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O.556 Bilateral sinus grafting: autogenous bone vs beta-TCP
Oral Presentations Friday, 12 September 2008, 11.00–13.00
Prostheses–epitheses, implantology and pre-prosthetic surgery I Sala Italia
Prostheses–epitheses, implantology and pre-prosthetic surgery I O.553 3D planning of a prosthetic reconstruction of the forehead A. Soehardi, G.J. Meijer, J. Plooij, T. Maal, S. Berg´e. UMC St. Radboud Nijmegen, dpt Oral & Maxillofacial Surgery, Nijmegen, Netherlands Introduction: In cases of posttraumatic skull defects, reconstruction is indicated to protect the brain, as well as to correct facial harmony. Materials to correct such defects differ from autologous bone grafts to prefabricated titanium models. However, as a high risk of failure existed in the presented case, reconstructive surgery was not conceivable. Therefore, an implant-retained prosthetic device was the treatment of choice. Method: A non-healing skull fracture, in a 40 years old patient, resulted in several episodes of osteomyelitis and meningitis. This finally ended up in a 10 cm frontal bone defect covered with atrophic skin. Despite this unfortunate course of disease, reconstruction was still the patient’s strongest wish. Using 3D digital software (Nobelguide), a surgical template was designed to achieve optimal implant installment. Results: The position of the surgical template differed during surgery from the position during the image capturing. Although, this pitfall led to differences between preoperative planning and actual installment of the implants, it did not influence the further treatment. After 3 months of consolidation, the healing abutments were replaced by magnets to fixate the prosthetic device. Conclusions: Utilisation of 3D planning software in case of an implantation procedure in the skull region, demands meticulous preoperative planning. Furthermore, the volume and the resilience of the overlying soft tissues and the orientation of the implant must be taken into account. 3D digital planning of implants may improve quality of life, however, the touch of a human hand must not be underestimated. O.554 A novel type of dental models: bone with artificial gum A. Gerasimov, N. Kalakutsky, V. Prihod’ko. Pavlov State Medical University, Saint-Petersburg, Russia Objectives: Development and clinical application of a novel type of dental models: bone with artificial gum (BAG-model). Study of its potential for dental implantation and for augmentation of the alveolar ridge. Methods: 1. Fabrication of BAG-model i. CT of maxillo-facial region with functionally impressed mucosa by radiopaque material ii. Creating of stereolithographic models of bone and soft tissues iii. Painting of inferior alveolar nerve, sinuses, dental roots iv. Positioning of the stereolithographic model in the impression of mucosa and filling the space between them with a gingival mask 2. Positioning of BAG-model on the articulator 3. Prosthodontic planning of dental implants axes and quantity of required bone 4. Fabrication of surgical templates 5. Surgical treatment and prosthodontic rehabilitation of the patient. Results: BAG-models were pioneered and used in two cases for patients after the reconstruction of mandible by revascularized autotransplants for the treatment planning in view of prosthodontic requirements. Templates were used for augmentation of the
S139
alveolar ridge and subsequent dental implantation. We obtained favorable prosthodontic conditions. Conclusions: Dental casts occupy an important place in dentistry. But for dental implantation and for augmentation of the alveolar ridge stereolithographic models are more opportune. BAG-models reveal functionally impressed mucosa, bone, inferior alveolar nerve, sinuses, dental roots. It can be used on an articulator. BAG-models not only combine benefits of dental casts and stereolithographic models, but offer new opportunities in fabrication of templates for surgery in view of prosthodontic requirements. O.555 Alveolar ridge augmentation using autologous iliac bone graft E. Iane¸s, F. Streian, S. Rosu. University of Medicine and Pharmacy, Victor Babes Faculty of Dental Medicine, Department of Oral & Maxillofacial Surgery, Timisoara, Romania Objectives: The aim of this study is to prove that the use of bone graft in alveolar ridge augmentation is a better option and the graft resorbtion can be delayed by the use of a titan mesh. Material and Method: The presentation is based on one of our female patients, totally edentulous, complaining of pain and intermittent numbness of the left side of the lower lip associated with severe mastication, esthetic and phonetic dysfunctions affecting her social and professional life. The therapeutic strategy was conceived in two steps: surgery under general anesthetic in order to increase the alveolar ridge by bone auto transplant harvested from the iliac crest and prosthetic rehabilitation. The graft was shaped and immobilized by a titan mesh. Results: The patient was fully satisfied by the result and the new denture fulfilled both her aesthetic and functional expectations. Adhesives were not needed any longer. The first relining was done after one year and four years later she still wears the same denture. Conclusions: The augmentation of the alveolar ridge severely atrophied is most successful using autologous bone graft. The above case shows that the rigid fixation significantly reduces the graft resorbtion and gives a better profile of the resulting alveolar ridge. Using this procedure, the graft resorbtion drops from 70% to 30% over three years, as reported in the medical literature. O.556 Bilateral sinus grafting: autogenous bone vs beta-TCP U. Garagiola1 , G. Santoro1 , G. Battaglia1 , C. Maiorana1 , G. Szabo2 . 