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Implant Dentistry

01. Maxillary Sinus Augmentation With Different Biomaterials: A Comparative Histologic and Histomorphometric Study in Man. 02. Tridimensional Analysis of Maxillary Sinus Anatomy Related to Sinus Lift Procedure. 03. Pericardium Membrane and Xenograft Particulate Grafting Materials for Horizontal Alveolar Ridge Defects. 04. Reintegration Success of Osseotite(R) Implants After Intentional Countertorque Liberation in the Endentulous Human Mandible. 05. An Alternative Sinus Floor Elevation Procedure: Trephine Osteotomy. 06. The Role of Platelet-Rich Plasma in Sinus Augmentation: A Critical Review. 07. Immediate Load Protocol for Anterior Maxilla With Cortical Bone From Mandibular Ramus. 08. Hemorrhage in the Floor of the Mouth After Second-Stage Surgery: Case Report. 09. Posttraumatic Dental Implant Placement in a Patient With Maple Syrup Urine Disease. 10. Advanced Surgical Guidance Technology: A Review 11. Passive Definitive Fit of Bar-Supported Implant Overdentures 12. The Bone-Grafting Decision Tree: A Systematic Methodology for Achieving New Bone. 13. Implant Recommendation as a Replacement Option After Tooth Loss for Periodontal Reasons. 14. Effect of Microcapsules Containing TAK-778 on Bone Formation Around Osseointegrated Implants: Histomorphometric 15. Comparison of Bone Grafting Materials in Human Extraction Sockets: Clinical, Histologic, and Histomorphometric Evaluations. 16. Heat Transfer of Impression Plasters to an Implant-Bone Interface. 17. Profilometric and Standard Error of the Mean Analysis of Rough Implant Surfaces Treated With Different Instrumentations 18. Collagen Fiber Orientation Near a Fractured Dental Implant After a 5-Year Loading Period: Case Report 19. Analysis of Aspartate Aminotransferase and Alkaline Phosphatase in Crevicular Fluid From Implants With and Without Peri-implantitis 20. Titanium Membranes in Prevention of Alveolar Collapse After Tooth Extraction. 21. Alveolar Distraction Osteogenesis Before Placement of Dental Implants 22. Surgical Navigation in Oral Implantology 23. Immediate Loading of Implant Overdentures Using Modified Loading Protocol. 24. Attachment Systems for Implant Retained Overdentures: A Literature Review. 25. Early Osteotomy With Delayed Implant Placement: A Step Further for Immediate Loading. 26. "PASS" Principles for Predictable Bone Regeneration. 27. Ridge-Splitting Technique with Simultaneous Implant Placement

Ridge-Splitting Technique with Simultaneous Implant Placement Samuel Koo, DDS, MS; Serge Dibart, DMD; and Hans-Peter Weber, DMD Abstract Bone augmentation procedures are routinely required before dental implant placement. Several techniques for this procedure may be considered, such as guided bone regeneration, bone block grafting, and ridge splitting for bone expansion. These case reports describe the technique for ridge splitting and gradual expansion in the maxilla and the mandible. Simultaneously, dental implants were placed within the split ridge, surrounded by the particulate bone graft and covered by a resorbable membrane. Six months later, the implants were uncovered followed by impression and final restoration with implant-supported porcelain-fused-to-metal crowns. The resorption process of the alveolar ridge after tooth loss is routinely encountered in patients requiring dental implant treatment. Several methods have been described to augment the alveolar crest using bone graft from various sources (block or particulate) in conjunction with membranes.1,2 Another method to increase bone availability in the narrow alveolar ridge is the ridge-splitting technique. This approach creates a sagittal osteotomy of the edentulous ridge using instruments such as chisels between the two cortical plates to expand the ridge width and consequently allow for the placement of implants. Tatum described a technique to expand the cortical wall in cases with inadequate buccolingual thickness of bone using various sizes of channel formers.3 Subsequently, other clinical cases were reported with some variation of this technique, allowing placement of implants simultaneously.4,5 To start, adequate bone height for implant placement should be present because the splitting of the crest will not increase bone volume vertically. A minimum of 3 mm of bone width, including at least 1 mm of cancellous bone, is desired to insert a bone chisel between cortical plates and consequently expand the cortical bones.6 A pyramidal form ridge with a wider base is the ideal indication for this technique because it will prevent the risk of buccal plate fracture. This approach allows simultaneous placement of implants, shortening the overall treatment time. In some cases, the expansion of the buccal plate with the ridge-splitting technique may correct the buccal concavity caused by ridge resorption. Morbidity related to second donor site also is eliminated with this approach. Because this technique does not add vertically to the alveolar ridge, its use is limited when the alveolar ridge is overangulated, especially in the maxillary anterior areas. This condition makes implant restoration a challenge. Also, when a single site is planned, this technique is difficult to perform in the mandible because of space. The main complication is fracture of the buccal plate, especially in the mandible. If this occurs, bone fixation screws need to be used to stabilize the buccal plate. This article describes implant placement in atrophic maxillary and mandibular alveolar crests using the ridge-splitting technique. CASE REPORTS Ridge Splitting in the Maxilla A 65-year-old woman was referred for implant placement and prosthetic treatment in the area of teeth Nos.11 through 14. The teeth had been extracted 3 years before and the patient was not wearing any denture. The computerized tomography (CT) scan evaluation revealed adequate bone height for implant placement, but a narrow ridge of 3 mm to 4 mm at the crest (Figure 1A through Figure 1C View Figure). The CT scan also revealed a posterior pneumatized maxillary sinus. Because the patient wanted to avoid a sinus elevation procedure, it was decided not to place an implant in the area of tooth No.14. It was decided to place a 10-mm length, 3.7-mm diameter Tapered Screw Vent® MTX (Zimmer Dental, Carlsbad, CA), with a rough, acid-etched surface, using the ridge-splitting technique in the area of teeth Nos. 11 through 13. At the time of the surgery, local infiltrative anesthesia was administered (lidocaine 2%, epinephrine 1:100,000). A full-thickness mucoperiosteal flap was raised, confirming the presence of a narrow crest ridge previously observed in the CT scan (Figure 2 View Figure). The initial osteotomy was performed on midcrestal bone using a No. 15 blade. Chisels of increasing width and a mallet were used to further enlarge the osteotomy to a point 3 mm shorter than the final length of the implants to be placed. Approximately 2 mm to 3 mm of expansion was achieved without performing vertical incisions in the bone (Figure 3 View Figure). To prepare the osteotomy site for implant placement, sequential surgical burs according to standard implant placement protocol were used up to the final length of the implants (10 mm). The implants presented initial primary stability (Figure 4 View Figure), the cover screws were placed, and the implants were submerged for a healing period of 6 months. The widened space between cortical plates was filled with a mix of bovine anorganic bone filler, Bio-Oss® (Osteohealth, Shirley, NY), and demineralized freeze-dried bone allograft (DFDBA) (Pacific Coast Tissue Bank, Los Angeles, CA), and covered with a bioresorbable membrane, Bio-Gide® (Osteohealth). The tissue was approximated and the patient was instructed not to wear any denture or to place pressure on the healing site. Second-stage surgery was performed 6 months later, healing abutments were placed (Figure 5 View Figure), and the soft tissue was allowed to heal for an additional 5 weeks. Splinted porcelain-fused-to-metal (PFM) crowns supported by custom gold abutments then were delivered (Figure 6 View Figure).
