How to avoid intraoperative and postoperative complications in maxillary sinus elevation.

Maxillary sinus floor elevation, via the lateral approach, is one of the most predictable bone augmentation procedures performed in implant dentistry. but both intra- and postoperative complications can occur, and some of them are severe. Our aim is as follows: To review the pertinent literature on the topic, especially assessing the risk factors related to complications. To give clinical recommendations to minimize intra- and postoperative complications with the ultimate scope of improving the standard of clinical care and patient safety.

Immediate postextraction implant placement using plasma rich in growth factors technology in maxillary premolar region: a new strategy for soft tissue management.

Achieving an excellent aesthetic outcome in postextraction dental implant placement in the anterior maxilla is a challenging procedure for clinicians. In fact, there is an increased risk for soft tissue recession at the facial aspect which may require supplementary connective tissue grafts to accomplish the final aesthetic result. The aim of this case report is to describe a regenerative technique using autologous plasma rich in growth factors fibrin plug for preservation of soft tissue architecture around an implant immediately placed into an extraction site in the anterior maxilla. Such a procedure allowed for guided bone regeneration without the need for vertical releasing incisions and primary healing, thus showing a pleasant gingival contour at the facial aspect after a single stage surgery. Integrating this technique into common practice could provide important benefits for the patients regarding aesthetics, without any risk of infection or transmission of diseases.

Immediate placement and loading of implants with laser-microgrooved collar in combination with an anorganic porcine bone mineral matrix in the esthetic zone. Twelve-month results of a prospective multicenter cohort study.

BACKGROUND: Many techniques have been proposed to address post-extraction ridge resorption, which often represents a concern, especially in the esthetic region. PURPOSE: The purpose of the present, prospective, multicenter, single cohort study was to investigate, up to 1 year of function, the effectiveness of a protocol for alveolar ridge preservation involving implants with laser-microgrooved surface immediately placed in fresh extraction sockets. MATERIALS AND METHODS: Twenty eight patients candidate to tooth extraction in the esthetic zone (site 15-25 and 35-45) were treated by immediate placement of a single laser-microgrooved implants with the adjunct of a highly porous anorganic porcine bone mineral matrix and a collagen wound dressing. Peri-implant marginal bone level (MBL) was evaluated at time of loading, 3 and 12 months after loading. Gingival index, plaque index, probing depth, and bleeding on probing were measured at 3, 6, and 12 months after loading. Dimensional changes at implant sites were digitally evaluated using the best-fit superimposition of pre-and post-socket preservation models. Implant aesthetic score (IAS) as well as patients' post-operative quality of life were also evaluated at 12 months. Comparisons between data relative to thick and thin gingival phenotypes were made using Student's t-test or Mann-Whitney test, as appropriate. The significance level was set at p = 0.05. RESULTS: No patient dropped out, and 28 implants were evaluated at 12 months post-loading. The overall MBL was found to be 0.92 ± 1.11 mm. Volumetric analysis of superimposed models showed an alveolar bone tissue displacement at the buccal aspect of -0.57 ± 0.52 mm in thin phenotypes and -0.46 ± 0.31 mm in thick phenotypes (p = 0.58, unpaired Student's t-test). No signs of soft tissue recession or esthetically unpleasant buccal gingiva were reported. CONCLUSIONS: The clinical protocol herein employed showed benefits in maintaining marginal bone levels and soft tissue contour around post-extraction implants in the esthetic zone.

Split-Thickness Flap for the Management of a Maxillary Sinus Wall Bony Fenestration During Lateral Window Sinus Augmentation: Case Reports and Technical Surgical Notes.

Maxillary sinus wall fenestration at the lateral wall or floor of the sinus can result from many potential factors, such as the repair of oro-antral communication, Caldwell-Luc antrostomy, tooth extraction after an endodontic or periodontal infection that eroded the sinus wall, and the combination of sinus pneumatization and alveolar ridge resorption after teeth removal. When sinus wall fenestration is observed on radiographs, it usually indicates adhesion between the sinus membrane and buccal flap, which makes the reentry surgery for subsequent sinus augmentation challenging. To minimize surgical complications in these challenging scenarios, this paper presents a split-flap surgical technique for the management of soft tissue adhesion between the sinus membrane and alveolar mucosa when attempting a lateral window sinus augmentation.