1 University of Milan, School of Dentistry I, Department of Oral Surgery, ICP, Milan, Italy; 2 Department of Oral and Maxillofacial Surgery, Semmelweis University, Budapest, Hungary Aim: Two different graft materials, Beta-tricalcium phosphate and autogenous bone, were used in the same patient. The aim of this study was to determine whether donor site morbidity could be avoided by using pure-phase Beta-TCP. Materials and Methods: Bilateral sinus grafting was performed on 20 selected patients; Beta-TCP was used on the experimental side. Autogenous bone was used on the control side. In each patient, one side was randomly designated the experimental side. Eighty bone biopsy specimens were taken at the time of implant placement. Results: Histologically and histomorphometrically, there was no significant difference between the experimental and control grafts in terms of the quantity and rate of ossification. For each histologic sample, the total surface area, the surface area that consisted of bone, and the surface area that consisted of graft material were measured in mm2, and bone and graft material were analyzed as percentages of the total. The mean percentage bone areas were 36.47±6.9% and 38.34±7.4%, respectively; the difference was
S140
Journal of Cranio-Maxillofacial Surgery 36(2008) Suppl. 1
not significant (P = 0.25). The autogenous bone was initially less visible than the Beta-TCP, but new bone formation was clearly observed for both materials. The rate of graft resorption was lower on the experimental side than on the control side. The mean graft area percentages were 13.95±5.38% and 8.47±3.17%, and the difference was highly significant (P < 0.001). Conclusion: Comparisons with other studies reveal that BetaTCP is a satisfactory graft material for maxillary sinus floor augmentation, even without autogeneous bone. O.557 Bone graft healing in reconstruction of maxillary atrophy M. Sj¨ostr¨om1 , L. Sennerby2 , S. Lundgren1 . 1 Department of Oral & Maxillofacial Surgery, Ume˚a University, Ume˚a, Sweden; 2 Department of Biomaterials, University of Gothenburg, Sweden Objectives: To evaluate possible correlations between loss of volume of free iliac crest bone grafts in the maxilla during six months of healing and factors such as bone mineral density, bone volume fraction and haematological bone metabolic factors in blood. The aim was to identify possible indicators of implant failure. Methods: Forty-six consecutive patients (31 women/15 men, mean age 57 years, range 44−74) had their edentulous atrophic maxilla reconstructed with free autogenous bone grafts from anterior iliac crest. Endosteal implants were placed after six months of bone graft healing. Radiographic examination using computer tomography was performed in 30 patients with onlay bone grafts within 3 weeks after bone grafting and after six months of bone graft healing, and the graft volume change (GVC) during the first six months of healing was calculated. The bone volume fraction (BVF) was estimated from biopsies taken from the internal table at the donor site. Blood samples were collected from 25 of the patients, and in 21 patients the bone mineral density (BMD) was measured with dual-energy x-ray absorptionsmetry. Implant stability was measured at the time for implant placement with resonance frequency analysis (RFA) and expressed as implant stability quotient (ISQ). Implant failure was registered for each patient prior to loading (early failures) and up to three years after loading (late failures). Results: The mean decrease in onlay bone volume after 6 months was 37% (range 16−59). The mean BVF in iliac crest biopsies was 32% (range 15−74). Serum-IGFBP3 was the only haematological parameter differing from the normal range with 79% of the samples over the normal range. Fifteen patients had one or more implant failures prior to loading (early failures). Forty-two out of 46 patients were followed for a minimum of 3 years after loading of the implants. In addition, 6/42 patients had to have one or more implants removed during the three-year follow-up period (late failures). GVC (loss) was correlated with decreased BMD of the lumbar vertebrae L2-L4 (Kruskal Wallis test, p = 0.017). No correlation was found between GVC and haematological factors (Pearson correlation test) or between GVC and BVF (Kruskal Wallis test). No correlation was found between ISQ and graft volume change (Pearson correlation test, p = 0.865). The association between the early and late implant failures and the described factors were evaluated with unconditional logistic regression, and no significant correlations were found. Conclusions: The volume of onlay bone grafts in the maxilla decreased by, on average 37% during the 6-month healing period prior to implant placement. The amount of loss was significantly correlated with BMD of lumbar vertebrae L2-L4. BVF and haematological factors did not correlate to GVC. No correlations were found between graft volume change and implant stability expressed in ISQ nor between implant failure and the other factors evaluated in this study.