Figure 2 Clinical aspect of the alveolar crest after full-thickness flap elevation.
Figure 1A through Figure 1C The preoperative CT scan for implant surgery planning of the area near tooth No. 11 (A), No. 12 (B), and No. 13 (C) revealing a narrow ridge with 3 mm to 4 mm width at crestal level Figure 3 Expansion of 2 mm to 3 mm of the buccal plate achieved by splitting the ridge with chisels and a mallet.
Figure 4 Placement of three implants at the expanded ridge. Figure 5 Periapical radiograph of implants at uncovering phase 6 months after the implant surgery.
Figure 6 Delivery of final implant-supported PFM restoration. Figure 7A and Figure 7B The preoperative CT scan for implant surgery planning of area near tooth No. 19 (A) and No. 20 (B) revealing crestal ridge width of 3 mm to 4 mm.
Figure 8 To facilitate the bone expansion, vertical osteotomy was performed in the buccal plate joint by osteotomy with a round bur at the apical portion. Figure 9 Placement of two implants at site of teeth Nos. 19 and 20 after the ridge expansion.
Figure 10 Periapical radiograph of the implants at uncovering phase 6 months after the implant surgery. Figure 11 Clinical aspect of the surrounding bone at the uncovering phase 6 months after the implant placement.
Figure 12 Delivery of the final splinted implant-supported PFM restoration.
Ridge Splitting in the Mandible A 60-year-old woman without medical complications presented for the replacement of a missing mandibular right second premolar and first molar. The teeth had been extracted 2 years before. The CT scans revealed the presence of 16 mm of bone above the mandibular inferior alveolar nerve at each implant site, with a crestal ridge width of approximately 3 mm to 4 mm (Figure 7A and Figure 7B View Figure). At the time of the surgery, a full-thickness mucoperiosteal flap was raised. For the initial midcrestal osteotomy, a carbide tungsten bur, Flat-end Fissure 701 (Brasseler USA, Savannah, GA), was used. Because of the thickness of the cortical bone in the mandible, two vertical osteotomies were required, extending from the edges of the initial midcrestal osteotomy. The length of these "vertical bony release" osteotomies is usually tailored to the length of the implant. Typically the length of the bony cut will be 3 mm shorter than the final length of the implant. To prevent a fracture of the buccal plate during the expansion process, an apical osteotomy with a carbide round bur was performed connecting the apical ends of the two "bony verticals" (Figure 8 View Figure). Expansion of 3 mm between cortical plates was achieved using chisels with gentle hand motion buccolingually. Two implants, 4 mm x 11.5 mm (Osseotite®, parallel walled, Biomet 3i, Inc, Palm Beach Gardens, FL), were placed following standard protocol (Figure 9 View Figure). The expanded site was filled with a mixture of bovine anorganic bone filler, Bio-Oss, and DFDBA and covered with a bioresorbable membrane, Bio-Gide. After 6 months of healing, the second-stage surgery was performed to expose the implants (Figure 10 View Figure and Figure 11 View Figure). Custom abutments were fabricated to be restored with the splinted PFM crowns (Figure 12 View Figure). DISCUSSION The ridge-splitting technique allows placement of implants in a narrow crestal ridge in a single procedure. Chiapasco and colleagues evaluated the success of different surgical techniques for ridge reconstruction and success rates of implants placed in the augmented areas.7 The surgical success and the implant survival rates were as high as the guided bone regeneration and onlay graft procedure, with the advantage of a shorter treatment time. Several authors have suggested the use of a partial thickness flap to help immobilize the displaced buccal cortical plate.5,6,8 In the presented cases, the use of a full-thickness flap helped to avoid excessive bleeding, resulting in better visualization of the operating sites and better handling of the surgical steps. In cases where there is thin connective tissue, the partial-thickness flap procedure becomes extremely difficult, and the remaining tissue over the alveolar bone is too thin to protect the bone adequately.9 In cases of buccal plate fracture, the mobile plate may be retained with bone fixation screws.10 Finally, when the primary stability of the implants is compromised, implants are placed only after the healing period of the augmented site. Generally, mandibular bone has higher density compared with maxillary bone, requiring a different approach in ridge splitting. In the maxilla, the osteotomy of the crest may be achieved with chisels and without the assistance of surgical burs. A mallet may be used to expand the plates without vertical osteotomy. In the mandible, however, the initial osteotomy is achieved using a surgical carbide bur on the alveolar crest and two vertical osteotomies. Additionally, an apical osteotomy connecting both verticals with a round bur allows the expansion and minimizes any chance of bone fracture. Instead of a mallet, hand motion is used with the chisels, resulting in slow bone expansion. To separate the ridge gently, Chiapasco et al11 reported 45 cases using a wedge-type device with two surgical steel arms hinged apically and a transversal screw, which allows a progressive activation of the device. A fracture of the mandibular buccal plate occurred in one patient. In nine patients, the expansion was achieved gradually in 4 to 5 days by activating the device 1 mm per day. CONCLUSION This article described implant placement in atrophic maxillary and mandibular alveolar crests using the ridge-splitting technique. The correct indication associated with careful clinical maneuver of the ridge-splitting technique allows predictable placement of implants even in narrow alveolar ridges. REFERENCES 1. Garg AK, Morales MJ, Navarro I, et al. Autogenous mandibular bone grafts in the treatment of the resorbed maxillary anterior alveolar ridge: rationale and approach. Implant Dent. 1998;7(3):169-176. 2. Buser D, Dula K, Lang NP, et al. Long-term stability of osseointegrated implants in bone regenerated with the membrane technique. Five-year results of a prospective study with 12 implants. Clin Oral Implants Res. 1996;7(2):175-183. 3. Tatum H. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986;30(2): 207-229. 