Maxillary sinus vascular anatomy and its relation to sinus lift surgery.

OBJECTIVES: To investigate the prevalence, location, size and course of the anastomosis between the dental branch of the posterior superior alveolar artery (PSAA), known as alveolar antral artery (AAA), and the infraorbital artery (IOA). MATERIAL AND METHODS: The first part of the study was performed on 30 maxillary sinuses deriving from 15 human cadaver heads. In order to visualize such anastomosis, the vascular network afferent to the sinus was injected with liquid latex mixed with green India ink through the external carotid artery. The second part of the study consisted of 100 CT scans from patients scheduled for sinus lift surgery. RESULTS: An anastomosis between the AAA and the IOA was found by dissection in the context of the sinus anterolateral wall in 100% of cases, while a well-defined bony canal was detected radiographically in 94 out of 200 sinuses (47% of cases). The mean vertical distance from the lowest point of this bony canal to the alveolar crest was 11.25 ± 2.99 mm (SD) in maxillae examined by CT. The canal diameter was <1 mm in 55.3% of cases, 1-2 mm in 40.4% of cases and 2-3 mm in 4.3% of cases. In 100% of cases, the AAA was found to be partially intra-osseous, that is between the Schneiderian membrane and the lateral bony wall of the sinus, in the area selected for sinus antrostomy. CONCLUSIONS: A sound knowledge of the maxillary sinus vascular anatomy and its careful analysis by CT scan is essential to prevent complications during surgical interventions involving this region.

Management of a neurological lesion involving Canalis Sinuosus: A case report.

This case report describes the management of a lesion involving the Canalis Sinuosus (CS), that is a bone channel originating from the infraorbital canal below the orbital margin and posterior to the infraorbital foramen and coursing in an anterolateral direction to the anterior wall of the nasal cavity. A female patient, 62y, ASA 1, wearing full mobile dentures, came to our clinic asking for upper jaw rehabilitation. Due to a severe bone atrophy, a graft procedure was performed and the placement of eight implants was planned. One week after implants were positioned, the patient referred pain in the upper right central incisor region, that was compatible with a normal post-operative healing. After 15 days, since the symptoms worsened and became localized and persistent, a more detailed CBCT analysis was carried out. The images demonstrated that a CS on the right side was compressed by the apex of the implant in position #11. The implant was replaced with a shorter one and adequate pharmacological therapy was prescribed. All the symptoms completely disappeared after 30 days.

Maxillary sinus septa: a cadaveric study.

PURPOSE: The goal of this study was to investigate the incidence, location, and height of antral septa and to offer the clinician, through an accurate investigation of the anatomy of the maxillary sinus region, the tools to carry out sinus-lift procedures under safe conditions. MATERIALS AND METHODS: The study consisted of 60 sinuses from 30 human cadavers with an age range of 59 to 90 years. Only septa measuring 3.0 mm or greater in height were considered in our analysis. RESULTS: A total of 20 incomplete septa were found, showing an incidence of 33.3%, and no more than 1 septum per sinus was identified. All septa were located in the anterior-lateral wall and were either sagittal or transversal. Of the septa, 6 (30%) were located in the anterior region of the antral wall (between the second premolar and first molar roots), 8 (40%) were in the middle region (between the first and second molar roots), and 6 (30%) were in the posterior region (distal to the third molar roots). Antral septa height showed great variability, with a mean value of 8.72 mm (SD, 4.26; range, 3.7-18.4 mm). Our study also showed that 40% of our specimens (12 of 30 maxillas) have bony septa that can partially divide the sinus, and they were symmetric in 8 of 12 cases. CONCLUSIONS: A sound knowledge of the maxillary sinus anatomy and of the possible anatomic variations is essential to prevent complications during surgical interventions involving this region.

Replacement of vertically root-fractured endodontically treated teeth with immediate implants in conjunction with a synthetic bone cement.