Abstracts, EACMFS XIX Congress O.558 Clinical evaluation of DBX in sinus lift procedure U. Zanetti1 , G. Nicoli2 . 1 U.S.D. Maxillo Surgery, Brescia, Italy; 2 Maxillo Facial Surgeon Private-Practitioner, Italy Introduction: A clinical evaluation of the use of DBX alone or associated with autogenous bone graft in sinus lift procedures is esposed. Material and Methods: 18 sinus lift procedures in 10 patients, 8 bilateral, 2 monolateral, were performed in a period during 1 year from 2006 to 2007. In 10 sinus lift, DBX was associated with autogenous bone graft collected from the same side without any other incision, while in 8 cases DBX was used alone. Results: after a healing period (from 6 to 8 months) during the phase of implants placements, a sample of new tissue was analyzed by pathologist and results compare. In all cases enough bone for implant placement was obtained, but preliminary results show a better mineralization where DBX was used associated with bone graft. The osteo-inductive capacity of autogenous bone, even if in small quantity, seem to determine the better results. O.559 Current treatment concepts with immediate implantation W. Wagner, R. Noelken, M. Kunkel. Clinic for Maxillofacial Surgery, Mainz, Germany Purpose of these retrospective studies is to evaluate implant success, marginal bone level and gingival esthetics of 159 NobelPerfectTM implants with immediate provisionalization in the esthetic zone and to explore the performance of a new flapless surgical approach for immediate implant placement, simultaneous alveolar ridge augmentation and immediate provisionalization in case of total loss of the facial bony lamella due to long-axis root fracture. 32 NobelPerfect™ implants with machined neck and 127 NobelPerfect™ Groovy implants were inserted in 99 patients and restored immediately with provisional crowns (follow up period 6 to 48 months). 21 Nobel Perfect™ implants were placed in 19 patients (follow up 3 to 36 months), which had sustained complete loss of the facial bony lamellae. In a flapless technique, implants were inserted simultaneous to subperiostal bone augmentation with autogenous bone chips and underwent immediate provisionalization. Outcome variables were implant success rates, marginal bone levels and Pink Esthetic Score (PES). In the follow up period one implant of the NobelPerfect™ group (cumulative success rate 96.9%) and one implant of the NobelPerfect™ Groovy group (99.2%), but no implant of the group without facial bony lamella (100%) got lost. Marginal bone levels averaged 1.7 mm in the NobelPerfect™ group, 1.99 mm in the NobelPerfect™ Groovy group and 1.87 in the group without facial bony lamella coronal to the first thread. The mean PES of the NobelPerfect™ and NobelPerfect™ Groovy implants was 11.3, of the group without facial bony lamella 12.5. The Groovy design improved the possibility to keep the PES of the initial clinical situation stable or even improve it. Oral hygiene (SBI) was predictive for the esthetic result. The presented data suggest proof of principle for the preservation of the marginal soft tissue height and the reduction of marginal bone remodeling and show that modern implant designs and surfaces make immediate function to a predictable and successful treatment concept. Oral hygiene status should be considered for patient allocation to single stage or multiple stage treatment.
