man
alternatives often unprecedented in their clinical practice. The who sought treatment to eliminate a removable partial prosthe-
fact is that many of these cases would benefit from orthog- sis. The patient reported frustration with the results of all previ-
nathic surgery techniques. To explain this statement, one must ous attempts at rehabilitation because he never had adequate
look back in history. masticatory function. His occlusal relationship was inadequate,
In the development of modern implantology, the techniques presenting a very low level of dental intercuspation associated
underwent several trials to prove that implants were capable with an anterior open bite.
of replacing the teeth for anchorage of prostheses. Other chal- Maxillary advancement surgery was performed, with adjust-
lenges arose in regard to surface treatment, developing the best ment of the occlusal plane followed by oral rehabilitation includ-
designs of implants and prosthetic connections, and achieving ing the placement of osseointegrated implants in the mandible
better mechanical results with greater longevity. and a tooth-supported fixed prosthesis in the maxilla. As a result
When there were no longer doubts about the feasibility of of the surgical correction, it was possible to perform rehabili-
the use of dental implants, the search for indications were tation with prostheses of normal dimensions and to offer the
expanded. Success is directly linked to having strong bone for patient adequate intercuspation with closure of the anterior open
implant anchorage; therefore, bone regeneration techniques bite and absolutely satisfactory masticatory function. In addition
using grafting and distraction and even new regions for implant to this, the maxillary advancement provided greater volume for
placement, such as the zygoma, became the subject of research. support of the upper lip, considerably improving his facial profile.
The fact is that often in the search for bone for the placement of These atypical cases are treated by professionals in oral
the implants, clinicians forget to properly evaluate the positioning rehabilitation as well as orthodontists and oral and maxillofa-
of this receptor bed. An anchorage point must be found, regard- cial surgeons; however, they are not infrequent, and the broader
less of the region. Thus, it is not uncommon to see cases with view of therapeutic possibilities is fundamental to achieving
implants anchored to completely misplaced arches and prosthetic results such as these. Interaction between the specialties is
reconstructions with unrealistic volumes and shapes. It is certain mandatory for this level of resolution.
429

f g h
i j
k l m
n o
Fig 24-8 (cont) Case 3: (f to j) Intraoral views with the provisional prosthesis. (k to o) Intraoral views with the definitive prosthesis.
EXTREME CASES and therapies they have at hand, and their ability to keep an
open mind.
There are cases that are more than atypical, for which even Figures 24-9 to 24-12 present a 39-year-old female Caucasian
miraculous prosthetic solutions cannot minimally solve the need patient who in her initial search for treatment, envisioning the
presented by the patient. These cases are outside of any stan- replacement of her missing teeth, sought an implant dentist who
dard, and often their resolution is unique. In such cases, clinical was basically limited to placing implants in the spaces available
experience associated with good interdisciplinary vision can for later prosthetic rehabilitation. At the time of prosthetic reha-
result in therapeutic solutions. The resolution of these cases bilitation, the dentist realized that the dimensions of the dental
is often based on the creativity of the professional, the tools arches were absolutely incompatible with each other and that
430

Extreme Cases
a b c d
f g h
i j
Fig 24-9 Case 4: First visit. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) 3D reconstruction. (e) Panoramic radio-
graph. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal view of mandible.
the maxillary dimensions were incompatible with the face of made to pursue surgical correction of the maxillary hypertrophy
the patient. However, as the implants had already been placed, together with maxillomandibular repositioning and the insertion
the prosthesis was produced, creating a result that could not of a new dental prosthesis.
be considered even minimally satisfactory. In this surgical procedure, maxillary alveolar reduction was
Faced with this situation, the patient presented to the author’s performed with the removal of alveolar bone segments and the
office for treatment. Evaluation revealed that in addition to a maxillary premolars as well as a reduction of the palatine raphe
change in the positioning of the arches, there was highly signifi- to create a new maxillary contour. After the surgical procedure,
cant maxillary hypertrophy. Since the patient had multiple miss- new prosthetic rehabilitation was performed in both arches for
ing teeth and already had implants placed, the decision was occlusal stabilization.
431

a b c
d e
f g h
i j
Fig 24-10 Case 4: End of initial treatment. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric radiograph. (d) Panoramic radiograph.
(e) 3D reconstruction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i) Occlusal view of maxilla. (j) Occlusal
view of mandible.
The case remained stable for about 11 years; however, the lesion in the mandibular teeth, indicating the need for endodontic
patient returned to the clinic with complaint of discomfort in the treatment and a new mandibular rehabilitation with osseointe-
region of the mandibular teeth that were serving as abutments for grated implants. The maxillary arch, however, presented complete
the prosthesis. Radiographic evaluation revealed an endodontic stability, without any damage to the final postoperative condition.
432

Extreme Cases
Fig 24-11 Case 4: 11-year follow-up. Panoramic radiograph showing endodontic lesions in the mandibular dentition.
a b c
d e
f g h
i j
Fig 24-12 Case 4: End of follow-up treatment with new mandibular prosthesis. (a) Frontal view smiling. (b) Profile view. (c) Lateral cephalometric
radiograph. (d) Panoramic radiograph. (e) 3D reconstruction. (f) Intraoral right lateral view. (g) Intraoral frontal view. (h) Intraoral left lateral view. (i)
Occlusal view of maxilla. (j) Occlusal view of mandible.
433

CONCLUSION de Almeida Cardoso M, de Molon RS, de Avila ED, et al. Facial and
occlusal esthetic improvements of an adult skeletal Class III
The author believes that listening to the patient’s complaints malocclusion using surgical, orthodontic, and implant treatment.
Korean J Orthod 2016;46:42–54.
should always be the main guide to any treatment. In general,
de Avila ED, de Barros LA, Del’Acqua MA, Nogueira SS, de Assis
paying careful attention to what is presented provides the best
Mollo F Jr. Eight-year follow-up of a fixed-detachable maxillary
opportunity to develop a treatment plan that approaches an opti- prosthesis utilizing an attachment system: Clinical protocol for
mal result. Not listening to the patient and allowing professional individuals with skeletal Class III malocclusions. J Oral Implantol
will to override is the best recipe for failure. One must always 2014;40:307–312.
keep in mind that the patient’s desire is sovereign and that the Honda K, Hirota M, Iwai T, et al. Orthognathic surgery and implant-
clinician has the obligation to make available as many tools as supported bridge in a Class III patient injured in a motor vehicle
possible to meet the patient’s expectations as efficiently and accident. J Craniofac Surg 2018;29:e296–e298.
accurately as possible. This is the key to a recipe for success Khojasteh A, Payaminia L, Alikhasi M. Implant assisted ortho-surgery
in dental care. in edentulous jaws: A clinical report. Clin Case Rep 2015;3:
920–926.
Lopes JF, Pinto JH, Lopes MM, Mazottini R, Soares S. Interrela-
tionship between implant and orthognathic surgery for the reha-
bilitation of edentulous cleft palate patients: a case report. J Appl
REFERENCES Oral Sci 2015;23:224–229.
Muñoz R, Gajos G, Bladimir J, Carvajal D, Luis A, Del Valle Speranza
1. Kim YK. Complications associated with orthognathic surgery. J G. Protocol for mandibular reconstruction with zygomatic implants
Korean Assoc Oral Maxillofac Surg 2017;43:3–15. (zygomatic mandibular implant). Oral Maxillofac Surg 2018;22:
2. Olate S, Sigua E, Asprino L, de Moraes M. Complications in orthog-
39–44.
nathic surgery. J Craniofac Surg 2018;29:e158–e161.
3. Robl MT, Farrell BB, Tucker MR. Complications in orthognathic Nocini PF, D’Agostino A, Chiarini L, Trevisiol L, Procacci P. Simul-
surgery: A report of 1,000 cases. Oral Maxillofacial Surg Clin N taneous Le Fort I osteotomy and zygomatic implants placement
Am 2014;26:599–609. with delayed prosthetic rehabilitation. J Craniofac Surg 2014;25:
1021–1024.
Ohba S, Nakatani Y, Kawasaki T, et al. Oral rehabilitation with orthog-
nathic surgery after dental implant placement for Class III maloc-
clusion with skeletal asymmetry and posterior bite collapse.
RECOMMENDED READING Implant Dent 2015;24:487–490.
Runyan CM, Sharma V, Staffenberg DA, et al. Jaw in a day: State
Arnett GW, McLaughlin RP. Facial and Dental Planning for Ortho- of the art in maxillary reconstruction. J Craniofac Surg 2016;27:
dontists and Oral Surgeons. Edinburgh: Mosby, 2004. 2101–2104.
Arshad M, Shirani G, Rasouli K. Step by step full mouth rehabilita- Seo YJ, Lin L, Kim SH, Chung KR, Nelson G. Strategic camouflage
tion of a Class III edentulous patient by implant-supported pros- treatment of skeletal Class III malocclusion (mandibular progna-
thesis: A case report. Clin Case Rep 2018;6:1246–1251. thism) using bone-borne rapid maxillary expansion and mandib-
ular anterior subapical osteotomy. Am J Orthod Dentofacial
Orthop 2016;149:114–126.
434

25 STUART J. FROUM • PARNWARD HENGJEERAJARAS •
KUAN-YOU LIU • PANPICHA MAKETONE • YE SHI
Etiology and Management

of Post-Loading
Complications: Implant
Loss or Failure and
Peri-implantitis
Implant Loss or Failure
Peri-implantitis
435

25 | Etiology and Management of Post-Loading Complications: Implant Loss or Failure and Peri-implantitis
a b c
Fig 25-1 (a) Clinical view of implant fracture. (b) Radiograph showing implant removal. (c) Cross-sectional views of implant removal instruments
engaging with tissue- (left) and bone-level (right) implants.
I
mplant therapy over the past two to three decades has ever, in this study, the complication rate of implant-supported
demonstrated high success rates (ranging from 90% FPDs was 38.7%.12 This would impact implant success. Ini-
to 98%) after at least 10 years in function.1–6 However, tially implant success was defined by Albrektsson et al13 as
dental implants are not immune from complications. These an implant with no pain, no mobility, no radiolucent areas, and
include surgical, biologic, placement and loading, prosthetic or no more than 0.2 mm of bone loss annually following the first
mechanical, and esthetic and phonetic complications.7 Since year of loading. Roos-Jansåker et al14 added to this by defin-
the use of implants to restore missing teeth is increasing, the ing a successful implant as one that lost no more than 1 mm
prevalence of implant-related complications is also increasing.8,9 of bone during the first year in function. Others have defined
Moreover, dentists with a minimal background in surgical train- implant success as when (1) the implant-retained restoration is
ing are currently placing implants, and this has been shown present as intended in the original treatment plan and functions
to reduce implant survival and success rates.10 This chapter without complications; (2) peri-implant hard and soft tissues
discusses the management of biologic implant complications, are healthy; and (3) both the patient and treating clinician are
including implant loss or failure and peri-implantitis. satisfied with the esthetic results.15 With these strict criteria
(absence of complications), only 61.3% of implant restorations
would be considered successful after 5 years in function.15 The
success/failure definitions often require a non-mobile implant
IMPLANT LOSS OR FAILURE to be removed. When this occurs, it should be done with the
least trauma to preserve surrounding bone and tissue. Implant
Failure of implants may be defined as early or late. Early fail- removal techniques have been discussed with the least trau-
ure is described as the inability to establish osseointegration, matic methods described.16 This would entail reverse torquing
whereas the inability to maintain the achieved osseointegration, the implant (Fig 25-1). If this is not possible, the implant can be
under functional conditions, is described as late failure.11 This removed with a trephine bur, although this entails more trauma,
chapter covers late failures, ie, those that occur after prosthe- bone loss, and risk of complications (Fig 25-2). Treatment alter-
sis placement, which are related to a variety of reasons. These natives for failed implants have also been thoroughly reviewed.17
include occlusal overload, infection, implant fracture, reces- Authors recommend that failed implants be removed as quickly
sion and dehiscence, peri-implantitis (discussed later in this as possible to preserve the alveolar ridge.17,18 Potential treatment
chapter), and prosthesis failure (discussed in another chapter). alternatives are described, with replacement with a new implant
Implant survival and implant success are not necessarily identi- recommended as the one most often selected (Fig 25-3). How-
cal in definition. Implant survival is easy to define based on the ever, a literature review of five studies shows survival rates for
presence or loss of the implant. Survival denotes the presence implants placed in previously failed sites vary from 71.0% to
of a functioning implant. Survival of implants supporting fixed 92.3%.19–23 Moreover, another study reported a 60% survival
partial dentures (FPDs) was reported in one study to be 95% rate of a third attempt to place an implant in a previously failed
at 5 years and 86.7% at 10 years.12 This was similar to the sur- site.24 Other alternative treatment plans include rehabilitation
vival of tooth-supported FPDs, which was 93.8% at 5 years and with remaining implants or modification of the treatment plan
89.2% at 10 years. This was also similar to implant-supported to a tooth-supported FPD, an implant/tooth–supported FPD, or
single crowns (94.5% at 5 years and 89.4% at 10 years). How- a removable prosthesis17 (Fig 25-4).
436

Fig 25-2 Implant removed by a trephine bur.
a b c
Fig 25-3 Radiographs showing failed implant (a), site after implant removal (b), and new implant in place (c).
a b
Fig 25-4 (a) Radiograph of a maxillary fixed restoration on six implants (maxillary right canine to second premolar and left lateral incisor to first
premolar). Two of the six implants failed (red arrows). (b) Cement-retained restoration that loosened and detached when the implants in the left
lateral incisor and canine sites failed. (c) Panoramic radiograph showing recementation of the original restoration on the remaining implants (max-
illary right canine to second premolar and left first premolar).
437

Fig 25-5 (a) Radiograph showing peri-implant

bone level at the time of definitive restoration
placement. (b) Radiograph shows marginal bone
loss around implant after definitive restoration
placement. (Courtesy of Dr Paul Rosen, Yardley,
Pennsylvania.)
a b
Clinical indications of implant failure over, each implant should be monitored as an independent unit
when assessing bone loss for a clinical evaluation of success,
Implant failure is the term used for implants that require removal survival, or failure.25
or have already been lost. Clinical indicators to identify implant
failure include pain, mobility, radiographic crestal bone loss,
Probing depth
probing depths, and untreatable peri-implant disease.25
Probing depths around natural teeth are an excellent proven
parameter to assess health or disease, but probing depths
Pain
around implants, to have diagnostic value, must be evaluated
After the implant has healed, pain should not be associated with with the presence of signs (eg, bleeding, radiographic radio-
the implant. When present, it is often the result of an improper lucency, purulent exudate) and/or symptoms (eg, discomfort,
fitting prosthetic component or pressure on the soft tissue from pain). A recent article by Froum and Wang27 concluded that light
the prosthesis. Percussion tests on the implants are used to probing around dental implants (≤ 25 Ncm) is a valuable, nonin-
test for pain, not for the audible effect associated with integra- vasive method to determine peri-implant disease and whether
tion. Oftentimes, pain from the implant does not occur unless radiographs are needed. Together with assessments of bleeding
the implant is mobile and surrounded by inflamed tissue or on probing (BOP), suppuration, and radiographs, probing can be
has osseointegrated and impinges on a nerve. Therefore, pain used to determine the extent of peri-implant disease, suggest
during function of an implant, unless able to be eliminated by treatment methods (nonsurgical versus surgical management),
treatment, is a subjective criterion that places the implant in and evaluate treatment outcomes. Probing around natural teeth
the failure category.25 and implants remains a valuable parameter in assessing health,
disease, and ongoing loss of soft and hard tissue around natural
teeth and implants27 (Figs 25-6 and 25-7). Sulcus depths greater
Implant mobility
than 5 to 6 mm around implants have a greater presence of
Another clinical factor associated with implant failure is implant anaerobic bacteria and may require intervention (eg, mechanical
mobility. A clinically mobile implant indicates the presence of debridement with local antibiotics, surgery, systemic antibiotics)
connective tissue between the implant and bone, loss of osse- in the presence of inflammation or exudate. Probing not only
ointegration, clinical failure, and the need to remove the implant.26 measures pocket depth but also measures mucosal recession,
bleeding, and the presence of exudate and determines whether
an adequate amount of the keratinized mucosa exists around
Marginal bone loss
the implant.27
The marginal bone level around the implant is usually a signif- According to the Pisa implant health scale,25 an implant should
icant indicator of implant health. The most common method be removed if any of the following conditions are present:
to assess marginal bone loss is by conventional periapical
radiographs, which are compared with radiographs taken after 1. Pain on palpation, percussion, or function
placement of the definitive restoration (Fig 25-5). According to 2. Horizontal and/or vertical mobility
International Congress of Oral Implantologists Pisa Consensus 3. Uncontrolled progressive bone loss
Conference in 2007, bone loss more than 50% of the implant 4. Uncontrolled exudate
length on a radiograph indicates an implant failure (however, 5. More than 50% bone loss around the implant
see section at the end of this chapter on peri-implantitis). More- 6. Implants surgically placed but unable to be restored
438

Fig 25-6 (a) Clinical view of probing

around a healthy implant without bleed-
ing. (b) Radiograph showing no marginal
bone loss around this implant.
a b
Fig 25-7 (a) Clinical view of BOP

and a deep distal pocket around
an implant with peri-implantitis.
(b) Radiograph showing marginal
bone loss around this implant.
a b
In conclusion, the primary criteria for assessing implant crestal support.29 Rangert et al30 found 39 patients with frac-
disease are pain and mobility. The presence of either one greatly tured implants after placing 10,000 implants. They also indicated
compromises the implant, and removal is usually indicated. that most of the fractures were in posterior partially edentulous
Level of bone loss is most often evaluated with radiographs. segments, where the generated occlusal forces are greater, as
However, only mesial and distal marginal bone adjacent to opposed to the anterior segments.
the implant can be monitored with conventional radiographs. In general, the reported incidence of implant fractures is
Limited-field cone beam computed tomography (CBCT) scans 0.16% to 1.5%.31 According to Balshi et al,32 the cause of implant
provide three-dimensional (3D) information when indicated.28 fracture may be broadly divided into: implant design and manu-
Implant failure is easier to describe than implant success or facturing defects, lack of passive fit of the prosthetic frame-
survival and may consist of a variety of factors. Any pain, mobil- work, and physiologic or biomechanical overload. Other possi-
ity, or uncontrolled progressive bone loss warrants implant ble causes of fracture can also include failure in the production
removal.13 and design of dental implants, bruxism or large occlusal forces,
superstructure design, implant localization, implant diameter,
metal fatigue, and bone resorption around the implant.33
Etiology of late (post-loading) implant Treatment of fractured implants definitely represents a clinical
challenge. First, the fractured fragment must be atraumatically
failure removed with minimum bone removal. A new implant is then
Peri-implantitis placed simultaneously or after a healing period to allow osse-
ointegration to take place. Oftentimes it is necessary to perform
Post-loading implant failure may be caused by peri-implantitis bone augmentation prior to implant placement. Only after heal-
(discussed later in the chapter). The term peri-implantitis ing does the prosthetic phase begin34 (Fig 25-8). As suggested by
describes soft tissue inflammation and bone loss resulting from Balshi,35 there are three methods for treating fractures of dental
the microbiome around an implant. implants: removal of the fractured implant (replace the implant
and manufacture a new prosthesis), alteration of the existing
prosthesis and submergence of the osseointegrated fractured
Implant fracture
part, and alteration of the fractured implant and replacement
The fracture of a dental implant that has undergone osseointe- of the prosthetic portion (Fig 25-9). If an implant with an “over-
gration may adversely affect the prosthesis through loss of sized” platform has been inappropriately chosen for the site, it
439

a b c d
e f g
Fig 25-8 (a to c) Fractured implant with definitive restoration and radiographs showing bone loss and fracture line (arrows). (d) Clinical view of the
apical portion of the implant remaining in bone. (e) Removal of the remaining implant portion with a piezoelectric instrument. (f) Removed residual
portion of the implant. (g) Guided bone regeneration procedure after implant removal.
a b
Fig 25-9 Radiographs showing three fractured implants (arrows) before (a) and after (b) definitive restoration, in which they were submerged.
is sometimes possible to reduce the diameter of the platform a relationship between endodontic failure and peri-implantitis.38
through careful preparation of the implant shoulder. This tech- Some studies found that retrograde peri-implantitis could be
nique is only possible for tissue-level implants and may risk related to a remaining scar or granulomatous tissue at the recip-
weakening the implant and creating a risk for fracture.36 ient site from endodontic pathology of the extracted tooth (scar
tissue–impacted tooth)37 or injury to adjacent teeth.39
Implant periapical lesions (IPLs) are defined as an infection
Apical (retrograde) peri-implantitis
located at the apex of an implant.40 These lesions have been
Another cause of implant failure is apical (retrograde) peri- shown to have three possible etiologies: (1) implant factors,
implantitis due to persistent periapical pathology in implant which include contamination of the implant surface; (2) patient
sites from which previously endodontically treated teeth factors, which include the presence of a preexisting or adjacent
were extracted. 37 From the study of López-Martínez et bone pathology (of endodontic or periodontal origin); and (3)
al, peri-implantitis was present in 31.5% of implants replacing iatrogenic factors, which include overheating of the bone and
teeth with previous root canal treatment, which demonstrated excessive tightening or overloading of the implant.40
440

Fig 25-10 (a) Radiograph show-

ing mesial implant in contact with
the neighboring natural tooth. (b)
Extracted natural tooth showing
the mark of implant threads.
(Courtesy of Dr Harold Sussman,
West Palm Beach, Florida.)
a b
Fig 25-11 (a) Radiograph showing a periapical lesion around a mandibular lateral
incisor adjacent to an implant site. The implant was placed, and pathology per-
sisted around it, causing it to fail. (b) Radiograph showing that the failed implant
was removed. (Courtesy of Dr Harold Sussman, West Palm Beach, Florida.)
a b
Periapical implant pathology as a distinct entity was first ical or osseointegration failure46,47 (Fig 25-12). If the bone sur-
reported as endodontic-implant pathology in the dental litera- rounding implants is in the “mild overload” range (1,500–3,000
ture in 1993.41 The lesion was found to occur infrequently when microstrain), there appears to be biologic apposition of bone.
implants are placed adjacent to natural teeth.42–45 Sussman called However, if strain in the bone is beyond this range, at some point
the problem endodontic implant pathology (EIP) and described fatigue fracture and bone resorption will occur. Experimental
two types. Type 1 EIP is implant-to-tooth, which occurs when a data on implants with peri-implantitis indicate that increasing the
tooth with a vital pulp adjacent to an implant becomes devital- occlusal load may cause marginal bone loss. Moreover, occlu-
ized after implant placement (Fig 25-10). The etiology is probably sal overload in combination with peri-implantitis was observed
related to direct trauma during osteotomy preparation. Type 2 clinically, showing that the overload may increase when there
EIP is tooth-to-implant, which occurs shortly after implant place- is bone resorption.47
ment when there is an exacerbation of a preexisting apical lesion
associated with an adjacent tooth (Fig 25-11).
Implant malposition compromising esthetics
Treatment varies according to the type of lesion. The primary
goal of IPL treatment is to eliminate any infection, and the Esthetic complications can be caused either by malpositioned
secondary objective is implant and/or tooth survival. The treat- implants or by an inappropriate number and/or size of implants.36
ment guidelines are based on four phases: (1) recognition of The presence of sufficient bone to support the soft tissue is a
early signs and symptoms, (2) identification of etiology, (3) necessity in achieving esthetic outcomes in the anterior maxilla.
removal of the source of infection, and (4) reconstruction of In addition, the importance of correct 3D implant placement has
the lost host tissue for immediate or future implant placement.43 also been recognized, from which the term restoration-driven
The most predictable method to prevent the injury of the natu- implant placement was derived.48,49
ral tooth by implants is by using radiographic CBCT scans for Proper 3D implant placement has been described as place-
treatment planning prior to implant surgery.44 ment of the implant shoulder such that there is ≥ 2 mm buccal
bone and ≥ 3 mm mesiodistally between implants or ≥ 2 mm
between the implant and an adjacent tooth. Apicocoronally, the
Force overload
implant shoulder should be 2 to 3 mm apical to the cemento
Implant overload has been defined as occlusal forces that enamel junction of adjacent teeth or 3 mm apical to the antic-
exceed the mechanical or biologic tolerance capacity of the osse- ipated gingival margin.50,51
ointegrated implants or the prosthesis, causing either mechan-
441

a b c
Fig 25-12 (a) Clinical view showing the poor design of a three-unit prosthesis with two implant crowns and a distal cantilever. (b) Radiograph
showing the initial marginal bone level around the implants. (c) Radiograph showing the marginal bone loss caused by implant overload.
Fig 25-13 (a) Implant abutments placed

too close to each other. (b) Pink porcelain
was required to mimic the missing papilla
and soft tissue.
a b
Fig 25-14 (a) Radiograph showing apical placement

of the implant. (b) Clinical view showing facial gingival
recession at the implant restoration and reduced papillae
around the implant.
a b
The three types of implant malposition in esthetic areas improve primary stability of the implant. This apical malposi-
include the following: tion can cause recession of the facial mucosa if the implant
only has a thin facial wall of bone at implant placement (Fig
1. Mesiodistal malposition: implant is placed too close to an 25-14). The apical placement of an implant can also lead to
adjacent natural tooth or implant. In this position, there is a persistent inflammation of the peri-implant mucosa, diffi-
risk of a reduced papilla height at the adjacent tooth due to culty in maintaining adequate plaque control, and a poor
crestal bone resorption and remodeling during the healing soft tissue esthetic outcome.36
phase (Fig 25-13). These complications are often caused by 3. Orofacial malposition: implant placed too far palatally/
an oversized implant with a platform that is too large for a lingually or labially. Overly palatal or lingual placement of
single-tooth gap. When the mesiodistal malposition of the the implant will often lead to the need for a ridge-lap design
implant is extreme and differs 2 to 3 mm from the ideal of the implant crown (Fig 25-15). This may make it difficult
prosthetic position, this can lead to significant and perma- for the patient to maintain optimum plaque control with
nent loss of hard and soft tissue support with extremely subsequent long-term implications for the health of the
adverse esthetic outcomes.36 peri-implant tissues.36 The second complication is recession
2. Apicocoronal malposition: implant placed too shallow or too of the labial mucosa if the implant is positioned too far labi-
deep. If the implant is not inserted apically enough into the ally (Fig 25-16). This can cause severe esthetic complications
tissues, the metal implant shoulder can be visible, causing since the harmonious gingival contours are significantly
an unpleasant esthetic outcome. Another complication is disturbed and often requires the removal of the implant.
implant placement that is too deep into the tissues. This These complications have frequently been observed in
often happens with immediate implant placement when patients with immediate implant placement.
the clinician places the implant deeper into the bone to
442

Fig 25-15 (a) Occlusal view showing that

the implant in the lateral incisor site was po-
sitioned too palatally. (b) Resulting ridge-lap
design of the implant restoration.
a b
Fig 25-16 (a) Gingival recession at an im-

plant restoration in a mandibular central
incisor site. (b) Occlusal view of the healing
abutment showing that the implant was
positioned too labially.
a b
Fig 25-17 (a) Malpo-

sitioned implant with
an esthetically poor
restorative outcome.
(b and c) Radiograph
and CT scan showing
the implant was too
apically and labially
positioned. (d) Block
graft placed after
implant removal. (e) a b c
Radiograph showing
new implant placed
in an ideal position. (f)
New restoration with
improved esthetics.
d e f
There are several ways to prevent implant malposition, and the removal of the implant or submerging the implant and
these depend on the experience and surgical skills of the clini- replacing it with a pontic where applicable36 (Fig 25-17).
cian, thickness of the facial bone, contour of the ridge, anatomy • Soft tissue grafting: This is performed in cases of recession
of the nasopalatine canal, evaluation of the extraction sites, of the labial marginal mucosa36 (Fig 25-18).
preoperative planning using radiographic assessment, and the
use of surgical guides. Successful treatment of esthetic compli-
cations due to implant malposition is usually determined by the
degree of the malposition and the size of the implant. Treatment Implant failures associated with vital
of implant malposition include the following: anatomical structures
• Implant removal and new implant placement: When esthetic Implant failures can also occur when an implant contacts or dis-
complications caused by a severe implant malposition cannot turbs an anatomical vital structure (eg, maxillary sinus, inferior
be corrected with soft tissue grafting, the only solution is alveolar canal) or an adjacent tooth or implant.
443

a b c
d e
Fig 25-18 (a) Gingival recession on the implant restoration in the maxillary right central incisor site. (b and c) A free gingival graft was harvested from
the palate and de-epithelialized to be used as a connective tissue graft. (d) After changing the definitive restoration to a provisional one, soft tissue
grafting procedure was performed with a tunneling technique. (e) Healing after soft tissue surgery and definitive restoration with improved esthetics.
a b
Fig 25-19 Radiograph showing an implant that migrated into the sinus Fig 25-20 (a and b) CT scans showing the displacement of the implant
after sinus augmentation. into the IAN canal.
Oroantral communication is a pathologic connection between approach with anterolateral window access to the maxillary
the oral cavity and the maxillary sinus. Implant displacement/ sinus,65 and no intervention with follow-up only.52 However,
migration into the maxillary sinus, resulting from poor plan- when implant displacement occurs, regardless of the simulta-
ning or surgical inexperience, have been reported as rare and neous presence of sinus disorders and/or oroantral fistula, the
sporadic52–61 (Fig 25-19). Implant migration into the sinus may displaced foreign body should be removed in order to prevent
also be caused by loss of osseointegration due to peri-implantitis the development of chronic sinus mucosa irritation, functional
or, in the case of loaded implants, inaccurate distribution of impairment, and subsequent infections. To avoid dental implant
occlusal forces.52,53,60,62 The etiology of perioperative displace- displacement or migration into the maxillary sinus, good primary
ment of implants has been related to sites with inadequate stability and sufficient bone quality and quantity at implant place-
bone height and volume, surgical inexperience with the anatom- ment are essential factors.66 Using CBCT as a preoperative
ical landmarks of the maxillary sinus, improper surgical proce- planning tool is the best way to evaluate morphology, quality,
dure, or perforation of the sinus membrane during the drilling quantity, and density of bone.66
sequence.63 There are three ways of treating dental implant One of the most serious complications is the alteration of
displacement into the maxillary sinus: transnasal and tran- sensation after implant placement in the posterior mandible.67,68
soral endoscopic surgery,64 implant removal using an intraoral The prevalence of such complications has been reported to be
444

Peri-implantitis
as high as 13%.69,70 Inferior alveolar nerve (IAN) injury can result be prescribed. An alternative would be a large dose of nonste-
from trauma due to local anesthetic injections, dental implant roidal anti-inflammatory drugs (eg, 800 mg ibuprofen) three
site preparation or placement,71 or poor surgical technique.72–76 times daily for 3 weeks.84,86 In addition, according to a study by
This injury is a highly unpleasant experience, with effects vary- Misch and Resnik, adrenocorticosteroids (eg, dexamethasone)
ing from mild paresthesia to complete anesthesia and/or pain.77 were recommended. Adrenocorticosteroids have been shown
Damage to the IAN can occur when the twist drill or implant to minimize neuropathy after nerve injuries if administered in
encroaches on, transects, or lacerates the nerve.78 Other causes high doses within 1 week of injury.86
of injury to the IAN are the displacement of an implant into
the canal (Fig 25-20) or low-density bone, which can cause the
twist drills to drop into trabecular bone spaces during prepa-
ration, thus leading to more apical placement of the implants PERI-IMPLANTITIS
than planned.79–83 The IAN may be affected by positioning the
implant close to the canal and the subsequent formation of an Peri-implantitis has been defined as an inflammatory disease of
adjacent hematoma that presses against the nerve.83 To be able the soft tissues surrounding an implant accompanied by bone
to successfully manage an IAN injury, it is important to evaluate loss that exceeds normal physiologic remodeling.94,95 The etiol-
possible related factors that include general, intraoperative, and ogy of this disease has been considered by many to be related
postoperative risk factors.78 General risk factors include patient to the bacterial biofilm forming on the implant surface, which
expectations as well as the possibility of IAN injury. Prior to interacts with the host tissue, leading to the destruction of
implant surgery, the patient must sign an informed consent form supporting bone.96–99 Some authors have also suggested that
that includes risk of the latter in the posterior mandible.76 Under- there are “triggering factors” that can act synergistically with
standing the possible complication, it is important for clinicians each of the etiologic agents.100
to perform a neurosensory examination, especially mandibular However, seven published studies identified bacteria (oral
nerve function, before placing the implant to rule out preexisting microbiome) as a main etiologic agent in peri-implantitis.101–107
altered sensation.77 Intraoperative factors can be an indicator of A recent article on the bacterial etiology of peri-implantitis
possible IAN injury (eg, IAN injury due to injection,76 pain during discussed newer advances in identifying the microbiota of
bone preparation,75 and deeper preparation of the osteotomy [drill implants affected by peri-implantitis (16S ribosomal RNA and
slippage], which can be triggered by the low resistance of spongy next generation sequencing) and suggested that the microbiome
bone84). Postoperative risk factors are often associated with associated with peri-implantitis resembles that reported for the
postsurgery nerve compression due to infection or swelling.80 periodontitis microbiota. Well-recognized pathogens (Bacteroi-
Using CBCT scans to obtain accurate measurement of the detes, Spirochetes, Synergistetes, and Treponema), as well as
bone available for implant support coronal to the IAN canal is newly proposed pathogenic microorganisms, several of which
the best way to avoid IAN injuries. The use of CT-based surgi- have not yet been cultivated, were present around implants
cal stents or navigation systems may also help prevent nerve affected by peri-implantitis.108
injury.70 Moreover, in cases of IAN injury, the sooner the diag- Recently, an association between clinical and microbiologic
nosis and treatment, the better the nerve injury recovery.80,84–86 profiles of peri-implantitis has been suggested. The authors
In addition, the early removal of implants associated with IAN concluded that certain local factors might be associated with
injury may minimize or even resolve the IAN neuropathy.84,86 peri-implantitis because they increase plaque retention. Modi-
Furthermore, management of the problem will depend on the fiable factors, such as surgical, prosthetic, or biomechanical
cause of the IAN injury. If the implant is impinging on the nerve, factors, might also promote the onset of unfavorable condi-
it should be immediately removed or at least unscrewed a few tions, impacting the translation from physiologic bone loss to
threads to relieve the pressure on the nerve in order to minimize peri-implant disease.109 A peri-implantitis classification with five
permanent nerve damage.80 If the implant causing the problem distinct categories based on etiology was proposed.110
is already osseointegrated, it can be removed by a trephine drill.87 In addition, it has been suggested that foreign particles such
Often the injury of the IAN resolves spontaneously; however, as cement and metal might be associated with this disease.111
it may become permanent, with varying degrees of neuropa- Significant increased levels of dissolved titanium were detected
thy.87–89 Although implant removal may improve sensory func- in the submucosal plaque of implants with peri-implantitis
tion, the results generally fail to restore complete nerve function. compared with healthy implants, thus indicating an associa-
However, it is possible to increase neurosensory function post- tion between titanium dissolution and peri-implantitis.112
surgically, thus greatly improving a patient’s quality of life.89,90 If
IAN transection occurs intraoperatively or if there is dysesthesia
or complete anesthesia postsurgically, referral to a neurosurgeon Prevalence of peri-implantitis
and microneurosurgical treatment may be indicated.91 Primary
surgical repair of the IAN has been shown to be highly effec- The prevalence of peri-implantitis has been shown to vary from
tive in restoring sensory nerve function.92,93 To control inflam- 6% to 54%.113–119 The reason for the range of the prevalence
matory reactions in the injured nerve, a course of steroids can has been shown to depend on the definition of peri-implantitis
445

