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Dental caries and periodontal disease are the major causes for tooth loss. While dental caries commonly involve the posterior teeth in both jaws, the teeth most commonly lost due to periodontal problems are the first and second molars in the maxilla. As a consequence, the upper posterior jaw is frequently edentulous. Implant therapy today is a predictable treatment modality for prosthetic reconstruction of edentulous patient. Insufficient amounts of bone, due to atrophy following loss of teeth or due to the presence of the maxillary sinus, can make it impossible to insert implants in the posterior maxilla. During the 1970s and 1980s, Tatum, Boyne and James and Wood and Moore first described maxillary sinus floor augmentation whereby, after the creation of a lateral access point, autologous bone grafts are inserted to increase crestal bone height and to create the necessary conditions for the insertion of implants. This surgical procedure requires a two-stage approach and a double surgical site: first, bone is harvested from a donor site and transplanted to the recipient site; then, after a proper healing period of between 4 to 6 months, the implants are inserted. This kind of bone reconstruction, even if well documented, has its limitations, not least in the creation of two different surgical sites and the consequent increased risk of morbidity. In 2004, Lundgren et al. described a new, simplified technique for the elevation of the sinus floor. The authors showed that by lifting the sinus membrane an empty space was created in which blood clot formations resulted in the establishment of new bone. The implants were placed simultaneously to function as “tent poles”, thus maintaining the sinus membrane in a raised position during the subsequent healing period. An essential prerequisite of this technique is to obtain optimal primary implant stability from the residual bone in the sinus floor. An extremely resorbed maxillary sinus floor, with, for example, less than 2-3 mm of poor quality residual bone, could impair implant insertion.

The aims of the present research project were (i) to evaluate the donor site morbidity and the acceptance level of patients when a bone graft is harvested from the anterior iliac crest, (ii) to evaluate implant stability, new bone formation inside the maxillary sinus and marginal bone resorption around the implants in long term follow up when maxillary sinus floor augmentation is performed through sinus membrane elevation and without the addition of any grafting material, (iii) to investigate new bone formation inside the maxillary sinus, in experimental design, using a resorbable space-maker device in order to maintain elevation of the sinus membrane where there is too little bone to insert implants with good primary stability.

In Paper I, 70 consecutively treated patients were retrospectively evaluated in terms of postoperative donor site morbidity and donor site complications. With regard to donor site morbidity, 74% of patients were free of pain within 3 weeks, whereas 26% had a prolonged period of pain lasting from a few weeks to several months. For 11% of patients there was still some pain or discomfort 2 years after the grafting surgery. Nevertheless, patients acceptance was high and treatment significantly improved oral function, facial appearance, and recreation/social activities and resulted in an overall improvement in the quality of life of formerly edentulous patients.

In Paper I and III, some differently shaped space-making devices were tested on primates (tufted capuchin - Cebus apella) in two experimental models aimed at evaluating whether a two-stage procedure for sinus floor augmentation could benefit from the use of a space-making device to increase the bone volume and enable later implant installation with good primary stability, without the use of any grafting material. An histological examination of the specimens showed that it is possible to obtain bone formation in contact with both the Schneiderian membrane and the device. In most cases the device was displaced. The process of bone formation indicated that this technique is potentially useful for two-stage sinus floor augmentation. The lack of device stability within the sinus requires further improvement in space-makers if predictable bone augmentation is to be achieved.

In Paper IV, a total of 84 patients were subjected to 96 membrane elevation procedures and the simultaneous placement of 239 implants. Changes of intra-sinus and marginal bone height in relation to the implants were measured in intraoral radiographs carried out during insertion after 6 months of healing, after 6 months of loading and then annually. Computerised tomography was performed pre-surgically and 6 months post-surgically. Resonance frequency analysis measurements were performed at the time of implant placement, at abutment connection and after 6 months of loading. The implant follow-up period ranged from a minimum of one to a maximum of 6 years after implant loading. All implants were stable after 6 months of healing. A total of three implants were lost during the follow-up period giving a survival rate of 98.7%. Radiography demonstrated an average of 5.3 ± 2.1 mm of intra-sinus new bone formation after 6 months of healing. RFA measurements showed adequate primary stability (implant stability quotient 67.4 ± 6.1) and small changes over time.

