Bone Augmentation in Implant Dentistry: A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting - Michael A. Pikos, Richard J. Miron - (2019) 272 pp., ISBN: 9780867158250 part 1

Augmentation Bone Implant Dentistry IN MICHAEL A. PIKOS, dds with Richard J. Miron, dds, msc, phd A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting Graft Window Extraction Site.

[Audio] Bone Augmentation in Implant Dentistry: A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting.

[Audio] AugmentationBoneINImplantDentistryMICHAELA.PIKOS,ddsFounderandCEOPikosInstitutePrivatePracticeTrinity,FloridawithRICHARDJ.MIRON,dds,msc,phdGroupLeader,TheMironResearchLabLeadEducator,AdvancedPRFEducationVenice,FloridaAStep-by-StepGuidetoPredictableAlveolarRidgeandSinusGraftingBerlin,Barcelona,Chicago,Istanbul,London,MexicoCity,Milan,Moscow,Paris,Prague,SãoPaulo,Seoul,Tokyo,Warsaw.

[Audio] Library of Congress Cataloging-in-Publication Data Names: Pikos, Michael A., author. | Miron, Richard J. (Richard John), 1983 author. Title: Bone augmentation in implant dentistry / Michael A. Pikos and Richard J. Miron. Description: Batavia, IL : Quintessence Publishing Co Inc, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2019005043 | ISBN 9780867158250 (hardcover) Subjects: | MESH: Alveolar Ridge Augmentation--methods | Bone Regeneration | Bone Transplantation | Dental Implantation--methods Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23 LC record available at https://lccn.loc.gov/2019005043 ��� ©2019 Quintessence Publishing Co, Inc Quintessence Publishing Co Inc 411 N Raddant Rd Batavia, IL 60510 www.quintpub.com 5 4 3 2 1 All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher. Editor: Leah Huffman Design: Sue Zubek Production: Angelina Schmelter Printed in China.

[Audio] Contents Preface vi 1 INSTRUMENTATION FOR ALVEOLAR RIDGE AUGMENTATION AND SINUS GRAFTING 1 2 MEMBRANES, GRAFTING MATERIALS, AND GROWTH FACTORS 11 EXTRACTION SITE MANAGEMENT 41 3 ALVEOLAR RIDGE AUGMENTATION 95 4 SINUS GRAFTING 169 5 6 GUIDED FULL-ARCH IMMEDIATE-FUNCTION TREATMENT MODALITY FOR THE EDENTULOUS AND TERMINAL-DENTITION PATIENT 235 Index 258.

[Audio] 6 : Guided Full-Arch Immediate-Function Treatment Modality for the Edentulous and Terminal-Dentition Patient prefaCe Implant dentistry has evolved tremendously over the past three decades and is rapidly progressing as new materials and protocols become available. While biomaterials and clinical guidelines were once believed to turn over every 3 to 5 years, new advancements are now being brought to our field every year. Today, implant dentistry is perhaps the most widely researched discipline in our field and mandates that clinicians stay updated on current trends and protocols. With the number of advancements made in digitally based media and marketing, it is imperative that the clinician be able to separate new trends from evidence-based protocols. It is without question that the goal of every clinician is that each patient be treated with the best possible outcome in mind. As such, we should strive to implement rational evidence-based decisions grounded on available literature to allow us to make sound and predictable choices. The goal of this textbook is to share my clinical experiences, both successes and failures, with my colleagues to facilitate learning through documented cases that I have performed over the past 35+ years. To accomplish this, this textbook has been separated into six core chapters. Each clinical case is supplemented with italicized personal notes describing learned experiences from each case, clinical tips and pearls from that case, technical notes geared toward facilitating the reader's clinical ability to perform similar cases/techniques, as well as in-depth analysis and critical evaluation on how I would perform each case today (many of the cases were performed 10+ years ago). Two chapters are dedicated to biomaterials and instruments utilized for bone augmentation protocols and form the basis for the biomaterials and surgical instrumentation utilized throughout the surgical chapters. It is clear that the number of changes made in material design/instrumentation has facilitated (and in many cases improved) the ability of clinicians to perform surgical procedures. Parallel to this and equally as important, a great deal of advancement has been made in biomaterial sciences. While biomaterials were once considered to act as a passive structural material aimed at filling voids, today they act as bioactive molecules responsible for rapidly stimulating new tissue regeneration. Chapter 2 presents barrier membranes, bone grafting materials, as well as growth factors utilized for bone augmentation procedures and describes their biologic background and clinical use in implant dentistry. Chapter 3 is the first surgical chapter and is dedicated to extraction socket management. A brief overview of dimensional changes occurring postextraction is presented, and thereafter clinical guidelines with step-by-step protocols are covered. Discussion of the use of various biomaterials and their ability to minimize dimensional changes postextraction in both the esthetic and nonesthetic zones is provided. Furthermore, protocols for ridge preservation in the absence of buccal/lingual plates are included as well as an introduction to the concept and clinical indication for "socket shield" therapy. Chapter 4 covers the topic of alveolar ridge augmentation. Specific indications and a description of patient selection criteria, step-by-step surgical procedures, and aspects of postoperative treatment are presented. This chapter also includes background information on guided bone regeneration, intraoral bone.