4. Simion M, Baldoni M, Zaffe D. Jawbone enlargement using immediate implant placement associated with a split-crest technique and guided tissue regeneration. Int J Periodontics Restorative Dent. 1992;12(6):462-473. 5. Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion technique: a five-year study. Int J Periodontics Restorative Dent. 1994;14(5):451-459. 6. Guirado JL, Yuguero MR, Carrión del Valle MJ, et al. A maxillary ridge-splitting technique followed by immediate placement of implants: a case report. Implant Dent. 2005;14(1):14-20. 7. Chiapasco M, Zaniboni M, Boisco M. Augmentation procedures for the rehabilitation of deficient edentulous ridges with oral implants. Clin Oral Implants Res. 2006;17(Suppl 2):136-159. 8. Ferrigno N, Laureti M. Surgical advantages with ITI TE implants placement in conjunction with split crest technique. 18-month results of an ongoing prospective study. Clin Oral Implants Res. 2005;16(2):147-155. 9. Wood DL, Hoag PM, Donnenfeld OW, et al. Alveolar crest reduction following full and partial thickness flaps. J Periodontol. 1972;43(3): 141-144. 10. Basa S, Varol A, Turker N. Alternative bone expansion technique for immediate placement of implants in the edentulous posterior mandibular ridge: a clinical report. Int J Oral Maxillofac Implants. 2004;19(4):554-558. 11. Chiapasco M, Ferrini F, Casentini P, et al. Dental implants placed in expanded narrow edentulous ridges with the Extension Crest device. A 1-3–year multicenter follow-up study. Clin Oral Implants Res. 2006;17(3):265-272. -------------------------------------------------------------------------------- 1 Faculty, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine, Boston, Massachusetts 2 Associate Professor and Clinical Director of Postdoctoral Periodontology, School of Dental Medicine, Boston University, Boston, Massachusetts 3 Professor and Chair, Department of Restorative Dentistry and Biomaterials Sciences, Harvard School of Dental Medicine,Boston, Massachusetts This paper was presented at the 12th Annual Northeast Postgraduate Implant Symposium, which was held November 10-11, 2006, at the University of Connecticut Health Center in Farmington, and sponsored by the Prosthodontic Residency at University of Connecticut School of Dental Medicine. Maxillary Sinus Augmentation With Different Biomaterials: A Comparative Histologic and Histomorphometric Study in Man. Implant Dentistry. 15(2):197-207, June 2006. Antonio Scarano, DDS, MD; Marco Degidi, MD, DDS; Giovanna Iezzi, DDS, PhD; Gabriele Pecora, MD, DDS; Maurizio Piattelli, MD, DDS; Giovanna Orsini, DDS, PhD; Sergio Caputi, MD, DDS; Vittoria Perrotti, DDS, PhD; Carlo Mangano, MD, DDS; Adriano Piattelli, MD, DDS Abstract: Objective: Rehabilitation of the edentulous posterior maxilla with dental implants can be difficult because of insufficient bone volume caused by pneumatization of the maxillary sinus and crestal bone resorption. Different biomaterials have been used for sinus augmentation. The aim of the study was to compare different materials in maxillary sinus augmentation in man. Methods: A total of 94 patients participated in this study. Inclusion criteria were maxillary partial (unilateral or bilateral) edentulism involving the premolar/molar areas, and the presence of 3-5-mm crestal bone between the sinus floor and alveolar ridge. A total of 362 implants were inserted. There were 9 biomaterials used in the sinus augmentation procedures. Each patient underwent 1 biopsy after 6 months. A total of 144 specimens were retrieved. Results: None of the 94 patients had complications. All implants were stable, and x-ray examination showed dense bone around the implants. Mean follow-up was 4 years. There were 7 implants that failed. Histologic resultsshowed that almost all the particles of the different biomaterials (i.e., autologous bone, demineralized freeze-dried bone allograft Biocoral(R) [Inoteb, St. Gonnery, France], Bioglass(R) [US Biomaterials, Alachua, FL], Fisiograft(R) [Ghimas, Bologna, Italy], PepGen P-15TM [Dentsply Friadent CeraMed, Lakewood, CO], calcium sulfate, Bio-Oss(R) [Geistlich Pharma AG, Wohlhusen, Switzerland], and hydroxyapatite) were surrounded by bone. Some biomaterials were more resorbable than others. Included are the histomorphometry clarified features of the newly formed bone around the different grafted particles. Conclusion: All biomaterials examined resulted in being biocompatible and seemed to improve new bone formation in maxillary sinus lift. No signs of inflammation were present. The data are very encouraging because of the high number of successfully treated patients and the good quality of bone found in the retrieved specimens. Tridimensional Analysis of Maxillary Sinus Anatomy Related to Sinus Lift Procedure. Implant Dentistry. 15(2):192-196, June 2006. Glauco Rodrigues Velloso, DDS, MSc; Guaracilei Maciel Vidigal Jr, DDS, MSc, PhD; Marcos Motta de Freitas, DDS, MSc; Oldemar F. Garcia de Brito, DDS, MSc; Marcelo Corrêa Manso, DDS, MSc; Mario Groisman, DDS, MSc Abstract: Purpose: To evaluate the angulation of the maxillary sinus walls at the apical sinus region. Materials and Methods: Using preoperative computerized tomographies of 15 patients selected for sinus lift procedures, the angulation of the maxillary sinus floor was measured drawing straight lines tangential to the mesial and lateral walls. The measurements were taken from sagittal images at specific areas (i.e., second bicuspid, first molar, and second molar). Results: The results showed that the second bicuspid sites have a sharper angulation than the second molar sites, and these second molar sites have a sharper angle than the first molar sites. Conclusion: The sharper angle observed in the second bicuspid area can influence the feasibility of schneiderian membrane evaluation when compared to the molar areas. Pericardium Membrane and Xenograft Particulate Grafting Materials for Horizontal Alveolar Ridge Defects. Implant Dentistry. 