In conclusion, harvesting bone from the iliac crest could result in temporary donor site morbidity, but in 11% of patients pain or discomfort was still present up to 2 years after surgery. However, patient satisfaction was good despite this slow or incomplete recovery, as showed by the quality of life questionnaire. Maxillary sinus membrane elevation without the use of bone grafts or bone substitutes results in predictable bone formation both in animal design, where the sinus membrane is supported by a resorbable device, and in clinical conditions, where the membrane is kept in the upper position by dental implants. This new bone formation is accompanied by a high implant survival rate of 98.7% over a follow-up period of up to 6 years. Intra-sinus bone formation remained stable in the long-term follow-up. It is suggested that the secluded compartment allowed bone formation in accordance with the principle of guided tissue regeneration. This technique reduces the risks of morbidity related to bone graft harvesting and eliminates the costs of grafting materials.

BACKGROUND: Clinical studies on immediate loading of implants in the posterior atrophic maxilla are rare.

PURPOSE: The study aims to evaluate immediate loading of implants placed with sinus membrane elevation without additional grafting material for bone augmentation of the maxillary sinus floor.

MATERIALS AND METHODS: The study group comprised of 10 patients in whom a total of 10 maxillary sinus floor augmentations were performed. A total of 21 dental implants (1 to 4) were inserted through the residual bone to protrude into the maxillary sinus under the elevated sinus membrane. The implant site was underprepared to improve primary stability. All the implants were inserted with a torque insertion no less than 20 Ncm. Implants were loaded immediately after surgery with a screw-retained temporary acrylic restoration. Intraoral X-rays were taken at implant insertion, after 6 months loading, and after 1st and 2nd year of loading. Resonance frequency analysis (RFA) was performed at the time of initial placement and after 6 months of functional loading. RESULTS: RFA after implant insertion gave an implant stability quotient (ISQ) level with a range from 62 to 72. All implants remained clinically stable during the follow-up period of 2 years. Radiography demonstrated on average 5.7 ± 3.4 mm of intrasinus new bone formation after 6 months of implant loading. RFA measurements showed ISQ mean values of 67 (range: 62-72) and 68 (range: 62-71) at placement and after 6 months of loading, respectively.

CONCLUSION: Within the limits of this case series report, it is concluded that maxillary sinus membrane elevation with simultaneous placement and immediate loading of implants without the use of any additional grafting material shows predictable results after 2 years of functional loading. Moreover, evidence of intrasinus bone formation around the implants was found in all patients. Further studies are needed to study the influence of immediate loading on the mineralization of bone forming at dental implant sites.

BACKGROUND: Bone grafting is a surgical technique for the reconstruction of the atrophic edentulous maxilla prior to treatment with endosseous implants. The anterior iliac crest is a commonly used donor site.

PURPOSE: The aim of this study was to evaluate the donor site morbidity and complications when harvesting corticocancellous bone from the medial table of the anterior iliac crest and compare this with results when bone was harvested from the lateral and superior table of the anterior iliac crest. In addition, the outcome of the oral rehabilitation was evaluated by means of a quality-of-life questionnaire.

MATERIAL AND METHODS: The study was composed of 70 consecutively treated patients with a mean age of 56 years. The patients were retrospectively evaluated with regard to postoperative donor site morbidity and complications at the donor site.

RESULTS: For the donor site morbidity, 74% of the patients were free of pain within 3 weeks, whereas 26% of the patients had a prolonged period of pain lasting from a few weeks to several months. For 11% of the patients, there was still some pain or discomfort 2 years after the grafting surgery. For gait disturbance the figures were similar: 79% had no problems after 3 weeks. For the eight patients who still had some pain after 2 years, which was considered permanent, three also had gait disturbance. There was a total of three major complications (4%), one iliac wing fracture and two neurologic injuries.