Fig 25-21 Implant prosthesis design with pink porcelain Fig 25-22 Implant with plaque accumulation.
and no accessibility/capability for proper oral hygiene.
in the study.113 Two systematic reviews and a meta-analysis of on peri-implant health, it was concluded that lack of adequate
the literature reported that the prevalence of peri-implantitis KM around endosseous dental implants was associated with
was approximately 10% of implants and 20% of patients 5 to more plaque accumulation, tissue inflammation, mucosa reces-
10 years after implant placement.118,119 sion, and attachment loss.125 In a recent human histologic study,
it was shown that implants placed in alveolar mucosa showed
more apical position of the coronal level of osseointegration in
Risk factors for peri-implantitis respect to the implant margin as compared with those placed
in KM.126 Moreover, a systematic review concluded that insuf-
The consensus report of the Sixth European Workshop in Peri- ficient keratinized tissue in the presence of poor oral hygiene
odontology listed seven risk factors associated with peri-implant may lead to an even greater level of peri-implantitis127 (Figs
disease.94 These included poor oral hygiene, history of periodon- 25-23 and 25-24). Excess dental cement has been reported to
titis, cigarette smoking, diabetes with poor metabolic control, be associated with signs of peri-implant disease in the majority
alcohol consumption, genetic traits, and the implant surface (81%) of cases when evaluated using a dental endoscope128 (Fig
itself. A number of these factors have been shown to correlate 25-25). An in vitro study showed that 99% of used abutments
with peri-implantitis. For example, in a case-control study, Serino that were removed and sterilized showed remaining protein
and Strom found that 48% of implants with no accessibility/capa- contamination after cleaning. This would caution against reuse
bility for proper oral hygiene were affected by peri-implantitis, of healing abutments even after cleaning and sterilization as this
compared with only 4% of the implants with good hygiene practice could be considered a risk factor.129 A meta-analysis
access120 (Figs 25-21 and 25-22). In a 5-year follow-up study, evaluated abutment disconnection/reconnection and concluded
Costa et al showed that without preventive maintenance, that this significantly affected peri-implant marginal bone levels.
patients with preexisting peri-implant mucositis were asso- However, the review did not relate peri-implantitis to the etiology
ciated with a higher incidence of peri-implantitis (44% vs of loss of bone.130 Other factors that have been mentioned previ-
18%).121 Roos-Jansåker et al reported that smoking was asso- ously as risk factors require additional studies and verification.
ciated with mucositis, reduced bone levels, and peri-implantitis. In addition, although two studies cited a positive relationship
They also reported that peri-implantitis was related to a previous between peri-implantitis and cardiovascular disease, there is a
history of periodontitis.122 Although implant surface character- need for more studies on this and other comorbidities to deter-
istics were shown to effect experimental peri-implantitis in a mine the systemic effects of peri-implantitis.131,132
dog model,123 a literature review concluded that “there is no
evidence that implant surface characteristics have a significant
effect on the initiation of peri-implantitis.”124 Other factors listed Treatment of peri-implantitis
by the workshop included diabetes, alcohol consumption, and
genetic traits, but these have not as yet been proven to be risk Treatment of peri-implantitis varies so significantly that eight
factors for peri-implantitis. Additional risk factors not included systematic literature reviews on the subject concluded that
in the consensus report of the Sixth European Workshop on no specific recommendation for the therapy of peri-implantitis
Periodontology include poor prosthetic fit/micromotion, poor was allowed by the available evidence because of widespread
implant positioning, malocclusion, retained cement, hyperten- variations in peri-implantitis definitions, severity of disease,
sion, inadequate keratinized mucosa (KM), growth and devel- study designs, lengths of follow-up, and inclusion/exclusion
opment, reuse of healing abutments, foreign particles/titanium, criteria.133–140 However, five of these reviews reported that the
and abutment disconnection/reconnection. regenerative procedures that included bone graft techniques
Some of these have been evaluated as follows. In a systematic with and without the use of barrier membranes resulted in an
review and meta-analysis investigating the effect of KM width increased degree of success.136–140
446

Peri-implantitis
Fig 25-23 Implant crowns with adequate keratinized mucosa.
a b c
Fig 25-24 (a) Two mandibular implants without keratinized mucosa present with gingival recession and thread exposure. (b and c) Radiographs
show marginal bone loss around implants without keratinized mucosa.
Fig 25-25 Failed implant with excess cement on the implant shoulder.
Three decision trees and a prognosis table have been published However, in three systematic reviews (two in humans and
to guide clinicians in the treatment of peri-implantitis.141–144 One one in animals and humans), it was concluded that nonsurgi-
confounding factor in the reviews as well as in the decision cal treatment has been shown not to be effective for treating
trees was defining the severity of the disease. In an attempt to peri-implantitis.146–148 Mechanical nonsurgical therapy could be
clarify this, a peri-implantitis classification was proposed based effective in the treatment of peri-implant mucositis lesions.
on probing depth, BOP, and bone loss around the diseased Furthermore, the adjunctive use of antimicrobial mouthrinses
implant.145 The classifications of disease were divided into (1) enhanced the outcome of mechanical therapy of mucositis
early: probing depth (PD) > 4 mm, presence of BOP and/or lesions. Adjunctive chlorhexidine application had only limited
suppuration (S), and bone loss (BL) up to 25% of the implant effects on clinical and microbiologic parameters, while adjunc-
length (IL); (2) moderate: PD > 6 mm, BOP/S, BL 25% to 50% tive local or systemic antibiotics were shown to reduce BOP and
of IL; and (3) severe: PD > 8 mm, BOP/S, BL > 50% of IL. probing depths. However, with peri-implantitis lesions, nonsur-
This classification specifies that PD and BOP and/or suppura- gical therapy was not found to be effective.146
tion must be present on two or more aspects of the implant Another study reported that nonsurgical therapy was not effec-
to avoid recession or dehiscence on the buccal aspect of an tive in the treatment of advanced peri-implantitis cases where
implant being diagnosed as peri-implantitis. The three decision access to the contaminated implant surface was limited.149 In a
trees recommend nonsurgical therapy for early to moderate review of successful treatment outcomes, surface access was
forms of the disease. stated to be a critical factor in the decontamination process.140 In
447

addition, defect morphology was described as having a potential 5-year prospective case series using this same surgical approach
impact on the clinical outcomes following surgical regenerative showed efficacy in maintaining peri-implant health in 63% of the
therapy of peri-implantitis lesions.150 All systematic reviews on the patients treated. This study stressed the importance of thorough
treatment of peri-implantitis report that surgical therapy has been debridement, good oral hygiene, and closely monitored recall.158
demonstrated to result in significantly reduced probing depth However, another 5-year study that used the surgical and antimi-
and gains in clinical attachment levels around affected implants. crobial strategy reported only a 58% success rate for this form
However, to ensure a successful surgical outcome, contam- of treatment.159 Moreover, in a retrospective longitudinal study
inated implant surfaces must be totally detoxified. Currently, on the surgical treatment of 382 implants with peri-implantitis
there is a lack of consensus on which agents/techniques should in 150 patients in a periodontal clinic, it was reported that the
be used in detoxifying the contaminated implant surface.151,152 mean success rate of treatment at the patient level was 69%.160
A literature review by Valderrama and Wilson reported that a The three decision trees differ on their recommendations for
combination of physical and chemical approaches possibly with when an implant affected by peri-implantitis should be removed.
appropriate laser therapy may provide more predictable results One recommends removal when bone loss involves most of the
in terms of reattachment of bone to previously diseased implant length and circumference of the implant. The second advises
surfaces.151 Another literature review on surface decontamina- it when bone loss exceeds half of the implant length, and the
tion by Suarez et al recommended implantoplasty as one of the third when bone loss is equal to or greater than two-thirds of
tools that has been shown to be effective in treating contami- the implant length.141–143 A prognosis table based on accurate
nated implant surfaces.152 However, its effectiveness regarding diagnosis of favorable, questionable, unfavorable, and hopeless
re-osseointegration, the impact of downsizing the implant diam- recommended that implants with advanced peri-implantitis with
eter upon implant strength, and possible inclusion of titanium bone loss greater than half the implant length (or exhibiting
particles in the bone defect and soft tissue associated with the mobility) should be removed.144 Although the removal option is
lesion are possible limitations to implantoplasty, and the effect the one frequently used in cases of advanced peri-implantitis, it
of these remain to be determined. often entails multiple surgeries, pain, morbidity, risk of compli-
In both of these reviews on implant surface detoxification, cations, and tremendous cost additional to the initial care and
no one method of surface decontamination was found to results in a decreased replacement implant success rate accord-
be superior to another.151,152 Again, the homogeneities of the ing to studies that have evaluated survival rates of replacement
studies reviewed did not allow any conclusions to be made. A implants.20,21,24 This is the reason many clinicians prefer to treat
study using an erbium:yttrium-aluminum-garnet (Er:YAG) laser these implants using a regenerative approach. Success in the
for surface decontamination suggested its superiority to other treatment of peri-implantitis with a regenerative approach is
methods.153 However, a 7-year follow-up study of the treatment clinically determined by surrogate clinical parameters, includ-
of peri-implantitis using combined surgical therapy evaluated ing decrease or elimination of BOP, PD reduction, and radio-
two methods of surface detoxification (Er:YAG laser or plastic graphic bone fill. However, the latter does not indicate whether
curette + cotton pellets + saline) together with access flap, or not re-osseointegration has occurred on an implant surface
granulation tissue removal, and implantoplasty at buccal and with bone loss due to peri-implantitis. A recent systematic
supracrestal exposed implant surfaces, followed by placement review of re-osseointegration after peri-implantitis treatments
of natural bone mineral and a natural collagen membrane. The in monkeys and dogs concluded that promising results were
results of this study concluded that the successful outcomes observed in studies that used a combination of bone grafts or
achieved were not influenced by the method of surface detox- bone substitutes together with GBR for regeneration therapy.161
ification.154 Moreover, a systematic literature review on laser A recent case report using surface detoxification, bone substi-
disinfection concluded that no meaningful conclusions could be tutes, and a membrane barrier to treat advanced peri-implantitis
made regarding the effectiveness of different types of lasers for showed histologic evidence that re-osseointegration was possi-
decontamination and recommended additional longitudinal stud- ble in humans.162 However, in a recent systematic review and
ies.155 A systematic review of the treatment of peri-implantitis meta-analysis by Khoshkam et al, the authors concluded that
with laser therapy comparing different types of lasers concluded there is limited evidence in the literature reporting long-term
that no firm conclusions could be drawn and that there was a results of the regenerative approach and that this approach may
need for more well-designed randomized controlled studies.156 be considered equally with other options for treatment, includ-
The three decision trees for the treatment of peri-implantitis ing implant removal.163 However, a more desirable option might
recommend surgical treatment for bone loss with concomitant focus on retaining an implant affected by peri-implantitis with
antibiotics.141–143 In one study, an anti-infective protocol incor- moderate to severe bone loss using a regenerative approach,
porating surgical access, implant surface detoxification, and considering the time and expense involved with the removal
systemic antimicrobials followed by a strict postoperative proto- option to restore the patient back to heath, comfort, and func-
col was used to treat 36 implants (24 patients) with moderate to tion. A retrospective analysis evaluating a regenerative surgical
advanced peri-implantitis. Results showed a statistically signif- approach using surface detoxification, implantoplasty, bovine
icant reduction in mean PD, BOP, and suppuration at 3 months bone, and a membrane barrier reported on the results of treat-
and that these outcomes were maintained at 12 months.157 A ment of 158 implants in 107 patients 49 to 56 months after
448

Peri-implantitis
a b c
d e f g
Fig 25-26 (a) The implant surface was decontaminated with air-powder abrasive with glycine, followed by saline irrigation, citric acid, and thor-
ough irrigation with sterile water. (b) After surface decontamination, the defect was filled with a combination of bovine bone and mineralized
freeze-dried bone mixed with platelet-derived growth factor. (c) A subepithelial connective tissue graft was placed over the graft to increase the
KM. (d and e) Comparison of preoperative (d) and 13-year postoperative (e) clinical views, showing adequate keratinized tissue with gain in the
mucosal marginal soft tissue level. (f and g) Comparison of preoperative (f) and 13-year postoperative (g) radiographs, showing maintenance of
the regenerated marginal bone level.
therapy. Successful results based on stable reductions in PD or antimicrobial) application, and thorough irrigation with ster-
and BOP and positive implant survival were reported in 90.5% ile water for 2 minutes. The surface of the decontaminated
of patients treated. Although these results are impressive, the implant is then coated with a biologic (enamel matrix deriva-
authors noted that of the 637 implants referred back to their tive or platelet-derived growth factor), using nonwoven gauze
practice because of peri-implantitis, 471 were deemed hope- to apply the material. The defect is then filled with an allograft
less and extracted immediately. This represented removal of and/or bovine bone mixed with platelet-derived growth factor
73.9% of the implants referred for peri-implantitis treatment.164 and covered with a resorbable membrane if there is adequate
However, in a prospective study, positive predictability was KM or a subepithelial connective tissue graft if there is inade-
demonstrated using a regenerative protocol to consecutively quate KM. The flap is coronally positioned with vertical mattress
treat 170 peri-implantitis–affected implants in 100 patients. The sutures. The last (and essential) aspect for success is regular
outcomes of this treatment protocol were positive for decrease professional maintenance and monitoring. In a retrospective
in BOP (91%), average PD reduction (5.03 mm), mean gain in study that evaluated the factors related to the clinical outcomes
radiographic bone levels (1.77 mm), and mean gain in marginal of this protocol, maintenance frequency ≤ 3 months compared
soft tissue levels (0.52 mm). During the follow-up period of 2 to with > 3 months was found to be a significant factor in deter-
10 years, only 2 of 170 consecutively treated implants were lost, mining treatment outcomes166 (Fig 25-26).
yielding a 98.8% survival rate.165 A significant aspect of this study Two 5-year follow-up studies have confirmed the importance of
and protocol was that 47 of the 48 successfully treated implants maintenance following surgical treatment of peri-implantitis.158,167
had bone loss more than or equal to that which would have been Finally, in a commentary on maintenance, the authors stress the
recommended for implant removal according to the three treat- importance of routine maintenance and monitoring not only to
ment decision trees and the prognosis table.141–144 This protocol aid in maintaining the results of therapy but for early identifica-
identifies eight essential factors for success. Case selection is tion of recurrence of disease.168 Thus, at each maintenance visit,
the first of these. Any patient contraindicated for periodontal light probing should be performed, and BOP and any increase in
or peri-implantitis surgical treatment due to medical problems, PD should be recorded; if present, a radiograph should be taken
pregnancy, medications, or being noncompliant is excluded and compared with earlier radiographs to detect any mucositis or
from treatment. Locally if an implant surface does not allow evidence of early bone loss. Early treatment of those diseases
access for surface detoxification, treatment is not performed. has been recommended, along with oral hygiene improvement
Surface decontamination is performed using an air-powder abra- and control of smoking, as the best means to prevent disease
sive with glycine, followed by saline irrigation, citric acid (and/ progression and establish health.168
449

In conclusion, peri-implantitis has been recognized as one of 12. Pjetursson BE, Brägger U, Lang NP, Zwahlen M. Comparison of
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14. Roos-Jansåker AM, Lindahl C, Renvert H, Renvert S. Nine-to
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454

26 STEFANO PARMA-BENFENATI • CARLO TINTI •
MARISA RONCATI
Regenerative Protocol to
Treat Peri-implantitis
Peri-implant Defect Debridement and Implant
Surface Decontamination and Detoxification
Classification and Diagnosis of Peri-implant
Defects
Clinical Cases
455

26 | Regenerative Protocol to Treat Peri-implantitis
R
egenerative techniques for peri-implantitis treat- bone-implant contact on a previously contaminated implant
ment are specifically indicated for intrabony defect surface. This phenomenon has been demonstrated in experi-
management and are a valid and suitable therapeu- mentally created peri-implantitis defects in animals.17
tic solution, as largely demonstrated by numerous There are two recent human cases of histologic re-
clinical studies and case reports.1–9 The aim of this chapter is osseointegration using different regenerative materials and
to guide clinicians toward predictable, long-term regenerative methods of surface decontamination.18,19 Based on these find-
peri-implantitis treatments based on the bony defect morphol- ings, it may be concluded that regenerative approaches for the
ogy and peri-implant bone loss. treatment of peri-implantitis defects yielded encouraging clini-
In the case of advanced lesions, mechanical nonsurgical ther- cal results and some recent evidence of re-osseointegration in
apy alone is insufficient, and a surgical intervention is often humans, influencing the clinical decision regarding whether im-
needed. The clinician must evaluate the result of nonsurgical plants should be removed or treated.
therapy before considering a surgical approach. The primary aim
of a surgical treatment is to provide access for decontamina-
tion and detoxification of the infected implant surface, which
will allow undisturbed healing and reduce the risk for further PERI-IMPLANT DEFECT
disease progression. If the regenerative approach seems to be DEBRIDEMENT AND IMPLANT
the ideal therapy, it should always follow nonsurgical etiologic
therapy and only be used if the latter cannot provide a resolu-
SURFACE DECONTAMINATION
tion. It is possible that, as reported in a recent study, advanced AND DETOXIFICATION
peri-implantitis sites that are planned for surgical intervention
can be completely resolved following the initial therapy without The goal of any regenerative therapy that attempts to success-
the need for a surgical approach.10 fully treat a bacterially contaminated dental implant is to elim-
The clinical therapeutic goals of regenerative therapy include inate the bacterial etiology and provide the potential for osse-
reducing the probing depth, obtaining bone regeneration, and ointegration to occur.20,21
also minimizing gingival recession in esthetic sites. To date, there is no universally accepted method. Despite
The use of several different regenerative materials have numerous European and international workshops, opinion lead-
enhanced clinical attachment gain, defect fill, and probing depth ers have not yet described a specific preferred surgical proce-
reduction, as shown by bone sounding and standard periapical dure. Therefore, the authors illustrate the clinical protocol, first
radiographs.5,6,11 Human reentry studies also show bone fill; published in a case report in 2001,22 that they have adopted for
these studies are used to confirm the radiographic evidence12 nearly 20 years.
and to visualize close bone-implant approximation.4,9 Protocol adherence is essential for technique success, inde-
Peri-implant bone loss can be managed with a nonsub- pendent of the surgical approach, type of defects, or implant
merged or with a submerged implant. Even when a supracrestal surface characteristics. The clinical protocol provides for a
peri-implant defect is present, a submerged approach yields sequence of three distinct therapeutic phases, each based on
encouraging clinical results. In the case of a nonsubmerged a detailed biologic rationale. Following a chronologic sequence,
approach, bone regeneration is limited mainly to the intrabony it is recommended to start with (1) debridement of the bone
component, and to a lesser extent to the suprabony compo- defect, (2) decontamination of the implant surface, and finally
nent. Both are treated with guided bone regeneration (GBR) (3) detoxification of the implant surface. Figure 26-1 shows the
principles for vertical ridge augmentation procedures. Patient instruments used in each phase of the protocol.
functional, phonetic, and esthetic issues have to be evaluated
because of the need for implant-supported prosthesis removal
for the entire healing period.2 Peri-implant defect debridement
A reasonable alternative to a regenerative approach is certainly
implant removal. However, this raises a series of challenges Every surgical procedure must begin with removal of the granu-
that should not be underestimated: morbidity following multi- lomatous soft tissue collar around the exposed implant threads
ple surgeries, costs exceeding the initial estimated care, risk (Figs 26-1a, 26-1b, and 26-2) without contacting the implant sur-
of complications, and last but not least decreased successful face with metallic instruments. Ideally, the implant prosthetic
implant outcomes, according to studies that have evaluated superstructure can be removed to gain improved surgical access
survival rates of replacement implants.14–16 and allow the treated implant to be submerged following surgery.
Although human studies using a clinical reentry procedure Initially, a tungsten carbide long shank bur with a “Christmas
have reported encouraging outcomes such as close bone-implant tree” shape (see Fig 26-2a) is used on the bony side, away from
approximation, it is important to note that they do not represent the implant surface, in order to avoid any accidental contact (see
evidence of re-osseointegration. The ultimate goal of regen- Fig 26-2b). The removal of granulation tissue allows the clini-
erative procedures in peri-implantitis treatment is to achieve cian to expose the underlying bone surface. A Hirschfeld file is
re-osseointegration, defined as histologic evidence of new direct subsequently used to eliminate minute residues of soft tissue.
456

Peri-implant Defect Debridement and Implant Surface Decontamination and Detoxification
Fig 26-1 Instruments indicated Defect debridement Implant surface decontamination Implant surface detoxification
to implement the clinical proto-
col, performing defect debrid-
ment (a and b), decontamination
(c to g), and detoxification (h to
k) phases.
a b c d e f g h i j k
a b a b
Fig 26-2 The long shank bur, made of tungsten car- Fig 26-3 Hirschfeld file (a) with the working surface in direct contact with
bide and forming a “Christmas tree” shape (a), is used the bony wall (b).
on the bony side, away from the implant surface (b).
a b
Fig 26-4 Clinical decontamination phase using a Fig 26-5 (a) Stainless steel, Fig 26-6 Clinical use of a titanium brush for more
PEEK insert (Combi). titanium-coated Micerium Uni- complete implant thread debridement.
versal curet. (b) Clinical use of
KLS Martin Universal curet with
horizontal strokes.
The small size of this instrument (Figs 26-1b and 26-3) provides First, ultrasonic instruments with specific inserts are used for
access to the narrow, deeper parts of the defect, with the work- exposed implant thread debridement. Depending on the equip-
ing surface in direct contact with the bony walls to avoid touch- ment, they can be made of plastic fused to metal (Piezon Master
ing the implant surface. 700, EMS; Fig 26-1c), polyether ether ketone (PEEK) material
(Combi, Mectron; Figs 26-1e and 26-4), or carbon composite
(Satelec, Novaxa). In the case of magnetostrictive devices, a
Implant surface decontamination disposable green cap (Cavitron Jet Plus, Dentsply; see Fig 26-1d)
can be used.
No single method of surface decontamination has been found Then manual instrumentation, either a titanium curet (Mice-
to be superior23; consequently, the following implant surface rium Universal curet; Figs 26-1f and a) or a KLS Martin Univer-
decontamination is suggested. sal curet (Fig 26-5b), are applied in a circular direction around
The main objective of mechanical decontamination is the each exposed implant thread to remove or disrupt the biofilm
complete removal of biofilm and mineralized deposits from the and mineralized deposits on the implant surface. Some recom-
implant surface. Implant surface decontamination is achieved mend the use of titanium instruments, curets, and brushes
through a combination of tools and techniques, considering that because they produce a lower degree of roughness compared
the implant surface is quite different from root anatomy. Therefore, with metal instruments and diamond burs.24 A titanium brush
this justifies more than a single approach and the use of a combi- (PeriBrush, Tigran; Figs 26-1g and 26-6) can be used to contact
nation of different instruments, mainly made of pure titanium. the inner parts of the threads with titanium bristles in order to
457

a b a b
Fig 26-7 (a) Airborne particle–abrasion system with glycine (EMS). (b) Fig 26-8 (a) Airborne particle–abrasion system with sodium bicarbon-
The plastic tip, positioned very close to the exposed threads, is used to ate powder (EMS). (b) A specific metallic insert (Combi) is used near
detoxify the contaminated implant surface. the outermost contact of the exposed implant threads.
a b
Fig 26-9 Intraoral air polishing device (a) and its clinical use (b). Fig 26-10 A cotton pellet that has been soaked in tetra-
cycline powder dissolved in physiologic solution is rubbed
on the implant surface.
remove the microbial biofilm in an even more effective way. A Airborne particle–abrasion devices used to cleanse the implant
number of other methods for decontamination, such as the use surface may result in improved clinical parameters when they
of lasers or abrasive devices and implantoplasty of the exposed are used in combination with surgical treatment.31
implant threads, have been suggested as adjuncts to surgical The first detoxification phase is carried out using one of the
resective or regenerative surgery, but the clinical improvements two airborne particle–abrasion systems, with a specific plastic
reported are limited.25–27 insert that allows delivery of antiseptic and slightly abrasive
substances, such as glycine and/or erythritol powder, for a few
minutes (Figs 26-1h and 26-7). The subsequent detoxification
Implant surface detoxification phase uses sodium bicarbonate powder (Figs 26-1i and 26-8),
a more abrasive system than the previous one. The clinician
Current evidence suggests that thorough removal of the micro- can also use an intraoral air polishing device associated with
bial biofilm and accretions by ultrasonic and mechanical instru- the use of sodium bicarbonate (Figs 26-1j and 26-9). Following
ments alone is extremely difficult and rather ineffective.28,29 A this detoxification phase, the affected implant surface has to
number of airborne particle–abrasion devices have been recom- be thoroughly rinsed with a sterile solution.
mended for the detoxification of implant surfaces, and in vivo The third phase of detoxification involves the topical applica-
and in vitro benefits have been demonstrated.30 tion of tetracycline powder (tetracycline hydrochloride), dissolved
A major advantage of airborne particle–abrasion systems is in physiologic solution (50 mg/mL) and rubbed on the implant
their ability to reach extremely narrow areas. However, care surface with cotton pellets for 3 minutes (Figs 26-1k and 26-10),
must be taken because of the risk of developing subcutane- followed by rinsing with physiologic solution for 30 seconds.
ous air emphysema.31 This can be avoided by keeping the spray In addition to the acidic action of this substance, it is recog-
tip very close to the implant surface and packing the site with nized as having a prolonged antibacterial and anticollagenolytic
sterile lint-free gauze to prevent air from getting under the flap. effect. Although a large number of other substances have been
458

Classification and Diagnosis of Peri-implant Defects
proposed, such as citric acid, hydrogen peroxide, sodium chlo- In this section, a clinical classification based on defect diag-
ride, chloramines, chlorhexidine gluconate, and a 24% ethylene- nosis is proposed to facilitate treatment planning and surgical
diaminetetraacetic acid (EDTA) gel, from the evidence available, technique selection. It is suggested to classify bone defects as
no single method has been proven superior.32–34 follows (Figs 26-11 and 26-12):
• Mucogingival defects combined with bony defects

• Bony defects
CLASSIFICATION AND DIAGNOSIS –– Horizontal bony defect
OF PERI-IMPLANT DEFECTS –– Vertical bony defect
–– Combined vertical and horizontal bony defect
The treatment planning and therapeutic processes are subject –– Loss of osseointegration or bone loss ≥ 2/3 implant
to a proper preclinical diagnosis as well as a subsequent intra- length
operative assessment.
By definition, peri-implant disease is characterized by a bone
lesion, which can also be associated with soft tissue involve-
ment. In case of a mucogingival problem, the clinician is facing Mucogingival defects combined with bony
both conditions. Furthermore, the position of the affected defects
implant should impact clinical decision making regarding the
most suitable surgical approach. In areas of low esthetic value, Soft tissue recession accompanied by marginal bone resorption
and therefore exposure of the titanium components is not a associated with exposed implant threads are common esthetic
major problem, resective surgery and an apically positioned problems. The “pure” dehiscence is characterized by exposed
flap are advantageous for reducing probing depth and enhanc- implant threads with no vertical resorption. When implants are
ing hygiene access. In esthetic areas, the decision is usually inserted in a thin gingival biotype with thin alveolar ridges or in
based on the morphology of the defect and the degree of bone postextraction sites, or when implants are buccally positioned,
loss, but above all, a regenerative approach is used to minimize gingival recession and subsequent exposure of the most cor-
gingival recession. onal part of the implant surface may be an unavoidable conse-
In addition, soft tissue quality and quantity and the possibility quence.35 Implants that are integrated in bone, with only a few
of removing the prosthetic superstructure are of fundamental buccal exposed threads, usually require only a mucogingival
importance to the choice of therapeutic approach. Retrievabil- correction, with no bone augmentation procedure.36,37
ity of the prosthesis plays a major role in the decision-making
process because it allows not only better access to the surgical
site but above all a submerged (two-stage) technique, rather Bony defects
than a transmucosal (single-stage) approach. The patient’s
Horizontal bony defect
desires also influence the therapeutic choice. Consequently,
clinical cases that are apparently very similar from a diagnos- Horizontal bone resorption results in the total absence of bony walls
tic point of view often are treated with different therapeutic surrounding the implant surface (see Fig 26-12a and Fig 26-13).
approaches. It is a comprehensive alveolar ridge reduction at a right angle
Radiographic and clinical examinations (preoperative diagno- to the implant surface and very frequently associated with a
sis) may provide an indication of bony defect morphology but suprabony pocket. To correct mild to moderate horizontal bone
do not present the complete picture. The three-dimensional resorption, an apically positioned flap is recommended, with
morphology of a defect and the size of residual bony walls can or without a resective surgical approach for areas that are not
only be determined following flap elevation and granulation esthetically important. This procedure is indicated when one or
tissue removal (intraoperative diagnosis). more implants show osseointegration loss of <1⁄3 of the implant
Clinical experience confirms that the most frequently found length. The remaining osseointegration, approximately equal to
bony defect is the combined bony defect, characterized by both 2⁄3 of the implant length, can ensure stable implant anchorage
an intrabony vertical component at its apical part and a supra- and predictable clinical outcomes.
bony horizontal component at a more coronal level. The bony
architecture, namely the residual walls, will not only dictate the
Vertical bony defect
selection of the proper regenerative material but also influence
the esthetic and functional result. A peri-implant vertical bony defect refers to bone loss apical to
To facilitate its management, the soft tissue has to be free the alveolar crest with a deepening of the peri-implant sulcus. The
of inflammation and feature an adequate band of keratinized vertical defect can present with two different morphologies: (1)
tissue. Therefore it is necessary to decide whether or not to a contained intrabony defect, a funnel-shaped three-wall defect
augment a minimal zone of keratinized tissue. (see Fig 26-12b), or (2) a noncontained defect (see Fig 26-12c). A
regenerative approach is highly recommended for both defects.
459

Gingival recession and "pure"

bony dehiscence
Gingival recession and bony

dehiscence with intrabony
defect
Gingival fenestration and

bony dehiscence
Fig 26-11 The three different morphologies of mucogingival defects associated with a bony lesion on implants affected by peri-implantitis.
Intrabony "contained" defect Intrabony "uncontained" defect
a b c
Horizontal bony defect Vertical bony defect
Major Intrabony component Major suprabony component
d e f
Combined horizontal and vertical bony defect Bone loss ≥ 2⁄3 of implant length or loss of osseointegration
Fig 26-12 (a to f) The four different types of peri-implant bony defects.
460