[Audio] Guided Full-Arch Immediate-Function Treatment Modality For the Edentulous and Terminal-Dentition Patient 235 Lastly, chapter 6 covers full-arch reconstruction utilizing conventional conversion protocols and newer fully guided immediate-reconstruction protocols in a detailed step-bystep manner utilizing the nSequence patented technology. My hope is that through the numerous cases presented throughout this textbook, clinicians will be better able to implement evidence-based clinical decisions that will lead to predictable bone augmentation results and long-term success. We live in an age where information can be obtained through social media at an ever-increasing speed. Clinicians are now free to post cases directly to social media following surgery and obtain nearly live feedback on their work. This provides the clinician and reader with direct responses to their surgical work; however, with the number of new techniques and protocols being utilized and promoted online, it remains difficult to assess and scientifically critique many of these newer protocols without proper long-term follow-up. Having practiced implant dentistry for more than 35 years, I consider follow-up times of 1 year, 5 years, and 10 years to be immeasurably important. This book focuses exclusively on the protocols that have been developed over numerous years with established long-term follow-ups to provide the reader with a set of surgical guidelines and principles with predictable long-term documented outcomes. Furthermore, an online video series available at www.pikosonline.com will supplement the book to further guide the clinician with surgical demonstrations provided within our online teaching library. I sincerely hope that these videos in conjunction with the content of this book will provide an enjoyable learning experience, and I look forward to your future feedback. Acknowledgments My fellow clinicians and staff whom I have had the honor of working with during my 36 years of private practice. The thousands of clinicians whom I have had the honor and privilege to meet both at my Institute and from main podium lectures throughout the world. The thousands of patients for entrusting me with their implant surgical care over all these years. Rick Miron, an awesome, highly intelligent, yet so humble colleague and friend without whose help this book would definitely not be possible. The entire team at Quintessence Publishing, including Leah Huffman (Senior Editor), Angelina Schmelter (Digital & Print Production Specialist), Bryn Grisham (Director of Book Publications), and especially William Hartman (Executive Vice President & Director). This book certainly has been improved many times over, and I thank each of you for your dedication, patience, and helpfulness leading to its completion. And Almighty God for blessing me with a profession that I have had such great passion for, and more importantly for giving me the skill sets necessary to help transform people's lives on a daily basis. Although the acknowledgments are typically found in the first pages of a book, they are usually the last piece to be written. And for good reason, as they allow the author to reflect on those individuals who have contributed in one way or another to its completion. For the development and production of this book, I owe a deep sense of gratitude to the following people: My incredible and selfless wife Diane, daughter Lindsey, and son Tony for.

[Audio] chapter 1 InstrumentatIon for alveolar rIdge augmentatIon and sInus graftIng.