CONCLUSION: When harvesting a large amount of unicortical corticocancellous bone blocks from the the superolateral site of the iliac crest with a "peel off" technique, morbidity and complication rates do not differ significantly compared with those of the traditional anterior medial approach. Oral rehabilitation with maxillary reconstruction with bone grafts from the iliac crest and endosseous implants significantly improved oral function, facial appearance, and recreation/social activities and resulted in an overall improvement in quality of life in formerly edentulous patients.

Background: Previous studies have pointed out that the mere elevation of the maxillary sinus membrane promotes bone formation without the use of augmentation materials.

Purpose: This experimental study aimed at evaluating if the two-stage procedure for sinus floor augmentation could benefit from the use of a space-making device in order to increase the bone volume to enable later implant installation with good primary stability.

Materials and Methods: Six male tufted capuchin primates (Cebus apella) were subjected to extraction of the three premolars and the first molar on both sides of the maxilla to create an edentulous area. The sinuses were opened using the lateral bone-wall window technique, and the membrane was elevated. One resorbable space-making device was inserted in each maxillary sinus, and the bone window was returned in place. The animals were euthanatized after 6 months, and biopsy blocks containing the whole maxillary sinus and surrounding soft tissues were prepared for ground sections.

Results: The histological examination of the specimens showed bone formation in contact with both the schneiderian membrane and the device in most cases even when the device was displaced. The process of bone formation indicates that this technique is potentially useful for two-stage sinus floor augmentation. The lack of stabilization of the device within the sinus demands further improvement of space-makers for predictable bone augmentation.

Conclusions: It is concluded that (1) the device used in this study did not trigger any important inflammatory reaction; (2) when the sinus membrane was elevated, bone formation was a constant finding; and (3) an ideal space-making device should be stable and elevate the membrane to ensure a maintained connection between the membrane and the secluded space.

BACKGROUND: Previous studies have shown that membrane elevation results in predictable bone formation in the maxillary sinus provided that implants can be placed as tent poles. In situations with an extremely thin residual crest which impairs implant placement, it is possible that a space-making device can be used under the sinus membrane to promote bone formation prior to placement of implants.

PURPOSE: The present study was conducted to test the hypothesis that the use of a space-making device for elevation of the sinus membrane will result in predictable bone formation at the maxillary sinus floor to allow placement of dental implants.

MATERIALS AND METHODS: Eight tufted capuchin primates underwent bilateral sinus membrane elevation surgery, and a bioresorbable space-making device, about 6 mm wide and 6 mm in height, was placed below the elevated membrane on the sinus floor. An oxidized implant (Nobel Biocare AB, Gothenburg, Sweden) was installed in the residual bone protruding into the created space at one side while the other side was left without an implant. Four animals were sacrificed after 6 months of healing. The remaining four animals received a second implant in the side with a space-making device only and followed for another 3 months before sacrifice. Implant stability was assessed through resonance frequency analysis (RFA) using the Osstell (Osstell AB, Gothenburg, Sweden) at installation, 6 months and 9 months after the first surgery. The bone-implant contact (BIC) and bone area inside the threads (BA) were histometrically evaluated in ground sections.

RESULTS: Histologically there were only minor or no signs of bone formation in the sites with a space-making device only. Sites with simultaneous implant placement showed bone formation along the implant surface. Sites with delayed implant placement showed minor or no bone formation and/or formation of a dense fibrous tissue along the apical part of the implant surface. In the latter group the apical part of the implant was not covered with the membrane but protruded into the sinus cavity.

CONCLUSIONS: The use of a space-making device, with the design used in the present study, does not result in bone formation at the sinus floor. However, membrane elevation and simultaneous placement of the device and an implant does result in bone formation at the implant surface while sites with implants placed 6 months after membrane elevation show only small amounts of bone formation. It is suggested that lack of stabilization of the device and/or a too extensive elevation of the membrane may explain the results.

