34 - GBR Flashcards
Sinus and ridge augmentation implant survival
• Aghaloo 2007
○ Sinus survival for implants: 81-96%. Xenograft best, alloplast worst
Ridge augmentation survival for implants: 75-96%. GBR 95% w/ good long term studies, others are lacking good long term data.
Soft tissue complications
Lim 2018 - SR MA, soft tissue complications 16.5%. Of these, 35% membrane exposure and 35% soft tissue dehiscence. Resorbable vs non-resorbable membrane, no difference.
Membrane exposure complications
Garcia 2018 - SR MA, membrane exposure. 74% more ridge width gain and 27% more defect reduction for implants without membrane exposure.
Block graft complications
Chaushu 2010 - SR MA, block grafts. Membrane exposure 30%, associated with ~20% graft failure. Incision line opening 30%, associated w/ ~20% graft failure. 40% infection of grafted site
Decortication
Greenstein - animal studies, no evidence
2 horizontal ridge augmentation techniques
○ Sterio 2013 - Cancellous MCBA + bovine pericardium. 86% success w/ 2.6mm width gain and 66% graft resorption
Caldwell 2015 - Alloderm GBR + tacks + bone (Block graft from mandibular ramus ground up + FDBA or FDBA alone). 88% success w/ 3.2mm width gain and 14% graft resorption No difference between the two grafts
Titanium mesh ridge augmentation
Ricci 2013 - SR for titanium mesh. 98% success, graft type did not matter. 4.16mm horizontal gain. 22% mesh exposure, did not result in increased infection or decreased bone formation.
Block graft ridge augmentation
El-Nayef 2018 - SR MA, block graft better maintained volume of augmentation. Horizontal gain, 4mm for block and 2.5mm for GBR
Vertical ridge augmentation
Camps - Font 2016. MA, vertical augmentation vs short implants. No difference for implant or prosthetic failure. Vertical 44% complication rate, OR 8
Chin/iliac crest graft
Matsumoto 2012 - Chin/iliac crest graft. 4 months sufficient healing time. Histologically, woven bone + marrow spaces + osteoblasts on trabecular layer + Haversian systems present
Implant defects, best for augmentation
Schwarz 2010 - Only circumferential defect w/o dehiscence were favorably treated
Best predictor of sinus disease
Beaumont - No difference in age/gender/smoking status for sinus conditions. Significant relationship between history of symptoms and a positive diagnosis of sinus disease.
When is ENT referral needed?
Carmeli 2011 - >5mm irregular mucosal thickening, circumferential thickening, or complete mucosal thickening w/ high risk for ostium obstruction. Referral to ENT needed
ChP and membrane thickening
Phothikhun 2012 - Mucosal thickening 42% and mucosal cysts 16% of patients. Severe periodontitis patients (>50% bone loss) were 3X more likely to have mucosal thickening. Mucosal thickening not associated w/ PARL or RCT.
Who first introduced sinus lift?
Tatum
Boyne
Increased sinus pneumatization w/:
Sharan 2008 - Increased sinus pneumatization: Teeth surrounded by a superiorly curving sinus floor, tooth roots protruding into sinus cavity (CBCT), extraction of 2nd molars, and extraction of several adjacent posterior teeth or extraction of a tooth with missing adjacent tooth
Septa
○ Van Zyl 2009 - 69% patient prevalence, 56% sinus prevalence. Average height 6.2mm. 25% anterior, 51% middle, 24% posterior. Medial-lateral orientation w/ mesial slant
No significant difference between edentulous and dentate
Vasculature
○ Rosano 2011 - Cadaver dissection, 100% anastomosis between alveolar antral artery and infraorbital artery.
Radiographically, bony canal seen 47% of the time. Lowest border of AAA may be adhered to sinus membrane. Use caution when not visualized radiographically and residual ridge is <3mm tall
Buccopalatal distance
Avila 2010 - As bucco-palatal distance increases, the % vital bone formation after augmentation decreased. Allow more healing time in larger sinus cavities for additional bone formation. Vital bone based on BP distance:
Palatonasal recess
Chan 2013 - Palatal wall + lateral nasal wall. High risk sites for perforation are PNR <15mm from alveolar crest and angulation <90 and are more common at premolars. Molar sites PNR more obtuse angles but likely closer to alveolar crest
Membrane perforation. Thick or thin?