15(2):186-191, June 2006. Marius Steigmann, Dr.medic.stom Abstract: Purpose: The purpose of this study was to evaluate the clinical feasibility of using a native collagen physical resorbable barrier made of bovine pericardium to augment localized alveolar ridge defects for the subsequent placement of dental implants. Materials & Methods: There were 8 systemically healthy patients with 19 implant sites (aged 35 to 68 years), with inadequate dental alveolar ridge widths, selected for study. All patients completed initial therapy, which included scaling, root planning, and oral hygiene instruction. All ridge defects were augmented with bovine xenograft and a collagen pericardium membrane. Horizontal (width) hard tissue measurements were taken the day of ridge augmentation surgery, or implant placement and augmentation (baseline), and at the 6-month (reentry or uncovering) surgery. Results: The change in ridge width varied from a loss of 0.2 mm to a gain of 7.8 mm, measured clinically with a mean value of 3.0368 and a median of 2.8 mm from baseline. Conclusions: The results suggested that pericardium collagen membrane may be a suitable component for augmentation of localized alveolar ridge defects in conjunction with different xenografts. Reintegration Success of Osseotite(R) Implants After Intentional Countertorque Liberation in the Endentulous Human Mandible. Implant Dentistry. 15(2):178-185, June 2006. Jose Lucente, DDS, Odont; Jorge Galante, Odont; Paolo Trisi, DDS, PhD; James N. Kenealy, PharmD Abstract: Purpose: Implants that rotate during abutment screw tightening may not necessarily constitute implant failure. This prospective study was designed to determine to what degree integrated implants could gain a state of reintegration after intentional countertorque to liberation from the bone. Materials and Methods: There were 11 patients with fully edentulous mandibles restored with 2 "clinical" implants (3.75 x 10 mm) placed in the canine sites and an additional nonused "test" implant (3.75 x 10 mm) placed at the symphysis of the anterior mandible. At second-stage surgery, the test implant was countertorqued (T1) using a torque-metering wrench until it detached from the bone. The implant was returned to its original position and allowed to heal for a period until a second countertorque test (T2) was performed. In group A, patients (n = 5) received the countertorque T1 at 3 months and T2 at 5 months. In group B (n = 6) T1 was at 1.5 months, and T2 was at 3.5 months. After completion of T2, the group A test implants were removed with a 5-mm trephine for histologic examination. Results: For both groups, peak forces, all higher than 37.4 Ncm at T1, indicate that all implants were integrated. At T2, torque values were higher than T1 values for most of the test implants. The clinical implants were restored with "patrix" abutments and an overdenture. Histology staining showed distinction between old and new bone, which formed during the remodeling process. Discussion: The increase in peak forces needed to detach implants at T2 may be explained by bone-to-bone healing or the additional bone contact promoted by bleeding that occurred during the T1 procedure. Conclusion: The results suggest that all implants were reintegrated after being intentionally countertorqued to liberation and resumed healing in the original osteotomy position. An Alternative Sinus Floor Elevation Procedure: Trephine Osteotomy Implant Dentistry. 15(2):171-177, June 2006. Shahram Emtiaz, DDS; João M. M. Caramês, DMD, PhD; Ana Pragosa, DMD Abstract: Today, the sinus floor elevation procedure is not only being used on a routine basis, but clinicians are reporting high success rates. The sinus floor graft has become an important option in the treatment of the edentulous posterior maxilla, where vertical bone height is less than ideal. A review of maxillary sinus floor elevation as an integral part of restoring the posterior maxillary is discussed. The related anatomy of the area and current osteotomy techniques are reviewed. This article describes a trephine osteotomy, which is an alternative technique to the existing lateral antrostomy approach currently being used. The Role of Platelet-Rich Plasma in Sinus Augmentation: A Critical Review. Implant Dentistry. 15(2):160-170, June 2006. Lakshmi Boyapati, BDS; Hom-Lay Wang, DDS, MSD Abstract: Although the lateral wall sinus lift is a predictable clinical procedure to increase vertical bone height resulting in implant success rates comparable to that of native bone, the issue of extended healing periods remains troublesome. Clinicians and researchers have investigated several methods, including addition of growth factors and peptides, to reduce this healing time and enhance bone formation within the subantral environment. Platelet-rich plasma (PRP) is an autologous blood product containing high concentrations of several growth factors and adhesive glycoproteins. The incorporation of PRP into the sinus graft has been proposed as a method to shorten healing time, enhance wound healing, and improve bone quality. This article reviewed pertinent literature assessing the effect of PRP on sinus augmentation. Currently, the literature is conflicting with respect to the adjunctive use of PRP in sinus augmentation. Factors that may contribute to this variability include variable/inappropriate study design, underpowered studies, differing platelet yields, and differing graft materials used. In addition, methods of quantifying bone regeneration and wound healing differ between studies. At present, because of limited scientific evidence, the adjunctive use of PRP in sinus augmentation cannot be recommended. Further prospective clinical trials are urgently needed. Immediate Load Protocol for Anterior Maxilla With Cortical Bone From Mandibular Ramus. Implant Dentistry. 15(2):153-159, June 2006. Cameron Y.S. Lee, DMD, MD Abstract: Objective: To evaluate the concept of a nonfunctional immediate load protocol with single implants placed in the anterior maxilla that has been bone grafted with autogenous, block cortical grafts harvested from the ramus of the mandible. Methods: There were 19 hydroxyapatite-coated dental implants surgically placed in 19 patients, and immediately loaded between 48 hours and 3 days later with a custom acrylic provisional restoration that was placed out of functional occlusion. After 12 weeks, the definitive ceramo metal restoration was cemented to the custom abutment. Results: Over a 1-year observation period, all implants continue to function. Conclusion: The preliminary results of this clinical study indicate that immediate, nonfunctional load with single implants is a predictable protocol in the bone grafted anterior maxilla in select cases. Hemorrhage in the Floor of the Mouth After Second-Stage Surgery: Case Report. Implant Dentistry. 