Objectives: To investigate the long-term clinical and radiographic results of the maxillary sinus membrane elevation technique where implants were inserted in a void space created by the elevation of the sinus membrane without adding any graft material.

Materials and methods: A total of 84 patients were subjected to 96 membrane elevation procedures and simultaneous placement of 239 implants. Changes of intra-sinus and marginal bone height in relation to the implants were measured in intraoral radiographs taken at insertion, after 6 months of healing, after 6 months of loading and then annually. Computerized tomography was performed pre-surgically and 6 months post-surgically. Resonance Frequency Analyses measurements were performed at the time of implants placement, at abutment connection and after 6 months of loading. The implant follow-up period ranged from a minimum of one to a maximum of 6 years after implants loading.

Results: All implants were stable after 6 months of healing. A total of three implants were lost during the follow-up period giving a survival rate of 98.7%. Radiography demonstrated on average 5.3±2.1 mm of intra-sinus new bone formation after 6 months of healing. RFA measurements showed adequate primary stability (implant stability quotient 67.4±6.1) and small changes over time.

Conclusion: Maxillary sinus membrane elevation and simultaneous placement of implants without the use of bone grafts or bone substitutes result in predictable bone formation with a high implant survival rate of 98.7% during a follow-up period of up to 6 years. The intra-sinus bone formation remained stable in the long-term follow-up. It is suggested that the secluded compartment allowed for bone formation according to the principle of guided tissue regeneration. The high implant survival rate of 98.7% indicated that the implants sufficiently supported the fixed bridges throughout the study period. This technique reduces the risks for morbidity related to harvesting of bone grafts and eliminates the costs of grafting materials.

As research proceeds on treatment of the resorbed posterior maxilla, new techniques and innovations continue to be adopted to solve this clinical problem. While the previous edition of this book provided detailed information on the types of grafting materials and procedures available at the time, this completely revised version looks to the future with new strategies for treatment, some of which avoid grafting altogether. This book not only reviews the time-tested lateral window approach for sinus elevation and grafting but also describes a variety of techniques to approach the sinus transcrestally with or without grafting material. One section of the book is devoted entirely to the different types of implants and implant placement techniques available, many of which are designed specifically to avoid sinus elevation. In addition to clinical case studies and descriptions of how to perform specific surgical procedures, this book includes discussions on the science of bone formation and how continued research brings us closer every day to the ultimate goal of using tissue engineering to completely regenerate new teeth.

Background: The bone tissue responses to Cyanoacrylate have been described in the literature, but none used N-butyl-2-cyanoacrilate (NB-Cn) for bone graft fixation.

Purpose: The aims of the study were: (a) to analyze the bone grafts volume maintenance fixed either with NB-Cn or titanium screw; (b) to assess the incorporation of onlay grafts on perforated recipient bed; and (c) the differences of expression level of tartrate-resistant acid phosphatase (TRAP) protein involved in bone resorption.

Materials and Methods: Eighteen New Zealand White rabbits were submitted to calvaria onlay grafting on both sides of the mandible. On one side, the graft was fixed with NB-Cn, while on the other hand the bone graft was secured with an osteosynthesis screw. The computed tomography (CT) was performed just after surgery and at animals sacrifice, after 1 (n = 9) and 6 weeks (n = 9), in order to estimate the bone grafts volume along the experiments. Histological sections of the grafted areas were prepared to evaluate the healing of bone grafts and to assess the expression of TRAP protein.

Results: The CT scan showed better volume maintenance of bone grafts fixed with NB-Cn (p ≤ 0.05) compared with those fixed with screws, in both experimental times (analysis of variance). The immunohistochemical evaluation showed that the TRAP expression in a 6-week period was significantly higher compared with the 1-week period, without showing significant difference between the groups (Wilcoxon and Mann-Whitney). Histological analysis revealed that the NB-Cn caused periosteum damage, but provided bone graft stabilization and incorporation similar to the control group.