○ Monje 2016 - Thickness 1.17mm. Histologic 0.48mm, CBCT 1.3mm. Smoking, age, and periodontal status trend towards thicker membrane. Trend for more perforations w/ thicker membrane. Perforation 15%
Lum 2016 - Perforations occur more frequently in patients w/ minimal ridge height and thinner membranes. Thickness: Perforation 0.84mm, no perforation 2.6mm. Ridge height: Perforation 2.8mm, no perforation 4.2mm. Perforations 28%
Membrane perforation and implant survival
De Almedia Ferreira - No difference in implant survival in augmented sines + perforation. Similar amounts of vital bone. 51% residual BioOss at 6 months
Smoking
Peleg 2006 - Simultaneous implant placement, Stage 2 surgery 6-9 months later. Smoking decreased to 2-5 cigarettes/day 1 week prior, 0 cigarettes day prior and 10 days post-op. Failure rates not significant between smoking and non-smokers at 9 years.
Membrane changes after lift
Makary 2015 - Transient thickening of sinus membrane at 1 week due to inflammatory reaction. Reaches baseline at 9 months. Physiological re-adaptation and increased ciliary action leads to thinner sinus membrane at 12 months
Volume changes after lift
Shanbhag 2014 - SR MA, volumetric changes. 14-75% volume reduction at 6 months. Expect 20-30% volume reduction at 6 months using bone substitute or composite graft (autogenous/allograft)
Crestal sinus lift - best scenario
Chen 2017 - 35% reduction in bone volume over 3 years w/ osteotome sinus lift. More stable w/ concave sinus floor w/ small intruding angle (angle between implant axis and tangent line of maxillary sinus floor) due to more native bone. More reduction w/ obtuse intruding angle and flat sinus floor
Amount of crestal lift per vertical height
Sonoda 2017 - 6mm of vertical bone height can be achieved w/ a 0.3mL of bone graft. A ratio of vertical elevation height to buccopalatal or mesiodistal <0.8mm needed to avoid sinus membrane perforation AKA can’t have a tall peak of bone but need a wide bubble of bone.
Crestal lift w/o graft
Si 2016 - Osteotome sinus floor elevation w/o bone graft. 2-3mm of lift remained stable over 9 years. Implant survival 90%
BPPV
• Sammartino 2011 - Benign paroxysmal positional vertigo: Short term recurrent episodes of vertigo and nystagmus (involuntary eye movement). Incidence increases w/ age, females 2X.
○ Otoliths (calcium carbonate grains in inner ear) detached and float around in endolymph into the semicircular canals
○ Epley Maneuver
○ Sit upright, turn head to symptomatic side at 45 degree angle and hold for 20 seconds
○ Turn head 90 degrees to other side and hold for 20 seconds
○ Roll the body in the facing direction, pointing head/nose down and hold for 20 seconds
○ Return to sitting position and remain for 30 seconds
Repeat 3 times, patients w/ experience vertigo
Ridge split ridge augmentation
El-Nayef 2015 - SR, 95-97% implant survival. Better horizontal bone gain w/ partial thickness flap and with addition of bone grafting materials. Mills - maxilla partial thickness, mandible full thickness
Borg
70%/30% FDBA and DFDBA vs FDBA
dPTFE
36% vs 24% vital bone
Eskow
Cortical vs cancellous FDBA + Collaplug
18-20 weeks
No difference
Greater cortical residual graft
Demetter & Calahan
Cortical vs cancellous vs 50/50
No difference vital bone
Wood
FDBA vs DFDBA + Collaplug
38% DFDBA
25% FDBA
Iasella
FDBA/TCN/BioMend vs no ridge preservation
4-6 months
1.2 vs 2.6mm HZ loss
Gain buccal soft tissue
Whetman
DFDBA 8-10 vs 18-20
47% vs 32% vital bone
Vital bone inversely related to % residual graft
Nelson
70/30 8-10 vs 18-20 weeks
40% vs 18% vital bone
Lai
BioOss vs Porcine ZCore
No difference
Walker
Molars
FDBA + dPTFE vs control
No difference width, better for height
Al-Harthi
FDBA + Collaplug
Duong
Histo from Walker and Al-Harthi
Control 37%