PURPOSE: The purpose of this prospective study was to evaluate the clinical outcome of implants immediately placed into fresh extraction sockets for the replacement of endodontically treated teeth with signs of vertical root fracture. MATERIAL: Sixteen partially edentulous patients, with 1 tooth scheduled for extraction and showing clinical signs and symptoms and/or radiological evidence of vertical root fracture, were included in the study. Sixteen transmucosal implants were installed immediately after extraction and careful debridement. The gap between the implant surface and the socket walls was filled using synthetic bone grafting cement. Prosthetic phase occurred 3 to 4 months after surgery. Implant success and survival and radiographic bone loss were evaluated after 1 year of function. Patient satisfaction for mastication function, phonetics, and aesthetics was also assessed by means of a questionnaire. RESULTS: No implant failure occurred. The overall implant success and survival was 100% at 1 year. The mean follow-up was 13.5 months. All prostheses were successful. Periimplant bone loss after 1 year averaged 0.48 ± 0.20 mm. All patients reported full satisfaction for mastication function, phonetics, and aesthetics. CONCLUSIONS: The use of a synthetic bone grafting cement in combination with immediate implant placement procedure can be considered a safe, effective, and predictable treatment option for the rehabilitation of fresh postextraction sockets.

Anatomic assessment of the anterior mandible and relative hemorrhage risk in implant dentistry: a cadaveric study.

OBJECTIVES: To evaluate prevalence, size, location and content of foramina and bony canals located on the lingual side of the mandibular midline. MATERIAL AND METHODS: The prevalence and the size of midline lingual foramina and canals visible above and/or below genial spines and their distances from the mandibular base were measured in 60 dry mandibles from adult human cadavers. In addition, macro-anatomic dissections were performed on another 20 mandibles injected with red latex to investigate the vascular canal contents associated with these midline lingual foramina and canals. RESULTS: A total of 118 foramina were detected. All mandibles investigated had at least one lingual foramen at the midline above the genial spines, located at a mean height of 12.5+/-2.1 mm (SD) from the inferior border of the mandible. Macro-anatomic dissections showed a clear vascular branch entering the mandibular midline as a single vessel from a sublingual-sublingual anastomosis in 19 out of 20 mandibles studied (95%). CONCLUSION: Blood vessels in the floor of the mouth may be in close proximity to the lingual cortical plate of the mandibular midline in most cases. This implies that bleeding can occur when the mandibular cortical plate is perforated even minimally. As a consequence, the authors suggest a careful planning of implant positioning at mandibular midline, possibly opting for the use of an even number of implants in the interforaminal region, avoiding the risk of surgical trauma to the lingual cortical plate of the mandibular midline.

Maxillary sinus vascularization: a cadaveric study.

The goal of this study was the investigation of the arterial blood supply to the maxillary sinus to give clinicians the basis for a better understanding of the origin of vascular complications that can derive from surgical procedures at this level. The study consisted of 30 sinuses from 15 human cadavers with an age range of 59 to 90 years. To define the complex vascularization of the maxillary sinus, the afferent vascular network was injected with liquid latex mixed with red india ink through the external carotid arteries. An intraosseous anastomosis between the dental branch of the posterior superior alveolar artery, also known as alveolar antral artery, and the infraorbital artery was found in 100% of cases. Such an anastomosis seemed to guarantee the blood supply to the sinus membrane, to the periosteal tissues, and especially to the anterior lateral wall of the sinus. Moreover, the gingival branch of the posterior superior alveolar artery was found to anastomose an extraosseous branch of the infraorbital artery in 10 sinuses. The examination of the maxillary sinus also showed a close anatomic relationship among the sinus posterior wall, the descending palatine artery, and the sphenopalatine artery in all 30 sinuses. Small branches deriving from the posterior lateral nasal arteries have been found to perforate the nasal wall laterally and reach the mucosa of the maxillary sinus. A sound knowledge of the maxillary sinus vascularization is essential to prevent vascular complications during surgical operations involving this region.