Classification and Diagnosis of Peri-implant Defects
Fig 26-13 Clinical image of a peri-implant horizontal bone defect.
Fig 26-14 Radiographic (a) and clinical (b)

views of a combined vertical/horizontal
peri-implant bony defect.
a b
More frequently the remaining walls are the mesial and distal, noncontained defects, such as one-wall or two-wall defects, the
while the most vulnerable is the thin buccal surface. When an most recommended regenerative therapeutic approach involves
implant is placed distally to a tooth, usually its distal bony wall is using different biomaterials, such as a barrier membrane and
maintained, resulting in a peri-implant one-wall defect. The same fillers, to create space, improve soft tissue support, and stabi-
classification can be used when two implants are inserted at lize the blood clot to obviate the anatomical deficit.
an insufficient distance from each other, with consequent inter-
proximal wall resorption, which tends to aggravate the defect,
Combined horizontal/vertical bony defect
complicating the regenerative treatment.
Intraoral autogenous bone, harvested with a bone scraper or A combined vertical/horizontal peri-implant bony defect can be
with a bone rongeur and mixed with mineralized allograft and/ defined as horizontal bone resorption associated with a vertical
or xenograft, is shown to improve blood clot stability and main- intrabony defect, necessitating treatment of both horizontal and
tain space to allow bone regeneration, preventing flap collapse vertical components (Fig 26-14). Combined bony defects are
into the defect. The flap is placed to completely cover the graft frequently encountered and may differ significantly, presenting
material positioned within the defect. If the clinical situation either a major intrabony component (see Fig 26-12d) or a major
does not allow the surgeon to remove the prosthesis, there- suprabony component (see Fig 26-12e).
fore necessitating a transmucosal approach (nonsubmerged The defect location, ie, anterior versus posterior sextants,
technique), an internal horizontal U-shaped mattress suture is and esthetic assessment play a major role. In sextants of low
recommended to coronally advance both flaps. esthetic importance, osseous resective surgery and an apically
A more severe contained defect can be treated using a filling positioned flap would reduce the pocket depth and enhance
material in combination with a resorbable membrane and possi- hygiene access. It is possible to perform a minor regenerative
bly a connective tissue graft if the clinician evaluates the quality procedure for the residual vertical bony component. In esthetic
and amount of soft tissue as absolutely inadequate for regen- sextants, the regenerative approach is recommended for ideal
erative techniques. The coronally positioned flap completely case management and to minimize unwanted gingival recession.
covers the graft and the resorbable membrane. By definition, this type of bone defect, which has more
Whenever it is possible to remove the prosthetic superstruc- horizontal bone resorption and a less pronounced intrabony
ture, the clinician has the option to select a submerged tech- component, indicates the need to treat both components with a
nique, which allows better blood clot protection and a more regenerative approach. This clinical situation should be managed
predictable clinical outcome. Conversely, in the presence of with a GBR submerged approach, which requires removing the
461

a b c
Fig 26-15 Illustration (a) and clinical (b) and radiographic (c) images of peri-implant bony defects characterized by severe bone loss
exceeding two-thirds of the implant length.
prosthetic superstructure for a 9-month healing period. It may length, and presence of acute recurrent abscesses on adjacent
provide bone regeneration in both suprabony and intrabony implants or teeth41,44 (Fig 26-15).
components but creates functional and esthetic issues for the Even in advanced peri-implant bone loss, the remaining
patient. However, using the same prosthesis after healing is a osseointegration, which may be limited only to one-third of the
significant financial saving to the patient. implant length, can provide implant stability. Minimal mobility
Three mandatory objectives to be fulfilled are (1) to create of the implant must be considered as a total loss of osseointe-
sufficient space in the interface between the instrumented gration and requires the removal of the implant. The diagnostic
implant surface and the flap to enhance blood clot stabilization, value of implant mobility is limited because implants may be
(2) to exclude soft tissue ingrowth into the bony defect, and (3) connected to each other or to teeth by prosthetic superstruc-
to obtain predictable primary soft tissue closure at the surgical tures or other prosthetic components.
site to allow a prolonged and uneventful healing period.
Vertical bone loss can be corrected with a nonsubmerged
or a submerged approach. Regenerative outcomes have been
more predictable when a submerged approach is performed CLINICAL CASES
due to undisturbed healing and a reduced risk of infection.38,39
The submerged environment creates more predictable clini- Case 1
cal outcomes based on vertical ridge augmentation procedure
principles.40–42
Diagnostic phase
In case of a nonsubmerged solution, the bony defect must
be packed with bone graft and further secured by a connective A 31-year-old woman presented with a chief complaint of
tissue graft or a resorbable membrane.43 This will provide bone increasing recession and fenestration at a maxillary lateral inci-
regeneration limited to the intrabony component, with no func- sor implant-supported crown, which had been in place for 4
tional and esthetic improvement. Intraoral autogenous bone years (Fig 26-16a). She reported that a concave morphology had
grafts, mineralized allografts, and/or xenografts are routinely always been present; however, she started to be concerned after
used to augment blood clot stability and provide space main- noticing additional gingival fenestration. In the lateral view, it
tenance, accommodating bone regeneration by preventing flap was possible to see the exposure of the prosthetic component
collapse into the defect. The flap is positioned to completely and a soft tissue perforation. The periapical radiographic image
cover the grafted defect. The so-called contained intrabony showed a correctly positioned long implant with minimal bone
defects, in particular the narrow three-wall bony lesions, in loss (Fig 26-16b). Probing depths ranged from 6 mm distobuc-
which the space maintenance and blood clot stability are optical and mesiobuccal and 5 mm midbuccal. After removal of the
mal, require minimum regenerative material. prosthetic crown, collapsed keratinized mucosa due to buccal
bone loss on the implant’s most coronal surface was observed.
Bone loss ≥ 2⁄3 of implant length or loss of

osseointegration Selected treatment option
The clinical decision of whether implants should be removed or The therapeutic choice was oriented toward a reconstructive
treated with bone resective surgery and a regenerative approach mucogingival approach with a bilaminar technique because of
may be based on clinical parameters. They include implant mobil- the high esthetic value and minimal buccal bone loss. A beveled
ity, increased bone resorption equal to two-thirds of the implant “hockey stick” vertical releasing incision was initiated distal to
462

Clinical Cases
a b c
d e f
Fig 26-16 Clinical (a) and radiographic (b) images of an implant-supported crown in a maxillary lateral incisor site. (c) Illustration of the flap de-
sign. (d) Clinical image of the peri-implant bony lesion. (e) Buccal view. The harvested soft tissue wedge graft is positioned to cover the exposed
threads. (f) Clinical image showing the suturing techniques used for the de-epithelialized connective tissue graft.
the canine and continued intrasulcularly to the buccal aspect was then de-epithelialized and inserted, as an inlay graft, at the
of the canine. A horizontal incision was performed at the base coronal aspect of the implant surface and tightly adapted for
of the distobuccal papilla. It continued into the buccal aspect of intimate contact with the exposed threads and bony surfaces,
the peri-implant lesion, maintaining the integrity of the residual entirely filling the lateral osseous defects (Fig 26-16e). In this
keratinized tissue at the base of the mesial papilla. It further way, the graft thickness fills and seals the space of the lesion.
extended intrasulcularly at the right central incisor site and finally An additional epithelial-connective tissue graft, harvested from
to the papilla between the two central incisors (Fig 26-16c). With the opposite palatal wall, was planned for use as a resorbable
a 15c surgical blade, a partial-thickness flap was elevated. The barrier membrane.
periosteal bed presented the ideal blood supply for the connec- The gingival graft harvested from the palate maintained a
tive tissue graft. Using a small CTGO bone chisel (Nike Dental thickness of about 1.5 mm. Its epithelial component was fully
Supply), a full-thickness flap was raised from the canine to the removed, and the connective tissue graft was placed over the
implant site for access to the implant surface (Fig 26-16d). There distal wedge previously positioned and stabilized with a single
were five exposed implant threads and mineralized filling mate- sling suture to the prosthetic abutment. It extended on the recip-
rial embedded in granulomatous tissue lateral to the exposed ient periosteal bed to both the right canine and central incisor
implant surface. The previously described surgical protocol of in order to increase blood supply and augment the keratinized
decontamination and detoxification of the exposed threads was mucosa thickness.
meticulously applied. Three different suturing techniques, all with resorbable mate-
After removing the granulation tissue, it was possible to see rial, were used: (1) single interrupted sutures at the mesial and
six more threads covered only by a thin layer of bone tissue. distal aspects of the graft, anchored to the de-epithelialized
Furthermore, limited to the lateral portions of the five more coro- papillae in order to stabilize it; (2) single sling sutures to fix the
nal exposed threads, minor intrabony defects were detected. connective tissue graft with a very tight adaptation at the cemen-
A connective tissue graft from the retromolar tuberosity toenamel junction (CEJ) of the neighboring teeth and around
area was harvested and used as a filling material. Two inci- the prosthetic abutment; and (3) horizontal periosteal mattress
sions extended to the bone crest to harvest a wedged, thick soft stabilizing sutures to favor intimate contact between the graft
tissue graft. A third incision was executed with a Kramer-Nevins and the periosteal recipient bed, promoting graft nourishment
no. 7 gingivectomy knife to connect the two previous incisions, and avoiding blood clot formation that could jeopardize graft
gaining access into the sulcus, reaching the bone crest at the survival (Fig 26-16f). The flap was coronally advanced to fully
distal aspect of the maxillary molar, and then, with a firm push cover the grafts and the previously de-epithelialized papillae 2
from the mesial to the distal direction, removing the graft. It mm coronal to the CEJ. Two suturing techniques were used: (1)
463

g h i
Fig 26-16 (cont) (g) Clinical view after flap suturing and provisional crown cementation. (h) Clinical view 3 years after surgical treatment. (i) During
a checkup, the prosthetic restoration was removed to evaluate the maturation process.
single sling sutures around each tooth and the implant and (2) associated with a bony defect. Full-thickness buccal and palatal
single interrupted sutures at the vertical releasing incision (Fig flaps were elevated to expose the peri-implant bone defect. The
26-16g). Healing was uneventful, and after 3 years, complete palatal flap design was different from the buccal one because
implant surface coverage was evident (Figs 26-16h and 26-16i). of the minimal probing depths (Fig 26-17e). In order to optimize
The gingival margins were perfectly harmonious, with no scar the regenerative objective, the palatal incision was made at the
tissue. Furthermore it is possible to observe the increased thick- base of the palatal papillae.45 The flap design began with this
ness of the gingival tissue, associated with a markedly convex incision, supported by healthy bone and far from the vestibu-
morphology. lar papillae supported by bony defects. The incision extended
one tooth, mesially and distally, beyond the implant site. The
buccal flap started with a 45-degree beveled “hockey stick”
Case 2 releasing incision distal to the second premolar, initiated 2 to
3 mm apical to the mucogingival line (Fig 26-17f). It continued
Diagnostic phase
intrasulcularly to the mesial line angle of the second premolar
A 55-year-old woman presented with a peri-implantitis lesion and then into the interproximal space to reach the previously
associated with a screw-retained implant, positioned 22 years made palatal incision. A second incision from the distal line
previously in the maxillary right first premolar site. Her medical angle of the canine continued mesially at the base of the papil-
history was unremarkable, other than a moderate smoking habit lae, between the canine and the lateral incisor. A subsequent
of 10 cigarettes per day, which she had reduced to 4. Despite intrasulcular incision was performed at the implant site, both on
periodic maintenance care for 18 years, the implant developed its mesiobuccal and distobuccal aspects, in such a way that the
acute symptomatology, characterized by tenderness and swell- interproximal tissues between the teeth and the implant could
ing (Fig 26-17a). The periapical radiograph revealed a moderate be freed and then dislocated to the vestibular side, maintaining
radiolucency affecting the coronal third of the implant structure their integrity. A full-thickness buccal flap was elevated intrasul-
(Fig 26-17b). Probing depths ranged from 9 mm distobuccal and cularly, from the distal aspect of the right second premolar to
10 mm mesiobuccal to 12 mm midbuccal. However, the prob- the mesial aspect of the right canine. A blunt-ended instrument
ing depths on the palatal side were within normal limits and was used to reinforce the previous incision performed by the
showed no bleeding or suppuration. After the screw-retained surgical blade in order to remove tissue tags. A small CTGO
prosthesis was removed, gentle digital pressure released puru- bone chisel was then used to obtain clean access to the under-
lent exudate from the peri-implant gingival margin on the buccal lying bone structure, and the full-thickness flap was elevated.
aspect (Fig 26-17c). The same surgical protocol for debridement, decontamina-
tion, and detoxification that was previously described was rigor-
ously applied at the peri-implant defect.
Selected treatment option
Exposure of the implant revealed an advanced buccal dehis-
The severely compromised periodontal condition, with probing cence with a two-wall component at both the mesial and
depths ranging from 9 to 12 mm on the buccal aspect, played a distal aspects and the exposure of nine threads buccally (Fig
key role in treatment selection (Fig 26-17d). Careful and metic- 26-17g). The bone defect measured 7 mm midfacially, between
ulous periodontal probing allows the clinician to evaluate and the base of the implant shoulder and the most coronal visible
select the appropriate regenerative surgical approach relative to bone-implant contact. A small cylindrical bur was used on a
the esthetic needs and to optimize the regenerative goal. The slow-speed handpiece to create numerous bony cortical perfora-
two implant papillae in the palatal area were associated with tions in order to gain access to the underlying medullary cavities,
healthy bone; conversely, on the buccal side, the papillae were consequently involving the endosteum in the healing process. A
464

Clinical Cases
a b c
d e f
g h i
Fig 26-17 Clinical image (a) and periapical radiograph (b) showing a peri-implantitis lesion on a machined implant replacing the maxillary right first
premolar. (c) Presence of purulent exudate under gentle digital pressure. (d) A 9-mm probing depth was detected on the distobuccal aspect. (e)
Palatal flap design. (f) Buccal flap design. (g) Clinical image of the peri-implant bony defect after the decontamination and detoxification phases.
There was a moderate to advanced buccal dehiscence associated with the implant. (h) Tension-free buccal flap. (i) A combination of filling materials
were used to fully cover the bony defects.
hydrated acellular dermal matrix (AlloDerm GBR, BioHorizons), was positioned above the bone grafting materials (Fig 26-17j) in
properly trimmed to completely cover the defect, was stabilized order to completely cover it, stabilize the blood clot, and prevent
with a titanium pin buccally and apically at the maxillary second the connective tissue cells and the epithelial flap structures from
premolar root. At the apical portion of the buccal flap, held by interfering with blood clot maturation. The primary goal of using
atraumatic surgical tweezers, the periosteum was released with a resorbable membrane as a “cell selector” is to avoid having
a 15c surgical blade, starting from the distal end of the flap (Fig the bone graft particles embedded by the connective fibers of
26-17h) and reaching the most mesial margin. Subsequently, the inner wall of the flap. Favored by the previous periosteal
with the use of a blunt-ended instrument, a further dissection releasing incision at the base of the buccal flap, made to obtain
was performed to reinforce the previous incision in the vestibular a completely tension-free flap, it was possible to reposition it
mucosa with a “jiggling” movement in order to release super- in a more coronal position and completely cover the regenera-
ficial muscle insertions and obtain a tension-free buccal flap. tive materials, providing transmucosal healing by first intention.
A composite graft, composed of hydrated mineralized Primary flap closure was therefore obtained by the combination
freeze-dried human allograft (cancellous and cortical bone; of two suturing techniques: (1) suspended, interrupted sling
MinerOss, BioHorizons) combined with autogenous bone chips sutures and (2) horizontal internal mattress sutures.
harvested from the same site using a bone scraper, was posi- The fixed screw-retained restoration was repositioned in
tioned to completely cover the exposed buccal threads and place, allowing a functional and esthetic result (Fig 26-17k).
fill the contiguous mesial and distal bony defects (Fig 26-17i). The postoperative phase and initial healing proceeded without
The acellular dermal matrix resorbable membrane (AlloDerm any complications and with minimal postoperative discomfort.
GBR), previously stabilized with a titanium pin at its apical end, The 9-month healing period was uneventful; no membrane or
465

j k l
Fig 26-17 (cont) (j) The resorbable mem-

brane is sutured around the prosthetic abut-
ment. (k) Buccal view with the screw-retained
prosthesis in situ at the end of the procedure.
(l) A 3-mm probing depth was recorded on the
distobuccal aspect. (m) Buccal view of clinical
evaluation at 22 months after peri-implantitis
treatment and regenerative techniques. (n)
Note the increased buccal bony thickness
and the ideal convex anatomy.
m n
grafting materials became exposed. At approximately 22 months his mandibular left first premolar had been extracted, and as
after peri-implantitis treatment, the distal aspect of the adjacent a result his masticatory function suffered. The implants in this
tooth, the maxillary right second premolar, required a surgical area were placed and restored by his referring dentist 10 years
crown lengthening procedure to address the presence of recur- ago. The patient had not shown any discomfort during chew-
rent caries, which created the opportunity to perform a reentry ing for the first 9 years (Fig 26-18a) but recently had noticed
procedure. The periapical radiograph revealed a mild radiolu- gingival discomfort relative to the most distal implant. A mild
cency at the two most coronal implant threads. The probing gingival inflammatory process was observed surrounding the
depths for the implant in the first premolar site were reduced most distal implant.
to 3 mm on the distal aspect, 2 mm on the buccal aspect, and After removing the implant-supported prosthesis, periodontal
4 mm on the mesial aspect. No bleeding on probing was pres- probing was measured between 6 and 9 mm, with bleeding
ent. All biometric periodontal parameters were within normal on probing at the most distal implant. A new treatment plan
limits (Fig 26-17l). The patient did not report any symptoms and proposed by his referring dentist included a new fixed rehabil-
expressed satisfaction with the surgical outcomes. A small itation anchored by three implants. The first therapeutic phase
horizontal incision was performed in the periosteum to visual- involved the resolution of the peri-implantitis inflammatory
ize the underlying regenerated tissue, in correspondence with process, present at the first molar, and the subsequent place-
the previously exposed implant threads (Fig 26-17m). Exposure ment of another implant in the area of the missing first premolar.
of this area revealed the following results: seven of nine buccal
threads were covered by bonelike tissue, indistinguishable from
the host bone, and increased bone thickness, even though the
achieved bone regeneration was not 100%. The residual defect The accurate preoperative diagnostic evaluation by periodontal
depth was 2 mm, with approximately 5 mm of bone fill. The probing and radiographic evaluation showed that despite the
occlusobuccal view reveals a marked increase in buccal bony moderate degree of this contained intrabony defect, it required
thickness, achieving an ideal convex anatomy (Fig 26-17n). a regenerative approach. After the removal of the implant res-
torations, the intraoperative diagnosis of the peri-implant bone
defect noted the presence of numerous bony walls adjacent to
Case 3 the exposed implant threads (Fig 26-18b). With the exception
of the buccal wall, which was slightly lower in height, the other
Diagnostic phase
three bony walls were well represented in the immediate vicin-
A 66-year-old nonsmoking man was referred by his family dentist ity of the exposed implant threads. Autogenous bone collected
for a slight but continuous discomfort that would arise sponta- with a bone scraper from the area distobuccal to the implant site
neously during the day, especially upon mastication. Recently, was used as the only bone filler material (Fig 26-18c). The posi-
466

Clinical Cases
a b c
Fig 26-18 (a) Buccal view 10 years after implant placement. (b) Occlusobuccal view of the peri-implant
bony defect after a thorough therapeutic protocol for treatment of the exposed threads. (c) Autoge-
nous bone graft in situ. (d) Clinical view after 9 months, showing complete resolution of the bony
defect after peri-implantitis surgical treatment.
tioning of a membrane was not considered necessary because sented ideal surgical access for a submerged technique. A
the residual bony walls guaranteed blood clot protection and moderate to severe peri-implant bony lesion was assessed on
space maintenance. the buccal side. The defect on the buccal side had a contained
After an uneventful 9-month healing period, the complete intrabony defect (Fig 26-19b), whereas the defect on the lin-
resolution of the previous peri-implant defect was assessed gual side was severely noncontained (Fig 26-19c). A two-stage
during subsequent implant therapy (Fig 26-18d). Complete submerged technique was chosen, applying the clinical pro-
coverage of the previously exposed implant threads following tocol of vertical bone ridge augmentation with GBR widely
peri-implantitis surgical treatment was demonstrated. described in the literature.40–42 Also in this case, the degranu-
lation protocol of the peri-implant defect and the subsequent
decontamination and detoxification of the threads were strictly
Case 4 implemented. A resorbable acellular dermal matrix membrane
(AlloDerm GBR) was used with a combination of filler materials,
Diagnostic phase
including freeze-dried mineralized human allograft (cancellous
A 68-year-old man reported repeated inflammatory episodes at and cortical bone; MinerOss) together with autogenous bone
the mandibular right first molar implant. The radiographic image chips. After a 9-month healing period with no complications, the
revealed a marked radiolucency involving about two-thirds of second implant surgery phase was undertaken to replace the
the implant surface (Fig 26-19a). There was an adequate dimen- previous prosthetic crown. This allowed the clinician to visual-
sion of keratinized mucosa at the buccal and lingual surfaces. ize the postsurgical maturation process of the peri-implantitis
The failure to resolve the inflammatory process following with a regenerative approach. The buccal side presented com-
nonsurgical periodontal therapy, the persistence of pain upon plete fill of the previous space-maintaining defect without any
masticatory function, the progressive increase in probing depth, exposure of the implant threads (Fig 26-19d). However, the
and the finding of radiolucency induced the clinician to undertake lingual side, although demonstrating significant bone fill, still
peri-implantitis surgical treatment. After removal of the prosthetic showed a few exposed threads due to a slight residual dehis-
components, the periodontal probing on the buccal side ranged cence defect (Fig 26-19e). The definitive crown cementation
from 7 to 11 mm and on the lingual side was greater than 10 was carried out during the surgical procedure, prior to flap
mm, associated with bleeding on both mesial and distal aspects. closure, to avoid leaving any residual cement below the soft
tissues. At a checkup visit 5 years after the regenerative pro-
cedure, a periapical radiograph showed hard tissue stability
after loading (Fig 26-19f).
The selected regenerative approach indicated the removal of
the temporarily cemented prosthetic restoration, which pre-
467

a b c
d e f
Fig 26-19 (a) A follow-up radiographic image revealed a marked radiolucency involving two-thirds of the implant surface. (b) Buccal view of the
peri-implant defect. (c) Lingual view of the peri-implant defect. (d) Buccal view at the reentry procedure. Complete coverage of the previously
exposed threads can be appreciated. (e) Lingual view at the reentry procedure. A slight residual defect is still present. (f) Periapical radiograph 5
years after the surgical regenerative approach to treat the moderate to severe peri-implantitis lesion.
Case 5 merged approach for 11 months. One advantage was that the
patient could use the same fixed prosthesis after completion
Diagnostic phase of the treatment.
A 50-year-old woman with an unremarkable medical history pre- The authors applied step by step the specific vertical bone
sented with a peri-implantitis lesion on a machined implant that ridge augmentation surgical protocol described in the litera-
was serving as an intermediate abutment of a three-unit screw- ture.40–42 Full-thickness flaps were elevated from the distal aspect
and cemented-retained fixed implant restoration. Three implants of the third molar to the mesial aspect of the first premolar, at
have been positioned in native bone in the mandibular right sex- the buccal and lingual sites, thereby exposing the peri-implant
tant for 7 years. Six years after loading the intermediate implant, bone defects. Buccally, a “hockey stick” vertical releasing inci-
progressive bone loss was reported, along with increased prob- sion was placed on the mesial aspect of the premolar, while
ing depths ranging from 7 to 9 mm both buccally and lingually lingually the incision was extended intrasulcularly and at the
with bleeding, despite regular maintenance care. Furthermore, base of the papillae of three teeth mesial to the first premolar.
initial clinical and radiographic signs of incipient peri-implantitis Both flaps were considered clinically tension-free when they
were present on the distal aspect of the implant at the mandib- passively reached or exceeded the occlusal plane of the adja-
ular right second premolar. The radiographic images (Fig 26-20a) cent dentition with the use of surgical atraumatic tweezers
showed bone loss of approximately 50% of the implant length (Fig 26-20b). At the intermediate implant, a combined osseous
for the intermediate implant and a minor radiolucency on the defect was detected, characterized by a more pronounced hori-
distal aspect of the mesial implant. The amount of keratinized zontal component compared with the shallow mesial and distal
mucosa appears to be extremely reduced buccally and lingually intrabony components (Fig 26-20c). The bone defect, measured
and slightly inflamed; however, it did not appear to present con- midfacially between the base of the implant shoulder and the
traindications. The restoration was removed. The periodontal most coronal visible bone-implant contact, was 7 mm. More
biometric parameters were within normal limits for the distal exposed implant threads coronal to the residual bone crest
implant. The mesial implant had a 4-mm probing depth asso- (suprabony component) were observed compared with those
ciated with bleeding. The exposure of the three most coronal surrounded by the residual bony walls (intrabony component).
implant threads was noted at the intermediate implant. On the lingual side, six and two threads, respectively, were
exposed at the intermediate implant and at the distal aspect
of the mesial implant (Fig 26-20d).
The previously described peri-implant defect degranulation
Following careful risk/benefit evaluation and assessment of protocol and the subsequent decontamination and detoxification
different treatment options, it was decided to use a GBR sub- of the implant threads were rigorously applied. Because this
468

Clinical Cases
a b c
d e f
Fig 26-20 (a) Radiographic image revealing a radiolucency of a higher degree at the intermediate implant and of a lower degree on the distal
aspect of the mesial implant. (b) A tension-free buccal flap. (c) Buccal aspect of the peri-implant bony defects. Five implant threads are exposed.
(d) Lingual view of the peri-implant bony defects. Six threads are exposed on the lingual aspect. (e) Suturing techniques used to obtain primary
closure for healing by first intention. (f) Buccal view at 11 months during the uneventful healing phase.
combined osseous defect demonstrated a more pronounced The postoperative phase was uneventful; no membrane
horizontal than intrabony component, the clinician decided to or grafting materials became exposed. At monthly postoper-
manage it via a submerged approach. A small cylindrical spiral ative checkups, evaluation of the healing process confirmed
carbide bur on a slow-speed handpiece was used to create the complete absence of any postsurgical complications (Fig
numerous bony perforations, increasing the bleeding surface of 26-20f). A reentry procedure was performed 11 months later for
the recipient bed and gaining access to the underlying medullary abutment connection, repositioning of the original fixed prosthe-
cavities, consequently involving the endosteum in the healing sis, and placement of a gingival graft to improve the quality and
process. Hydrated acellular dermal matrix (AlloDerm GBR), a quantity of the keratinized tissue. A buccal partial-thickness flap
resorbable membrane properly trimmed to completely cover the was elevated to create the ideal recipient bed for the planned
defect, was stabilized with two small osteosynthesis screws reconstructive mucogingival procedure, to allow the position-
apical to the peri-implant osseous lesion and then displaced ing of the prosthetic components, and to provide an opportu-
buccally for graft material positioning. A composite graft of nity to assess the results of the regenerative peri-implantitis
hydrated mineralized freeze-dried human allograft (cancellous treatment. The lingual flap was minimally elevated on its most
and cortical bone; MinerOss) combined with autogenous bone coronal aspect to allow bone fill measurements. Clinical reentry
chips graft, with the addition of a small amount of tetracycline revealed bonelike tissue formation to the cover screw and clin-
powder (ratio of 5:1), was positioned to completely cover the ical gain in the width of the buccal ridge. A complete elimina-
exposed buccal and lingual threads of the bone defects. Ideal tion of the combined defect, mainly characterized by a noncon-
primary closure over the regenerative materials and implant tained component, was achieved with complete coverage of
structures was attained with a combination of single interrupted the previously exposed threads and also complete resolution of
and horizontal internal mattress suturing techniques. Initially, the lesion on the distal aspect of the mesial implant. Bonelike
horizontal internal mattress U-shaped sutures were used, alter- tissue extending to the polished collar (Fig 26-20g), indistin-
nating with simple interrupted sutures on the occlusal surface. guishable from the host contiguous bone, may be suggestive
The papilla at the releasing incision mesial to the first premo- that the graft materials were completely remodeled during the
lar was stabilized with an anchored suture technique. In the 11-month healing period. It was possible to use the previous
remaining part of the releasing incision, single oblique inter- cemented/screw-retained fixed restoration. An adequate band
rupted sutures were used, and finally, at the most apical level of keratinized mucosa at not only the implant structures but
in the alveolar mucosa, an external vertical mattress suture was also the first premolar was achieved. Six years later masticatory
used to create an X and favor hemostasis. Complete primary flap function was good, and clinical (Fig 26-20h) and radiographic
closure ensured primary intention healing with the implant struc- (Fig 26-20i) views showed stable outcomes.
tures and regenerative materials fully submerged (Fig 26-20e).
469

g h i
Fig 26-20 (cont) (g) Buccal view of stage-two surgery. Newly regenerated tissue reaches the cover screw. (h) Buccal view at 6-year follow-up. (i)
Radiographic view at 4-year follow-up.
Case 6 implants presented a variable degree of bone resorption that

was morphologically differentiated into horizontal and vertical
Diagnostic phase components. The mesial implant presented mainly a circum-
The following case, published in 2001,22 is the first case report ferential intrabony lesion of approximately 3-mm depth, with
in the evidence-based literature of the treatment of peri-implant three exposed threads; the intermediate implant presented
bone defects by applying the surgical protocol of vertical bone mainly a 5-mm horizontal, suprabony component in combination
regeneration. In January 1998, a 57-year-old nonsmoking with a 2-mm vertical intrabony component, with five exposed
woman with a mandibular left implant-supported fixed pros- threads; and the distal implant presented mainly a 3-mm horizon-
thesis was referred by her dentist. She previously had been tal component in combination with a 1-mm vertical component,
successfully treated for periodontal disease. After a 30-month with two exposed threads (Fig 26-21b). The previously described
loading period, her dentist clinically and radiographically protocol for peri-implant defect degranulation and decontami-
diagnosed peri-implantitis lesions. The fixed prosthesis was nation and detoxification of the implant threads was rigorously
anchored by three machined implants replacing the mandibular applied. The cortical bone was perforated with the smallest
second premolar and first and second molars. After removal of carbide round bur to open the cancellous bone and create a
the implant prosthesis, generalized 5- to 6-mm pocket depths, bleeding bone surface. Autogenous and human demineralized
bleeding on probing, and a slight redness of both the buccal freeze-dried bone grafts were positioned around the exposed
and lingual mucosa were recorded. The quantity of keratinized threads to completely cover them. A titanium-reinforced
tissue averaged between 3 and 4 mm. Radiographic evidence expanded polytetrafluoroethylene (e-PTFE) membrane (TR9,
of bone resorption involving a combination of vertical and hor- W.L. Gore) was bent with fine tweezers to obtain close adap-
izontal bone loss was demonstrated with standard periapical tation to the underlying bone and the implants (Fig 26-21c). The
dental radiography (Fig 26-21a) and by computed tomographic titanium-reinforced membrane was relieved from the natural
scans before definitive treatment planning. tooth and stabilized to the bone with a titanium fixation screw
(Friatec). Horizontal U-shaped internal mattress sutures were
used to create two connective tissue contact surfaces (first line
of closure) and were alternated with simple interrupted sutures
All the treatment options were thoroughly explained to the (second line of closure) (Fig 26-21d). Any type of removable pros-
patient, and it was emphasized that this GBR staged approach thesis on the surgical site was avoided until stage-two surgery to
could make it impossible for her to masticate on the mandibular prevent any trauma to the augmented site. Healing was unevent-
left sextant. The patient gave her written consent. The decision ful, the barrier membrane remained completely submerged,
to select a regenerative technique, with the objective of treat- and the surrounding tissues were completely healthy, without
ing both the intra- and suprabony components, rather than a any sign of inflammation (Fig 26-21e). At reentry for abutment
resective approach, was dictated by several factors, such as the connection, after an uneventful 12-month healing period, the
reduced length of the implant structures as well as the avoid- titanium-reinforced membrane was removed and the regener-
ance of undesired biologic costs and any potential chewing dis- ated tissue could be clinically evaluated. All space underneath
comfort. Buccal and lingual mucoperiosteal full-thickness flaps the barrier membrane was completely filled with regenerated
were raised and managed step by step according to the specific hard, bonelike tissue (Fig 26-21f). At the most distal implant, it
vertical bone ridge augmentation surgical protocol described in reached the uppermost part of the implant, partially covering the
the literature.41 cover screw. After replacing the cover screws with the previous
The simultaneous coronal extension of both flaps and their components of the implant-supported three-unit prosthesis, the
tension-free status were carefully evaluated. All three machined flaps were sutured back to their original positions.
470