15(2):148-152, June 2006. Andi S. Budihardja, DDS; Christoph Pytlik, Drmed, Drmed dent; Stephan Haarmann, Drmed, Drmed dent; Frank Holzle, Drmed, Drmed dent Abstract: Placement of dental implants in the interforaminal region of the mandible is generally considered a routine, simple, and safe procedure. However, severe bleeding and hematoma in the floor of the mouth have been reported as a rare but potentially fatal complication related to the placement of an implant in this region. The following report describes a case of life-threatening hemorrhage in the floor of the mouth after second-stage surgery to place the healing abutment. The implants were forced to match with the prosthesis in a severely atrophic upper jaw, resulting in a perforation of the lingual cortex and mucosa of the floor of the mouth. Clinicians who place implants should be knowledgeable in the treatment of such a serious complication. Posttraumatic Dental Implant Placement in a Patient With Maple Syrup Urine Disease. Implant Dentistry. 15(2):143-147, June 2006. Dan Oelgiesser, DMD; Liran Levin, DMD; Orly Elpeleg, MD; Devorah Schwartz-Arad, DMD, PhD Abstract: Maple syrup urine disease (MSUD) is an inborn error of metabolism resulting from a defect in the oxidation of the branched-chain amino acids leucine, isoleucine, and valine. Patients present in early infancy with brain edema; delay in diagnosis and treatment is common and associated with residual neurologic damage, which includes alternating muscular hypotonia and hypertonia, dystonia, and seizures. These signs can result in trauma, especially to the anterior maxilla, which is the most traumatized region. In patients with MSUD, a fixed prosthesis is recommended because a removable one can be dangerous because of the risk of aspiration. Rehabilitation, using dental implants, is especially challenging in these patients because of the strong muscular forces of the tongue and lips. An implant-supported fixed prosthesis might provide an effective functional, esthetic, and predictable solution for patients with late-treated MSUD. The present report describes a 10-year follow-up of the successful, posttraumatic use of a dental implant to replace an anterior maxillary tooth in a patient with MSUD. Advanced Surgical Guidance Technology: A Review. Implant Dentistry. 15(2):135-142, June 2006. Marvin Jabero, DDS; David P. Sarment, DDS, MS Abstract: To maximize the outcome of implant placement, the use of advanced radiographic procedures such as computerized tomography, along with fabrication of surgical guides, has been advocated to inform surgeons of ideal implant location. More recently, simulation computer software has been introduced to view radiographic images and test potential implant locations. Yet, surgical guides are processed based on ideal tooth position, with little consideration for underlying anatomical limitations, which creates a disconnection between diagnostic planning and surgical restrictions. In response to this "missing link," computer-assisted design and computer-assisted manufacturing, as well as real-time surgical navigation were recently developed to obtain fully integrated surgical and prosthetic planning. Today, there are several technologies available, but, to our knowledge, a systematic assessment of surgical guidance has not yet been performed. Therefore, the aims of this review are to introduce advanced radiographic and software modalities, and present a detailed assessment of computer-assisted design and computer-assisted manufacturing methods and surgical navigation. Passive Definitive Fit of Bar-Supported Implant Overdentures. Implant Dentistry. 15(2):129-134, June 2006. Salvatore Longoni, MD, DDS; Matteo Sartori, DDS, DIU; Fabrizio Ariello, DDS; Marco Anzani, MD, DMD; Marco Baldoni, MD, DMD Abstract: A passive fit is an important prerequisite for implant-supported prostheses. It limits the amount of stress transferred to the bone-implant interface and ensures long-term osseointegration. A simplified technique is proposed for the fabrication of passive bar-supported implant overdentures. The use of titanium industrial components enhances the precision of fit, and the passivity is achieved with an intraoral luting sequence and laser welding. The method is quick and standardized, and does not require sophisticated steps. This article shows the results of 7 cases 18-24 months (mean 21.4) after the loading of cases. The Bone-Grafting Decision Tree: A Systematic Methodology for Achieving New Bone. Implant Dentistry. 15(2):122-128, June 2006. Dennis Smiler, DDS, MScD; Muna Soltan, DDS Abstract: Successful bone grafting requires that the clinician select the optimal bone grafting material and surgical technique from among a number of alternatives. This article reviews the biology of bone growth and repair, and presents a decision-making protocol in which the clinician first evaluates the bone quality at the surgical site to determine which graft material should be used. Bone quantity is then evaluated to determine the optimal surgical technique. Choices among graft stabilization techniques are also reviewed, and cases are presented to illustrate the use of this decision tree. Implant Recommendation as a Replacement Option After Tooth Loss for Periodontal Reasons. Implant Dentistry. 15(1):104-110, March 2006. Khalaf F. Al-Shammari, DDS, MS; Areej K. Al-Khabbaz, DDS, MS; Mohammad H. Akar, DDS; Jassem M. Al-Ansari, DDS, MS; Hom-Lay Wang, DDS, MSD Abstract: Purpose: The aim of this study was to examine the frequency of implant recommendation by general dental practitioners to patients who had extractions as a result of periodontal disease and factors that influenced their decisions. Materials and Methods: Dentists in each of 20 general dental practice centers in Kuwait were asked to document replacement options given to patients after all tooth extractions performed for periodontal reasons within a 30-day period. The association of demographic and medical/dental history variables with the decision to recommend an implant was statistically tested. Results: A total of 711 patients with a mean age +/- of 47.34 +/- 0.45 years (range 18-96) had 2202 teeth extracted for periodontal reasons during the study period. Only 21 implants for 12 patients were offered as a replacement option (1.7%). Factors significantly associated with a less likelihood of implant recommendation included older age, male gender, diabetes mellitus, inadequate compliance with regular periodontal maintenance visits, inadequate oral hygiene practices, and anterior tooth types (P < 0.05; [chi]2 test). Conclusion: Dental implants were rarely recommended to patients losing their teeth for periodontal reasons by general dentists in Kuwait. Effect of Microcapsules Containing TAK-778 on Bone Formation Around Osseointegrated Implants: Histomorphometric Analysis in Dogs. Implant Dentistry. 