Implant survival rates after maxillary sinus augmentation.

Implant therapy in the atrophic posterior maxilla becomes challenging in the presence of reduced maxillary bone height. Sinus augmentation can be performed for resolving this condition prior to implant placement. The aim of this article was therefore to evaluate implant survival rates in the grafted sinus taking into account the influence of the implant surface, graft material, and implant placement timing. A systematic review of the literature was performed. Articles retrieved from electronic databases were screened using specific inclusion criteria, and data extracted were divided according to: graft material (autogenous, non-autogenous, composite graft), implant surface (machined or textured), and implant placement (simultaneous with grafting or delayed). Fifty-nine articles were included. Survival rates for implants placed in grafts made of bone substitutes alone and grafts of composite material were slightly better than the survival rates for implants placed in 100% autogenous grafts. Over 90% of implants associated with non-autogenous grafts had a textured surface. Textured surfaces achieved better outcomes compared with machined surfaces, and this was independent of the graft material. Simultaneous and delayed procedures had similar outcomes. It may be concluded that bone substitutes can be successfully used for sinus augmentation, reducing donor-site morbidity. Long-term studies are needed to confirm the performance of non-autogenous grafts. The use of implants with a textured surface may improve the outcome in any graft type.

[Vascular anatomy of the mandibular symphysis and possible complications in oral surgery]. / Anatomie vasculaire de la symphyse de la mandibule et complications potentielles en chirurgie orale.

Surgical procedures carried out between the chin foramina at the anterior mandible level are usually considered free of severe neurovascular complications, due to the excellent bone density in that region and the absence of important neurovascular structures. However, the international scientific literature on this issue reports rare but severe hemorrhagic complications following implant surgery at this level. The aim of this review article is to offer the clinician, through an accurate investigation of the anatomy of the median mandibular region, the tools to carry out oral surgery operations at this level under safe conditions, reducing the possible intraoperative risks to a minimum.

[Advantages and limits of nickel-titanium instruments for root canal preparation. A review of the current literature]. / Avantages et limites des instruments en nickel-titane pour la préparation canalaire endodontique. Revue de la littérature récente.

In recent years, an important innovation in the field of dentistry has been the introduction of nickel-titanium alloy instruments. Superelasticity and shape memory are the main mechanical properties of this alloy which prompted its use in endodontics. Due to these characteristics, NiTi instruments have been demonstrated to preserve the original anatomy, the shape and position in space of the apical foramen. This literature review of mechanical properties of NiTi endodontic instruments aims to provide clinicians with a better understanding of their advantages and limits.

Treatment of through-and-through bone lesion using autologous growth factors and xenogeneic bone graft: a case report.

BACKGROUND: This pilot case study aimed at evaluating the possibility of achieving optimal hard and soft tissue regeneration using plasma rich in growth factors (PRGF) and anorganic bovine bone (ABB) for the surgical treatment of a large through-and-through periapical bone lesion. CASE REPORT: Maxillary incisors of a patient with through-and-through periapical lesion of endodontic origin were treated using modern endodontic surgical technique with the adjunct of PRGF. The PRGF clot was positioned over the palatal side of the lesion while the remaining bone defect was grafted with PRGF and ABB. A collagen membrane embedded with plasma very rich in growth factors covered the graft. Post-operative pain and swelling were negligible, and soft tissue healing was very fast. One-year clinical and radiographic outcome showed complete healing and functionality. DISCUSSION: The addition of PRGF to ABB could improve the regenerative process, reducing postoperative symptoms and resulting in a fast and predictable hard and soft tissue healing.

Endoscopic minimally invasive management of a periradicular lesion invading the maxillary sinus.

A referred patient presented with a lesion of endodontic origin located at the apex of tooth #27. The tooth had been endodontically treated and re-treated. A periapical radiograph revealed a close relationship between the lesion and the maxillary sinus. A cone-beam computed tomography scan confirmed that the lesion had invaded the sinus cavity. The treatment plan consisted of periapical surgery using an endoscope as a magnification device. Due to a sinus membrane perforation, a new sinus membrane repair technique was performed. Twelve months after surgery, a cone-beam computed tomography scan revealed successful healing of the lesion. The continuous preservation of the sinus physiology was also observed. The use of an endoscope as a magnification device and a tailored technique for sinus membrane management allowed us to achieve a successful treatment outcome in the case of an endodontic lesion invading the maxillary sinus.