Conclusions
a b c
d e f
g h
Fig 26-21 (a) The pretreatment radiograph revealed both vertical and horizontal bone resorption around the three implants in the mandibular left
sextant. (b) Intraoperative view demonstrating the vertical and the horizontal components of the defects around all three machined implants. (c)
An oval TR9 e-PTFE membrane was bent to obtain close adaptation to the underlying bone and to cover the heads of the implants prior to fixation.
(d) Flaps were sutured using two suturing techniques to achieve ideal connective tissue contact surfaces with intimate adaptation and closure.
(e) Uneventful soft tissue healing after a 12-month healing period. No membrane exposure occurred. (f) Intraoperative view immediately after
membrane removal. All the space underneath the membrane was completely filled with newly formed tissue. At the most distal implant, newly
formed tissue reached the uppermost part of the implant, partially covering the cover screw. (g) Periapical radiograph after a 12-month loading
period showing complete bone fill around the previously exposed threads and stabilization of the vertical bone loss process. (h) All the clinical
parameters were within normal limits over the course of a 20-year follow-up period.
After a 12-month loading period, a periapical radiograph This technique is, furthermore, considered dependent on the
showed radiographic bone fill that reached the implant necks (Fig operator, whose clinical experience can and should influence
26-21g). All clinical parameters and radiographic examinations treatment options.
were satisfactory over the course of a 20-year follow-up period, A successful procedure should result in resolution of inflam-
revealing stable bone levels and ideal function (Fig 26-21h). mation, re-adhesion of peri-implant soft tissues, bone regener-
ation, and re-osseointegration. The decontamination and detox-
ification of the exposed implant surfaces are absolutely crucial,
regardless of the frequently conflicting data reported in the
CONCLUSIONS literature and the selected approach. Unfortunately, the litera-
ture provides no precise guidelines for the clinician’s options,
The regenerative staged GBR approach is particularly indicated which could range from a conservative surgical approach to a
in the presence of the following factors: regenerative or resective one, with the possible use of partic-
ular materials or additional techniques. The authors strongly
1. Moderate to severe bone loss recommend that the surgical choice should be based on defect
2. Almost exclusively noncontained suprabony defects diagnosis, influenced by a careful evaluation of clinical factors
3. Adequate quantity and quality of residual soft tissue and parameters, from patient to patient and also from site to
4. A screw-retained restoration that allows its removal and site (Fig 26-22).
subsequent replacement at the end of the two-stage surgi- It is also important to keep in mind that the esthetic demands
cal procedure of the patient inevitably influence the therapeutic choice.
471

Vertical bone loss
Retrievable prosthesis In situ prosthesis
Intrabony defect Suprabony defect Intrabony defect Suprabony defect
1. One-stage GBR: 1. Two-stage GBR: AB 1. Biomaterials/filling 1. Access flap surgery

filling materials + nonresorbable materials 2. Osseous resective
+ resorbable membrane 2. One-stage
GBR: filling surgery
membrane 2. Two-stage GBR: AB + materials + CT graft and/
2. Biomaterials/filling resorbable membrane + or resorbable membrane
materials AB/FDBA
Fig 26-22 Summary of the treatment options for vertical bone loss. A key factor is the retrievability of the prosthesis. When it is possible to remove
the prosthetic restoration, in the presence of an intrabony defect, a one-stage regenerative technique is preferred, which will not affect patient
masticatory function; in the case of a suprabony defect, a two-stage submerged regenerative technique is selected, which consequently requires
no masticatory function for 9 months. If it is necessary to keep the prosthesis in situ, in cases of intrabony defects, the best therapeutic option will
be to perform a one-stage regenerative technique; in cases of suprabony defects, an osseous resective surgery will be implemented, particularly in
the posterior areas where esthetic requirements are not so high. AB, autogenous bone; FDBA, freeze-dried bone allograft; CT, connective tissue.
Despite the experience of the clinician and the use of advanced 3. Parma-Benfenati S, Roncati M, Galletti P, Tinti C. Peri-implantitis
regenerative techniques for both soft and hard tissues, it is not treatment with a regenerative approach: Clinical outcomes on
reentry. Int J Periodontics Restorative Dent 2015;35:625–636.
always possible to achieve optimal results, so it is important to
4. Froum SJ, Rosen P. Reentry evaluation following treatment of
fully explain the possible treatment outcomes to the patient. peri-implantitis with a regenerative approach. Int J Periodontics
It is the authors’ opinion that the predictability of regenerative Restorative Dent 2014;34:47–59.
techniques is highly technique-sensitive and strictly related to 5. Matarasso S, Iorio Siciliano V, Aglietta M, Andreuccetti G, Salvi
GE. Clinical and radiographic outcomes of a combined resective
respect of the clinical protocols.
and regenerative approach in the treatment of peri-implantitis: A
Finally, as always, the first and the most crucial feature is prospective case series. Clin Oral Implants Res 2014;25:
diagnosis. Peri-implantitis encompasses multifaceted types 761–767.
of lesions. Surgical approaches should be selected based on 6. Schwarz F, John G, Mainusch S, Sahm N, Becker J. Combined
surgical therapy of peri-implantitis evaluating two methods of
defect diagnosis and clinical expectations.
surface debridement and decontamination. A two-year clinical
follow up report. J Clin Periodontol 2012;39:789–797.
7. Schwarz F, John G, Becker J. Reentry after combined surgical
resective and regenerative therapy of advanced peri-implantitis:
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of peri-implantitis using an Er:YAG laser or an air-abrasive device: of peri-implantitis using an air-abrasive device or mechanical
A randomized clinical trial. J Clin Periodontol 2011;38:65–73. debridement and local application of chlorhexidine: A prospective,
11. Claffey N, Clarke E, Polyzois I, Renvert S. Surgical treatment of randomized, controlled clinical study. J Clin Periodontol
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12. Schwarz F, Hegewald A, John G, Sahm N, Becker J. Four-year 29. Renvert S, Polyzois I. Treatment of pathologic peri-implant pock-
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evaluating two methods of surface decontamination. J Clin Peri- 30. Parlar A, Bosshardt DD, Cetiner D, et al. Effects of decontamina-
odontol 2013;40:962–967. tion and implant surface characteristics on re-osseointegration
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with clinical re-entry. Clin Adv Periodontics 2015;5:235–241. 31. Tastepe CS, van Waas R, Liu Y, Wismeijer D. Air powder abrasive
14. Khoshkam V, Suarez Lopez Del Amo F, Monje A, Lin GH, Chan treatment as an implant surface cleaning method: A literature
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review and meta-analysis. Int J Oral Maxillofac Implants endotoxin-contaminated titanium and hydroxyapatite-coated
2016;31:1303–1310. surfaces utilizing various chemotherapeutic and mechanical modal-
15. Grossmann Y, Levin L. Success and survival of single dental ities. Implant Dent 1992;1:154–158.
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tol 2007;78:1670–1674. Effect of six different peri-implantitis disinfection methods on in
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attempt to place implants in sites where previous surgeries have 34. Esposito M, Grusovin MG, Worthington HV. Treatment of
failed. J Clin Periodontol 2011;38:195–198. peri-implantitis: What interventions are effective? A Cochrane
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ously contaminated surfaces: a systematic review. Clin Oral 35. Tinti C, Parma-Benfenati S. Clinical classification of bone defects
Implants Res 2009:20(suppl 4):216–227. concerning the placement of dental implants. Int J Periodontics
18. Wohlfahrt J, Aass AM, Ronold HJ, Lyngstadaas SP. Micro CT and Restorative Dent 2003;23:147–155.
human histological analysis of a peri-implant osseous defect 36. Lekholm U, Sennerby L, Roos J, Becker W. Soft tissue and
grafted with porous titanium granules: A case report. Int J Oral marginal bone conditions at osseointegrated implants that have
Maxillofac Implants 2011;26:e9–e14. exposed threads: A 5-year retrospective study. Int J Oral Maxillo-
19. Fletcher P, Deluiz D, Tinoco E, Ricci J, Tarnow D, Tinoco J. Human fac Implants 1996;11:599–604.
histologic evidence of reosseointegration around an implant 37. Rasmusson L, Sennerby L, Lundgren D, Nyman S. Morphological
affected with peri-implantitis following decontamination with ster- and dimensional changes after barrier removal in bone formed
ile saline and antiseptics: A case history report. Int J Periodontics beyond the skeletal borders at titanium implants. A kinetic study
Restorative Dent 2017;37:499–508. in the rabbit tibia. Clin Oral Implants Res 1997;8:103–116.
20. Lang NP, Berglundh T; Working Group 4 of the Seventh European 38. Roos-Jansåker AM, Renvert H, Lindahl C, Renvert S. Submerged
Workshop on Periodontology. Periimplant diseases: Where are healing following surgical treatment of peri-implantitis: A case
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Periodontology. J Clin Periodontol 2011;38(suppl 11):178–181. 39. Wohlfahrt JC, Lyngstadaas SP, Rønold HJ, et al. Porous titanium
21. Rosen PS, Qari M, Froum SJ, Dibart S, Chou LL. A pilot study on granules in the surgical treatment of peri-implant osseous defects:
the efficacy of a treatment algorithm to detoxify dental implant A randomized clinical trial. Int J Oral Maxillofac Implants
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Dent. 2018;38:261–267. 40. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a
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Oral Maxillofac Implants 2001;16:572–577. 41. Tinti C, Parma-Benfenati S. Vertical ridge augmentation: Surgical
23. Figuero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of protocol and retrospective evaluation of 48 consecutively inserted
peri-implant mucositis and peri-implantitis. Periodontol 2000 implants. Int J Periodontics Restorative Dent 1998;18:434–443.
2014;66:255–273. 42. Parma-Benfenati S, Tinti C, Albrektsson T, Johansson C. Histo-
24. Louropoulou A, Slot DE, Van der Weijden F. Titanium surface alter- logic evaluation of guided vertical ridge augmentation around
ations following the use of different mechanical instruments: A implants in humans. Int J Periodontics Restorative Dent
systematic review. Clin Oral Implants Res 2012;23:643–658. 1999;19:425–437.
25. Deppe H, Horch HH, Neff A. Conventional CO2 laser-assisted treat- 43. Schwarz F, Sahm N, Bieling K, Becker J. Surgical regenerative
ment of peri-implant defects with the concomitant use of treatment of peri-implantitis lesions using a nanocrystalline
pure-phase beta-tricalcium phosphate: A 5-year clinical report. Int hydroxyapatite or a natural bone mineral in combination with a
J Oral Maxillofac Implants 2007;22:79–86. collagen membrane: A four-year clinical follow-up report. J Clin
26. Romeo E, Lops D, Chiapasco M, Ghisolfi M, Vogel G. Therapy of Periodontol 2009;36:807–814.
peri-implantitis with resective surgery. A 3-year clinical trial on 44. Renvert S, Polyzois I, Claffey N. How do implant surface charac-
rough screw-shaped oral implants. Part II: Radiographic outcome. teristics influence peri-implant disease? J Clin Periodontol
Clin Oral Implants Res 2007;18:179–187. 2011;38(suppl 11):214–222.
27. Schwarz F, Sahm N, Mihatovic I, Golubovic V, Becker J. Surgical 45. Murphy KG. Interproximal tissue maintenance in GTR procedures:
therapy of advanced ligature-induced peri-implantitis defects: Cone Description of a surgical technique and 1-year reentry results. Int
beam computed tomographic and histological analysis. J Clin Peri- J Periodontics Restorative Dent 1996;16:463–477.
odontol 2011;38:939–949.
473

27 MARISA RONCATI
The Importance of
Dedicated Maintenance
Therapy for Long-Term
Success
Definition and Biologic Principles of Peri-implant
Maintenance
Therapeutic Goals of Peri-implant Maintenance
Peri-implant Maintenance as Prevention
Peri-implant Soft Tissue Management
Responsibility for Peri-implant Maintenance
Periodic Recall Frequency
Recall Appointments and Treatment Procedures
End of Peri-implant Maintenance Appointment
475

27 | The Importance of Dedicated Maintenance Therapy for Long-Term Success
a b c
Fig 27-1 The clinician needs to update the periodontal and peri-implant diagnosis at each recall appointment. The periodontal probe is the most
appropriate instrument for continuous clinical reevaluation. Circumferential probing around teeth and implants is recommended, as dissimilar values
can be detected, as shown in the three drawings: 6 mm (a), 3 mm (b), and 5 mm (c) (see also Fig 27-8). A conventional periodontal probe can be
used, provided that the probing force does not exceed 0.25 N (approximately 20 g) pressure1,2 to respect the integrity of peri-implant anatomy,
especially in case of healthy peri-implant tissues.
Fig 27-2 (a) Radiograph taken prior to implant placement in 1989 and (b) 29-year follow-up radiograph. Note that numerous implants are present in
the anterior area with consequent interimplant crowding. At the time of treatment, it was commonplace to use an implant to replace every missing
tooth. This approach still may be considered valid in posterior regions to create an ideal occlusion; however, in most cases today the number of
implants placed is limited, especially for treatment in the anterior area. Contemporary implant dentistry requires keratinized tissue for a better
esthetic result and to safeguard periodontal and peri-implant maintenance, providing a better long-term prognosis.7
P
eriodontal maintenance is an essential therapeutic Strict posttreatment implant maintenance care is absolutely
phase, and more importantly, it safeguards the clinical crucial in patients with high susceptibility to inflammatory
stability of any peri-implant treatment executed after disease.5 In order to control reinfection and limit biologic compli-
a correct diagnosis1,2 (Fig 27-1). cations, it is imperative to adhere to a scrupulous periodontal/
Implant therapy must not be limited to attaining short-term peri-implant follow-up treatment regimen6,7 (Figs 27-2 and 27-3).
success with dental implant placement and restoration but Following successful periodontal and implant therapy, the
should always include peri-implant maintenance therapy (PIMT) to patient should always be offered a maintenance care program
potentially prevent biologic complications and hence to increase that is adequately planned8 to fit individual needs9 and tailored to
the long-term success rate.3 Truly successful periodontal/ the patient’s risk profile.3 PIMT has proven to be a key factor in
peri-implant treatment outcomes are defined by stable clinical enhancing long-term outcomes of implant therapy by controlling
outcomes.4 reinfection.10
476

Definition and Biologic Principles of Peri-implant Maintenance
Fig 27-3 Pretreatment (a) and 26-year posttreatment follow-up (b) full-mouth radiographs.
DEFINITION AND BIOLOGIC program effectively reduces the risk of future attachment loss
since patients rarely are completely effective in plaque removal.
PRINCIPLES OF PERI-IMPLANT Because periodontal/peri-implant diseases are character-
MAINTENANCE ized by acute episodes alternating with remission phases,18,19
it is important that, following successful therapy, the patient
Wilson11 defined maintenance as the most significant stage of follows a customized, meticulous, and consistent periodontal
the entire periodontal treatment and supportive care as a life- peri-implant maintenance program to promote periodontal and
time commitment. The American Academy of Periodontology, peri-implant health.8,20 This concept, while obvious to the clini-
in a position paper published in 2003, stated that periodontal cian, it is not always so clear to the patient.11 Consequently,
maintenance is the preferred term for these procedures, for- strategies and protocols designed to educate the patient and
merly referred to as supportive periodontal therapy or periodon- achieve rigorous compliance with the appropriate established
tal recall, and includes maintenance of dental implants.12 intervals are required.21
Numerous studies have demonstrated periodontal and Supportive periodontal therapy, identified as a well-organized
peri-implant maintenance efficacy, showing that recurrent schedule of regular visits to the dental office for periodontal
peri-implantitis can be prevented or limited by appropriate control and maintenance, with the number of appointments per
oral home care13,14 combined with regular periodic profes- year determined using a risk assessment method,22 forms the
sional prophylaxis appointments.10,15 Other data have demon- basis of long-term success after periodontal/implant surgery.
strated12,16,17 that adherence to a personalized maintenance At the end of the first visit, the patient should be given printed
477

Cause-related laser-assisted
nonsurgical periodontal therapy
2nd 3rd
1st 20-minute 20-minute 4th
1-hour appointment appointment appointment 1-hour appointment
Two closely scheduled appointments, After approximately 30 days RECALL appointment

possibly on 2 consecutive days 3 months later (4 months after diagnosis)
Fig 27-4 Schematic representation of treatment protocol following diagnosis of peri-implant mucositis and/or peri-implantitis.
instructions in which the initial nonsurgical periodontal thera- • Increase the probability of locating and treating other condi-
peutic phases are listed, including related costs. Similar printed tions or diseases found within the oral cavity in a timely
reminders of the importance of patient involvement in terms manner12
of both effective oral hygiene skills and close adherence to
the personalized maintenance program, with regular follow-up Therefore, if at a follow-up recall appointment a critical situa-
appointments at the suggested frequency, should be provided tion is discovered, it is recommended to schedule two appoint-
at subsequent visits. It is highly important that both the clini- ments, possibly one day after the other, depending on clinic and
cian and the patient understand that supportive therapy should patient availability (Fig 27-4). The second short appointment is
start at the first visit. It is crucial to explain to the patient, from indicated above all to bring the patient’s attention to the problem
the very beginning, the importance of receiving professional and evaluate home care performance, the most crucial factor
comprehensive nonsurgical periodontal debridement and attend- in complete healing. It is intended to alert the patient and guar-
ing specialist checkup appointments on a regular basis to ensure antee a successful alliance in resolving an inflammatory lesion
successful results over the long term. In this way, patients while it still presents reversible features. In addition, the clinician
become co-therapists and their own primary caregivers,23 having has an opportunity to perform two closely scheduled treatments
the greatest influence on treatment outcomes, especially in in the peri-implant mucositis or peri-implantitis site, increas-
terms of long-term stability. ing the likelihood of successful clinical outcomes. Providing a
patient handout to illustrate treatment needs following detec-
tion of a significant peri-implant challenge is recommended.
The schedule for subsequent appointments, suggested at 1
THERAPEUTIC GOALS OF PERI- and 3 months (4 months from diagnosis), may be changed at
IMPLANT MAINTENANCE the clinician’s discretion, depending on patient-specific needs
and a case-by-case assessment.
The ultimate therapeutic goal is to achieve clinical stability
with a specific and customized plan, combining treatment
needs with ideal therapeutic solutions using a patient-centered Clinical case example
approach.
The therapeutic goals of effective periodontal maintenance The following clinical case (Fig 27-5) proves that before schedul-
are to do the following: ing any surgical therapy, it is essential to complete an appropriate
nonsurgical approach followed by a diagnostic reassessment. In
• Prevent or minimize recurrence of disease progression in this case, cause-related laser-assisted nonsurgical periodontal
patients who were previously treated for periodontitis and/ therapy successfully treated localized moderate peri-implantitis.
or peri-implantitis This result is not guaranteed, but in this example, the first acute
• Prevent or reduce the incidence of tooth or implant loss by episode was promptly intercepted and treated with an effective
monitoring the dentition and prosthetic replacements of the etiologic therapy combined with adequate home care, which
natural teeth, including fixed implant-supported prosthetic seem to be key factors in determining clinical success. This case
restorations currently has an uneventful 10-year follow-up.
478

Therapeutic Goals of Peri-implant Maintenance
a b c d
e f g
h i
j k l
Fig 27-5 The periodontal probe measured a 7-mm pocket depth (a) on the mesial aspect of the implant replacing the mandibular left second pre-
molar; marked swelling and bleeding on probing were also noted. (b) Probing at 10-year follow-up. (c) Periapical radiograph documenting loss of
supporting bone around five implant threads (red circle). (d) Radiograph at 10-year follow-up. (e) Radiograph taken 3 years before the peri-implant
abscess episode, with no pathologic alterations noticeable (orange circle and arrow). In order to make a peri-implantitis diagnosis, comparative
radiographs are necessary to assess progressive supporting bone loss beyond the physiologic bone remodeling that may occur within the first
year of implant placement. (f) During the first professional prophylaxis treatment, a diode laser was used in the inflamed area. (g) The following
day a second treatment was provided with the additional use of a diode laser. A comparison of the two clinical images (f and g) shows a marked
reduction in edema in a short period of time. Painful symptoms were gone, which made proper home hygiene care much easier. (h) Use of a
diode laser, initially oriented toward the exposed implant threads for a bactericidal and decontamination effect. (i) The fiber of the diode laser is
subsequently oriented toward the inflamed tissue to kill the more pathogenic bacteria, which are most numerous in the inner peri-implant pocket
walls. The diode laser vaporizes granulomatous tissues, forming blood clots as a result of its hemostatic action. (j) Clinical view of the periodontal
probe showing marked edema, which extends for 7 mm of horizontal component, at the initial visit. (k) Clinical image taken 5 years later showing
the absence of any plaque-induced recurrence. Edema had decreased significantly since the day after the first nonsurgical periodontal treatment
with the additional use of a diode laser. (l) Periapical radiograph 1 year after cause-related laser-assisted nonsurgical periodontal therapy, showing
significant improvement in peri-implant bone mineralization compared with the initial radiograph (c).
479

m n o
p q r
Fig 27-5 (cont) (m) The periodontal probe detected a 2-mm probing depth with no bleeding 1 year after cause-related treatment. (n and o) Clinical
reevaluation at 10-year follow-up. The probing depths were maintained within normal values (2 mm) in the absence of bleeding, and the quality of
the peri-implant mucous seal had clinically stable characteristics, verified by applying the probe horizontally to the vertical axis of the implant to
assess peri-implant tissue tone. (p to r) Instrumentation used during maintenance appointments. A universal titanium curet (Medesy) (p) is used
with horizontal movements, without engaging the prosthetic margin. An ultrasonic device combined with a plastic-fused-to-metal insert (Piezon
Master 700, EMS) (q) is used oblique to the vertical axis of the implant to gently penetrate the peri-implant sulcus. The movement is cautious
but never static, with care taken to cleanse the subgingival area without traumatizing soft tissue. Subsequently, an air/powder system (Combi,
Mectron) (r), using glycine or erythritol associated with copious irrigation, is utilized.
Case description in the protocol described previously (see Fig 27-4). At the
first appointment, the diode laser was used for its soothing,
A 45-year-old patient presented with the chief complaints of anti-edematous, bactericidal, and decontamination effects in
pain and swelling. The clinical examination revealed deep pocket the inflamed area (see Fig 27-5f). The next day, a second treat-
depth (7-mm probing depth) with bleeding and suppuration ment was performed with the use of the diode laser; in less
on probing at the mesial aspect of the mandibular left second than 24 hours, a marked reduction in edema could be noted
premolar implant (see Fig 27-5a). A marked edema was noted, (see Fig 27-5g), and pain was no longer present, factors that
which extended for about 7 mm buccally. The implants had been were greatly appreciated by the patient and facilitated more
placed in the author’s dental clinic, but the case was finalized effective home hygiene care.
by a prosthodontic colleague, who also provided periodontal A 20-minute checkup after about 1 month and a 1-hour first
maintenance therapy. The most recent radiographic evaluations recall appointment 3 months later (4 months following the acute
at the author’s clinical practice were 3 years old (see Fig 27-5e). peri-implant inflammation episode) were scheduled, as described
The patient was in good general health, did not take any medi- in Fig 27-4. In agreement with the prosthodontist, maintenance
cations, and was an occasional smoker (four to five cigarettes per care was provided at the author’s clinic, with 3-month frequency
day). No occlusal trauma or parafunctional habits were detected. for the first year and 4-month intervals in the following years,
Following clinical (≥ 6-mm initial probing depth; see Fig 27-5a) once clinical and radiographic stability was assessed.
and radiographic (five exposed threads; see Fig 27-5c) evalua-
tions, localized moderate peri-implantitis was diagnosed. The
most appropriate treatment was a surgical approach, following
adequate nonsurgical periodontal instrumentation, combined PERI-IMPLANT MAINTENANCE AS
with patient motivation. PREVENTION
Therefore, prior to any surgical peri-implantitis treatment, two
cause-related laser-assisted professional prophylaxis appoint- Peri-implant maintenance must begin long before implant place-
ments were scheduled on two consecutive days, as indicated ment. The entire dental team should inform the patient, at the
480

Peri-implant Soft Tissue Management
first visit, of the importance of following a maintenance protocol. Knowledge of these structural differences is essential in order
It is also useful to provide the patient with written instructions to achieve and maintain satisfactory clinical outcomes longitu-
highlighting the necessity of proper home hygiene care, together dinally. The type of surface and the healing abutment may have
with periodic prophylaxis appointments. It is essential to explain some influence on the amount of connective tissue attach-
that recall frequency will be established based on individual ment.34 In a case report with human histology, Nevins et al35
needs and diagnostic assessment of oral and general health demonstrated how implant surfaces and healing abutments,
conditions, considering any risk factors that may be detected.4,20 both laser treated, allow the formation of connective tissue
While it is possible to treat peri-implant disease, prevention is attachment, preventing apical migration of the junctional epi-
the true aim of peri-implant maintenance therapy.24 The following thelium and protecting the bony crest from early resorption. The
key issues have a significant clinical impact on the prevention anatomical differences in vascularization and cellular composi-
of peri-implant diseases: tion make the soft tissue seal around implants less resistant
to bacterial colonization, validating soft tissue management to
• To reduce the prevalence of peri-implantitis, it is absolutely prevent later complications.
necessary to treat all teeth affected by periodontal disease A relevant historical controversy, still a subject of heated
before the implant treatment plan is implemented. The pres- debate in the dental literature, concerns the quantity and quality
ence of untreated periodontal disease is an established risk of keratinized tissue and attached gingiva necessary to ensure
factor that compromises implant longevity.25,26 marginal tissue health.36–38 Previous clinical retrospective studies
• Adequate supportive periodontal therapy is able to positively consider dental implant survival independent from the amount of
influence long-term success, preventing bone resorption keratinized tissue,39 which did not affect implant maintenance.40
around implants and natural teeth.8,27–29 From a critical data evaluation, there are abundant studies, often
• Prevalence of peri-implantitis is higher in noncompliant contradictory, on implant survival, plaque-induced inflammatory
patients. A three-arm prospective cohort study on implants tissue response, probing depth, recession, and bone loss.41,42
in periodontally compromised patients10,13 reported 10-year Most clinicians agree that an “adequate” amount of attached
results for implants placed in periodontally compromised gingiva facilitates proper daily oral hygiene care. A specific quan-
patients. A higher implant failure rate was found in periodon- tity, however, has not been clearly defined. An important distinc-
tally compromised patients who did not completely adhere tion needs to be made between tooth- and implant-supported
to the recommended supportive peri-implant therapy.10,13 prosthetic restorations. Translating the principles supported by
Previous papers that compared patients with and without a Lang and Löe36 in 1972 to implant-supported prosthetic clinical
history of periodontitis clearly indicated a higher incidence of conditions is quite anachronistic and possibly imprudent.
late implant loss/peri-implantitis for the former.30 This import- In terms of patient-centered care, the presence of a
ant concept should be repeatedly emphasized: The active peri-implant keratinized mucosal collar is beneficial to facilitating
periodontal patient is at greater risk of complications than correct oral hygiene. The keratinized tissue offers greater resis-
periodontally healthy patients. tance to possible trauma resulting from brushing maneuvers
• A history of periodontitis per se is not crucial, but the degree and the use of auxiliary tools such as interdental brushes, tufts,
of plaque control is. 30 Therefore, teaching of effective oral and special flosses (Fig 27-6). This is crucial especially for less
hygiene skills associated with efficient biofilm removal is motivated patients, who could justify their oral hygiene negli-
absolutely imperative. gence if they are experiencing localized discomfort or mucous
• Risk assessment predicts a patient’s likelihood of devel- membrane lesions following self-injury due to inappropriate tool
oping peri-implant diseases and improves clinical decision use. This does not mean that oral hygiene maneuvers cannot
making. Secondary prevention is focused on the segment be carried out effectively if the peri-implant keratinized mucosa
of the population at higher risk (as demonstrated by having is minimal or even absent, but they are undoubtedly more diffi-
had periodontal disease). These patients, characterized by cult to perform properly. It has also been noticed that bleed-
individual preventive needs, should participate in a lifelong ing on probing (BOP) and redness and swelling of the mucosa
professionally supervised secondary prevention program. occur more frequently in the presence of less than 2 mm of
peri-implant keratinized tissue.43,44
These considerations would seem to suggest that a mini-
mal quantity of attached gingiva is necessary to make it easier
for the patient to perform oral hygiene maneuvers, reduc-
PERI-IMPLANT SOFT TISSUE ing possible inflammation. This is even more plausible if one
MANAGEMENT takes into account that peri-implant tissues are less resistant
to plaque-induced inflammation compared with periodontal
The peri-implant soft tissues protect implant anchorage to basal tissues.40 Another consideration applies to patients with poor
bone, safeguarding long-term marginal bone integrity31 and fos- home oral hygiene: A well-represented peri-implant band of
tering stable oral health conditions. The peri-implant soft tis- keratinized tissue may help prevent mucositis or delay its devel-
sues are quite similar, but not equivalent, to periodontium.32,33 opments into peri-implantitis. There is insufficient data to assert
481

ease.54–57 The recall frequency must have a specific periodicity,

and bone levels must be radiographically checked at least every
2 years, unless specific needs require a shorter interval.58 A quar-
terly frequency for the first year following implant placement is
always recommended; after that a 4-month interval may often
be sufficient, provided it is properly respected. Young patients
who have no family history of periodontal disease and are able
to maintain satisfactory plaque control may be adequately main-
tained with supportive care performed semiannually.
Additionally, it must be stressed that even with the estab-
a b lishment of peri-implant maintenance therapy, biologic
complications might occur.56 Hence, patient-, clinical-, and
Fig 27-6 (a) Super Floss (Oral-B) is recommended for intermediate
implant-related factors must be thoroughly explored.52 If an
elements to sanitize the mucous membrane. (b) The interdental tooth-
brush (Enacare interdental brush, Micerium) is undoubtedly the best inflammatory problem is detected, it is strongly advisable to
instrument for interproximal cleaning. modify the recall frequency. In a recent retrospective study,
following a regenerative approach treatment, patients with
more frequent postoperative maintenance care (≤ 3-month
intervals) demonstrated significantly greater radiographic bone
gain and a trend toward significantly greater soft tissue gain
that the presence of keratinized mucosa can influence implant compared with patients with less frequent maintenance care
survival and mucosal margin recession.45,46 (> 3-month intervals).59
The mucogingival surgical option can be legitimized by To summarize, the recommended follow-up recall frequency
periodontal biotype assessment and the effect on esthetic is as follows:
outcomes.47 Peri-implant soft tissue management and recon-
struction techniques are intended to optimize tissue anatomy, • Previous history of moderate or advanced peri-implant
quality, and quantity in order to prevent any complications that disease: every 3 months
may arise in the posttreatment phase.48,49 • History of mild peri-implant disease: every 4 months
• Little susceptibility to peri-implant disease: every 6 months
RESPONSIBILITY FOR PERI-

IMPLANT MAINTENANCE Compliance and adherence
Responsibility for periodontal maintenance lies with the entire The term adherence is being used with increasing frequency.
dental team. Patients with recurrent gingivitis or slight chronic It comes from the Latin word adhaerere, which means to cling,
mucositis/periodontitis traditionally have been maintained by stay close, or behave consistently. In the Oxford English Dictio-
their general dentist.50,51 nary, the term adherence is defined as respect for a principle and
Patients with a history of severe periodontal attachment loss persistence in a practice. This definition conjures up the tenacity
or aggressive forms of peri-implantitis/periodontitis often obtain that patients must have in sticking to the recommended ther-
periodontal maintenance at the periodontist’s office, with a apeutic regimen. Effective oral hygiene skills and patient com-
recall interval tailored on the basis of many factors, including pliance are certainly not easy goals to achieve. Compliance is
patient motivation, severity of the initial condition, treatment synonymous with adhesion, but in medical language it is defined
results, age, susceptibility to periodontal disease, presence of as “patient behavior according to clinician’s instructions.” It has
risk factors, motivation level, and plaque control efficiency, as been found that patients comply better when they are informed
well as mucositis or peri-implantitis detection.52,53 and positively reinforced.60
Patients with chronic conditions tend to show decreas-
ing compliance over time, particularly when the disease is in
remission61; however, the insertion of osseointegrated implants
PERIODIC RECALL FREQUENCY seems to have a reliably positive effect on compliance with
periodontal maintenance.62 The long-term outcomes of implant
There is evidence to suggest that a consistent and appropriate therapy appear to be enhanced by supportive periodontal treat-
professional and at-home maintenance regimen is absolutely cru- ment.14,63 Patients who are not compliant present a significantly
cial for patients with tooth-borne and implant-borne restorations, higher risk of implant loss10 and also show greater loss of attach-
especially if they have shown susceptibility to periodontal dis- ment over time.23
482

a b
Fig 27-7 (a) While it would be preferable to detect the same normal probing depth values around implants as around natural teeth, ie, ≤ 3 mm,
sites with > 3-mm initial probing depths up to 7 mm and occasionally even more, are sometimes detected, still in the absence of BOP or bone
loss. Neither the patient, the dentist, nor the dental hygienist is able to provide effective etiologic therapy so deeply subgingivally. Despite a
healthy peri-implant condition, they are considered to be at high risk because of the undeniable challenge of biofilm removal. These features are
clearly present in areas of high esthetic value. Although this is an indisputable clinical hazard, adequate patient motivation combined with very
strict follow-up monitoring could improve long-term prognosis. In such clinical conditions, it may be appropriate to use additional strategies for
prevention purposes such as laser-assisted therapy or other methods at the clinician’s discretion. (b) Circumferential peri-implant probing should
always include three sites on the buccal aspect. To diagnose peri-implant mucositis, even if the sulcus depth values are within normal limits and
in the absence of supporting bone loss, it is sufficient that only one out of six sites tested shows BOP.
RECALL APPOINTMENTS AND Recall treatment procedures