[Audio] T a he use of various instruments for alveolar bone augmentation and sinus grafting has played a pivotal role in modern regenerative dentistry. Many tools such as cone beam computed tomography (CBCT) have greatly improved the clinician's ability to diagnose and treatment plan cases with optimal accuracy and predictability in implant dentistry. Other devices such as Osstell's implant stability quotient (ISQ) tool can be utilized to accurately monitor implant stability over time. Furthermore, radio- frequency, Piezosurgery (Mectron), and osseodensification (OD) burs have greatly improved surgical outcomes for the clinician. This chapter provides an overview of the various instruments most frequently utilized by the author on a daily basis within his private practice and institute. Furthermore, a brief overview of their technologies and uses in alveolar ridge augmentation and sinus grafting is presented. Fig 1-1 (a) CBCT imaging system (Carestream [CS] 9600). (b) Notice the capability to create 3D reconstructions of bone and teeth with excellent resolution. CBCT b In the last decade, the use of 3D CBCT has dramatically increased.1,2 When computed tomography was first introduced (mainly in implantology), its use was limited to a small number of specialists, due primarily to its limited indications, high costs, and elevated dose of radiation. In the late 1990s, a new technology using a "cone beam" and a reciprocating detector, which rotates around the patient 360 degrees, entered the dental implant field, making high-definition 3D scans easily accessible to dentists and their patients. By 2005, I began utilizing CBCT technology in my own private practice and teaching institution. Because my practice has been limited to implant reconstruction for the past 25 years, I require ALL of my patients to have a CBCT scan, as this 3D technology plays an integral role in overall diagnosis and treatment planning. CBCT has seen widespread use in all fields of dentistry, including implantology, oral surgery, endodontics, and orthodontics.1,2 dentoalveolar structures led to its more frequent use owing to its higher safety standards. Today, all patients within my practice requiring implant dentistry or bone augmentation procedures must have a CBCT image taken prior to implant therapy, bone augmentation, or sinus augmentation in order to fully characterize anatomical features/abnormalities and diagnose potential pathology. Furthermore, the use of CBCT for postgraft evaluation prior to implant placement has become routine. Carestream Dental provides a high-quality CBCT system with state-of-the-art features3 (Fig 1-1). Advantages of the One of the major breakthroughs in CBCT technology was the ability to use significantly smaller doses of radiation when compared to conventional films.1,2 The establishment of sensitive radiographic techniques for assessing 1.

[Audio] 1 : Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting Fig 1-2 CS 9600 used to image a fullarch case. (a) Notice that a single scan can be useful to identify pathologies with much greater accuracy than with a conventional 2D radiograph. (b) Furthermore, the beauty of the CS 9600 is its capability to combine fullhead facial features into the program for better treatment planning. a b system include the ability to perform all necessary examinations with one system (CS 9600 family). Image resolution can reach up to 75 μm (sizes up to 16 × 17 cm), ideal for a wide range of applications from implantology to oral surgery, orthodontics, and endodontics (Fig 1-2). These features will only further improve over time. Low-dose imaging modes are also possible with 3D image quality, utilizing lower doses of radiation when compared to traditional panoramic radiographs. Box 1-1 provides a list of relevant features of the system. Hand Instruments Hand instruments are widely utilized within any dental office, with various companies now promoting sales of their individual items. Salvin Dental has been recognized as one of the leaders in the field, and together we have codeveloped many specific trays for implant surgery (Fig 1-3), soft tissue grafting (Fig 1-4), block grafting (Fig 1-5), and sinus grafting (Fig 1-6). Each kit contains various useful instruments that have assisted our team in surgery. Nevertheless, each instrument must be chosen according to the treating surgeon's preference. For example, one instrument used specifically when dealing with full-arch cases is the right-angle torque wrench (Salvin AccessTorq Right Angle Variable Torque Driver), with adjustable Ncm features from 10 to 35 Ncm (Fig 1-7). This instrument is valuable for hard-to-reach areas. Another tool frequently utilized in large bone augmentation procedures is the Pro-fix Precision Fixation System (Osteogenics).4,5 This system includes self-drilling membrane fixation screws, self-drilling tenting screws, and self-tapping bone fixation screws (Fig 1-8), shown in a number of bone augmentation procedures in chapter 4. 2.