Prostheses–epitheses, implantology and pre-prosthetic surgery I Sala Italia
Prostheses–epitheses, implantology and pre-prosthetic surgery I O.553 3D planning of a prosthetic reconstruction of the forehead A. Soehardi, G.J. Meijer, J. Plooij, T. Maal, S. Berg´e. UMC St. Radboud Nijmegen, dpt Oral & Maxillofacial Surgery, Nijmegen, Netherlands Introduction: In cases of posttraumatic skull defects, reconstruction is indicated to protect the brain, as well as to correct facial harmony. Materials to correct such defects differ from autologous bone grafts to prefabricated titanium models. However, as a high risk of failure existed in the presented case, reconstructive surgery was not conceivable. Therefore, an implant-retained prosthetic device was the treatment of choice. Method: A non-healing skull fracture, in a 40 years old patient, resulted in several episodes of osteomyelitis and meningitis. This finally ended up in a 10 cm frontal bone defect covered with atrophic skin. Despite this unfortunate course of disease, reconstruction was still the patient’s strongest wish. Using 3D digital software (Nobelguide), a surgical template was designed to achieve optimal implant installment. Results: The position of the surgical template differed during surgery from the position during the image capturing. Although, this pitfall led to differences between preoperative planning and actual installment of the implants, it did not influence the further treatment. After 3 months of consolidation, the healing abutments were replaced by magnets to fixate the prosthetic device. Conclusions: Utilisation of 3D planning software in case of an implantation procedure in the skull region, demands meticulous preoperative planning. Furthermore, the volume and the resilience of the overlying soft tissues and the orientation of the implant must be taken into account. 3D digital planning of implants may improve quality of life, however, the touch of a human hand must not be underestimated. O.554 A novel type of dental models: bone with artificial gum A. Gerasimov, N. Kalakutsky, V. Prihod’ko. Pavlov State Medical University, Saint-Petersburg, Russia Objectives: Development and clinical application of a novel type of dental models: bone with artificial gum (BAG-model). Study of its potential for dental implantation and for augmentation of the alveolar ridge. Methods: 1. Fabrication of BAG-model i. CT of maxillo-facial region with functionally impressed mucosa by radiopaque material ii. Creating of stereolithographic models of bone and soft tissues iii. Painting of inferior alveolar nerve, sinuses, dental roots iv. Positioning of the stereolithographic model in the impression of mucosa and filling the space between them with a gingival mask 2. Positioning of BAG-model on the articulator 3. Prosthodontic planning of dental implants axes and quantity of required bone 4. Fabrication of surgical templates 5. Surgical treatment and prosthodontic rehabilitation of the patient. Results: BAG-models were pioneered and used in two cases for patients after the reconstruction of mandible by revascularized autotransplants for the treatment planning in view of prosthodontic requirements. Templates were used for augmentation of the
S139
alveolar ridge and subsequent dental implantation. We obtained favorable prosthodontic conditions. Conclusions: Dental casts occupy an important place in dentistry. But for dental implantation and for augmentation of the alveolar ridge stereolithographic models are more opportune. BAG-models reveal functionally impressed mucosa, bone, inferior alveolar nerve, sinuses, dental roots. It can be used on an articulator. BAG-models not only combine benefits of dental casts and stereolithographic models, but offer new opportunities in fabrication of templates for surgery in view of prosthodontic requirements. O.555 Alveolar ridge augmentation using autologous iliac bone graft E. Iane¸s, F. Streian, S. Rosu. University of Medicine and Pharmacy, Victor Babes Faculty of Dental Medicine, Department of Oral & Maxillofacial Surgery, Timisoara, Romania Objectives: The aim of this study is to prove that the use of bone graft in alveolar ridge augmentation is a better option and the graft resorbtion can be delayed by the use of a titan mesh. Material and Method: The presentation is based on one of our female patients, totally edentulous, complaining of pain and intermittent numbness of the left side of the lower lip associated with severe mastication, esthetic and phonetic dysfunctions affecting her social and professional life. The therapeutic strategy was conceived in two steps: surgery under general anesthetic in order to increase the alveolar ridge by bone auto transplant harvested from the iliac crest and prosthetic rehabilitation. The graft was shaped and immobilized by a titan mesh. Results: The patient was fully satisfied by the result and the new denture fulfilled both her aesthetic and functional expectations. Adhesives were not needed any longer. The first relining was done after one year and four years later she still wears the same denture. Conclusions: The augmentation of the alveolar ridge severely atrophied is most successful using autologous bone graft. The above case shows that the rigid fixation significantly reduces the graft resorbtion and gives a better profile of the resulting alveolar ridge. Using this procedure, the graft resorbtion drops from 70% to 30% over three years, as reported in the medical literature. O.556 Bilateral sinus grafting: autogenous bone vs beta-TCP U. Garagiola1 , G. Santoro1 , G. Battaglia1 , C. Maiorana1 , G. Szabo2 . 