TREATMENT PROCEDURES Review and update medical and dental history
At each follow-up recall appointment, it is necessary to update
Time allotted for periodontal maintenance the medical history, which can change even over a short time.
It is therefore highly recommended to ask the patient to fill out
The follow-up recall appointment time allotment is influenced by a form annually.
several factors, including the number of teeth or implants present
in the patient’s oral cavity, access for instrumentation, degree of
Extra- and intraoral examination
patient compliance/adherence, home oral hygiene performance,
general health conditions, frequency of regular follow-up recalls, At each recall appointment, it is required to carry out a thorough
and distribution and depth of the peri-implant/periodontal pock- soft tissue assessment with the aim of intercepting any anoma-
ets.23,64 The maintenance appointment traditionally has been lies. All data recorded must be compared with previous baseline
delivered over a 45- to 60-minute period, which is sometimes measurements. Routine clinical and radiographic data should be
insufficient to achieve the goals of consistent overall peri-implant obtained once the definitive restoration has been placed to estab-
maintenance.65 The time required for effective supportive care lish a baseline reference for monitoring peri-implant changes.66
should be tailored to each patient’s needs.23 Scheduling appoint-
ments for 1 hour is therefore recommended, as this time is long
Dental/implant examination
enough to carry out the necessary instrumentation and clinical
activities, including motivation reinforcement. Tooth/implant mobility, fremitus, and occlusal factors should
If, at a follow-up recall appointment, the clinician should detect be monitored. Coronal and apical caries should be assessed,
a peri-implant inflammatory lesion, it is advisable to always along with restorative and prosthetic factors such as the fit
schedule two consecutive appointments (see Fig 27-4): a 1-hour of implant-supported restorations.
appointment for prompt treatment, followed by a second shorter
appointment of about 20 minutes. If it is indicated to remove a
Periodontal evaluation
screw-retained prosthetic restoration, it is advisable to schedule
at least 90 minutes for the appointment. Probing depths are measured circumferentially around all teeth
and implants present (Fig 27-7; see also Fig 27-1). Pocket depth,
483

Fig 27-8 Essential home hygiene aids. (box, top to the bottom)
Special implant floss with a spongy portion, always to be used
in the presence of pontic elements to clean the area facing the
mucous tissue. Interproximal brush (Enacare interdental brush,
Micerium), the best-performing instrument for interproximal
cleaning70 with implant-supported prosthetic restorations.
Electric toothbrush with an oscillating-rotating head (Oral-B).
Medicated gauze (Enacare digital brush, Micerium), wrapped
around the finger of the dominant hand and used with a rolling
movement in the coronoapical direction, as indicated by the
arrow. Site application of an implant toothpaste (Implaclean,
Dyna Dental). Effective decontamination of a deep peri-implant
sulcus is difficult even with these auxiliary devices, which
can clean only a few millimeters subgingivally. This creates
objective maintenance difficulties and increases the risk of
pathologic progression from mucositis to peri-implantitis;
therefore effective oral hygiene instruction, associated with
efficient biofilm removal, is absolutely crucial.
the presence of exudate, and BOP are recorded. The quantity, Full-mouth radiographic survey
quality, and distribution of soft and hard deposits as well as
furcation involvement are assessed. New recessions must be Radiographs of diagnostic quality should be current and based
recorded and existing recessions monitored to check for any on the patient’s diagnostic needs and must permit appropriate
relapse. Periodical circumferential probing around implants rep- evaluation and interpretation of the status of the oral structures,
resents a good technique for assessing the status of peri-implant including teeth, periodontium, and dental implants. Periapical
mucosal health or disease.67 Whereas in the past only plastic radiographs following implant placement and prosthesis place-
probes were recommended for probing, conventional periodon- ment should function as the baseline to which all future radio-
tal probes can now be used, provided that the probing force graphs are compared.67 These radiographs should be perpendic-
does not exceed 0.25 N (approximately 20 g)1,2 because of the ular to the implant body to show a clear demarcation between
delicate and unique anatomy of the peri-implant mucosa. In the threads of the implant.69 At subsequent examinations (eg,
fact, a probing pressure of 0.15 N might represent the thresh- during maintenance visits), additional radiographs should be
old pressure to be applied to avoid false positive BOP readings taken if there is clinical suspicion of peri-implant disease. There
around implants. Hence, probing around implants demonstrates are no widely accepted protocols regarding the frequency of
a higher sensitivity compared with probing around teeth. The key implant radiographic examination. However, if there are clinical
parameter for diagnosing peri-implant mucositis is bleeding upon signs of peri-implantitis, such as increased probing depth with
gentle circumferential probing (0.15 N),66 which should be reas- bleeding on probing, radiographs should be taken to confirm
sessed at regular intervals to adequately monitor peri-implant the diagnosis.4,58,69 Radiographs are used to detect nonparallel
biometric periodontal indices. BOP is a reliable inflammatory adjacent implants causing iatrogenic proximity and thus increas-
marker with high prognostic value. ing the risk of complications, a gap between the implant and
prosthetic components, and retained residual cement.4 The clin-
ical judgment, as well as the prevalence or degree of disease
Evaluation of implants and peri-implant tissues
progression, may help determine the frequency and number
The circumferential use of the periodontal probe around implants of radiographs.
records not only pocket depth, BOP, and presence of exudate,
but also mobility, quality of the prosthetic rehabilitation, and
Evaluation of the patient’s standard of home
occlusal stability. Any other signs and symptoms of pathologic
care and oral hygiene skills
activity, such as the presence of pain and discomfort, are also
charted. If the implants are placed in and surrounded only by Based on the clinical stability of the periodontium, the efficacy
the alveolar mucosa, with no keratinized mucosa, maintaining of biofilm removal is assessed. In particular, the presence of
periodontal health is challenging. Clinically, a narrow band of plaque and a high bleeding score can help the clinician to iden-
keratinized mucosa is often observed together with gingival tify neglected areas, requiring more awareness during home
recession and inflamed periodontium, giving the impression care procedures and possibly the use of different instruments
that a certain amount of keratinized mucosa might be neces- or changes in home care techniques70 (Figs 27-8 to 27-10).
sary for periodontal stability.48,49,64,68 Again, it is always appropriate to reinforce oral hygiene instruc-
tion and emphasize the importance of closely adhering to the
484

a b
Fig 27-10 Application of a liquid plaque-disclosing solution

that identifies the biofilm to be removed. In particular, when
a tri-colored substance (eg, Tri Plaque ID Gel, GC) is used,
acidophilic plaque takes on a bright turquoise color. The use
of such a product is recommended for patient motivation,
identifying any areas neglected during home hygiene tech-
niques, and above all to perform site-specific and effective
instrumentation that is never excessive, especially in the
presence of healthy peri-implant tissues, in the immediate
posttreatment phases, or even after the provisional and/
or definitive prosthetic restorations have been placed. The
c bacterial biofilm is removed using a titanium-coated stain-
less steel implant curet (Enacare Universal Curet, Miceri-
Fig 27-9 (a and b) In the case of implant-supported prosthetic restorations, it um). The plaque-disclosing solution can also be used at the
should always be possible to use an interproximal brush in both the posterior and end of nonsurgical periodontal instrumentation to evaluate
anterior areas. (c) The box shows a 2-mm minimum interproximal dimension to site-specific instrumental performance, indicating any areas
allow easy insertion of the interdental brush in an oblique direction, from bottom where additional treatment is required to complete an effec-
to top, at mandibular sites. tive, comprehensive decontamination phase.
personalized maintenance program at each appointment. It its increasing caries susceptibility, the clinician must inform
can also be useful to provide patients with short excerpts from the patient of the current status and the need for additional
the evidence-based dental literature to emphasize the need treatment if indicated.
for regular follow-up visits. Many scientific studies have been
published in the dental literature about the benefits of regular
Removal of bacterial plaque and supra- and
maintenance care and recall visits. Several studies have shown
subgingival calculus deposits
that patients who maintain regular periodontal maintenance
intervals experience less attachment loss and lose fewer teeth This includes comprehensive nonsurgical periodontal debride-
and implants than patients who receive less periodontal main- ment and decontamination of any implant surfaces present.72
tenance or none at all.14,17,23,63 Specific maintenance procedures are based on individual needs
as well as probing depth, the quantity and quality of soft and
hard deposits, presence of recessions or implant-supported
Control of risk factors
prosthetic restorations, and, most importantly, on the type
If the patient is a smoker, it is advisable to mention the benefi- of peri-implant treatment plan.
cial effects on the teeth and periodontal/peri-implant tissues, as Nonsurgical periodontal instrumentation must always be
well as on the patient’s general health, that would be achieved delicate, effective, and aimed at the complete removal of all
by quitting smoking. Smoking is the most influential risk factor deposits while respecting tissue integrity, particularly in case of
for periodontal/peri-implant disease, particularly if combined peri-implant tissue health. Use of the periodontal probe is always
with inconsistent support therapy.28 In addition, patients with recommended to detect calcified deposits, mostly subgingivally,
high stress levels and poor ability to manage them are twice prior to their removal. It is also prudent to pay particular atten-
as likely to be affected by periodontal disease.71 Patients with tion to prosthetic structures associated with healthy periodontal
aggressive periodontitis and/or very rough implants seem more tissues. Inadvertent instrumentation could cause changes in
susceptible to peri-implantitis/late implant loss.30 If other risk mucous membrane stability. For thorough yet gentle cleaning,
factors are present, such as systemic diseases or dietary habit could be useful to distribute polishing paste, following the
485

a b
Fig 27-12 (a) Polyether ether ketone material insert (Combi, Mectron) for ultrasonic
mechanical biofilm removal. The tapered shape facilitates peri-implant sulcus debride-
Fig 27-11 The use of a titanium-coated stainless steel ment. (b) Use of a glycine-filled air-flow device (Combi).
universal instrument (Enacare Universal Curet, Micerium),
similar to a Langer 1-2 curet, miniaturized (ie, mini type)
and with millimeter engravings on the shank to indicate
the extent of subgingival penetration, during nonsurgi-
cal periodontal debridement. It is recommended to use
this instrument, mainly with horizontal movements, for
effective decontamination without interfering with the
prosthetic margins.
Fig 27-13 The diode fiber is inserted subgingivally to reach the base of the peri-implant
pocket and activated via the pedal foot control. The insert is maintained in constant
motion, using a continuous, gradual, and delicate rocking stroke, following the profile
of the implant surface and attempting to deliver light energy between the threads and
to the peri-implant inflamed mucosal tissue. To prevent unintended photoactivation (a
possible risk when using the diode laser in close proximity to restorative materials), it
is recommended to apply an antimicrobial gel, thus avoiding carbonization of the tip of
the laser insert.
gingival outline, and then carry out movements with a curette, ably aggressive and properly customized. Systematic reviews
prioritizing instrument strokes in a horizontal direction (Fig 27-11). and controlled clinical trials fail to provide a consensus on what
The polishing paste will act as a lubricant, limiting instrument clinicians should do, particularly for implants with > 50% bone
aggressiveness, while preserving its ability to remove microbial loss.73–76 The elimination of biofilm from the contaminated
biofilm and any small calculus deposits, particularly in the pres- implant surface can be challenging, and furthermore no single
ence of healthy peri-implant tissues. If an ultrasonic instrument method of surface decontamination has been recognized as the
is selected, it is important to execute careful, delicate move- gold standard or found to be superior.15 The author suggests a
ments, applying very light pressure (Fig 27-12a). comprehensive nonsurgical periodontal debridement protocol,
Clinical technique is quite critical when using an ultrasonic consisting of two distinct therapeutic phases, each one based
device. If instrumentation is carried out with no interruptions, on a detailed biologic rationale:
there may be a risk of damaging the prosthetic margins, ie,
scraping or dislodging the cement or at least a portion of it. • Physical methods: mechanical decontamination of exposed
It is important to appropriately calibrate the power setting at implant threads and any laser-assisted disinfection techniques
medium or medium-low. The ultimate peri-implant maintenance • Chemical methods: detoxification of the implant surface
goal is to achieve long-term clinical stability of all treated cases, (Fig 27-12b)
whether managed with an ideal periodontal approach or with an
alternative therapy according to the patient’s wishes or other Nonsurgical laser-assisted therapy can be used, at least in the
patient-centered concerns. first phases of peri-implantitis management (Fig 27-13).4 Laser
On the other hand, in case of peri-implant tissue inflamma- decontamination works through a thermal effect that causes
tion, comprehensive nonsurgical debridement can be reason- protein denaturation and cellular necrosis.77 When used accord-
486

References
Fig 27-14 When implants are present, nonsurgical periodontal instrumentation

must use specific instruments and techniques that are often different or modified
compared with those used around teeth. The implant surface shows similarities
to the natural root surface only in the implant collar area, where it is advisable
to use instruments that are conventionally shaped but of a different material to
respect the integrity of the titanium. Where threads are exposed, it is advisable
to use additional procedures and devices to more effectively remove the biofilm.
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tol 2004;31:749–757. diode and 1064-nm extra-long-pulse neodymium-doped yttrium
65. Jamison CL, Bray KK, Rapley JW, Macneill SR, Williams KB. Anal- aluminum garnet lasers in implant disinfection. Photomed Laser
ysis of patient factors impacting duration of periodontal mainte- Surg 2010;28:273–280.
nance appointments: An exploratory study. J Dent Hyg 80. Moëne R, Décaillet F, Andersen E, Mombelli A. Subgingival plaque
2014;88:87–99. removal using a new air-polishing device. J Periodontol 2010;81:
66. Lang NP, Berglundh T; Working Group 4 of the Seventh European 79–88.
Workshop on Periodontology. Periimplant diseases: Where are 81. Petersilka GJ. Subgingival air-polishing in the treatment of peri-
we now?—Consensus of the Seventh European Workshop on odontal biofilm infections. Periodontol 2000 2011;55:124–142.
Periodontology. J Clin Periodontol 2011;38(suppl 11):178–181. 82. Tastepe CS, van Waas R, Liu Y, Wismeijer D. Air powder abrasive
67. Lindhe J, Meyle J; Group D of European Workshop on Periodon- treatment as an implant surface cleaning method: A literature
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suppl):282–285.
489

28 ALBERTO MONJE • HOM-LAY WANG
Peri-implant
Maintenance Therapy
for Long-Term Success
Etiology of Peri-implantitis
Diagnosis of Peri-implantitis
Risk Indicators for Plaque-Induced Peri-implant
Diseases
Professional Peri-implant Maintenance Therapy
Oral Hygiene Home Care
491

28 | Peri-implant Maintenance Therapy for Long-Term Success
a b
Fig 28-1 (a to c) Clinical illustration of peri-implant mucositis in which

peri-implant marginal bone loss has not migrated beyond physiologic
bone remodeling, but clinical signs of inflammation (bleeding on probing
and erythema) are present.
L
ong-term stability of dental implants has emerged as ETIOLOGY OF PERI-IMPLANTITIS
one of the main concerns in implant dentistry since
they are not immune to diseases and bone loss. Peri-implant diseases have demonstrated inflammation in
Implants are susceptible to bacterial plaque accu- response to anaerobic bacteria, viruses, and yeasts adhered
mulation and subsequent calculus formation similarly to the to biofilm and residual prosthetic cement. Peri-implant muco-
natural dentition. There is a greater risk of inflammation and sitis is limited to inflammation of the gingiva (Fig 28-1),
progressive bone loss around dental implants than natural teeth while peri-implantitis is recognized as bone loss demon-
when bacterial plaque accumulation occurs.1,2 strated on radiographs. In addition, it is noteworthy that there
It has been demonstrated that patients who comply with a are many non-plaque-induced conditions and deformities
regular periodontal maintenance program have less attachment due to improper three-dimensional implant placement that
loss and lose fewer teeth than patients who have irregular or affect the peri-implant tissues that should be diagnosed and
no maintenance.3–6 Peri-implant mucositis and peri-implantitis addressed to minimize the risk of progression to a pathologic
resemble gingivitis and periodontitis; hence it is conceivable that condition.
peri-implant maintenance therapy (PIMT) is a key for long-term Classical findings indicated the high resemblance between
implant durability. There are three major therapeutic goals of periodontitis and peri-implantitis, as it was understood to be
periodontal/peri-implant maintenance: (1) to prevent or minimize initiated by similar putative microbiota, such as Aggregatibacter
recurrence of disease progression in patients who were previ- actinomycetemcomitans, nonpigmented Bacteroides species,
ously treated for periodontitis or peri-implantitis; (2) to prevent or and staphylococci.8 However, peri-implantitis represents a differ-
reduce the incidence of tooth or implant loss by monitoring the ent ecosystem/niche compared with periodontitis.9 As such, it
dentition and prosthetic replacement of the natural teeth; and has been demonstrated that 60% of individuals shared less than
(3) to increase the probability of locating and intercepting other 50% of all species between their periodontal and peri-implant
conditions or diseases found within the oral cavity in a timely biofilms, and 85% shared less than 8% of abundant species
manner. To ensure adequate implant health, close monitoring between tooth and implant.
and professional care by the dental team and good personal The causative effect of oral hygiene restriction and plaque
home care are imperative.7 accumulation on peri-implant disorders has been reported.10–13
During PIMT, dentists and hygienists need to assess overall Comparing the reversibility of peri-implant mucositis and gingi-
implant conditions, such as presence of plaque/calculus, clinical vitis, when a patient’s oral hygiene was restricted for 3 weeks,
appearance of peri-implant tissues (including clinical parame- the crevicular fluid levels of matrix metalloproteinase-8 were
ters such as probing depth, bleeding on probing, suppuration), statistically significantly higher at peri-implant mucositis sites
radiographic bone level when compared with baseline (after than gingivitis sites at 6 weeks. However, the interleukin-1β
physiologic bone remolding in response to definitive prosthesis levels did not differ statistically significantly between the two.13
delivery), occlusal status, stability of the prostheses, and patient When plaque control was resumed, 3 weeks was not enough to
comfort during brushing and function. In addition, changes in achieve an inflammation-free peri-implant environment, indicat-
medical history, habits, and PIMT compliance should be recorded. ing that peri-implant mucositis takes longer to resolve.13
492

Diagnosis of Peri-implantitis
1 ROC curve
1
0.75
0.8
Sensitivity
0.5 BOP- MR- 0.6
BOP+ 0.4
0.25 MR+
0.2
BOP+ MR+
0
1 2 3 4 5 6 7 8 9 0
0.0 0.2 0.4 0.6 0.8 1.0
a b PD (mm) c Specificity
ROC curve
1 1
0.75 0.8
Sensitivity
MR- Pl- 0.6
0.5
Pl+
0.4
MR+
0.25
MR+ Pl+ 0.2
0
1 2 3 4 5 6 7 8 9 0
0.0 0.2 0.4 0.6 0.8 1.0
d e PD (mm) f Specificity
Fig 28-2 Diagnostic accuracy of peri-implant mucositis (a to c) and peri-implantitis (d to f) compared with healthy peri-implant conditions. MR,
marginal recession; ROC, receiver operating characteristic; AUC, area under the curve; CI, confidence interval. (Reprinted from Monje et al31 with
permission.)
DIAGNOSIS OF PERI-IMPLANTITIS peri-implantitis. On the contrary, suppuration indicates the necro-

sis of peri-implant tissues, which are rich in polymorphonuclear
It is of paramount importance to understand that peri-implant cells, and as such, it is a sensitive indicator of bone turnover.26
tissues represent a different structure than the periodontium. Although it may not be present in chronic peri-implantitis,26–29
While tight adherence to the tooth structure through the long it could potentially be present during an acute episode. This
junctional epithelium is present in the periodontal appara- happens in roughly 10% of peri-implantitis sites.30
tus, peri-implant connective tissue fibers have a parallel orien- When peri-implant mucositis is compared with healthy condi-
tation that cannot stop the apical migration of the epithelium,14 tions, BOP, mucosal redness, and suppuration are the significant
with the exception of on a laser-microgrooved implant surface.15 clinical parameters for diagnosing the disease, having a specific-
Furthermore, probing depth (PD) also varies according to the ity of 90%.31 Similarly, when peri-implantitis is compared with
apicocoronal position. As such, PD alone does not seem to healthy conditions, BOP, marginal recession, and suppuration
completely accurately reflect disease condition.16,17 PD is a diag- are clinical parameters used for diagnosing peri-implantitis with
nostic indicator but should be considered in comparison to the high specificity (92%). PD was the only clinical tool that differ-
baseline PD and combined with other diagnostic tools such as entiated between peri-implant mucositis and peri-implantitis.31
clinical inflammatory parameters and radiographic bone level Hence, the diagnosis of peri-implant diseases does not rely
changes for definitive diagnosis.18,19 on individual but rather a combination of clinical parameters
Bleeding on probing (BOP) has been demonstrated to have (Fig 28-2).31–33
a high specificity in monitoring peri-implant disease.20–22 In the In summary, there is a greater variability concerning the
presence of inflammation, BOP has a high sensitivity when diagnostic accuracy of monitoring peri-implantitis. The course
probing deeper sites,23 and its presence in healthy conditions is driven by a series of cellular events, namely significantly
does not seem to translate high sensitivity.24 It is noted that larger proportions, numbers, and densities of CD138-, CD68-,
the mucogingival junction can shift after implant placement, and myeloperoxidase-positive cells and a larger inflammatory
leading to insufficient keratinized mucosa.25 Therefore, although connective tissue infiltrate.34 It is reasonable to accept the pres-
BOP might reliably indicate presence of disease, it does not ence of profuse BOP and marginal recession together with an
seem to be a 100% accurate diagnostic parameter to monitor increased PD as the disease indicators and diagnostic criteria.35
493

a b
c d
e f
Fig 28-3 Lack of keratinized mucosa causing patient discomfort upon

brushing and plaque accumulation that led to the development of
peri-implant mucositis. A free gingival graft obtained from the palate
guaranteed a better environment for implant longevity. (a) Patient com-
pliance with brushing was compromised by discomfort in the mandibu-
lar peri-implant tissues. When the prosthesis was retrieved, plaque and
calculus accumulation as a consequence of discomfort was obvious.
(b) A free gingival graft obtained from the palate was used to augment
g the band of keratinized mucosa while increasing the width of the tis-
sues. (c) Three weeks postoperative. Note the lack of plaque around
the healing abutments. (d) Eight weeks postoperative. Clinical signs of
peri-implant inflammation are no longer present. (e and f) Twelve-month
postoperative images during PIMT displaying peri-implant tissue stability.
(g) Twelve-month evaluation showing peri-implant health.
RISK INDICATORS FOR PLAQUE- • No systemic diseases that may affect bone metabolism
• Cleansable prosthesis without occlusal interferences
INDUCED PERI-IMPLANT DISEASES
As the onset and progression of periodontal diseases occurs, the

individual’s susceptibility may trigger an inflammatory response,
which plays a role in how the preventive therapy is executed. It PROFESSIONAL PERI-IMPLANT
is of paramount importance to consider factors such as a his- MAINTENANCE THERAPY
tory of periodontal disease, tobacco smoking, residual cement,
lack of keratinized mucosa, diabetes mellitus/hyperglycemia, PIMT every 3 to 6 months significantly reduces the incidence
prosthetic factors/considerations, occlusal overloading, genetic of plaque-induced peri-implant diseases 29,36–42 (Table 28-1).
factors, and other systemic conditions in order to create a suc- This is similar to supportive periodontal maintenance ther-
cessful maintenance program that will ensure the longevity of apy.6,43,45,48,49 Interestingly, in one study only 18% of individuals
dental implants. The following clinical conditions are preferred: adhered to the recommended PIMT, and almost 44% of them
were noncompliers.37 It is not surprising that dental implant
• Healthy periodontal environment (plaque-free, nonbleeding failure rate is reduced 90% in patients who have regular main-
tissues) tenance versus no maintenance.38,50–52 Similarly, patients who
• Smokeless environment are PIMT compliers are associated with 86% less incidence
• Screw-retained restorations of peri-implantitis. On the contrary, erratic compliers and non-
• A band of 2 mm of keratinized mucosa, if possible with 1 compliers develop peri-implantitis 24% more frequently.29 An
mm of attached mucosa (Fig 28-3) alarming fact is that there are countries with no dental hygien-
• Controlled diabetes mellitus/hyperglycemia ists or inadequate hygienist training, which makes it difficult
494

TABLE 28-1 Characteristics of studies supporting regular peri-implant maintenance therapy (PIMT) to prevent
peri-implantitis
Outcomes
Mean Peri- Peri-

Follow- interval Mucositis Mucositis implantitis implantitis
Authors Study up Patients of PIMT Implants (patient (implant- (patient (implant
and year design (months) (n) (months) (n) Protocol of PIMT level, %) level, %) level, %) level, %)
Aguirre-Zorzano Cohort 12 27 4 123 PI, PD, and GI measurements, 18.5 NR 3.7 NR

et al 201343 prophylaxis in implants (titanium
22 0 123 50.0 NR 22.7 NR
curettes, carbon-fiber curettes,
rubber cup and prophylaxis
paste), and teeth (piezoelectric
ultrasound), occlusal analysis,
reinforcement of motivation, radio-
graphs every 6 months
Costa et al Cohort 60 39 11 157 Periodontal and peri-implant NR NR 18.0 10.8
201241 status assessment, application
41 0 183 NR NR 43.9 28.4
of disclosing agents, oral hygiene
instruction, coronal prophylaxis,
mechanical debridement
Swierkot et al Cohort 60–192 35 3 22 Oral hygiene control, motivation, 74.2 56.0 42.8 26.0
201244 and reinstruction; professional
18 3 30 44.4 40.0 11.1 10.0
cleaning (steel curettes for teeth
and plastic for implants) and
polishing; SRP when necessary
Ferreira et al Cross- 6–60 94 3.5 578 Examination, reinforcement of oral 64.6 61.70 8.9 8.5
200645 sectional (range: 1–6) hygiene, polishing of teeth and
implants with rubber cups, SRP
118 >6 66.95 9.3
when necessary
Marrone et al Cross- 102 58 NR 266 NR 31.0 38.0 34.5 23.0
201346 sectional
45 NR 40.0
Monje et al Cross- 46 115 3–6 206 Examination (PD, PI, MR, suppura- NR NR 4.5 2.4
201729 sectional tion) oral hygiene reinforcement,
>6 26.3 19
polishing of teeth and implants
None with rubber cups, SRP when 14.3 8.7
necessary, SPT and PIMT with
ultrasonic device and mechanical
instrumentation
Rinke et al Cross- 68 58 4.5 (3–6) NR Examination (PD, BOP, PI), rein- 43.1 NR 3.44 NR
201147 sectional struction, motivation, profes-
31 5 (4–6) NR 48.3 NR 25.8 NR
sional cleaning (ultrasonic and
hand instruments), polishing,
fluoridation
PI, plaque index; GI, gingival index; NR, not reported; SRP, scaling and root planing; MR, marginal recession; SPT, supportive periodontal therapy.
to provide proper implant maintenance. It is important to have lists the factors that should be assessed during PIMT to mini-
adequate and regular professional and personal plaque control, mize the incidence of developing peri-implant disease.
especially for patients who have had implants for longer than
3 years since this is the time point where the rate of onset
increases.53 Objectives
PIMT is the key to long-term implant stability. To ensure ade-

Assessment of patient risk profile quate long-term implant health, close monitoring and professional
care by the dental team and good home care are imperative.
As stated previously, several risk indicators have been linked to Moreover, periodic evaluation and monitoring of implants, sur-
the incidence of peri-implant diseases. It is important during the rounding tissues, and oral hygiene are vital to the long-term suc-
PIMT appointment to assess these factors carefully to minimize cess of dental implants. Therefore, during each maintenance visit,
the likelihood of developing peri-implant diseases. Table 28-2 the dental team has to cautiously evaluate the following factors:
495

TABLE 28-2 Assessment of risk profile according to systemic, local, and patient-related factors
Risk
profile Systemic factors Local factors Patient-related factors Clinical conditions
Low None None Female < 20% full-mouth plaque/bleeding score

Single crown Nonsmoker No mucosal recession
No peri-implant PD > 5 mm
No peri-implant BOP
Moderate History of periodontitis Minimal keratinized mucosa (< 2 mm) Female or male < 20% full-mouth plaque/bleeding score
Light or former smoker Prosthetic plaque-retentive factors Former smoker Clinical mucosal recession
Fixed partial denture Unmotivated behavior and unawareness No peri-implant PD > 5 mm
No profuse peri-implant BOP
High Uncontrolled periodontitis Lack of keratinized mucosa (0 mm) Male > 20% full-mouth plaque/bleeding score
History of periodontitis Prosthetic plaque-retentive factors Heavy smoker Clinical mucosal recession
Heavy smoker Peri-implant residual cement Unmotivated behavior and unawareness Peri-implant PD > 5 mm
Uncontrolled diabetes Fixed complete denture Profuse peri-implant BOP
• Changes in the medical history the paradigm of not using a metal curette as an instrument to
• Full-mouth plaque index (preferred < 20%) scale the implant surface in order to avoid scratches or surface
• Full-mouth BOP (preferred < 20%) modifications is no longer an issue. In fact, if plastic instruments
• Clinical appearance of peri-implant tissues: check for redness are to be used, they should be strong enough to not leave any
and swelling remnants and small enough to gain access to the implants. Sev-
• Peri-implant radiographic bone level compared with previous eral specially designed titanium or carbon-fiber scalers have been
radiographs, including the baseline images taken 6 months developed with the goal of minimizing damage to the implant
after definitive prosthesis delivery surface. However, currently available designs are ineffective
• Technical complications such as screw or prosthesis loos- for cleaning implants with microstructures and rough surface.54
ening, abutment fracture, or prosthesis chip and/or fracture
• Implant PDs under light probing force (≤ 20 Ncm)
Sonic and ultrasonic devices
• Presence of exudate or BOP under light probing force
• Patient comfort during brushing and function A similar dilemma is faced when using sonic or ultrasonic instru-
• Retentive areas related to prosthesis emergence profile and mentation. To avoid implant surface damage, the use of plastic
hygiene access, in particular for a hybrid fixed prosthesis or polytetrafluoroethylene-coated tips is recommended. How-
• Occlusal scheme to detect any overloading ever, calculus and plaque removal is largely dependent on the
• Reinforcement of oral hygiene instructions and use of home tip micromovements rather than the instrument itself. In clin-
oral hygiene instruments customized to fit patient needs ical practice, the use of plastic tips coated with graphite has
been recommended due to its increased rigidity, although data
Moreover, it is important to note that according to the showed it is also ineffective in terms of cleaning implant micro-
patient’s risk profile, the PIMT interval is subject to change structures and rough surfaces.54
(see Table 28-2).
Floss and interdental cleaning devices

Instruments and agents These instruments are primarily used by the patient as oral
hygiene tools. They are used during professional PIMT for two
When using dental instruments to clean implant-supported important reasons: (1) to check for any restorative factors that
prostheses, to ensure the integrity of the implant, clinicians and may impede adequate home care and (2) to motivate and edu-
hygienists should clean the implant abutment surface instead of cate the patient to use them on a daily basis (Fig 28-4). Regu-
the implant itself if there is no peri-implantitis. When cleaning lar floss, rather than Super Floss (Oral-B), should be used very
an implant affected by peri-implantitis, the instruments used carefully since remnants of dental floss might be left behind
should not break, bend, or damage the implant. and trigger inflammation.55 On the other hand, use of Super
Floss with either a triclosan/copolymer dentifrice or fluoridated
toothpaste helps to reduce the load of putative bacteria as well
Curettes
as the Plaque Index and Gingival Index56 (Fig 28-5). A Waterpik
PIMT should be carried out with instruments that do not harm Water Flosser (Water Pik) can also help to keep the implant
the implant structure or leave any materials behind. Interestingly, surface clean and remove food trapped between prostheses.
496

Two major local factors:

• Lack of keratinized mucosa
• Inappropriate prosthetic device
Detection using:
• Interproximal brush
• Floss
Fig 28-4 Peri-implantitis associated with a scenario lacking keratinized mucosa and Fig 28-5 Flossing should be carried out during profes-
an inadequate prosthetic design that precludes proper patient hygiene procedures. sional and personal oral hygiene care.
a b c
d e f
g h
Fig 28-6 (a to f) Locally delivered application of antibiotic (doxycycline gel) and chlorhexidine in combination with mechanical debridement have
shown effectiveness in resolving peri-implant mucositis. (g and h) Three weeks after application. Note the clinical resolution of mucosal erythema
and lack of bleeding.
Chemotherapeutic agents PIMT as it represents a reversible entity.13 It has been demon-

strated that the nonsurgical treatment of peri-implant mucosi-
Several antimicrobial agents have been used during PIMT. tis was effective, and the adjunctive use of antimicrobial rinses
Amongst them, subgingival irrigation and application of chlorhex- in conjunction resulted in optimal outcomes.60,61 Furthermore,
idine 0.12% has shown to be an adjunct to mechanical debride- mechanical debridement plus adjunctive tetracycline fibers was
ment to reduce plaque, inflammation, and PD in peri-implant shown to successfully treat peri-implant mucositis.62 Therefore,
mucositis.57,58 Hence, during PIMT it is recommended to brush it seems that the use of locally delivered agents as anti-infective
and floss regularly and use an antimicrobial mouthrinse such therapy adjunctively to mechanical debridement is beneficial
as chlorhexidine as an occasional adjunct. Combined mechan- for the interceptive treatment of peri-implant mucositis during
ical therapy with povidone-iodine rinse resulted in signifi- PIMT (Fig 28-6).
cant clinical improvements (BOP and PD reduction and gain
of clinical attachment level) after 12 months.59 This suggests
Polishing
that povidone-iodine can be used as an alternative antiseptic
agent with combination therapy. The use of polishing cups and other polishing devices is encour-
The use of locally delivered agents was further proposed aged for supramucosal elimination of retentive/irritant areas and/
for the treatment of peri-implant mucositis during interceptive or elements such as irregularities on the restoration or supramu-
497