Ligation of an unusually large vessel during maxillary sinus floor augmentation. A case report.

PURPOSE: The purpose of the present case report was to document a maxillary sinus floor augmentation procedure involving ligation of a blood vessel with a nearly 3-mm diameter in the lateral wall of the maxillary sinus. MATERIALS AND METHODS: A bilateral maxillary sinus floor augmentation procedure was performed in a 51-year-old healthy man. The preoperative computed tomography scan revealed a bony canal within the lateral maxillary sinus wall of the right as well as the left side close to the alveolar ridge. RESULTS: A vessel with a diameter of nearly 3 mm was identified during the sinus floor augmentation on the left side. The vessel was exposed and ligated. A vessel with a diameter of approximately 1 mm was identified on the right side and the sinus floor augmentation was performed without ligation. No complications were observed and the postoperative healing was uneventful. CONCLUSIONS: Although accidental laceration of vessels with an unusually large diameter during maxillary sinus floor augmentation is not life-threatening, impaired visualisation may compromise the augmentation procedure, including the elevation of the Schneiderian membrane. Moreover, postoperative bleeding and formation of a haematoma may occur. Therefore, ligation of vessels with an unusually large diameter is recommended during maxillary sinus floor augmentation to minimise intra- and postoperative complications.

Scanning electron microscopic analysis of the integrity of the root-end surface after root-end management using a piezoelectric device: a cadaveric study.

INTRODUCTION: The introduction of piezoelectric instruments in endodontic surgery allowed clinicians to manage the bone tissue with precision reducing the risk of damaging soft tissues. Although such instruments can also be used to prepare root-end cavity, few information is available on the effect of piezosurgery on dentine. This cadaveric study investigated the integrity of root apices after root-end cavity preparation by piezoelectric instruments at different device settings. METHODS: Fifty maxillary anterior teeth underwent endodontic treatment and apical resection in situ. Ten teeth were used as control. Retrograde cavities were prepared in 40 teeth (10 per group). In three groups, the piezoelectric device was set at constant vibration mode (CV), and three power levels were used. In another experimental group (n = 10), vibration + pulsation mode (VP) was selected, and low power was used. Each root was duplicated and analyzed by scanning electron microscopy for the presence of cracks and marginal chipping. RESULTS: The number of cracks was significantly higher in the VP group, whereas no significant difference was found among CV groups. No difference between groups was found for crack type. The VP group showed a significantly poorer quality of cavity margin respect to the CV groups. CONCLUSION: Constant vibration mode is recommended for retrograde preparation with piezosurgery.

A new surgical technique for preservation of endodontically treated teeth with coronally located vertical root fractures: a prospective case series.

OBJECTIVE: The purpose of this study was to present a new surgical preservation technique for teeth with incomplete vertical root fracture. STUDY DESIGN: Seventeen patients with 1 endodontically treated maxillary anterior tooth in which an incomplete vertical root fracture involving only the buccal side was suspected underwent a flap elevation procedure to visualize the pattern of bone loss and assess the type of root fracture. If the preoperative diagnosis was confirmed, a groove following the fracture line was prepared using retro-tips driven by an ultrasonic device and sealed with mineral trioxide aggregate after filling of the bone defect with calcium sulfate. RESULTS: A total of 10 vertical root fracture repair procedures were performed. At 12 months' follow-up, all cases showed clinical and radiographic success. After 33 months, 7 patients were available for a follow-up: 5 cases remained successful, and 2 teeth (lateral incisors) failed. CONCLUSIONS: The present surgical approach for preservation of teeth with incomplete vertical root fracture demonstrated satisfactory results regarding clinical outcome.