1 University of Milan, School of Dentistry I, Department of Oral Surgery, ICP, Milan, Italy; 2 Department of Oral and Maxillofacial Surgery, Semmelweis University, Budapest, Hungary Aim: Two different graft materials, Beta-tricalcium phosphate and autogenous bone, were used in the same patient. The aim of this study was to determine whether donor site morbidity could be avoided by using pure-phase Beta-TCP. Materials and Methods: Bilateral sinus grafting was performed on 20 selected patients; Beta-TCP was used on the experimental side. Autogenous bone was used on the control side. In each patient, one side was randomly designated the experimental side. Eighty bone biopsy specimens were taken at the time of implant placement. Results: Histologically and histomorphometrically, there was no significant difference between the experimental and control grafts in terms of the quantity and rate of ossification. For each histologic sample, the total surface area, the surface area that consisted of bone, and the surface area that consisted of graft material were measured in mm2, and bone and graft material were analyzed as percentages of the total. The mean percentage bone areas were 36.47±6.9% and 38.34±7.4%, respectively; the difference was
S140
Journal of Cranio-Maxillofacial Surgery 36(2008) Suppl. 1
not significant (P = 0.25). The autogenous bone was initially less visible than the Beta-TCP, but new bone formation was clearly observed for both materials. The rate of graft resorption was lower on the experimental side than on the control side. The mean graft area percentages were 13.95±5.38% and 8.47±3.17%, and the difference was highly significant (P < 0.001). Conclusion: Comparisons with other studies reveal that BetaTCP is a satisfactory graft material for maxillary sinus floor augmentation, even without autogeneous bone. O.557 Bone graft healing in reconstruction of maxillary atrophy M. Sj¨ostr¨om1 , L. Sennerby2 , S. Lundgren1 . 1 Department of Oral & Maxillofacial Surgery, Ume˚a University, Ume˚a, Sweden; 2 Department of Biomaterials, University of Gothenburg, Sweden Objectives: To evaluate possible correlations between loss of volume of free iliac crest bone grafts in the maxilla during six months of healing and factors such as bone mineral density, bone volume fraction and haematological bone metabolic factors in blood. The aim was to identify possible indicators of implant failure. Methods: Forty-six consecutive patients (31 women/15 men, mean age 57 years, range 44−74) had their edentulous atrophic maxilla reconstructed with free autogenous bone grafts from anterior iliac crest. Endosteal implants were placed after six months of bone graft healing. Radiographic examination using computer tomography was performed in 30 patients with onlay bone grafts within 3 weeks after bone grafting and after six months of bone graft healing, and the graft volume change (GVC) during the first six months of healing was calculated. The bone volume fraction (BVF) was estimated from biopsies taken from the internal table at the donor site. Blood samples were collected from 25 of the patients, and in 21 patients the bone mineral density (BMD) was measured with dual-energy x-ray absorptionsmetry. Implant stability was measured at the time for implant placement with resonance frequency analysis (RFA) and expressed as implant stability quotient (ISQ). Implant failure was registered for each patient prior to loading (early failures) and up to three years after loading (late failures). Results: The mean decrease in onlay bone volume after 6 months was 37% (range 16−59). The mean BVF in iliac crest biopsies was 32% (range 15−74). Serum-IGFBP3 was the only haematological parameter differing from the normal range with 79% of the samples over the normal range. Fifteen patients had one or more implant failures prior to loading (early failures). Forty-two out of 46 patients were followed for a minimum of 3 years after loading of the implants. In addition, 6/42 patients had to have one or more implants removed during the three-year follow-up period (late failures). GVC (loss) was correlated with decreased BMD of the lumbar vertebrae L2-L4 (Kruskal Wallis test, p = 0.017). No correlation was found between GVC and haematological factors (Pearson correlation test) or between GVC and BVF (Kruskal Wallis test). No correlation was found between ISQ and graft volume change (Pearson correlation test, p = 0.865). The association between the early and late implant failures and the described factors were evaluated with unconditional logistic regression, and no significant correlations were found. Conclusions: The volume of onlay bone grafts in the maxilla decreased by, on average 37% during the 6-month healing period prior to implant placement. The amount of loss was significantly correlated with BMD of lumbar vertebrae L2-L4. BVF and haematological factors did not correlate to GVC. No correlations were found between graft volume change and implant stability expressed in ISQ nor between implant failure and the other factors evaluated in this study.