Peri-implant condition
Nonsurgical and/or surgical

Nonsurgical treatment Peri-implant mucositis Peri-implant health Peri-implantitis
treatment
Risk profile
Low-risk profile Moderate-risk profile High-risk profile
• Motivation
Uncontrolled
• Reinforcement of oral History of periodontitis No history of periodontitis History of periodontitis
hygiene measures periodontal disease
Smoking cessation
Plaque- No plaque- Plaque- No plaque- counselling
retentive retentive Active periodontal
retentive retentive
factors factors therapy
factors factors
Remove Remove • Motivation

• Reinforcement of oral hygiene measures
• Smoking cessation counselling
• Motivation
• Reinforcement of oral hygiene Presence of keratinized Lack of keratinized
measures mucosa mucosa
• Smoking cessation counselling
3-month recall • Motivation Free gingival graft

• Reinforcement of oral hygiene
If motivated, adequate oral measures
hygiene and smoking cessation • Smoking cessation counselling
for > 6 months
6-month recall 3-month recall 6-month recall 3-month recall 3-month recall
Fig 28-7 Decision-making algorithm according to the patient’s risk profile.
cosal calculus on the implant neck. A glycine powder airborne It should be noted that when using regular floss, care should
particle–abrasion device has been suggested as an adjunctive be taken to avoid leaving remnants of dental floss since this
tool for mechanical debridement.44,45 may lead to inflammation.55 Super Floss, on the other hand,
seems to be effective in reducing gingival inflammation and
plaque surrounding the implants and should be recommended
Laser-assisted therapy
to patients. This is particularly important for hybrid prostheses,
Laser-assisted implant surface disinfection has recently gained in which interproximal brushes might not have passive access.
attention for its potential benefit without significant alteration of
the implant surface topography. The main roadblock of applying
a laser nonsurgically is access and limited tactile sensation for
its application. There is limited evidence on the predictability CONCLUSIONS
of the potential use of lasers for the nonsurgical application
during PIMT.46 Implant maintenance should be incorporated in the initial treat-
ment plan. Patients who are unwilling to adhere to regular PIMT
and administer daily home care should not be considered candi-
dates for dental implants. These two elements are considered
ORAL HYGIENE HOME CARE key for long-term implant success. For professional support-
ive peri-implant maintenance therapy, hand instrumentation,
Prevention of peri-implantitis with personal oral hygiene polishing, chemotherapeutics, and subgingival irrigation are the
therap
ies is a major factor in long-term implant outcomes. treatments of choice. Individuals with a low-risk profile should
Patient-administered mechanical plaque control is an effective be scheduled for a 3- to 6-month PIMT recall, while those with
preventive measure. Therefore, the goal is to provide patients moderate- and high-risk profiles should participate in a 3-month
access and capability to perform good oral hygiene. A report PIMT recall program (Fig 28-7). The clinician and dental hygienist
showed peri-implantitis incidence of 48% in implant prostheses should be aware of local contributing factors that could lead to
that provided no interproximal accessibility for proper oral hygiene plaque retention and challenge implant health. Clinical param-
compared with 4% in implants with accessibility.47 eters should be used on a daily basis to monitor peri-implant
498

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29 MARK LUDLOW • LYNDON F. COOPER
Implant Complications:
A Reality Requiring
Prevention
Implant Failure and Fracture Complications
Abutment-Mucosa Complications
Abutment Failure and Fracture Complications
Abutment Screw Fracture and Loosening
Prosthetic Screw Loosening and Fracture
Prosthesis Attrition and Fracture
Careful Diagnosis and Planning to Reduce
Complications
501

29 | Implant Complications: A Reality Requiring Prevention
Fig 29-1 Innate biologic and bio-

TABLE 29-1 Innate risks influencing implant success mechanical risk factors influence
implant success. An implant il-
Risk factor Examples
lustrated with an abutment and
Systemic factors influencing Bone density, genetic factors crown successfully integrated
osseointegration with bone and mucosa. Innate
risks affecting success include:
Systemic factors influencing History of periodontitis, genetic factors local and systemic factors influ-
mucosal integration encing osseointegration (1), local
Implant factors Surface roughness and systemic factors influencing
mucosal integration (2), implants
Implant component factors Abutment screw dimension and components (3), prosthesis
(4), biofilm (5), and functional
Prosthesis design Cantilever dimension
loading (6).
Prosthesis construction Monolithic zirconia versus metal/acrylic
Prosthetic component factors Internal versus external connection
Functional loading Bruxing habit
A
s dental implant therapy becomes more main- IMPLANT FAILURE AND
stream in the world of restorative dentistry, an
increasing number of indications and a broader FRACTURE COMPLICATIONS
spectrum of experiences have encouraged a wider
vision of dental implant success. Failure may be regarded simply Post-loading implant failures and fractures are fortunately rela-
as an implant lost from the mouth. However, success can be tively rare complications, comprising less than 1% of all com-
considered with greater granularity. The outcomes of implant plications reported.1 However, they are devastating events for
therapy can be assessed with regard to patient-based, biologic all involved. Implant fractures occur horizontally or vertically.
(bone and mucosa), functional (mastication, speech), esthetic, Horizontal fractures are associated with inappropriately placed
and component outcomes. While there exists no equation that narrow implants or occur within the implant at the point of thin-
compiles these factors into a single outcome measure, different nest implant wall (typically at the base of the abutment screw
implant therapies in individual patients offer unique challenges channel) (Fig 29-2). Relative fracture rates of conical versus exter-
to the daily practice of implant therapy. nal hex implants were addressed in an in vitro study comparing
The innate risks influencing implant success can be catego- 3.5-mm conical versus 3.75-mm external hex implants. There
rized into several areas (Table 29-1 and Fig 29-1). These innate was no difference in the bending elastic limit of the two implant
risks embody the molecular and cellular factors that promote designs.2 Vertical fractures occur among internal abutment con-
osseointegration and its preservation, the antagonizing factors nection implants and should be investigated in instances of
that cause bone loss and peri-implantitis, and the biomechan- repeated abutment loosening and where vertical bone loss is
ical forces acting within the prosthesis, components, implant, observed at an implant (Fig 29-3). The diagnosis is simple to
and bone. Clinical decisions and patient behaviors modify these make and typically catastrophic.
innate risk factors and can magnify deleterious biologic or biome- The causes of failure are frequently attributed to a defective
chanical actions that lead to implant failure. implant, poor implant manipulation (eg, over-torquing at inser-
Recognition of these innate biologic, biomechanical, and tion), poor implant location leading to overloading, undersized
component risk factors requires that the profession also implants for the ascribed function, or parafunctional habits.
acknowledge that over time—even under ideal circumstances— Suggested methods of treating implant fractures include (1)
these innate risks may result in implant complications or even removal, (2) maintaining or burying the fractured implant and
failure. Excellent clinical performance should not be confused modifying the prosthesis, or (3) alteration of the implant and
with perfection. Components break, prostheses degrade, and reconstruction of the prosthesis.3
patients age and change. In addition, clinicians may make errors The authors refer to implant complications as situations that
in planning and execution that increase the innate risks influ- make the integrated dental implant nonrestorable. This chapter is
encing implant success. concerned with biomechanical and pragmatic (iatrogenic) compli-
The aim of this chapter is to identify the clinical factors that cations. A truly nonrestorable implant may present as one that is
amplify the mechanisms of these innate risk factors, leading placed too shallow and cannot be restored functionally or esthet-
to complications and failures. It focuses largely on component ically (Fig 29-4). Alternatively, a truly nonrestorable implant may
and prosthetic complications, addressing the clinical challenges be so lingually or facially oriented that it cannot be functionally or
they present and offering possible solutions for them. Further, in esthetically restored (Fig 29-5). A third situation in which implants
each case, preventive strategies are offered in terms of planning, may not be restorable is when two implants are placed with a
execution, and long-term management of implant prostheses. proximity that precludes impressions and abutment placement
502

Implant Failure and Fracture Complications
Fig 29-2 (a) A horizontal fracture

of the implant has occurred. This
can happen if thin-walled implants
of certain designs are used in
high-force areas. (b) The compo-
nents are removed and unfortu-
nately are not reusable. When this
complication occurs, removal of
the implant is required.
a b
a b
Fig 29-3 Vertical fracture of the implant. (a) What was originally observed as vertical distal bone loss progressed to mobility and loss of the abut-
ment. (b) Radiograph taken at the subsequent visit demonstrating fractured abutment fragment and complete displacement of the distal wall of
the implant. The terminal single tooth or abutment should be carefully managed in terms of prosthesis design, implant diameter, and occlusal
function. The implant requires removal.
a b
c d
Fig 29-4 (a) Implant is placed too shallow in both the right lateral and left central incisor locations. (b) Various prosthodontic modifications were
used to overcome the shallow implant position. (c) After 8 months in use, these modifications failed due to the absence of sufficient restorative
dimension. (d) The components could not be reassembled. The depth of implant placement must be determined during planning and should be
identified or directed by a surgical guide (or navigation system).
503

Fig 29-5 (a and b) Implants

are placed too far facially and
distally to allow the restorative
plan to be accomplished. One
of the implants required modifi-
cations to the platform to allow
for the seating of the restorative
components. Surgical guides
demonstrating the location of
the planned prostheses should
be used in all implant surgeries
a b
to avoid these obvious yet non-
restorable situations.
TABLE 29-2 Abutment-mucosa complications

Complication Possible cause(s)
Peri-implant mucositis Biofilm

Loose abutment
Residual cement
Discoloration Thin mucosa
Abutment color
Recession Facial implant orientation/thin mucosa
Post-inflammatory recession
Therapeutic recession
Hypertrophy Chronic inflammation beneath or adjacent to prosthesis
Fig 29-6 Two implants were placed too close in proximity
to one another, requiring the cutting of the platform of
one of the implants to allow for seating of the restor-
ative components. This can result intraoperatively when
implants that are wider than planned are selected and
encroachment of the interimplant space occurs.
(Fig 29-6); similarly, a single implant may be oriented too closely probing,5 and there should be minimal probing depths (< 5 mm)
to an adjacent tooth to allow restoration. These are complications and no purulence. Ideally, the peri-implant mucosa should be
of an iatrogenic nature. Implants may become nonrestorable if composed of keratinized mucosa as systematic reviews have
an adjacent tooth moves mesially into the edentulous space demonstrated the mucosal and bone-related complications
during healing; modifying the mesial surface of the offending associated with its absence.6 The peri-implant mucosa, there-
tooth can often solve this complication. Relative implant malpo- fore, should be similar in color, texture, and contour to that on
sition can be addressed restoratively, or in multi-implant cases, the adjacent and contralateral teeth. This is a basis for the pink
the implant might be left beneath the mucosa. esthetic scoring system.7
Complications associated with the mucosa are due to (1)
biofilm-mediated changes in the mucosa, (2) foreign body
changes in the mucosa, (3) architectural changes associated
ABUTMENT-MUCOSA with implant-induced alterations in bone and mucosal form,
COMPLICATIONS and (4) color changes related to abutment placement within
the mucosa (Table 29-2).
In conditions of health, the peri-abutment mucosa should be free Inflammation of the mucosa can lead to peri-implant bone
of inflammation, have proper coloration, and demonstrate appro- loss (peri-implantitis). Further, it can be associated with discom-
priate contour that is stable over time. While it is not the intent of fort and esthetic limitations related to redness and bleeding.
this chapter to discuss peri-implant mucositis or peri-implantitis Mucosal inflammation is the result of the host immune system’s
in detail, this biofilm-mediated complication occurs with rela- response to accumulating biofilm or foreign bodies such as
tively common frequency: Peri-implant mucositis occurs in 40% cement.8 Mucosal inflammation also results from the mechan-
of patients and 20% to 25% of implants, while peri-implantitis ical stimulation caused by micromotion of the implant-abutment
afflicts 20% of patients and 10% of implants.4 The peri-abutment interface. Macroscopically loose abutments present retrograde
sulcus should display an absence of or minimal bleeding on biofilm exposure and mechanical trauma to the mucosa.
504

Abutment-Mucosa Complications
TABLE 29-3 Factors influencing residual cement at implant crowns

Factor Impact Reference
Implant location More residual cement in posterior versus anterior sites Kappel et al 201619
Implant diameter Limited effect Vindasiute et al 201520
Depth of placement > 1 mm results in increased residual cement Linkevicius et al21
Undercut dimension > 2 mm results in increased residual cement Vindasiute et al 201520
Emergence profile More residual cement in convex versus concave profiles for shallow designs Sancho-Puchades 201722
Type of cement More residual cement associated with polymethyl methacrylate versus zinc oxide–eugenol Korsch and Walther 201512
a b
Fig 29-7 (a) One of the most detrimental outcomes associated with the lack of cement removal leading to sepsis is com-
plete failure of osseointegration. This photograph reveals how much cement can be placed beyond the abutment-crown
interface during an immediate loading scenario. (b) This periapical radiograph is more typical, showing residual cement
tenaciously bound to the abutment. Only the interproximal surfaces are revealed. If necessary, the interproximal tissue
can be retracted for access and removal. Alternatively, the abutment and crown can be removed to assure cement is
removed circumferentially around the abutment.
Residual cement is an iatrogenic cause of mucosal inflamma- sion of excess cement prior to clinical cementation of the crown
tion and has garnered much attention. With early reports surfac- or venting crowns prior to cementation.16–18
ing in the late 1990s,9 it was a decade later when a retrospective Residual cement is commonly found on dental implant abut-
cohort study implied cause and effect related to peri-impantitis.10 ments.11,19 A variety of factors are thought to promote the reten-
The incidence of finding previously undetected cement upon tion of cement in the sulcus or adherent to abutments following
abutment and crown removal is high, approaching 75% in one cementation12,19–21 (Table 29-3). Many relate to the technique
study.11 The role of resin cements versus zinc oxide–eugenol of cementation, and certainly residual cement can be reduced
cements in peri-implantitis have been investigated.12 Resin by diligent efforts to remove cement following cementation.
cements (eg, Temp-Bond, Kerr), not zinc oxide cements, are Attempts to reduce residual cement on abutments using custom
associated with clinical signs of peri-implantitis, and replace- versus stock abutments or alteration in the submucosal form of
ment of resin cements with zinc oxide cements was associated the abutment has not proven beneficial. Reducing the depth of
with the reversal of inflammation.13 Moreover, the study demon- the crown-abutment interface circumferentially around the tooth
strated that red-complex bacteria were prevalent at abutments is one factor to enhance cement management (Fig 29-7). Use
cemented with resin-based cements but not zinc oxide–eugenol of radiopaque cements and trial cementation of crowns with
cements.14 With the advent of patient-specific computer-aided abutment analogs are commonly recommended methods to
design/computer-assisted manufacture (CAD/CAM) abutments reduce the amount of retained cement at implants.
with minimally tapered axial walls, a zinc oxide–eugenol cement Screw-retained crowns represent the alternative solu-
may provide an alternative for cementation of implant crowns tion to cement-retained restorations. The concern regard-
to limit the risk of peri-implantitis. The risk of debonding from ing cement-associated peri-implant inflammation has led to
well-designed abutments appears to be low.15 Solutions to fundamental changes in restoration preference. The use of
cementation have been repeatedly suggested, such as extru- screw-retained crowns is suggested, and the recent introduc-
505

a b c
Fig 29-8 (a) The application of an angled screw access channel is facilitated by new components
and CAD/CAM technology. Specific screwdrivers are required, and often designated screws are
provided. Angle corrections of 20 to 30 degrees can be achieved. (b) The angled screw access
directs the screw channel lingually. (c) The definitive crown has the screw access displaced
approximately 10 degrees to avoid the incisal edge. (d) Delivery of the screw-retained crown
through the angled screw access channel.
a b
Fig 29-9 Recession is an unwanted outcome for esthetic implants. (a) An example of recession that reveals the zirconia
abutment. Facial implant position is the leading cause of recession following implant placement and restoration. (b) Attempts
to cover exposed implants may not fully account for recession. The depth and facial position of this implant may have caused
the recession.
tion of angled screw access abutments enables the physiologic popularity of immediate implant placement. In such instances,
placement of an implant in the anterior maxilla that is consistent peri-implant mucosal recession was reported to approach a
with use of a screw-retained crown (Fig 29-8). median frequency of 26% in reported studies.26 The prominent
Abutment discoloration of mucosa is a complication that is factors influencing peri-implant mucosal recession include (1)
related to the architecture of the implant site. Peri-implant muco- thin mucosal biotype, (2) smoking, (3) deep implant placement,
sal graying is related to the thickness of the mucosa overlying a and (4) facial implant placement.27 To prevent this outcome, the
silver-colored titanium abutment and is well documented in the implant-abutment interface should be placed approximately 3
literature. Different restorative materials all result in measurable mm apical and 2 mm palatal to the planned mucosal zenith.28
discoloration that decreases with increasing mucosal thick- Under such restrictions, the axial orientation should be directed
ness.23–25 In ideal circumstances, ≥ 2 mm of mucosa should to the incisal edge or slightly lingual.
exist facial to the abutment. When tissues are thinner, the gray- Among the attributed factors, facial implant placement is the
ing can be ameliorated by use of a gold-colored abutment or a predominant cause of recession.29 When faced with causes
white zirconia abutment. attributable to thin biotype or minor facial angulation/displace-
Peri-implant mucosal recession is frequently reviewed in the ment of the implant, it is possible to augment the mucosal
literature, suggesting its problematic nature in clinical practice thickness using a subepithelial connective tissue graft and syner-
(Fig 29-9). This issue has become more important with the rising gistically alter the transition contour of the abutment. When
506

Abutment Screw Fracture and Loosening
a b c
Fig 29-10 Fracture of titanium abutments is a rare but possible occurrence. (a) Fracture of a stock titanium abutment for a single crown. (b)
Fracture of four abutments for a full-arch prosthesis. (c) Fractured abutments in the prosthesis immediately following its removal from the mouth.
Fig 29-11 A fractured zirconia abutment retrieved from the implant. The comminuted fracture
requires that all pieces be removed from the implant, and it often takes considerable time to
dislodge the fragments from the threads of the implant.
the implant is angled or displaced too far facially with greater Abutment fractures arise when zirconia is used in other situ-
than 2 to 3 mm of recession occurring, implant removal and ations, such as for molar implant restorations. While the zirco-
replacement may be required. Such procedures have multiple nia abutment can be replaced and a new crown fabricated,
stages, requiring months to years, and may yield only modest one striking aspect of this failure is that the apical aspect of
improvements. This multistep process is beyond the scope of the abutment is frequently tightly retained within the implant.
this chapter and requires assessment of the existing tissues Its removal requires patience and extreme care to dislodge
and prognostication of the biologic impact of future interven- the abutment fragment while preserving the integrity of the
tions. Guided implant placement can assure proper placement threaded internal aspect of the implant.
of implants in high-risk areas.
ABUTMENT SCREW FRACTURE

ABUTMENT FAILURE AND AND LOOSENING
FRACTURE COMPLICATIONS
Abutment loosening is perhaps among the most frequent compli-
Titanium abutment fracture is a relatively rare event in clinical den- cations observed in clinical implant dentistry. Early reports regard-
tistry (Fig 29-10). However, previous castable custom abutments ing single-tooth implants were associated with high rates of abut-
and zirconia abutments do present fractures30 (Fig 29-11). The ment screw loosening. Over time, with the development of new
advent of CAD/CAM patient-specific abutments has improved abutment designs (particularly conical connections) and the gen-
the manufacturing process and precluded rotary instrument mod- eralized use of torque drivers for insertion of abutment screws,
ification of zirconia abutments, which weakens the bulk zirconia there has been a reduction in the reported incidence of abutment
material. The authors’ prospective clinical evaluation of zirconia screw loosening. In a 2012 systematic review of single-tooth
abutments demonstrated the absence of fractures at approxi- implants, the rate of screw loosening approached 5%.33
mately 3 years; however, these were restricted to single-tooth Abutment screws loosen when there is a reduction in preload
anterior maxillary implant restorations.31 A 4- to 10-year evaluation (the clamping force the screw exerts on the two opposing parts).
of CAD/CAM zirconia abutments also indicated low complication This reduction can arise by deformation of the screw caused by
rates.32 Nonetheless, it is recommended that zirconia abutments excessive bending moments (lateral loads). Such events typi-
be limited to use for single anterior implant restorations. cally occur only after a period of function. Systematic reviews
507

Fig 29-12 The patient presented with a broken section of her

implant prosthesis due to the loosening and fracture of the
abutment screws. (a) The loosening of abutment screws can
lead to a multitude of clinical complications, the most severe
of which is noted in this case. Here the patient fractured not
only the heads of the abutment screws but also the implant
prosthesis at the connector. (b) The retrieved fragments of
the abutment screws and fixed dental prosthesis. Saving the
implants with intact threads and abutment interfaces is the
focus of future treatment.
a b
a b c d
Fig 29-13 Managing loose abutment screws beneath cement-retained crowns. (a) A periapical radiograph is essential to guide the clinician from
the occlusal surface to the screw chamber. As shown here, access perpendicular to the occlusal surface of the crown would eventually perforate
the crown and destroy the abutment. (b) The clinical appearance of the crown does not inform the clinician regarding abutment screw position.
(c) Successful access using a small round diamond bur to identify the screw channel beneath the crown is followed by opening of the access to
engage the screw with a screw driver. (d) The crown and abutment are successfully removed.
have not fully addressed all of the risk factors for screw loos- delayed seeking treatment. Abutment screw fracture may also
ening. Yet, practically speaking, some abutment screw loosen- occur after repeated attempts to retighten a loose abutment.
ing risk factors to consider include the following: (1) anterior Abutment screw fractures are also seen in large prostheses
versus posterior crown location, (2) opposing dentition, (3) coni- where cantilevers or a poorly fitting prosthesis increase the
cal versus internal parallel versus external hex connections, (4) bending moments or magnify the forces on the screw. When
excess incisogingival crown height, (5) cast abutment versus a screw fracture is noted, it is important to seek the root cause
CAD/CAM abutment, and (6) use of a torque-control device. of the screw fracture. Replacement of the screw without inves-
Abutment screw loosening may result from two distinct iatro- tigating the cause of fracture implies that the clinician believes
genic causes. One is simply applying the wrong torque or arbi- only the screw fatigued or was flawed.
trary torque control (not using a torque controller). The other A loose abutment screw beneath a cement-retained crown
is the placement of an abutment against existing cortical bone requires careful diagnosis and stepwise management. Patients
during insertion. This can occur when the diameter of the abut- often call concerned about a loose implant. Reassurance is
ment is wider than the implant osteotomy and the implant is important as loose abutment screws occur with greater
in a subcrestal location (and not necessarily circumferentially). frequency than failing implants. A radiograph is valuable to
In such cases, torquing the abutment develops screw preload examine the potential for a vertically or horizontally fractured
with the abutment seated against the cortical bone and not implant. It is also valuable to estimate the position and trajectory
against the implant. Over several weeks, impending cortical of the screw channel as it emerges from the implant through
bone resorption ensues, and the abutment screw becomes the abutment to the crown. While managing a loose abutment
loosened as preload is lost. In such cases, abutment screw screw beneath a crown is time consuming, more time may be
loosening occurs soon after restoration. involved if one attempts to cut the crown from the abutment.
Abutment screw fractures (Fig 29-12) may be expected in a It is suggested to identify the screw channel and drill through
practice with many implant restorations. They are not particularly the occlusal surface of the crown to gain access to the screw
rare events. When observed, they are chiefly associated with so it may be tightened or replaced. This process often saves the
undersized implants and abutments that use narrower abut- metal-ceramic or all-ceramic crown cemented onto the abut-
ment screws. Abutment screw fracture may be associated with ment (Fig 29-13). Importantly, when the abutment screw has
a history of a loose implant abutment for which a patient has been accessed, it is beneficial to remove the abutment and
508

Prosthesis Attrition and Fracture
a b
Fig 29-14 (a) Loose full-arch implant-supported fixed prosthesis. Note there is no anteroposterior spread of the five implant positions. The cantile-
vers are four to five times longer than the anteroposterior spread and may have contributed to the forces leading to component fracture. (b) Two
prosthetic screws had fractured heads and a third had been stripped, requiring slotting to remove the screw. Significant time is required. Prosthetic
screws are accessible above tissue level and present less complex access than abutment screws. Abutment screws often require mucoperiosteal
flap elevation to expose the abutment to gain access to the abutment screw fragment within the implant.
cemented crown to (1) access loose cement, (2) assess the single study. Additionally, single crown restorations demon-
integrity of the implant-abutment interface, and (3) clean the strated the vast majority of screw loosening.37
implant chamber with an antimicrobial rinse. Prosthetic screws are subject to lateral loads and force magni-
fication from offset occlusal forces and cantilevers. Increasing
cantilever length only increases the stresses in the small pros-
thetic screws.
PROSTHETIC SCREW LOOSENING
AND FRACTURE
Prosthetic screws are the smallest components of PROSTHESIS ATTRITION AND
an implant-supported prosthesis. They attach the prosthesis to FRACTURE
an implant abutment (Fig 29-14). Prosthetic screw loosening is
the ultimate result of cyclic torsional loading associated with Several systematic reviews have now clearly demonstrated
function and varies among different implant-abutment connec- that there is both attrition and fracture of implant prostheses
tions.34 The type of material, screw geometry, type of abutment, on single-unit, multiple-unit, and full-arch prostheses. Single
and passivity of fit also contribute to screw loosening behavior. implant crown fracture rates are higher than implant failure rates
Generally speaking, tapered internal connections stabilize the and represent one of the more frequent complications reported
connection along relatively long conical interfaces, whereas for single implants.33 In addition, debonding of single crowns is
the abutment screw bears the forces in external connections. also reported and could reflect the use of temporary cements
The move to conical interfaces may underscore the reduction on suboptimal abutments. Less is known about the longer-term
in recently reported incidence of screw loosening for single behavior of short-span fixed dental prostheses supported by
implant crowns.35 implants. It is assumed that a similar rate of fracture occurs for
The incidence of loosening has been reduced with experi- these as for single-unit restorations.
ence and the use of torque-control devices. One key factor in Regarding full-arch implant-supported fixed prostheses, a
reducing prosthetic screw loosening and fracture is passivity synopsis of multiple systematic reviews and prospective or
of the prosthesis on abutments. A recent systematic review retrospective cohort studies is that there is a time-dependent
indicates that measurement of misfit is complicated in a clini- and continuous increase in prosthetic complications, including
cal setting, and while misfit may not negatively influence osse- failure (as defined by replacement). Metal-acrylic restorations
ointegration, it does negatively influence complications such as are associated with complications and require maintenance and
screw loosening.36 Presently, the use of CAD/CAM prostheses repair, most frequently related to veneer fracture and wear.38 A
may dramatically enhanced the ability to deliver passively fitting recent cohort study involving 94 screw-retained metal-acrylic
prostheses, and with this screw loosening and fracture may implant-supported fixed dentures revealed a 17% rate of
also be reduced. mechanical complications after average use of 35 months.39
Another factor influencing abutment screw complications is These included fractured teeth and screw loosening. It has been
the location of the restoration; mandibular molars and maxillary reported that after 20 years only 11% of metal-acrylic prostheses
anterior teeth experienced the greatest rate of loosening in a were free of complications.40 Regarding porcelain-fused-to-metal
509

Fig 29-15 (a and b) Two different views

of a fractured prosthetic screw still lodged
in the multi-unit abutment and requiring
removal. Note the head of the prosthetic
screw had fractured and separated from
the body of the screw.
a b
TABLE 29-4 Key treatment-planning factors affecting biomechanical complications

Factor Impact Suggestions
Implant dimension Narrower implants possess smaller implant-abutment interfaces with Use implants of sufficient dimension for function. Perform horizontal
smaller abutment screws. bone grafting to accommodate where needed.
Implant position May increase cantilever length and bending moments. Place implants beneath center of crown. Use angled screw access to
place screw channel directly within center of restoration.
Restorative dimension May reduce height of “beam,” leading to increased flexure and forces Control depth of implant placement. Plan and prescribe alveolectomy
within the implant-abutment complex. where needed.
restorations, one study41 reported a 20% complication rate prosthesis longevity and reduced complications when restor-
for porcelain chipping. Most recently, 22.1% 5-year and ative space is limited.
39.3% 10-year metal ceramic chipping rates were reported
for metal-ceramic complete-arch implant-supported fixed
dentures.42 Regarding monolithic zirconia restorations for
full-arch treatments, early systematic reviews have indicated CAREFUL DIAGNOSIS AND
that there are few complications.43,44 While the monolithic pros-
PLANNING TO REDUCE
theses appear robust, there is a unique complication of tita-
nium cylinder debonding that has been reported.43,44 From many COMPLICATIONS
reports,42–44 it may be concluded that (1) metal-acrylic prosthe-
ses demonstrate relatively high complication rates represent- Dental implants and components do loosen, fracture, or oth-
ing veneer wear and fracture, (2) metal-ceramic and veneered erwise fail. However, they do so at rates that suggest they are
zirconia restorations do not escape the risk of fracture, and (3) sufficiently strong for a large majority of clinical situations. The
monolithic zirconia restorations appear robust in the relatively failure of implants, components, and supported prostheses are
short term (Fig 29-15). likely the result of overtaxing the constructed system. While
Large prostheses resemble beams in their structure. The biologic integrity can be reduced due to local inflammatory and
stresses that accumulate in these prostheses approximate the systemic changes that influence bone and mucosal function,
laws governing beams. As such, one of the most effective ways the biomechanical integrity of the implant prosthesis complex
to reduce the stress in a beam/unit force is to increase the height is due to the impact of masticatory force. Careful diagnosis and
of the beam. In considering any plans for an implant prosthe- treatment planning can reduce the risk of functional overloading
sis with a large span or cantilever, the restorative dimension or and assure sufficient dimension for robust prostheses.
height of the prosthesis must be managed. Taller prostheses Implant planning is complex. However, three key factors can
will possess greater resistance to deformation (stress genera- assist the clinician in avoiding biomechanically related compli-
tion) upon loading. Another approach to reducing force-induced cations (Table 29-4). The first is to plan for implants of suffi-
deformation of a prosthesis is to select materials with a larger cient dimension to provide strength to the implant and the
modulus of elasticity. For example, moving from commer- implant-abutment interface. The second is to place implants
cially pure titanium to a cobalt-chrome alloy as a material for a in positions that reduce or eliminate large bending moments,
metal-acrylic prosthesis results in nearly a 10-fold increase in eg, do not construct a prosthesis with excessive cantilevers.
the modulus of elasticity. This may be particularly important to The third critical guiding principle is to provide for sufficient
510

Careful Diagnosis and Planning to Reduce Complications
a b
c d
Fig 29-16 No material is impervious to complication and fractures. Examples of fracture in metal-acrylic (a), porcelain fused to metal (b), monolithic
zirconia (c), and acrylic resin (d).
restorative dimension and to match this dimension to both the tional implants merits careful consideration in such cases. Most
physical properties of the restorative material and the esthetic/ significantly, moderately rough-surfaced dental implants have
phonetic/hygienic requirements of the situation. been shown to increase implant survival in type 4 bone and are
Implants are sold by many manufacturers and are provided recommended as part of a strategy to overcome implant loss
in varying dimensions. In some systems, increasing implant in this situation.48
diameters are associated with larger abutments and often larger Implant location relative to the occlusal force can influence
abutment screws. Varying implant lengths may be less import- functional loading. The authors have learned that nonaxial
ant for longevity; short implants have proven to be successful implant placement is congruent with implant survival. This is
when compared with longer implants of identical design. Select- observed with anterior maxillary implants with angulations
ing sufficiently large implant-abutment interfaces to support from the occlusal plane of approximately 20 to 30 degrees
increasing functional loads is essential for longevity planning. It and with tilted posterior implants used in all-on-four treat-
has been reported that implant fracture is reduced significantly ment plans. However, implant placement remains critical to
with a 1-mm increase in implant diameter.45 the performance of the attached abutment and crowns. In
It is important to consider the affiliated requirement of hori- a recent in vitro cyclic loading test, eccentric loading had a
zontal bone grafting to accommodate sufficiently large implants dramatic effect on screw behavior and structure. However,
with ample surrounding bone when planning. It should be noted this negative impact was not observed for internal joint system
that some investigations have supported the use of narrow reverse-torque measures.50 The focus in planning requires that
implants to avoid horizontal grafting associated with posterior the implant be located beneath the center of a single crown
implant placement. Relatively high short-term implant survival or central to the mesiodistal borders of a multi-unit splinted
has been reported; however, longer-term and broader experi- prosthesis (Fig 29-16).
ences are warranted.46 Bending moments can markedly increase the force acting
It is also important to consider the local and systemic factors on implant components.51 The use of cantilevers should be
that may influence functional loading. Bruxism is associated carefully considered. A systematic review of the few studies
with increased risk of implant failure,47 and markedly low bone available suggest that cantilevers may not influence marginal
density remains a concern when considering implant outcomes bone loss but can contribute to increased technical complica-
in type 4 bone.48,49 Thus, the distribution of loading should be tions.52 With the use of splinted implant cases using distally
carefully reconsidered in such cases. Larger implants increase tilted implants, a single molar cantilever may be tolerated in
bone-implant surface area incrementally; however, improved ideal situations. Mesial cantilevers supporting a single tooth
distribution of implants by avoiding cantilevers and adding addi- may also be managed under ideal conditions.
511