15(1):97-103, March 2006. Adalberto Luiz Rosa, DDS, PhD; Clícia Santos Rodrigues de Oliveira, DDS; Márcio Mateus Beloti, DDS, PhD; Samuel Porfírio Xavier, DDS, PhD; Paulo Tambasco de Oliveira, DDS, PhD Abstract: Purpose: The aim of this study was to evaluate the in vivo effect of TAK-778 on osseointegration of titanium implants. Materials and Methods: Mandibular premolars were extracted from 8 dogs. After 3 months, 2 titanium implants were bilaterally placed, and each implantation site randomly received 1 of the following treatments: sustained-release microcapsules of TAK-778, placebo microcapsules, or no treatment. At 8 and 12 weeks after implantation, the hemi- mandibles containing the implants were removed, and processed for morphologic and histomorphometric analysis. Data were submitted to 2-way analysis of variance. Results: The histologic sections of the 3 experimental groups at 8 and 12 weeks did not show morphologic differences related to applied treatment. The percentage of bone-implant contact, mineralized bone matrix between implant threads, and mineralized bone matrix within mirror area were not affected either by treatments or evaluated periods. Conclusions: No effect of TAK-778 was observed on osseointegration of titanium implants, which most likely occurred because microcapsules may not be retained and, therefore, available at the implant sites. An alternative is the manufacture of a release system, which can be immobilized on implant surface, ensuring the drug permanence in the implant site at least at the initial periods of bone formation. Comparison of Bone Grafting Materials in Human Extraction Sockets: Clinical, Histologic, and Histomorphometric Evaluations. Implant Dentistry. 15(1):89-96, March 2006. Dennis M. Thompson, DDS, MS; Michael D. Rohrer, DDS, MS; Hari S. Prasad, BS, MDT Abstract: Purpose: Although there are a number of bone replacement graft materials that are currently available for clinical use, there are few studies that directly compare efficacy among graft treatments before implant placement. The purpose of this report was to compare 3 bone replacement graft materials (PepGen P-15 228 FLOW [DENTSPLY Friadent CeraMed, Lakewood, CO], Puros(R) [Zimmer Dental, Carlsbad, CA], and C-Graft 228 [Clinician's Preference, Golden, CO]) for bone formation by clinical, histologic, and histomorphometric evaluation. Materials and Methods: In this prospective, intraoral pilot study, 13 maxillary sockets in 2 patients (both smokers) were grafted immediately after tooth extraction with C-Graft 228, Puros(R), or PepGen P-15 228 FLOW (containing additional PepGen P-15 228 particles; FLOW PUTTY). After 4 months, bone cores were retrieved and analyzed histologically. Results: PepGen P-15 228 FLOW PUTTY produced a significantly (P <0.01) higher amount of vital bone than C-Graft 228 or Puros(R). The amount of vital bone for FLOW PUTTY was 12-fold higher than for C-Graft 228 and 4-fold higher than Puros(R). Of 7 FLOW PUTTY treated sites, 7 showed >14% vital bone versus 0 of 3 C-Graft 228 and 0 of 3 Puros(R) treated sites. FLOW PUTTY treated sites showed new vital bone between particles of residual graft. C-Graft 228 treated sites showed residual particles in a background of connective tissue with very little bone. Puros(R) treated sites showed nonvital bone particles in a background of connective tissue, with some new vital bone forming around the nonvital bone. Conclusion: PepGen P-15 228 FLOW PUTTY produced significantly greater vital bone as compared to Puros(R) and C-Graft 228 after 4 months. A larger clinical study is required to confirm these results. Heat Transfer of Impression Plasters to an Implant-Bone Interface. Implant Dentistry. 15(1):83-88, March 2006. Joseph Nissan, DMD; Martin Gross, BDS, LDS, MSc; Zeev Ormianer, DMD; Eitan Barnea, DMD; David Assif, DMD Abstract: Purpose: The purpose of this in vitro study was to measure heat generated at the implant-bone interface caused by exothermic setting reaction of 2 impression plasters. Materials and Methods: The study consisted of 20 titanium-alloy abutment impressions connected to a titanium-alloy cylindrical implant embedded in an acrylic-resin mandible in a 37[degrees]C water bath. There were 2 types of impression plaster used, Snow-White (Kerr, Romulus, MI) and Xantano (Kulzer, Dormagen, Germany). Temperature changes were recorded via embedded thermocouples at the cervix and implant surface apex. Analysis of variance for repeated measures was used to compare 2 treatment groups. Results: Temperature increased less at the implant apex (1.5[degrees]-2.1[degrees]C) than at the implant cervix (7.4[degrees]-10.5[degrees]C). Differences between the 2 impression plasters were statisticallysignificant only at the implant cervical level (P < 0.05). A lower temperature increase was shown with the Snow-White compared with the Xantano. Although both plasters generated an exothermic reaction on setting (mean temperature change 22[degrees]C), the increase in the temperature rate of the Snow-White was slower than the Xantano. Conclusions: Under the conditions of the present study, Snow-White impression plaster appears to be safer to use in implant prosthodontics compared with the Xantano because of its slower and lower exothermic reaction at the implant- bone interface. However, use of the material with the rapid setting time would require more care, such as limiting the volume of material used (e.g., by using a custom tray). Profilometric and Standard Error of the Mean Analysis of Rough Implant Surfaces Treated With Different Instrumentations. Implant Dentistry. 