Análise comparativa do crescimento ósseo sobre implantes cilíndricos e cônicos com superfície jateada por particulas de óxido de titânio em tíbias de coelhos / Comparative analysis of growth bone on dental implants cylindrical and conical with sandblasted surface of particles of titanium oxide in rabbit tibiae

Nos últimos anos diferentes desenhos de implantes têm sido sugeridos e desenvolvidos para a utilização na substituição de perdas dentais. Dentre esses, os mais comuns são os implantes cilíndricos e cônicos, sendo esse último, atualmente mais procurado pela sua facilidade de inserção e melhor estabilidade primária. O objetivo deste estudo foi avaliar a interface osso/implante da superfície tratada por jateamento com micropartículas de óxido de titânio em dois tipos modelos de implantes dentais, analisando comparativamente a diferença e direcionamento do crescimento do tecido ósseo em contato de cada modelo através de fotomicrografias obtidas pela microscopia eletrônica de varredura (MEV). Foram utilizados três coelhos New Zelands, adultos, com peso médio de 3,5Kg, obtido no Biotério Central da Universidade Federal de Santa Maria (UFSM). Foram utilizados 6 implantes cilíndricos e 6 implantes cônicos de hexágono interno fabricados pela empresa Implacil Material Odontológico (Implantes Bortoli), os quais apresentam superfície jateada por óxido de titânio. Marcadores ósseos (Alizarina, calceina, tetraciclina) foram injetados subcutaneamente em diferentes intervalos de tempo após a implantação para avaliar o tempo de formação do novo osso no período de 8 semanas. Após as oito semanas os animais foram sacrificados e os implantes removidos com uma porção de tecido ósseo e fixadas em e fixadas solução a base de formol por três dias. Na sequência essas foram desidratadas em álcool e incluídas em resina especial para microscopia. Foram realizados cortes em um micrótomo para a obtenção das amostras, sendo obtidos 3 cortes de cada, as quais foram analisadas e comparadas verificando-se as áreas de contato das superfícies com o tecido ósseo por microscopia de luz, de fluorescência e de varredura. Os resultados demonstraram que a superfície proposta promove uma osseointegracão muito efetiva e em uma sequência de tempo adequada e esperada e, que o desenho do implante cônico parece ter direcionado o crescimento do osso cortical em uma maior área de superfície. Concluiu-se que o modelo de desenho do implante pode influenciar a qualidade e quantidade de osseointegracão dos implantes dentais e pode direcioná-la, porém novos estudos sobre essa área de contato osso/implante devem ser propostos.

In recent years various designs of implants have been suggested and developed for use in replacing tooth losses. Among these, the most common implants are cylindrical and conical, the latter being currently most sought by its ease of insertion and better primary stability. The aim of this study was to evaluate the bone-implant interface surface treated by sandblasting with microparticles of titanium oxide models into two types of dental implants, comparatively analyzing the difference and direction of growth of bone tissue in contact for each model by photomicrographs by scanning electron microscopy (SEM). We used three rabbits New Zelands adults, with an average weight of 3.5 kg, obtained from Central Animal of University Federal of Santa Maria (UFSM). Six implants cylindrical and six conical implants with internal hexagon were used, manufactured by the company Implacil Dental Materials (Implants Bortoli), which have blasted surface of titanium oxide. Bone markers (alizarin, calcein, tetracycline) were injected subcutaneously at different time intervals after implantation to assess the time of formation of new bone within 8 weeks. After eight weeks the animals were sacrificed and the implants removed with a portion of bone tissue and fixed and fixed based solution of formaldehyde for three days. Following these were dehydrated in alcohol and embedded in special resin for microscopy. Cuts were made in a microtome to obtain the samples, obtained from three sections of each, which were analyzed and compared by checking whether the contact areas of surfaces with the bone tissue by light microscopy, fluorescence and scanning. The results demonstrated that the proposed surface promotes osseointegration in a very effective and proper time sequence and expected, and the tapered design of the implant seems to have driven the growth of cortical bone in a larger surface area. It was concluded that the model of implant design can influence the quality and quantity of osseointegration of dental implants and can direct it, but further studies on this area of bone to implant contact should be proposed.