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513

Index
Page numbers followed by “f” denote figures; “t” tables; and “b” boxes.
A augmentation of
description of, 131
Abutment(s). See also Implant-abutment junction. height classifications for, 265t
angled, 79 horizontal. See Horizontal bone augmentation/
Atlantis, 100f, 101 regeneration.
bio-activated, 402 maxillary sinus augmentation and, 254
cleansed, 401 maxillary tuberosity bone grafts used in, 186–188
customized, 400–401 recombinant human bone morphogenetic protein-2
decontamination of, 400 for, 343
definitive, 399, 401f sinus elevation for, 283
failure of, 507 vertical. See Vertical ridge augmentation.
fracture of, 507, 507f postextraction contour and dimensional changes in, 130
healing, 481 preservation of. See Alveolar ridge preservation.
loosening of, 77, 507 remodeling of, 130
mucosa and, complications involving, 504–507, 505f–506f Alveolar ridge preservation
one-abutment, one-time concept for, 399–404, 399f–404f alveolar ridge augmentation versus, 131
placement of, 442f barrier membranes for, 180
polyether ether ketone, 205 bone fillers for, 180
shape of, 402–404, 403f–404f bone grafting materials for, 132, 137
shoulderless, 402f, 403 definition of, 131
titanium, 507, 507f delayed implant placement after, 170f
zirconia, 391, 392f, 507f horizontal ridge loss managed with, 180
Abutment screw Alveolar ridge preservation via socket grafting
fracture of, 508, 508f autologous blood-derived products, 137, 144
loosening of, 507–508, 508f barrier membranes for, 132, 137, 180
Acellular collagen sponge bone grafting materials for, 132, 137
description of, 339, 342 description of, 131, 144
recombinant human bone morphogenetic protein-2 and, flap elevation in, 131
358, 359f, 360 Amoxicillin, 194
Acellular dermal matrix resorbable membrane, 465, 467 with clavulanic acid, 229–230
Acetaminophen codeine, 194 Angiogenesis, 129
Acidic fibroblast growth factor, 340 Angled abutment, 79
Adrenocorticosteroids, 445 Anterior mandibular vertical ridge augmentation, 334, 334f
Advanced periodontitis, 4f Anterior maxilla
Airborne particle–abrasion system, 458 implant placement in
Allergic rhinitis, 224 apicocoronal positioning, 167
“All-in-one” system, 102 buccolingual positioning, 165, 167
Allogeneic block graft, 360, 361f delayed, 169, 170f
All-on-four approach diagnosis, 162–165
applications of, 296–297, 298f–300f diagnostic wax-up in, 163, 163f
bone volume deficiencies treated with, 297 early, 169
clinical considerations for, 296 ideal outcomes of, 162f
complications of, 300–301 immediate, 154, 154f
extramaxillary configuration, 308f implant angulation, 167
failure of, 306f late, 169
history of, 296 mesiodistal positioning, 167
immediate loading benefits of, 297 multiple-tooth implants, 171, 172f–173f
in older adults, 296–297, 300f overview of, 162
skeletal malocclusion treated with, 297, 299f prosthetic evaluation, 163–165, 164f
soft bone treated with, 297, 299f radiographic evaluation, 165
zygoma implant and, 302–306, 302f–306f risk assessment before, 162
Alveolar antral artery, 228f, 229 single-tooth implants, 170–171, 171f
Alveolar bone defects, 137 site analysis before, 162
Alveolar process treatment planning for, 162–165
remodeling of, 74 zygomatic implants and, 287
resorption of, 131 maxillary tuberosity grafts in
Alveolar ridge biologic aspects of, 176–177
atrophy of harvesting-related complications of, 177–178
after tooth extraction, 131 indications for, 178
cortical bone graft for, 84f sinus intrusion, 304, 305f
514
Nevins/Wang_Index.indd 514 2/28/19 11:04 AM

Index | B
Anterior teeth. See also specific teeth. maxillary tuberosity

emergence angle for, 56 block, 186–188, 187f
Laser-Lok implant for, 35f bone thickness/height augmentation uses of, 186–188
maxillary. See Maxillary anterior teeth. guided bone regeneration uses of, 188–189, 189f
multiple-tooth implants in, 171, 172f–173f harvesting technique for, 181b, 181f–182f
single-tooth implants in, 170–171, 171f peri-implant bone regeneration, 190, 191f
Antibiotic prophylaxis, in maxillary sinus augmentation, 229–231, socket preservation uses of, 180–182, 181b, 181f–182f
230t, 240–241, 254–255 socket reconstruction uses of, 182–186, 183f–186f
Antrostomy technique for, 180–182, 181b, 181f–182f
bleeding associated with, 250 Bone loss
DASK, 235–236, 236f–237f after tooth loss, 74
lateral bone-planing, 235 around short implants, 80, 85, 85f
piezoelectric, 235 marginal
Apical pathosis, 7f around short implants, 80, 85, 85f
Apical peri-implantitis, 440–441 implant failure and, 438
Apicocoronal malposition, 442, 442f radiographic evidence of, 2, 3f, 23f
Apicocoronal positioning Bone marrow aspirate concentrates, 357f, 357t, 357–358
in anterior maxilla, 167 Bone morphogenetic proteins
description of, 55t, 391 biology of, 338
Apicoectomy, 22f development of, 338–339
ARP. See Alveolar ridge preservation. recombinant human. See Recombinant human bone
ARP-SG. See Alveolar ridge preservation via socket grafting. morphogenetic protein-2.
Atlantis abutment systems, 100f, 101 summary of, 339f
Augmentin, 240, 252, 254 Bone regeneration
Autogenous bone grafts digitally guided, 98, 99f
bone defects treated with, 312 guided. See Guided bone regeneration.
dermal/collagen matrix versus, 317 horizontal. See Horizontal bone augmentation/regeneration.
description of, 176–177 intraoral autogenous bone for, 461
guided bone regeneration and, 188 machined-surface implant placement in, 30, 32f
sinus augmentation uses of, 271 vertical. See Vertical bone regeneration.
Autologous blood-derived products, in alveolar ridge preservation Bone remodeling
via socket grafting, 137, 144 after tooth extractions, 30, 152–153
Azithromycin, 230 case study of, 53, 55f
platform switching effects on, 399
B Bone volume
cone beam computed tomography evaluations of
Barrier membranes for all-on-four approach, 299f
in alveolar ridge preservation via socket grafting, 132, 137, 180 description of, 177
growth factors and, 347 for zygomatic implants, 283–284, 284f
Basic fibroblast growth factor, 340 traditional measurement methods for, 297, 298f
Benign paroxysmal positional vertigo, 275–276 Bone-driven implant placement, 163
BIC. See Bone–implant contact. Bone–implant contact
Bio-activated abutments, 402 after implant placement, 25, 26f
Bio-Gide membrane, 240 case study of, 25, 26f
Biologic width, 170, 396, 512 description of, 150, 151f
Bioreactor, for in-situ tissue engineering, 356, 356f, 358 as implant success indicator, 22, 22f–23f
Bleeding on probing, 447, 449, 481, 483–484, 493 implant surface effects on, 33
BMACs. See Bone marrow aspirate concentrates. maintenance of, 14
Bone short implants, 75
buccal. See Buccal bone. Bone-level implants, 40f, 54f
crestal. See Crestal bone. Bony defects, peri-implant
formation of, 231 bone loss more than 2/3 of implant length, 462, 462f
harvesting of, from maxillary tuberosity, 176 horizontal, 459, 460f–461f
healing of, after implant placement, 199–201 horizontal/vertical, 461f, 461–462
in-situ tissue engineering formation of, 359, 359f illustration of, 460f
loss of. See Bone loss. location of, 461
peri-implant. See Peri-implant bone. mucogingival defects combined with, 459, 460f
remodeling of. See Bone remodeling. vertical, 459, 461
Bone atrophy BOP. See Bleeding on probing.
classification of, 312 Brånemark, P. I.
illustration of, 29f Novum system of, 301, 301f
mandible, 86, 296f osseointegration development by, 28, 28t, 92, 302
maxilla, zygomatic implants for. See Zygomatic implants. zygomatic implant protocol, 280–283, 281f–283f, 285–286, 288
Bone defects, 312. See also Bony defects. Brushing technique, 314
Bone grafts Bruxism, 511
for alveolar ridge preservation via socket grafting, 132, 137 Buccal bone
cortical, for atrophic ridge augmentation, 84f dehiscence of, 132f
extraction site defect in, 345f
515

B | Index
Buccal bone plate, 31f Cone beam computed tomography

Buccal flaps advantages of, 101
description of, 183, 371 bone density evaluations, 297
partial-thickness, 469 bone volume evaluations using
Buccolingual positioning description of, 177
in anterior maxilla, 165, 167 for zygomatic implants, 283–284, 284f
description of, 58t description of, 23, 23f, 29f, 92
guided bone regeneration results, 321f
C hard tissue evaluations, 177
history of, 101
CAD/CAM design, 98, 100f, 116, 124f, 505 in maxillary esthetic zone implant placement, 118–119
Calcium phosphate scaffolds, 350 before maxillary sinus augmentation, 229
Cancellous bone, 177 orthodontic treatment using, 109f
Cantilevers, 120, 122f questions associated with, 102
Cawood and Howell classification, 312 sinus membrane measurements on, 264
CBCT. See Cone beam computed tomography. soft tissue evaluations, 177
Cement Connective tissue grafts
excess case study of, 463
on abutments, 505, 505t coronally advanced flap over, 372
implant failure caused by, 447, 447f description of, 60f, 202, 203f, 212
peri-implantitis risks, 56 evaluation of, 177
residual, at implant crown, 505t in guided bone regeneration, 315–316
Cementoenamel junction, 11, 53, 382, 387, 463 in horizontal bone augmentation/regeneration, 315–316
Chlorhexidine, 194, 370, 378, 497 maxillary tuberosity harvesting of, 178–180
CIR. See Crown-implant ratio. positioning of, 372f
Class I furcation, 11 for soft tissue defects around submerged implants, 375f
Class II furcation, 11, 11f soft tissue dehiscence treated with, 388, 389f
Class II malocclusion, 297 soft tissue height and thickness increases using, 372f
Class III furcation, 11, 12f subepithelial, 178–179, 179f
Class III malocclusion, 20f, 297, 299f Coronal sliding flap, 190
Clindamycin, 254 Coronally advanced flap, 372, 377, 383, 384f, 387
Clinical crown height, 75–76 Cortical allografts, for alveolar ridge preservation via socket
Clinical root, 2, 3f grafting, 132
Cluster of differentiation, 357 Cortical bone graft, for atrophic ridge augmentation, 84f
Coagulum, 129 Countersinking, 27f
Collaborative accountability, 97 Cover screws, 42
Collagen membrane Crestal bone
growth factors and, 347 Laser-Lok technology effects on, 33, 37
for sinus membrane perforation, 240, 241f loss of, 398
Collar, implant. See Implant(s), collar of. maintenance of, 33–35, 40
CollaTape, 248, 249f platform switching and, 398
Compliance, 482 remodeling of, 33, 396–397
Complications Crestal window, for maxillary sinus augmentation, 236, 237f
abutment failure, 507 Cross-arch splinting, 293
abutment-mucosa, 504–507, 505f–506f Crown. See also Implant crown.
biomechanical, 510t independent, 81
description of, 7 lengthening of, 11, 12f
diagnosis of, 510–512 overcontouring of, 69, 70f
implant failure. See Implant failure. splinting of, 77f, 78–79
implant fracture, 502–504, 503f Crown-abutment height, 75
implant planning to reduce, 510–512 Crown-implant ratio
overview of, 502 abutment loosening and, 77
peri-implantitis. See Peri-implantitis. definition of, 75
prevention of, 510–511 description of, 68
prosthesis attrition and fracture, 509–510, 510f marginal bone loss and, 77
prosthetic screw loosening and fracture, 509, 509f for short implants, 75–78, 76f–78f
Computed tomography. See also Cone beam computed tomography. Curettes, 496
history of, 92 Customized abutments, 400–401
implant planning uses of, 93 Cystic defects, in-situ tissue engineering for, 361–362
radiography transition to, 92–93
surgical guide uses of, 96–97
wax-ups and, 95
D
Computer software-based treatment planning, 95 DASK preparation, of Lateral window for maxillary sinus
Computer-assisted implant placement augmentation, 234–236, 236f
advantages of, 380, 382 Decision making
indications for, 380 bone morphology effects on, 10
in maxillary esthetic zone, 119–120, 122, 380 in treatment planning, 2
in postextraction implants, 385 Decision tree models, 112
516

Index | G
Definitive abutments, 399, 401f in guided bone regeneration, 30–31, 31f

Delayed implant placement, 59, 131, 150, 169, 170f in maxillary sinus augmentation using lateral window
Delayed loading, in soft bone patients, 297 approach, 243
Demineralized allografts, for alveolar ridge preservation via socket Extended sinus elevation, for zygomatic implants, 286, 287f
grafting, 132 Extracellular matrix, 129, 349–350
Dense polytetrafluoroethylene barrier, 30 Extraction. See Tooth extraction(s).
DentaScan, 93, 93f Extraction sockets. See Tooth extraction sockets.
Dentition Extra-maxillary zygomatic implants, 286, 306, 307f–308f
bone loss around, 26, 27f Extra-short implants, 82, 86f
extraction of. See Tooth extraction(s).
preservation of
decision making for, 11, 11f–12f F
implants versus, 2, 6
Facial bone thickness, 56
root resection, 11
Facilitate, 97
summary of, 15
FESS. See Functional endoscopic sinus surgery.
technologic advancements that affect, 11
Fibroblast growth factor 2
teeth-to-jaw relationship of, 109, 111
biology of, 340
Dentium Advanced Sinus Kit. See DASK.
clinical application of, 340–341
Dentoalveolar bone, 109
clinical trials of, 342t
Deproteinized bovine bone matrix, 38, 39f
development of, 340–341
Dexamethasone, 194
recombinant human, 340–341
Diagnostic wax-up, 163, 163f
summary of, 339f
DICOM, 95, 98, 102, 284
Fistula, 8f, 25f
Digital dentistry, 23
Fixed partial dentures
Digital imaging
case study of, 414, 414f
computed tomography. See Computed tomography.
implant-supported, 436
history of, 92–105
for maxillary incisors, 14, 15f
3D diagnostics, 93, 93f–94f
three-implant, 301, 301f
Digital impressions, 98
Fontanelles, 226f
Digital Smile Design, 108
Fracture(s)
Digital workflow, 60
abutment, 507, 507f
Digitally guided bone regeneration, 98, 99f
enamel-dentin, 121f
Distraction osteogenesis, 82
implant. See Implant(s), fracture of.
Dix-Hallpike maneuver, 275
prosthetic screw, 509, 509f–510f
Dynamic navigation, 105–107, 106f
Free gingival graft, 67f, 369, 369f
Freehand surgery, 92–94
E Freeze-dried bone allograft, 37, 152f, 342, 465
Functional endoscopic sinus surgery, 250–251, 257
Early failure, of implant, 436
Early implant placement, 169
Ectodermal dysplasia, 304f
Edentulism, implants in. See also Partial edentulism.
G
description of, 86–87, 86f–87f GBR. See Guided bone regeneration.
immediate loading of GEM 21S, 343
description of, 198, 202 Gene therapy, 350
mandibular surgery, 202, 207 Genomics, 102
maxillary surgery, 207, 212 Gingival biotype, 157, 158f
postoperative prosthetic procedures, 212, 213f–217f Gingival graft, 67f, 316, 369, 369f
EIP. See Endodontic implant pathology. Gingival Index, 496
Emergence angles Gingival inflammation, 411
description of, 56, 56f Gingival recession, 15f, 165, 344f, 380, 443f–444f
peri-implantitis risks and, 68 Goblet cells, 226
Emergence profile, 371f Grafts. See Bone grafts; Connective tissue grafts; Gingival graft;
Enamel-dentin fracture, 121f Lateral window approach.
Endodontic implant pathology, 441 Growth differentiation factor 5, 341
Endodontics, 7 Growth factors
Epithelial-connective tissue graft, 320f, 369 biology of, 338t, 338–342
Epley maneuver, 275 clinical applications of, 342–348
e-PTFE. See Expanded polytetrafluoroethylene barriers. clinical trials using, 342
Esthetic zone. See Maxillary esthetic zone. description of, 177
Esthetics “dose dumping” of, 350
longevity versus, 13 fibroblast growth factor 2. See Fibroblast growth factor 2.
in treatment planning, 13–14, 14f–15f for flapless socket preservation, 347
Ethylene diaminetetraacetic acid, 374 growth differentiation factor 5, 341
EvalNav, 106f membranes and, 347
Evidence-based dentistry, 2 in platelet-rich plasma, 356–357
Evidence-based medicine, 218 properties of, 338t
Expanded polytetrafluoroethylene barriers, 470
517

G | Index
recombinant human bone morphogenetic protein-2. See haptic simulation, 107–108

Recombinant human bone morphogenetic protein-2. history of, 92–105
recombinant human platelet-derived growth factor BB. See personalized precision dental medicine, 102–105
Recombinant human platelet-derived growth factor BB. static guided surgery, 95, 96f, 97–98
scaffold delivery of, 350 surgical navigation guided with, 105–107, 106f
teriparatide, 341–342, 342t 3D digital diagnostics period of, 93, 93f–94f
Guided bone regeneration 3D interactive, integrated, computer software planning period
autogenous bone block grafts and, 188 of, 95–102
case studies of, 68f, 318–324, 318f–325f, 408, 409f, 413 timeline of, 104f
cone beam computed tomography of, 321f Immediate dentoalveolar restoration technique, 184–185, 185f
expanded polytetrafluoroethylene barriers in, 30–31, 31f Immediate implant placement
horizontal bone augmentation using, 312–326 advantages of, 150, 157–158
implant placement after, 30 after tooth extraction, 168–169
indications for, 471 algorithm for, 151f
intrabony defects treated with, 456 bone-implant contact for, 150, 151f
maxillary tuberosity bone grafts and, 188–189, 189f clinical considerations for, 153–158, 153f–159f
nonresorbable membranes with, 313 decision making for, 150–151, 150f–151f
in partially dentate patients, 202 description of, 35, 35f, 44, 45f, 59, 59t, 131
socket reconstruction uses of, 184 illustration of, 153f
soft tissue management after implant angulation for, 167
connective tissue grafting, 315–316 in infected sites, 153, 153f
gingival graft, 316 in interradicular septum, 156f
overview of, 315 in maxillary anterior sites, 154, 154f
surgical technique for, 313–315, 314f in molar sites, 155, 155f–156f
timing of, 314–315 in posterior sites, 155, 155f–156f
transcrestal sinus floor elevation and, 271 in premolar sites, 155, 155f–156f
vertical bone augmentation using, 322 provisionalization for soft tissue preservation, 157–158
Guided surgery soft and hard tissue grafting, 155, 157, 157f
description of, 23 Immediate loading
static, 95, 96f, 97–98 all-on-four approach benefits for, 297
for zygomatic implants, 290–291 authors’ clinical research in, 198–199, 199f
Gutta-percha, 7 clinical procedures, 201–202
clinical research on, 198–199, 199f
H definition of, 198
in edentulous patients
Haptic simulation, 107–108 description of, 198, 202
Healing, of extraction site, 128f, 128–129 mandibular surgery, 202, 207
Healing abutments, 481 maxillary surgery, 207, 212
Hemostatic phase, of extraction site healing, 129 postoperative prosthetic procedures, 212, 213f–217f
High smile line, 382, 383f failure after, 300
Home hygiene, 484–485, 484f–485f, 498 indications for, 198
Horizontal bone augmentation/regeneration literature review regarding, 198
case studies of, 317–324, 318f–324f osteoblastic activity affected by, 201
cone beam computed tomography of, 321f in partially dentate patients
flaps in case studies, 202f–206f
design of, 313–314 clinical procedures, 201–202, 202f–206f
passivation of, 314 decision making for, 206f
guided bone regeneration for, 312–326 description of, 198
implant positioning for, 315 peri-implant bone resorption associated with, 201
in-situ tissue engineering for, 360f, 360–361 progressive approach to, 198
soft tissue management of Schnitman protocol, 198
connective tissue grafting, 315–316 survival rates after, 198
gingival graft, 316 zygomatic implants, 288–289, 288f–289f
overview of, 315 Implant(s). See also specific implant.
surgical technique for, 313–315, 314f accuracy of, 92
vertical bone regeneration and, 322–324, 322f–324f in advanced periodontitis, 4f
Hydraulic pressure technique, for transcrestal sinus floor angulation of, 56, 167
elevation, 270, 271f apicocoronal malposition of, 442, 442f
bone volume for, 30
I case studies of, 8f
circumferential probing around, 484
IAJ. See Implant-abutment junction. collar of
IDT. See Interdisciplinary dentofacial therapy. convergent shape of, 404
Imaging. See also Digital imaging. divergent shape of, 403
analog diagnostics period of, 92–93 laser-microtexturing of, 33, 36
computed tomography. See Computed tomography. microgrooved, 401–402, 402f
cone beam computed tomography. See Cone beam computed placement of, 23, 24f
tomography. soft tissue attachment to, 34
in dynamic navigation, 105–107, 106f complications of. See Complications.
518

Index | I
contours of success of
importance of, 52 criteria for, 22, 22f–23f
soft tissue grafting for, 59–60 definition of, 436
crowding of, 476f factors that affect, 23, 502f
crown of. See Crown. innate risks influencing, 502, 502f
dentition maintenance versus, 2, 6 predictable, 92
design of, 38 rates of, 7, 38, 436
displacement of, 444, 512 surface of. See Implant surface.
emergence angles of, 56, 56f, 68 surgical variables that affect, 23f–24f, 23–25
endodontics versus, 7 survival of, 22, 22f–23f
failure of. See Implant failure. tilted, 199, 207, 212
force on wide-diameter, 75f, 75–76, 80f, 397
bending moments, 511 zygomatic. See Zygomatic implants.
overload of, 441, 442f Implant crown. See also Crown.
fracture of, 436f, 439–440, 440f, 502–504, 503f height of, 76f, 76–77
functional loading of, 511 residual cement at, 505t
hard contours of, 52 splinting of, 77–80, 77f–80f, 80b
history of, 21–22 Implant failure
hygiene for, 446, 446f anatomical structures and, 443–445
indications for, 7 definition of, 436
intraosseous, 38 description of, 300, 300f
lateral window approach for, 83f. See also Lateral window early, 436
approach. excess cement as cause of, 447, 447f
long-term results/success with indications of, 438–439
case studies of, 20f–23f, 39 inferior alveolar nerve damage and, 444f, 444–445
in native bone, 28–30 late
prerequisites for, 30 apical (retrograde) peri-implantitis as cause of, 440–441, 441f
randomized controlled trials, 42, 43f–45f definition of, 436
in regenerated bone, 30–31, 31f–32f etiology of, 439–443
studies on, 28t, 38–39 force overload as cause of, 441, 442f
malposition of, in esthetic zones, 441–443, 442f–443f fracture as cause of, 436f, 439–440, 440f
in maxillary esthetic zone, 120 malposition of implant as cause of, 441–443, 442f
mesiodistal malposition of, 442, 442f marginal bone loss as sign of, 438
migration of, 258f, 275, 444f mobility of implant and, 438
mobility of, 438 pain and, 438
mucosal interface with, 396 in periodontally compromised patients, 481
orthodontics and, for periodontally compromised teeth, 408– prevalence of, 502
417, 409f–416f probing depth and, 438–439, 439f
orthognathic surgery and, case studies involving, 420–434, radiographic imaging of, 437f
421f–433f rates of, 494
osseointegrated. See Osseointegrated implants. removal of implant after, 436, 437f, 438
overload of, 441, 442f treatment alternatives for, 436
patient categories for, 2 Implant periapical lesions
peri-implant bone thickness around, 56 definition of, 440
peri-implantitis around, 124. See also Peri-implantitis. radiographic imaging of, 441f
in periodontal disease patients, 7 Implant placement
placement of. See Implant placement. in anterior maxilla. See Anterior maxilla, implant placement in.
positioning of. See Implant positioning. in anterior region, 33
in posterior mandible, 82, 84f bone healing after, 199–201
precision of, 92 at bone level, 23, 24f, 54f
removal of bone volume assessments, 298f
after failure, 436, 437f, 438 bone-driven, 163
after peri-implantitis, 448–449, 456 bone-implant contact after, 25, 26f
criteria for, 462 computer-assisted
screw-form, 258 advantages of, 380, 382
selection of, 23, 23f indications for, 380
short. See Short implants. in maxillary esthetic zone, 119–120, 122, 380
shoulder of, 441 in postextraction implants, 385
single-tooth. See Single-tooth implants. cone beam computed tomography evaluations before, 23, 23f
soft tissue contours of, 52 consecutive implants, 53
stability of delayed, 59, 131, 150, 169, 170f
bone density effects on, 201 depths of, 54f
long-term, 492 early, 59, 59t, 169
in transcrestal sinus floor elevation, 275 guided, 95–96, 96f
Straumann’s designs of, 38 immediate. See Immediate implant placement.
stress distribution on, 75, 76f inferior alveolar nerve injury after, 444f, 444–445
submerged. See Submerged implants. late, in healed site, 59, 59t, 169
subperiosteal, 21 manufacturer directions for, 25
519

I | Index
in maxillary central incisors, 102f Induced pluripotent stem cells, 349

migration after, 258f, 275 Infection/infection control
multiple implants, 33, 34f, 53, 55f, 120, 121f antibiotic prophylaxis for, 254–255
in native bone, 28–30 immediate implant placement in sites with, 153, 153f
partial bone healing, 59, 59t in maxillary sinus augmentation, 229–231, 253f–254f, 253–255
in partial edentulism, 162 sinus graft, 253f–254f, 253–255, 256f
peri-implant bone resorption after, 201 in transcrestal sinus floor elevation, 274–275
planning for, 512 Inferior alveolar nerve, 64, 444f, 444–445
in posterior mandible quadrant Inflammatory cytokines, 52
anatomical considerations, 64–67 Inflammatory phase, of extraction site healing, 129
biomechanical complications of, 69, 70f Infraorbital nerve, 233f
biomechanical considerations, 68–69 Infuse Bone Graft, 338
case studies, 69, 70f In-situ tissue engineering
crown/implant ratio, 68 bioreactor for, 356, 356f, 358
inferior alveolar nerve, 64 bone formation with, 359, 359f
lingual concavity, 64, 67 bone marrow aspirate concentrates, 357f, 357t, 357–358
lingual nerve, 64, 66f cells used in, 356
mental nerve, 64 cystic defects treated with, 361–362
positioning considerations, 68 definition of, 356
restorative considerations, 68–69 horizontal ridge augmentation uses of, 360f, 360–361
soft tissue characteristics, 67 hospital costs for, 365, 365t
presurgical planning of, 100f mandibular continuity defects treated with, 363–365, 364f, 365t
in regenerated bone, 30–31, 31f–32f matrix for, 358
restoration-driven, 163, 441 maxillary defects treated with, 364
static guided surgery for, 95, 96f, 97 maxillary sinus augmentation uses of, 361, 361f
surgically driven, 169 molar socket of, 360f
3D, 441 nasoalveolar alveolar clefts treated with, 362f, 362–363
timing of, 59, 59t, 167–169 platelet-rich plasma, 356–357
tooth extractions before, 23f–24f proof of performance of, 365, 365t
Implant positioning signal for, 358
apicocoronal, 55t, 167 socket grafting uses of, 360, 360f
buccolingual, 58t, 165, 167 vertical ridge augmentation treated with, 365, 365t
mental foramen avoidance, 65f Insulin-like growth factor 1, 339
mesiodistal, 55f, 56t, 167 Interdisciplinary dentofacial therapy
in posterior mandible, 68 description of, 92
spatial, 52–58, 53f–58f jaws-to-face relationship, 111
splinting affected by, 79 jaw-to-jaw relationship, 111
3D spatial, 52–58, 53f–58f principles of, 108
Implant stability quotient, 101 surgically facilitated orthodontic therapy in, 108
Implant surface teeth-to-jaw relationship, 109, 111
bone-implant contact affected by, 33 tooth-to-tooth relationship, 109
decontamination of Interimplant papillae, 316
description of, 448, 449f Interpositional grafting, 82
instrumentation used in, 457f, 457–458, 487 Interproximal black triangles, 13, 22, 171
methods of, 487 Interproximal contact, 69
objective of, 457 Interradicular septum, 156f
detoxification of, 458–459 Intrabony defects, 3f, 9f, 11, 413
laser-microtextured, 33–35 Intraforaminal implants, 199
machined. See Machined-surface implants. Intraoral scan bodies, 98
modifications of, 33 IPL. See Implant periapical lesions.
roughened, 33 iPSCs. See Induced pluripotent stem cells.
sand-blasted, large-grit, acid-etched, 38 Island osteotomy, 234, 235f
of Southern Implants fixtures, 45 ISQ. See Implant stability quotient.
titanium plasma spray, 38 ISTE. See In-situ tissue engineering.
Implant-abutment junction
biologic processes in, 396–397
at bone level, 404
J
contamination of, 403 Jaw-to-jaw relationship, 111
functional loading affected by, 511 Jaws-to-face relationship, 111
horizontal inward repositioning of, 397–398
one-abutment, one-time concept, 399–404, 399f–404f
platform-switching concept, 397f, 397–399
K
with two-piece implants, 396 Keratinized mucosa
Implantology description of, 67
breakthroughs affecting, 92 increases in
evolution of, 92 description of, 368
Implant-supported crown, 463f free gingival graft for, 369, 369f
Implant-supported removable denture, mandibular full-arch, 42, 43f outcomes of, 370
520

Index | M
postoperative protocol for, 370, 370f dimensions of, 233

radiographic imaging of, 368f island osteotomy design, 234, 235f
surgical technique for, 368–369, 369f location of, 233–234, 234f
lack of, 494f loss of graft material through, 258, 258f
marginal tissue health affected by, 481 original technique for, 234
peri-implant health and, 446, 447f piezoelectric preparation of, 234–235
rotary instrumentation for preparation of, 234
L Leukocyte platelet-rich fibrin, 137, 144, 240, 248, 248f
Lingual concavity, 64, 67
Lamellar bone, 129 Lingual flap advancement technique, modified, 328, 329f
Lamina propria, 226 Lingual nerve, 64, 66f
Laser-Lok implants Lip line, high, 14f
case studies of, 35, 35f–36f Loading
crestal bone maintenance with, 37 delayed, 297
description of, 33 factors that affect, 511
failure of, 37 immediate. See Immediate loading.
full-arch stability with, 36f nonfunctional, 198
long-term results with, 36–37, 37f Loma Linda pouch, 246, 248
placement of, 34f L-PRF. See Leukocyte platelet-rich fibrin.
prototype, 34f
single-tooth replacement with, 35f
Laser-microtextured implant surface, connective tissue
M
attachment to, 33–35 Machined-surface implants
Late failure, of implant. See Implant failure, late. benefits of, 74
Late implant placement, 169 case study of, 29f
Lateral bone-planing antrostomy, 235 peri-implantitis resistance by, 28
Lateral window approach, for maxillary sinus augmentation short implants, 74
anesthesia for, 231, 232f in vertically regenerated bone, 30, 32f
antrostomy, 232–233 Magnitude of the moment of a force, 76, 76f
barrier membrane placement and stabilization in, 241–243, 242f Malocclusion
bone dehiscence considerations, 233f all-on-four approach in, 297, 299f
complications of Class II, 297
avoidance of, 243 Class III, 297, 299f
bleeding, 248–250 skeletal disharmony, 110f
implant migration into sinus graft, 258f, 258–259 Malposition of implant, in esthetic zones, 441–443, 442f–443f
infections, 252–255 Mandible
intraoperative, 243–251, 244f–245f, 247f–250f anatomy of, 298f
loss of graft material through window, 258, 258f atrophy of, 86, 296f
mucous retention cysts, 250–251, 251f–252f edentulous
postoperative, 252–259, 259b implants in, 86, 86f
recommendations for limiting of, 259t medical model of, 96f
sinus graft infections, 253f–254f, 253–255 posterior. See Posterior mandible.
sinusitis, 252, 255–257 Mandibular continuity defects
crestal window versus, 236, 237f in-situ tissue engineering for, 363–365, 364f, 365t
flap closure of, 243 zygomatic implant for, 302, 303f
flap design, 231–232, 233f Mandibular discontinuity defects, zygomatic implant for, 302, 303f
grafts Mandibular fixed screw-retained prosthesis, 44f
antibiotic placement in, 241 Mandibular foramen, 207
decontamination of, 241, 242f Mandibular molars, Class III furcation of, 12f
implant migration into, 258f, 258–259 Marginal bone loss
infection of, 253f–254f, 253–255, 256f around short implants, 80, 85, 85f
materials for, 231, 240 implant failure and, 438
packing pressure for, 241 Mattress sutures, 370f
placement of, 240–241 Maturation and remodeling phase, of extraction site healing, 129
postoperative infection of, 253f–254f, 253–255 MAX implant, 44, 45f
incisions, 232f Maxilla
palatal window versus, 236, 238, 238f anterior. See Anterior maxilla.
preoperative planning, 229 atrophy of
recommendations for, 242b classification of, 312
simplified antrostomy design, 238–239, 239f description of, 81
sinus membrane in zygomatic implants for. See Zygomatic implants.
elevation of, 239–240, 240f bone volume evaluations in, 297, 298f
perforation of, 240, 241f, 243–248, 244f–245f, 247f–249f edentulous, implants in, 87, 87f
summary of, 259 posterior
suturing of, 242f, 243 remodeling of, 264
window in short implants in, 81–82, 82f
DASK preparation of, 234–236, 236f vertical ridge augmentation, 335, 335f–336f
design of, 234 transcrestal sinus floor elevation of. See Transcrestal sinus
floor elevation.
521