15(1):77-82, March 2006. Luca Ramaglia, MD, DDS; Alessandro E. di Lauro, DDS, PhD; Fabio Morgese, DDS; Antonino Squillace, PhD Abstract: Purpose: This study evaluated, in vitro, the effects of different instrumentations used in the treatment of peri- implantitis on implant surfaces coated with hydroxyapatite or titanium plasma spray (TPS). Materials and Methods: There were 14 cylindrical rough implants used, including 7 hydroxyapatite and 7 TPS coated. Split in 2 parts for a total of 24 experimental surfaces, implants were treated with a stainless-steel curette, plastic curette, ultrasonic scaler tip, and air-powder-water spray. There was 1 hydroxyapatite and 1 TPS implant used as controls. Profilometry and scanning electron microscopy were used to examine instrumented surfaces for variations in surface topography. Results: All experimental procedures determined changes on tested rough implant surfaces. Such alterations were related to the implant coating material, and the procedure consisting in coating removal and/or leveling of surface roughness. Conclusion: Although a plastic curette and air-powder-water spray induced less implant surface alterations, these instrumentations left deposits on the surface that may affect, in vivo, the tissue healing process. Collagen Fiber Orientation Near a Fractured Dental Implant After a 5-Year Loading Period: Case Report. Implant Dentistry. 15(1):70-76, March 2006. Tonino Traini, DDS, PhD; Sergio De Paoli, MD, DDS; Sergio Caputi, MD, DDS; Giovanna Iezzi, DDS, PhD; Adriano Piattelli, MD, DDS Abstract: Purpose: Fracture of an implant is one of the possible complications of dental implants. It is a quite rare event but of high clinical relevance. Nevertheless, it represents an important opportunity for evaluating the peri-implant bone- tissue response to implant overloading in human beings. The aim of the present study was a scanning electron microscopy evaluation of a screw-shaped implant retrieved because of fracture and a birefringence analysis of the tissue near the fractured implant. Materials and Methods: There was 1 fractured screw-shaped implant retrieved from a patient with a trephine bur, and it was processed for histology. The specimen was analyzed under both scanning electron microscopy and circularly polarized light microscopy. Results: The scanning electron microscopy fractography analysis showed the typical signs of a fatigue-fracture, with large plastic deformations on the implant. The fracture seemed to start from the internal coil of the implant. Under circularly polarized light microscopy investigation, a bone-implant contact percentage of 81.6% +/- 1.5% (mean +/- standard deviation) was found. The amount of the transverse collagen fibers was of 68.3%, and the amount of the longitudinal collagen fibers was of 31.7%. The difference was statistically significant for z = 2.247 (P = 0.025). Conclusion: The fracture of the implant was most probably correlated to a fatigue of the material mainly associated to a lesion of the internal coil. The high level of bone-implant contact percentage was correlated to a predominant transverse collagen fiber orientation of the collagen fibers in the peri-implant bone. Analysis of Aspartate Aminotransferase and Alkaline Phosphatase in Crevicular Fluid From Implants With and Without Peri-implantitis. Implant Dentistry. 15(1):62-69, March 2006. Mojgan Paknejad, DDS; Shahram Emtiaz, DDS; Mohammad Mohsen Khoobyari, DDS; Mehrnoush Teimouri Gharb, DDS; Mojtaba Tabatabaei Yazdi, PhD Abstract: Purpose: The aim of this investigation was to determine the presence of aspartate aminotransferase (AST) and alkaline phosphatase (ALP) in crevicular fluid collected from implants with and without clinical and radiographic signs of peri- implantitis. Materials and Methods: There were 17 implants with symptoms of peri-implantitis in 12 subjects, including 4 females and 8 males, compared to 17 implants in 13 subjects, including 5 females and 8 males, with healthy peri-implant tissues. Filter paper strips were used to collect peri-implant crevicular fluid for 30 seconds in the base of the crevice/pocket. SPSS statistical software (SPSS, Inc., Chicago, IL) was used to determine AST and ALP activity. Results: The results showed that there was a significant difference in the activity of AST and ALP between the 2 study groups (P < 0.0001). AST activity was significantly associated with the amount of bleeding on probing (P = 0.02), but no statistical correlation was found between ALP activity and increased amount of bleeding on probing (P = 0.05). Conclusions: Within the limits of this study, our results may suggest that peri-implant crevicular fluid analysis could be further investigated in longitudinal studies as a suitable diagnostic strategy in the evaluation of dental implants. Titanium Membranes in Prevention of Alveolar Collapse After Tooth Extraction. Implant Dentistry. 15(1):53-61, March 2006. Márcia N. Pinho, MS; Virg`lio M. Roriz, MS; Arthur B. Novaes Jr, DDS, PhD; Mário Taba Jr, DDS, PhD; Márcio F. M. Grisi, DDS, PhD; Sérgio L. S. de Souza, DDS, PhD; Daniela B. Palioto, DDS, PhD Abstract: Background and Purpose: The resorption of alveolar bone following tooth extraction results in a narrowing and shortening of the residual ridge, which leads to esthetic and restorative problems, and reduces the bone volume available for implant therapy. The aim of this study was to evaluate the prevention of alveolar collapse after tooth extraction, using titanium membrane (Frios Boneshield; DENTSPLY Friadent, Mannheim, Germany), associated (or not) with autologous bone graft. Materials and Methods: A total of 10 nonsmoking healthy subjects, ranging from 35 to 60 years old, were selected for this study. Each patient had a minimum of 2 uni-radicular periodontally hopeless teeth, which were scheduled for extraction. After the procedure, 2 titanium pins were fixed on the vestibular bone surfaces that were used as references for the initial measures (depth, width, and height) of the socket. Of the sockets,1 was randomly chosen to be filled with autologous bone graft (test) removed from superior maxillary tuber, and the other one did not receive the graft (control). A titanium membrane was adapted and fixed, covering the sockets, which remained for at least 10 weeks. After a 6-month healing, the final measures were performed. Results: There was exposure of the membrane in 5 of the 10 treated subjects. Average bone filling (+/-standard deviation) among the 10 subjects was 8.80 +/- 2.93 mm (range 4-13) in the control group and 8.40 +/- 3.35 mm (range 4-13) in the test group. Average bone loss in width in both group was 1.40 +/- 1.97 mm (range -4-1) in the control group and 1.40 +/- 0.98 mm (range -4-0) in the test group. There was no significant statistical difference between groups considering the evaluated standards. Conclusion: The use of titanium membrane, alone or in association with autogenous bone, favored the prevention of alveolar ridge after tooth extraction. This membrane seems to be a possible and safe alternative to other nonresorbable membranes when the prevention of alveolar ridge resorption is the objective. Alveolar Distraction Osteogenesis Before Placement of Dental Implants. Implant Dentistry. 