Abstracts, EACMFS XIX Congress O.558 Clinical evaluation of DBX in sinus lift procedure U. Zanetti1 , G. Nicoli2 . 1 U.S.D. Maxillo Surgery, Brescia, Italy; 2 Maxillo Facial Surgeon Private-Practitioner, Italy Introduction: A clinical evaluation of the use of DBX alone or associated with autogenous bone graft in sinus lift procedures is esposed. Material and Methods: 18 sinus lift procedures in 10 patients, 8 bilateral, 2 monolateral, were performed in a period during 1 year from 2006 to 2007. In 10 sinus lift, DBX was associated with autogenous bone graft collected from the same side without any other incision, while in 8 cases DBX was used alone. Results: after a healing period (from 6 to 8 months) during the phase of implants placements, a sample of new tissue was analyzed by pathologist and results compare. In all cases enough bone for implant placement was obtained, but preliminary results show a better mineralization where DBX was used associated with bone graft. The osteo-inductive capacity of autogenous bone, even if in small quantity, seem to determine the better results. O.559 Current treatment concepts with immediate implantation W. Wagner, R. Noelken, M. Kunkel. Clinic for Maxillofacial Surgery, Mainz, Germany Purpose of these retrospective studies is to evaluate implant success, marginal bone level and gingival esthetics of 159 NobelPerfectTM implants with immediate provisionalization in the esthetic zone and to explore the performance of a new flapless surgical approach for immediate implant placement, simultaneous alveolar ridge augmentation and immediate provisionalization in case of total loss of the facial bony lamella due to long-axis root fracture. 32 NobelPerfect™ implants with machined neck and 127 NobelPerfect™ Groovy implants were inserted in 99 patients and restored immediately with provisional crowns (follow up period 6 to 48 months). 21 Nobel Perfect™ implants were placed in 19 patients (follow up 3 to 36 months), which had sustained complete loss of the facial bony lamellae. In a flapless technique, implants were inserted simultaneous to subperiostal bone augmentation with autogenous bone chips and underwent immediate provisionalization. Outcome variables were implant success rates, marginal bone levels and Pink Esthetic Score (PES). In the follow up period one implant of the NobelPerfect™ group (cumulative success rate 96.9%) and one implant of the NobelPerfect™ Groovy group (99.2%), but no implant of the group without facial bony lamella (100%) got lost. Marginal bone levels averaged 1.7 mm in the NobelPerfect™ group, 1.99 mm in the NobelPerfect™ Groovy group and 1.87 in the group without facial bony lamella coronal to the first thread. The mean PES of the NobelPerfect™ and NobelPerfect™ Groovy implants was 11.3, of the group without facial bony lamella 12.5. The Groovy design improved the possibility to keep the PES of the initial clinical situation stable or even improve it. Oral hygiene (SBI) was predictive for the esthetic result. The presented data suggest proof of principle for the preservation of the marginal soft tissue height and the reduction of marginal bone remodeling and show that modern implant designs and surfaces make immediate function to a predictable and successful treatment concept. Oral hygiene status should be considered for patient allocation to single stage or multiple stage treatment.