M | Index
Maxillary alveolar reduction, 431 cone beam computed tomography before, 229
Maxillary anterior. See Anterior maxilla. contraindications for, 224–225, 225t
Maxillary anterior teeth. See also specific teeth. crestal window for, 236, 237f
emergence angle for, 56 description of, 2, 40f
mobility of, 413, 413f, 415f–416, 415–417 difficulty score for, 229, 230b
Maxillary central incisors ENT contraindications for, 224–225, 225t
case study of, 58f ENT specialist involvement in, 224–225
extraction of, 54f evolution of, 224
illustration of, 154f grafting materials used during, 231, 271–273, 272f
implant placement in, 102f implant migration after, 444, 444f
Maxillary esthetic zone, implant placement in indications for, 224–225
abutment selection for, 120 infection control in, 229–231, 240–241
apicocoronal positioning, 167 in-situ tissue engineering for, 361, 361f
buccolingual positioning, 165, 167 lateral window approach for. See Lateral window approach, for
computer-assisted planning for, 119–120, 122 maxillary sinus augmentation.
cone beam computed tomography in, 118–119 preoperative diagnosis, 229
conventional treatment in, 163f residual alveolar bone considerations in, 224
diagnosis, 162–165 sinus membrane perforation, 227f
ideal outcomes of, 162f transcrestal elevation procedure for. See Transcrestal sinus
implant angulation, 167 floor elevation.
implant selection, 120 treatment planning for, 229–231
malposition of, 441–443, 442f vertical ridge augmentation and, 335, 335f–336f
mesiodistal positioning, 167 Maxillary sinus elevation. See also Maxillary sinus augmentation.
multiple implants, 120, 121f, 122 bilateral, 283
overview of, 116 difficulty score for, 229, 230b
patient expectations regarding, 116 lateral window approach for. See Lateral window approach, for
prosthetic design considerations, 120–124, 121f–124f maxillary sinus augmentation.
prosthetic evaluation, 163–165, 164f zygomatic implants versus, 283
prosthetic setup for, 116–117 Maxillary sinus grafting, 74
radiographic evaluation, 165 Maxillary tuberosity grafts
radiographic imaging for, 118–119 biologic aspects of, 176–177
soft tissue bone grafts
assessments of, 117–118 block, 186–188, 187f
augmentation of, 379–382 bone thickness/height augmentation uses of, 186–188
3D radiographic imaging for, 118–119 guided bone regeneration uses of, 188–189, 189f
treatment planning for, 162–165 harvesting technique for, 181b, 181f–182f
virtual superimposition, 118–119 peri-implant bone regeneration, 190, 191f
Maxillary first molars socket preservation uses of, 180–182, 181b, 181f–182f
extraction of, 152f socket reconstruction uses of, 182–186, 183f–186f
replacement of, 5f technique for, 180–182, 181b, 181f–182f
Maxillary first premolars, 3f harvesting-related complications, 177–178
Maxillary incisors. See also Maxillary central incisors. indications for, 178, 180
extraction of, 24f medication for, 194
implants for recommendations for, 194
description of, 24f, 166f subepithelial connective tissue grafts, 178–180, 190
multiple-tooth, 173f triple graft, 190–192, 193f
lateral, 346f Maxillomandibular advancement surgery, 424, 429
periodontally compromised, 14, 15f Maxillomandibular retrognathia, 110f
two implants for, 122 Mental foramen, 65f–66f
Maxillary sinus Mental nerve, 64, 65f, 330
anatomy of, 225–229, 226f–228f, 248 Mesenchymal stem cells, 129, 349, 356, 359, 363
floor elevation, 83f Mesiobuccal canals, 7
innervation of, 229 Mesiodistal malposition, 442, 442f
lateral wall of, 226f Mesiodistal positioning
medial wall of, 225 in anterior maxilla, 167
membrane elevation difficulties in, 244 description of, 55f, 56t
morphology of, 264–265 Metabolomics, 102
septa of, 227, 228f Metronidazole, 241
trigeminal nerve innervation of, 229 Michigan reamer approach, for transcrestal sinus floor elevation,
vascular supply of, 227–229, 228f 268–270, 268f–270f
ventilation of, 224 Microgrooved implant collars, 401–402, 402f
wall of, 228f, 229 Micron camera, 105, 106f
Maxillary sinus augmentation Microvascular fibular grafts, 365
alveolar ridge augmentation and, 254 Modified lingual flap advancement technique, 328, 329f
anesthesia for, 231, 232f Molar sites, immediate implant placement in, 155, 155f–156f
antibiotic prophylaxis before, 229–231, 230t, 240–241 MSCs. See Mesenchymal stem cells.
blood clots in, 271
522

Index | P
Mucosa
abutment discoloration of, 506
P
keratinized. See Keratinized mucosa. Pain, 438
recession of, 57f Pansinusitis, 257
Mucositis, 7, 492, 492f–493f, 497 PAOO. See Periodontally accelerated osteogenic orthodontics.
Mucous retention cysts, 224, 250–251, 251f–252f Papillae
Multiple-tooth implants, in anterior maxilla, 171, 172f–173f description of, 380
MVF grafts. See Microvascular fibular grafts. preservation of, for implant placement in extraction socket,
385–387, 386f
Paranasal sinuses
N embryologic development of, 225
maxillary. See Maxillary sinus.
Narrow-diameter short implants, 79, 79f
Parathyroid hormone, 341
Nasoalveolar alveolar clefts, in-situ tissue engineering for, 362f,
Partial edentulism
362–363
description of, 21, 41f
Native bone, implant placement in, 28–30
immediate loading in
Navident system, 105
case studies, 202f–206f
Navigator, 97
clinical procedures, 201–202, 202f–206f
Nickel titanium instrumentation, 7
decision making for, 206f
Nitric oxide, 226
description of, 198
NobelGuide, 97
implant placement in, 162
Nonfunctional loading, 198
medical model of, 96f
Novum system, 301, 301f
PASS principle, 273, 275
nSequence, 102, 103f
Pathologic tooth migration, 413f
Patient
O clinician and, relationship between, 218
consultation questions by, 2
Obstructive sleep apnea, 109 PDGF. See Platelet-derived growth factor.
Odontogenic keratocyst, 362f Penrose drain, 254f, 255
One-abutment, one-time concept, 399–404, 399f–404f Periapical lesions, 8f, 440, 441f
Onlay bone augmentation, 74, 82 Periapical pathosis, 8f, 13f
OP-1 Implant, 338 Pericytes, 264
Oral hygiene, 484–485, 484f–485f, 498 Peri-implant bone
Oroantral communication, 280, 280f, 288, 444 loss of
Oroantral fistula, 225b submerged implant for, 456
Orofacial malposition, 442, 443f treatment algorithm for, 472f
Orthodontics regeneration of, 190, 191f
implants and, for periodontally compromised teeth, 408–417, remodeling of, 397
409f–416f resorption of, 201
mandibular, 416 Peri-implant defects
periodontally accelerated osteogenic, 109, 411, 412f bony defects
Orthognathic surgery bone loss more than 2/3 of implant length, 462, 462f
atypical cases of, 428f–429f, 429 horizontal, 459, 460f–461f
classical and ideal cases of, 420, 421f–423f horizontal/vertical, 461f, 461–462
classical and not ideal cases of, 424, 425f–427f illustration of, 460f
extreme cases of, 430–431, 431f–434f location of, 461
stereotype of, 420 mucogingival defects combined with, 459, 460f
Osigraft, 338 vertical, 459, 461
Osseodensification bur, 83f case studies of, 462–470, 463f–471f, 465f
Osseointegrated implants classification of, 459–462
Brånemark system, 28, 28t, 92, 302 debridement of, 456–457, 457f
description of, 7 definition of, 459
history of, 21–22, 92 mucogingival defects combined with bony defects, 459, 460f
predictability of, 26 treatment algorithm for, 472f
Osseointegration Peri-implant maintenance therapy
history of, 28 adherence to, 482
predictive measures for, 101 agents used in, 496–497
time requirements for, 212 algorithm for, 498f
Osseoperception, 289 biologic principles of, 477–478
Osstell ISQ system, 101 case study of, 478–480, 479f–480f
Osteoblasts, 129, 201 chemotherapeutic agents in, 497
Osteocytes, 129 compliance, 482
Osteoprogenitor cells, 356 considerations for, 494
Osteotomes/osteotomy curettes in, 496
for transcrestal sinus floor elevation, 265, 266t definition of, 477
for zygomatic implants, 281, 281f, 286 efficacy of, 477
Ostiomeatal complex, 226, 226f floss, 496
Overbite, 414f frequency of, 494
523

P | Index
goals of, 492 treatment of

home hygiene, 484–485, 484f–485f, 498 algorithm for, 478f
in inflammatory disease patients, 476, 476f–477f description of, 446–449
instruments used in, 496 nonsurgical laser-assisted therapy, 486f, 486–487
interdental cleaning devices, 496 Periodontal biotype, 202
laser-assisted surface disinfection in, 498 Periodontal bone loss, 7f
objectives of, 492, 495–496 Periodontal disease
polishing in, 497–498 advanced, 408
prevention uses of, 480–481 alveolar bone loss with, 11
professional, 494–498 case studies of, 15f–16f, 23f, 27f, 408–417, 409f–416f
purpose of, 476, 476f description of, 2
recall/follow-up appointments implants in, 7
end of, 487 posterior bite collapse caused by, 408–417, 409f–416f
frequency of, 482 radiographic imaging of, 5f
home hygiene assessments, 484–485, 484f–485f Periodontal ligament, 130
oral hygiene assessments, 484–485, 484f–485f Periodontal maintenance, 477. See also Peri-implant maintenance
periodontal evaluation at, 483–484 therapy.
plaque removal at, 485–486 Periodontal pockets, 410, 417, 479f
probing depth assessments, 483, 483f Periodontal regeneration
supra- and subgingival calculus deposit removal, 485–486 case study of, 3f
time allotted for, 483 defect morphology and, 10
treatment procedures at, 483–487 definition of, 10
responsibility for, 482 grafting materials for, 10, 10f–11f
risk indicators, 494–495 intrabony defects as contraindication for, 3f
sonic devices used in, 496 options for, 9f, 9–10
studies of, 495t space maintenance for, 9
therapeutic goals of, 478–480, 479f–480f Periodontally accelerated osteogenic orthodontics, 109, 411, 412f
ultrasonic devices used in, 496 Periodontally compromised teeth
Peri-implant mucosal recession, 506 inflammation of, 408
Peri-implant mucositis, 492, 492f–493f, 497 maxillary incisors, 14, 15f
Peri-implant papilla, 170 mobility of, 408
Peri-implant soft tissue nonimplant rehabilitation of, 2, 3f–5f
dehiscence of. See Soft tissue dehiscence. orthodontics with implant therapy for, 408–417, 409f–416f
description of, 59–60 treatment of, 7
functions of, 481 Periodontitis
management of, 481–482 case study of, 411–413, 412f
mobility of, 369f malocclusion as risk factor for, 408
periodontium versus, 481 peri-implantitis and, 492
Peri-implantitis periodontal maintenance therapy for, 482
apical, 440–441 presurgical presentation of, 102f
bacteria that cause, 445 Periodontium
bleeding on probing and, 447 localized problem and, 8–9
cardiovascular disease and, 446 loss of, 6f
classification of, 447 peri-implant soft tissue versus, 481
definition of, 445 Periosteal elevators, 328
description of, 7, 408 Periosteo-elastic technique, 330
diagnosis of, 493 Personalized precision dental medicine, 102–105
etiology of, 445, 492 Physiolift device, 270
implant failure caused by, 439 Piezoelectric device
implant surface decontamination for, 448, 449f for lateral window preparation for maxillary sinus
machined-surface implant resistance to, 28 augmentation, 234–235
nonsurgical therapy for, 447–448 for posterior superior alveolar artery dissection, 249f
patient education about, 450 PIMT. See Peri-implant maintenance therapy.
peri-implant maintenance therapy for prevention of, 477, 480–481 Plaque Index, 496
periodontitis and, 492 Plaque removal, 485–486
prevalence of, 124, 445–446, 481 Platelet-derived growth factor
regenerative techniques for, 456 biology of, 339
removal of implant affected by, 448–449, 456 clinical trials of, 342t
retrograde, 440–441 ligands of, 339
risk factors for recombinant human. See Recombinant human platelet-derived
description of, 446, 446f growth factor BB.
excess cement, 56 summary of, 339f
restoration contour, 68 Platelet-rich fibrin, 137
rough-surface implants and, 85 Platelet-rich plasma, 356–357
short implants and, 78, 78f Platform-switching concept, 397f, 397–399
summary of, 450 Polishing, 497–498
surgical treatment of, 448–449 Polyether ether ketone abutments, 205
titanium and, 445 Polylactic acid, 363, 363f
524

Index | S
Polymorphonuclear leukocytes, 396 Recombinant human bone morphogenetic protein-2/acellular

Porphyromonas gingivalis, 410–411 collagen sponge, 358, 359f, 360
Posterior edentulism, 81 Recombinant human fibroblast growth factor 2, 340–341
Posterior mandible Recombinant human growth differentiation factor 5, 341
bilateral atrophy of, 84f Recombinant human platelet-derived growth factor BB
bone height in, 82 description of, 9, 9f, 82, 144
implants in development of, 339–340
description of, 82, 84f implant applications for, 343–348
placement of. See Implant placement, in posterior mandible insulin-like growth factor 1 and, 339
quadrant. periodontal applications of, 343–348
short, 79f, 85f vertical ridge augmentation uses of, 344–348, 348f
vertical augmentation in, 83f Remote flap, 328
Posterior mandibular vertical ridge augmentation, 328, 329f–334f Removal, of implant
Posterior maxilla after failure, 436, 437f, 438
remodeling of, 264 after peri-implantitis, 448–449, 456
short implants in, 81–82, 82f criteria for, 462
vertical ridge augmentation, 335, 335f–336f Rescue implants, 300, 397
Posterior superior alveolar artery, 229, 248, 249f–250f Resonance frequency analysis, 101
Posterior teeth Restoration-driven implant placement, 163, 441
immediate implant placement, 155, 155f–156f Restorative dentistry, 2
implant platform in, 56 Restorative leadership, 97
Laser-Lok implant for, 35, 35f Restorative space, 512
multiple crowns for, 80 Retrograde peri-implantitis, 440–441
single-tooth implants for, 57f Retromolar pad, 329f
Postoperative prostheses, 212, 213f–217f RFA. See Resonance frequency analysis.
Premolar sites, immediate implant placement in, 155, 155f–156f rhBMP-2. See Recombinant human bone morphogenetic
PRF, 137 protein-2.
Prichard periosteal, 330 rhBMP-2/ACS. See Recombinant human bone morphogenetic
Probing depth protein-2/acellular collagen sponge.
apicocoronal position and, 493 rhFGF-2. See Recombinant human fibroblast growth factor 2.
illustration of, 9f–10f, 480f rhPDGF-BB. See Recombinant human platelet-derived growth
implant failure and, 438–439, 439f factor BB.
peri-implant maintenance therapy, 483, 483f, 493 Robotically assisted dental surgery, 107–108
Proliferative phase, of extraction site healing, 129 Root(s)
Prolongation, 97, 98f fused, 11, 12f
Prosthesis attrition and fracture, 509–510, 510f resection of, 11
Prosthetic screw loosening and fracture, 509, 509f–510f resorption of, 2, 3f
Proteomics, 102 Root retention effect, 137
Provisional restorations, 417 Rough-surface implants
Provisionalization peri-implantitis around, 85
immediate survival rates and, 199, 511
with soft tissue augmentation, 382–385, 383f–384f
tooth extraction socket reconstruction and, 184–186,
185f–186f
S
for soft tissue preservation during immediate implant SAD. See Simplified antrostomy design.
placement, 157–158 SAFE SurgiGuide system, 96f, 96–97
PRP. See Platelet-rich plasma. Safety flap, 328, 335
Sand-blasted, large-grit, acid-etched implant surface, 38, 40
Q Scaffolds, for growth factor delivery, 350
Schnitman protocol, 198
Quad zygoma, 287–288, 289f, 305 Screw-retained crowns, 376f, 505
Screw-retained implant
R case study of, 53f
crowns, 368, 387f
RADS. See Robotically assisted dental surgery. Septa
Reamer approach, for transcrestal sinus floor elevation, anatomy of, 227
268f–270f, 268–270 in transcrestal sinus floor elevation, 265
Recall/follow-up appointments. See Peri-implant maintenance SFOT. See Surgically facilitated orthodontic therapy.
therapy, recall/follow-up appointments. Shank bur, 456, 457f
Recombinant human bone morphogenetic protein-2 Sharpey fibers, 129, 396
alveolar ridge augmentation uses of, 343 Short implants
anabolic effects of, 342 in atrophic mandible, 86, 86f
biology of, 338 bone–implant contact, 75
description of, 144 clinical crown height, 75–76
FDA-approved applications for, 339 cone beam computed tomography of, 74f
implant applications for, 342–343 crown height effects on, 77
periodontal applications for, 342–343 crown-implant ratio for, 75–78, 76f–78f
definition of, 74
525

S | Index
failure rates for, 75 height and thickness increases

machined-surface, 74 coronally advanced flap, 372, 377
marginal bone loss around, 80, 85, 85f description of, 371
microtextured surfaces of, 74 esthetic benefits of, 392
narrow-diameter, 79, 79f at implant placement, 377–379, 378f–379f
nonsplinted, 80–81, 81b outcomes, 372
off-axis load on, 76f postoperative protocol for, 372, 378f, 378–379
outcomes of, 74–75 surgical technique for, 371–372, 377–378
overdenture and, 86 with immediate provisionalization, 382–385, 383f–384f
peri-implantitis around, 78, 78f keratinized mucosa. See Keratinized mucosa, increases in.
in posterior mandible, 79f, 85f papillae preservation, 385–387, 386f
in posterior maxilla, 81–82, 82f Soft tissue defects, around submerged implants, 373–377,
recent advancements in, 74 374f–376f
single crown for, 78f Soft tissue dehiscence
stress distribution on, 75, 76f causes of, 388, 388f
studies of, 74–75 definition of, 387
summary of, 87 outcomes of, 392, 393f
vertical augmentation versus, 81–82, 82f–85f postoperative protocol for, 391, 392f
wide-diameter, 75f, 75–76 presurgical prosthetic protocol for, 389–390
SimPlant, 93, 93f, 101 prosthetic-surgical-prosthetic approach to, 387–393
Simplified antrostomy design, 238–239, 239f surgical alternatives for, 388, 388f
Single-rooted mandibular teeth, 11 surgical technique for, 390–391
Single-tooth implants Soft tissue grafts
abutment screw loosening, 507 harvesting of, from maxillary tuberosity, 179–180
in anterior maxilla, 170–171, 171f for implant contours, 59–60
case study of, 57f from maxillary tuberosity, 176–177
in esthetic zone, 184 Southern Implants fixtures
Laser-Lok, 35f history of, 42, 43f
for posterior teeth, 57f illustration of, 45f
survival rates for, 8 immediate placement of, 45f
Sinus(es), paranasal retrospective studies of, 42–44, 43f–44f
embryologic development of, 225 surface parameters of, 45
maxillary. See Maxillary sinus. Splinting, of dental implants, 77–80, 77f–80f
Sinus augmentation. See Maxillary sinus augmentation. Stage-two surgery, 373
Sinus membrane Static guided surgery, 95, 96f, 97–98
elevation of, 239–240, 240f Static guides
in lateral window approach to sinus augmentation, 239–243, 245f description of, 95, 96f, 97–98
in maxillary transcrestal sinus floor elevation, 264 dynamic navigation versus, 105
perforations of Stem cells, 349
collagen membrane repair of, 240, 241f Stereolithographic modeling, 98
CollaTape for, 248, 249f Stereolithographic static surgical guides, 94f
large, 246, 248, 248f Stereolithography, 95
in lateral window approach to sinus elevation, 240, 241f, Sterile, 230
243–248, 244f–245f, 247f–249f Straumann implants, 38
in maxillary sinus augmentation, 227f, 240 Subantral augmentation, 252
repair/treatment of, 245–248 Subepithelial connective tissue grafts, 178–180, 179f, 190
small, 246, 247f Subgingival calculus, 485–486
in transcrestal sinus floor elevation, 274, 274t Sublingual glands, 67f
very small, 246 Submerged implants
Sinus pneumatization, 81 description of, 396
Sinusitis illustration of, 43f
in lateral window sinus elevation, 252, 255–257 peri-implant bone loss treated with, 456
in transcrestal sinus floor elevation, 274–275 soft tissue defects around, 373–377, 374f–376f
zygomatic implants and, 280 Subperiosteal implants, 21
Skeletal disharmony malocclusion, 110f Summers osteotomy technique, for maxillary transcrestal sinus
SMAD signaling, 338 floor elevation, 265–268, 266f–267f, 276
Smoking, 485 Super Floss, 482f, 496
Socket. See Tooth extraction sockets. Supportive periodontal therapy, 477
Socket preservation, 180–182, 181b, 181f–182f Supracrestal soft tissue attachment, 396, 399, 402
Socket shield technique, 131 Supragingival calculus, 485–486
SocketKAGE, 137, 142f SureSmile system, 109, 109f
SocketKAP, 137, 142f Surgical drilling guides, 95
Soft tissue Surgical guides
interproximal, 390f description of, 94f, 98
in posterior mandible, 67 for zygomatic implants, 291
provisionalization of, 157–158 Surgical navigation, image-guided, 105–107, 106f
Soft tissue augmentation Surgical operating microscope, 7
in esthetic zone at implant placement, 379–382, 381f–382f Surgically facilitated orthodontic therapy, 108
hard tissue grafting with, 155, 157, 157f
526

Index | U
T Top-down planning, 95
Toronto modified bridge, 212
Teeth. See Anterior teeth; Dentition; Periodontally compromised Totally guided approach, 97
teeth; Posterior teeth; specific teeth. Transalveolar method, 276
Teeth-to-jaw relationship, 109, 111 Transcrestal sinus floor elevation
Telemedicine, 103 anatomical structures, 264–265
Temporary anchorage devices, 414 benefits of, 266t
Teriparatide, 341–342, 342t bone quality in, 264
Tetracycline powder, for implant surface detoxification, 458 complications of, 265
Third molar extraction, 64 benign paroxysmal positional vertigo, 275–276
3D digital diagnostics, 93, 93f–94f headaches, 275
3D imaging implant migration, 275
in anterior maxilla, 165 incision opening, 275
in personalized and precision medicine, 102 mucosal dehiscence, 275
3D printing, 350 overview of, 273–274, 274t
3D spatial positioning, 52–58, 53f–58f PASS principle for, 273, 275
Three-implant fixed partial denture, 301, 301f postoperative infection, 274–275
Tilted implants, 199, 207, 212 rotational instability, 275
Tissue engineering sinus membrane perforation, 274, 274t
cells for, 349 sinusitis, 274–275
description of, 144, 231 considerations for, 276
gene therapy, 350 grafting materials used during, 271–273, 272f
in-situ. See In-situ tissue engineering. guided bone regeneration and, 271
stem cells for, 349 history of, 264
Titanium abutments, 507, 507f hydraulic pressure technique for, 270, 271f
Titanium plasma spray, 38 implant stability in, 275–276
Tooth extraction(s) limitations of, 266t
alveolar ridge changes after, 130–131. See also Alveolar ridge. Michigan reamer approach for, 268–270, 268f–270f
biologic events associated with, 128 osteotomes used in, 265, 266t
bone remodeling after, 30, 152–153 postsurgical considerations for, 273
illustration of, 23f–24f reamer approach for, 268–270, 268f–270f
implant placement after residual alveolar bone dimensions, 264, 265f
early, 169 septa in, 265
immediate, 168–169 sinus floor morphology in, 264–265
late, 169 sinus membrane in
timing of, 167–169 description of, 264
presurgical evaluations, 133f–136f perforation of, 274, 274t
single-tooth implant after, 35, 36f soft thickness recommendations for, 276
Tooth extraction sockets summary of, 276
alveolar bone defects and, 137 Summers osteotomy technique for, 265–268, 266f–267f, 276
grafting of, using in-situ tissue engineering, 360 techniques for, 265–273, 266f–273f, 266t
healing of, 128f, 128–130 Transforming growth factor beta, 338
immediate implant placement in Transmandibular implants, 86
advantages of, 150, 157–158 Transosteal implants, 86
bone-implant contact for, 150, 151f Trapezoidal flap, 371
clinical considerations for, 153f–159f, 153–158 Treatment planning
decision algorithm for, 151f computer software-based, 95
decision making for, 150f–151f, 150–151 considerations for, 2, 3f–5f
illustration of, 153f decision making in, 2
in infected sites, 153, 153f diagnosis before, 158
in interradicular septum, 156f esthetic considerations in, 13–14, 14f–15f
in maxillary anterior sites, 154, 154f factors that affect, 9
in molar sites, 155, 155f–156f future directions for, 111
in posterior sites, 155, 155f–156f zygomatic implants, 283–284
in premolar sites, 155, 155f–156f Trefoil, 301, 301f
provisionalization for soft tissue preservation, 157–158 Trigeminal nerve, 229
soft and hard tissue grafting, 155, 157, 157f Triple graft, 190–192, 193f
soft tissue papillae preservation for, 385–387, 386f T-scan, 101
preservation of, with maxillary tuberosity graft, 180–182, 181b,
181f–182f
reconstruction of U
immediate dentoalveolar restoration technique, 184–185, 185f
Ultrasonic devices, 496
immediate provisionalization and, 184–186, 185f–186f
Underwood septa, 227, 228f
maxillary tuberosity bone graft for, 182–186, 183f–186f
Tooth mobility, 413, 413f, 415f–416, 415–417
Tooth-to-tooth relationship, 109
527

V | Index
V Zygoma anatomy guided approach, 284–286, 285f

“Zygoma drill guide,” 291
Vascular endothelial growth factor, 363 Zygomatic implants
Vasoconstrictors, 250 all-on-four approach and, 302–306, 302f–306f
Vertical bone augmentation anterior maxillary implants and, 287
in posterior mandible, 82 Brånemark protocol for, 280–283, 285–286, 288
short implants versus, 81–82, 82f–85f complications of, 288
supracrestal, 328 cone beam computed tomography evaluations of bone volume
Vertical bone height, 74 for, 283–284, 284f
Vertical bone regeneration crestal incision for, 282f
case studies of, 322–325, 322f–325f cross-arch splinting of, 293
horizontal bone regeneration and, 322–324, 322f–324f diagnostic imaging of, 283–284
Vertical ridge augmentation extended sinus elevation for, 286, 287f
anterior mandibular, 334, 334f extra-maxillary, 286, 306, 307f–308f
in-situ tissue engineering for, 365, 365t home care measures for, 288
modified lingual flap advancement technique for, 328, 329f immediate loading of, 283, 288–289, 288f–289f
periosteo-elastic technique for, 330 indications for
posterior mandibular, 328–333, 329f–334f ablation defects, 302, 303f
posterior maxillary, 335, 335f–336f anterior maxillary sinus intrusion, 304, 305f
recombinant human platelet-derived growth factor BB for, bone-related syndromes, 304, 304f
344–348, 348f mandibular discontinuity defects, 302, 303f
Vertical root fracture, 204f severe atrophy, 304–305, 305f
Vestibular grafts, 369 trauma, 302, 303f
Vestibular incision subperiosteal tunnel access, 142f–143f lengths of, 280
VISTA. See Vestibular incision subperiosteal tunnel access. maintenance of, 293
Vitronectin, 357 mandibular implant reconstruction and, 292
nighttime appliances, 293
osseoperception associated with, 289
W osteotomy/osteotomes for, 281, 281f, 285–286
palatal position of, 289, 289f
Waterpik Water Flosser, 496
prosthetically driven approach
Wide Neck implant, 40f
definitive prosthesis, 291, 291f
Wide-diameter implants, 75f, 75–76, 80f, 397
guided surgery, 290–291
WNT signaling pathways, 341
prosthesis contour, 289–290
Wound healing, 128f, 128–130
provisional prosthesis, 291
tooth position, 289–290
X quad zygoma, 287–288, 289f, 305
screw loosening considerations, 293
Xenografts, for alveolar ridge preservation via socket grafting, 132 sinus elevation versus, 283
Xerostomia, 296 sinusitis after, 280
X-Guide system, 105 summary of, 293
surgical guides for, 291
surgical technique for, 282f, 282–283
Y survival rates for, 280, 283, 287
tilted, 283f
Yomi Robot-Assisted Dental Surgery, 107–108, 108f
trajectory of, 283, 283f
treatment planning of, 283–284
Z zygoma anatomy guided approach for, 284–286, 285f
ZAGA. See Zygoma anatomy guided approach.

Zirconia abutments, 391, 392f, 507f
528

Nevins/Wang
CONTRIBUTORS
Edited by
Myron Nevins, dds
A. Ackermann F. Alfonsi L. Aranguren G. Avila-Ortiz L. Canullo D. Cardaropoli H. Chan C. Chen Y. Cho
Hom-Lay Wang, dds, mds, phd
Clinical Approaches and Evidence of Success, Second Edition

IMPLA NT THERAPY
J. Chow L. Cooper T. Cracknell M. de Araújo Nobre A. Decker M. Deflorian B. DeGroot M. Del Fabbro D. Ferreira
IMPL ANT
THERAPY
S. Froum J. Fu F. Galli J. Ganeles W. Giannobile C. Hämmerle P. Hawker P. Hengjeerajaras R. Herman
M. Iwata R. Jung D. Kim G. Liddelow C. Lin K. Liu M. Ludlow S. Maeda P. Maketone
P. Maló G. Mandelaris J. Martins da Rosa R. Marx T. Matsui C. Misch A. Monje S. Mühlemann K. Nakamura
Clinical Approaches and
Evidence of Success
M.L. Nevins M. Nevins F. Norkin Y. Ono S. Ono Rubin S. Parel A. Parenti W. Park S. Parma Benfenati SECOND EDITION
L. Pereira M. Roncati M. Ronda K. Saburi T. Sasaki R. Scaini D. Schneider C. Shapoff Y. Shi
M. Simion M. Stefanini T. Testori C. Tinti I. Urbán L. Velasco S. Wallace C. Wang H. Wang
ISBN 978-0-86715-798-7
H. Zadeh S. Zfaz G. Zucchelli 90000
9 780867 157987
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Nevins/Wang 

Clinical Approaches and Evidence of Success, Second Edition

M. Iwata R. Jung D. Kim G. Liddelow C. Lin K. Liu M. Ludlow S. Maeda P. Maketone

L. Pereira M. Roncati M. Ronda K. Saburi T. Sasaki R. Scaini D. Schneider C. Shapoff Y. Shi

M. Simion M. Stefanini T. Testori C. Tinti I. Urbán L. Velasco S. Wallace C. Wang H. Wang

Nevins/Wang cover spread.indd 1 3/19/19 9:24 AM

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I dedicate this book to my lovely family, my research collaborators,

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a 1995 b 1999 c 2009

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1962 1974 1983 1999

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TREATING PERIODONTALLY esthetics may be greatly affected, even in a posterior quadrant.

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However, this should not be perceived as a competition TREATING PATIENTS WITH

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d 1976 e 1977 f 1980 g 2000

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Fig 1-23 (a) The patient presented with es-

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Long-Term Results of Implants in Native

Connective Tissue Attachment to a

Long-Term Implant Success: Part I

Long-Term Implant Success: Part II

Long-Term Implant Success: Part III

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Osseointegrated Implants companies emerging and implants being placed by clinicians

MYRON NEVINS The author’s experience with subperiosteal implants ended

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Fig 2-7 (a) Imaging demonstrates extreme bone loss around

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1991 1992 2016 2016

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Fig 2-11 (a) A 19-year-old woman presented with a

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Fig 2-16 (a) An anterior view demonstrating a

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Lindquist et al (1996)26 98.9 273 47 15 1.2

Ekelund et al (2003)25 98.9 273* 47* 20 1.6 ± 0.90

Nevins/Wang