15(1):48-52, March 2006. Serhat Yalcin, DDS, PhD; Melike Ordulu, DDS, PhD; Yusuf Emes, DDS, PhD; Hasim Gur, DDS, PhD; Irem Aktas, DDS; Cem Caniklioglu, DDS, PhD Abstract: Distraction osteogenesis of the edentulous alveolar ridges may be considered an alternative to many other augmentation oriented surgical techniques. It is now being widely used for treating severe forms of alveolar ridge atrophy, especially before the placement of dental implants. Leibinger Endosseous Alveolar Distraction System (LEAD; Stryker Leibinger, Kalamazoo, MI) is an intraosseous distraction device used for edentulous ridges. In this study, the healing was uneventful in all 5 cases that were treated except 1, in which the vitality of the distraction segment could not be maintained. No complications related to the prosthodontic restoration were observed. Surgical Navigation in Oral Implantology. Implant Dentistry. 15(1):41-47, March 2006. Robert J. Miller, DDS; Jurgen Bier, MD, DMD, PhD Abstract: The ability to generate 3- dimensional volumetric images of the maxillofacial area has allowed surgeons to evaluate anatomy before surgery and plan for the placement of implants in ideal positions. However, the ability to transfer that information to surgical reality has been the most challenging part of implant dentistry. With the advent ofcomputer- assisted surgery, the surgeon may now navigate through the entire implant procedure with extremely high accuracy. A new portable laptop navigated system for oral implantology is discussed as an adjunct for complex implant cases. Immediate Loading of Implant Overdentures Using Modified Loading Protocol. Implant Dentistry. 15(1):35-40, March 2006. Zeev Ormianer, DMD; Arun K. Garg, DMD; Ady Palti, DMD Abstract: To our knowledge, this study shows the first longitudinal results (range 12-30 months) of immediate loading of implant- support overdenture with ball attachment connection placed in the anterior mandible. Immediately after surgery, the overdenture was connected to the implants with 2-ball attachments. The housings were filled with Impregum(TM) (3M Espe AG; Seefeld, Germany) impression material to provide retention as well as reduce forces in the initial phase of loading. Of the 28 implants placed, only 1 failed; the 1 failed implant for total implants placed represents a success rate of 96.4%. The minimal bone loss (1 mm) in 2 sites represents a success rate of 92.8%. Attachment Systems for Implant Retained Overdentures: A Literature Review. Implant Dentistry. 15(1):24-34, March 2006. Theodoros Trakas, DDS; Konstantinos Michalakis, DDS, PhD; Kiho Kang, DDS, DMD, MS; Hiroshi Hirayama, DDS, DMD, MS Abstract: This article presents a comparison between different attachment systems used to retain and support maxillary and mandibular overdentures in completely edentulous patients. A literature review based on a MEDLINE search limited to English-language articles published from 1988 to the present was performed, and a large number of attachments available in the dental market were reviewed with regard to several factors, including: (1) implant survival rate, (2) marginal bone loss, (3) soft tissue complications, (4) retention, (5) stress distri-bution, (6) space requirements, (7) maintenance complications, and (8) patient satisfaction. These factors are considered essential for the successful outcome and good long-term prognosis of the prostheses. Selection criteria previously published in the literature are discussed as well. Product names and manufacturers are mentioned only if related to attachment systems, as they are cited in the original articles. Early Osteotomy With Delayed Implant Placement: A Step Further for Immediate Loading. Implant Dentistry. 15(1):18-23, March 2006. M S. El Attar, BD, MS, MD, PhD; Hazem H. Mourad, BD; Aly Mahmoud, BD, MS, PhD; Mohamed Abdallah, BD; Hussien Garana, BD, MS, MD, PhD; Khaled Mansour, MS, PhD; Mohamed Fata, MD, DDS, PhD Abstract: The commonly used implantation technique involves a 2-stage surgical protocol for load-free and submerged healing to ensure predictable osseointegration. This article presents a new approach that benefits from previous bone and soft tissue protocols. It combines new surgical and insertion techniques to perform immediate loading with delayed implant placement, avoiding the problems of discomfort, inconvenience, and anxiety associated with healing periods. It maintains a similar success rate to the present common technique. After osteotomy, bone healing passes through 3 stages (i.e., inflammation, fibrous tissue, and maturation). In the new approach, implant insertion is performed 2 weeksafter drilling (i.e., during the fibrous phase). The insertion timing is so selected because collagen formation and revascularization represent an acceptable implant bed configuration. Flap surgery offers the optimal osteotomy approach, but esthetic outcomes are definitely compromised. Accordingly, adopting the punch technique alleviates several postoperative problems, such as pain, tenderness, and swelling. Moreover, the punch technique avoids the sutures needed to adjust the gingiva around the abutment. It provides both cosmetic and functional properties. "PASS" Principles for Predictable Bone Regeneration. Implant Dentistry. 15(1):8-17, March 2006. Hom-Lay Wang, DDS, MSD; Lakshmi Boyapati, BDS Abstract: Guided bone regeneration is a well-established technique used for augmentation of deficient alveolar ridges. Predictable regeneration requires both a high level of technical skill and a thorough understanding of underlying principles of wound healing. This article describes the 4 major biologic principles (i.e., PASS) necessary for predictable bone regeneration: primary wound closure to ensure undisturbed and uninterrupted wound healing, angiogenesis to provide necessary bloodsupply and undifferentiated mesenchymal cells, space maintenance/creation to facilitate adequate space for bone ingrowth, and stability of wound and implant to induce blood clot formation and uneventful healing events. In addition, a novel flap design and clinical cases using this principle are presented.