Conclusion: The perforation provided by screw insertion into the graft during fixation may have triggered early revascularization and remodeling to render increased volume loss compared with the experimental group. These results indicate that the NB-Cn possesses equivalent properties to titanium screw to be used as bone fixation material in osteosynthesis.

Background: Previous studies have shown predictable bone formation in the maxillary sinus after membrane elevation. However, how and where the bone is formed is not well understood.

Purpose: The aim of the study was to histologically and immunohistochemically study the early bone formation events in primates after membrane elevation in the maxillary sinus.

Materials and Methods: Nine adult male tufted capuchin primates (Cebus apella) were included in the study. Eight animals were subjected to bilateral maxillary sinus membrane elevation using a lateral replaceable bone window technique. One oxidized dental implant was placed into the maxillary sinus cavity on both sides. In four animals, one sinus was left without any additional treatment, whereas the contralateral sinus was filled with autologous bone grafts from the tibia. In two animals, the implants were inserted under the elevated sinus membrane on both sides. In two animals, the sinus membrane was totally removed. The animals were euthanized after 10 or 45 days. One nonoperated animal representing pristine tissue conditions served as control. The maxillary sinuses with implants were retrieved and further processed for light microscopic ground sections or decalcified sections for immune-histochemical analyses.

Results: Bone formation started from the bottom of the sinus floor, sprouting into the granulation tissue along the implant surface under the elevated membrane irrespective of time and surgical technique. Bone formation was not seen in direct conjunction with the sinus membrane. A distinct expression of osteopontin was observed in the serous glands of the lamina propria close to the implant within all groups.

Conclusion: Bone formation after sinus membrane elevation with or without additional bone grafts starts at the sinus floor and sprouts into the elevated space along the implant surface. The sinus membrane does not seem to present osteoinductive potential in sinus membrane elevation procedures in this study.

Background: Lateral sinus membrane elevation with simultaneous implant placement without grafting material (graft‐less LSFE) is a widely investigated method for bone augmentation of the maxillary sinus floor. Long‐term follow‐up studies are rare.

Purpose: This study aimed to investigate the long‐term effects of implants placed with graft‐less LSFE.

Materials and methods: The study group was comprised of 111 patients previously treated with graft‐less LSFE. The first follow‐up visit, which occurred after a mean of 5 years after surgery, included a clinical examination, cone beam computerized tomography, and panorama or intraoral radiography. The second follow‐up included panorama or intraoral radiography, and it was conducted after a mean of 8 years.

Results: Overall, 218 implants were placed in 127 sinuses. Nine of the 218 implants failed resulting in an overall implant survival of 95.9%. The average bone gain at the follow‐up was 4.0 ±2.0 mm.

Conclusion: The implant‐supported rehabilitation achieved using graft‐less LSFE was stable over time, and there was no or little impact on sinus health. Furthermore, it was concluded that the new bone formation and the amount of bone gain is proportional to the length of the implant protruding into the sinus cavity.

Implant treatment in an atrophied edentulous posterior maxilla constitutes a challenge for the therapeutic team. The authors of the present study acknowledge that modern micro-rough surface implants in lengths of about 8-10 mm or longer and of different brands are similarly successful. Consequently, the authors propose that the use of different sinus floor elevation techniques should be considered when < 8 mm of bone is available below the maxillary sinus. The type of sinus floor elevation technique selected is mainly based on residual vertical bone height, marginal bone width, local intrasinus anatomy and the number of teeth to be replaced, although other factors (such as surgical training and surgical experience) may have an impact. It is proposed that a transcrestal sinus floor elevation approach can be considered as a first-choice method for single tooth gaps in situations with sufficient width for implant placement and a residual bone height of 5-8 mm, while lateral sinus floor elevation, with or without grafting materials, is indicated when < 5 mm of bone is available and when several teeth are to be replaced. With regard to time of implant placement, a one-stage procedure is preferred provided that high primary stability can be ensured.