[Audio] Hand Instruments Box 1-1 Features of the CS 9600 system Cephalometric modality Sensor technology: CCD Exposure time: 0.1–3.2 seconds Radiologic examination options: Lateral, frontal AP or PA, oblique, submentovertex, carpus Acquisition format size (cm): 18×18, 18×24, 24×24, 24×30, 30×30 3D modality Technology: Dental volumetric reconstruction Sensor technology: CMOS Volume field of view (cm): 4×4, 5×5, 5×8, 6×6, 8×5, 8×8, 10×5, 10×10, 12×5, 12×10, 16×6, 16×10, 16×12, 16×17 Gray scale: 16,384; 14 bits Magnification: 1.4 Voxel size: 75 μm minimum Exposure time: 5.5–40 seconds (2 × 20 s) Scan mode: Continuous X-ray generator and other specifications Tube voltage: 60–90 kV Tube current: 2–15 mA Frequency: 140 kHz Tube focal spot: 0.3 or 0.7 mm Panoramic modality Sensor technology: CMOS Image field (mm): 6.4×140 (for adult patient), 6.4×120 (for child patient), 120×140 (for sinus one-shot examination) Magnification: 1.28 Exposure time: 0.5–13 seconds CMOS, complementary metal oxide semiconductor; CCD, charge-coupled device; AP, anteroposterior; PA, posteroanterior. Fig 1-3 The Pikos implant surgical kit: Quinn Type Periosteal Elevator, 2 Minnesota Retractors, Jacobson Long Castroviejo Needle Holder, Seldin Retractor, Dean Scissor, Siegel Round Scalpel Handle, Adson 1×2 Tissue Forceps, Adson Serrated Tissue Forceps, Gerald Micro Surgical Tissue Forceps–Serrated, Gerald Micro Surgical Tissue Forceps–1×2, Kelly Curved Hemostat, Crile-Wood Needle Holder, Castroviejo Micro Scissors–Curved, Periotome Straight, Molt Mouth Gag, Weider Tongue Retractor, Castroviejo Caliper, Friedman Rongeur, 10×6 Instrument Cassette, 10×6 Instrument Deep Cassette. (Courtesy of Salvin Dental.) Fig 1-4 The Pikos soft tissue grafting instrumentation kit: UNC Perio Probe, Frazier 3mm Surgical Aspirator, Siegel Round Scalpel Handle, Handle For Bendable Micro Blades, Bendable Micro Blades–Nordland #69 (Box of 6), Quinn Type Periosteal Elevator, Adson 1×2 Tissue Forceps, Adson Serrated Tissue Forceps, Gerald Micro Surgical Tissue Forceps–Serrated, Gerald Micro Surgical Tissue Forceps–1×2, Rhodes Chisel, Gracey 11/12 Curette, Kelly Curved Hemostat, Corn Plier, Crile-Wood Needle Holder, Dean Scissor, Micro Needle Holder, Castroviejo Micro Scissors, 10×6 Instrument Cassette, 10×6 Instrument Deep Cassette. (Courtesy of Salvin Dental.) 3.

[Audio] 1 : Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting Fig 1-6 The Pikos sinus elevation kit: Set of 5 Sinus Curettes (#1, #5, Freer, Pikos #7, Pikos #8), Graft Material Packer–Double Ended, Bone Spoon / 4mm Graft Packer Combination, Stainless Steel Organizing Cassette. (Courtesy of Salvin Dental.) Fig 1-5 The Pikos bone block grafting instrumentation kit: Tatum "D" Shaped Spreader #3, Tatum "D" Shaped Spreader #4, 6mm Cottle Curved Chisel, 6mm Sheehan Straight Chisel, Pikos Ramus Retractor, Quinn Type Periosteal Elevator, Siegel Round Scalpel Handle, Castroviejo Caliper–Short, Pikos Block Grafting Bur Kit, 1.5mm Wire Passing Bur, Stainless Steel Organizing Cassette. (Courtesy of Salvin Dental.) Fig 1-8 The Pro-fix Precision Fixation System is manufactured to precise tolerances to ensure easy pickup of screws, stable transfer to the surgical site, and quick engagement in cortical bone. (Courtesy of Osteogenics.) Fig 1-7 Right-angle torque wrench with adjustable Ncm features from 10 to 35 Ncm. (Courtesy of Salvin Dental.) Fig 1-9 The Osstell IDx is a fast, noninvasive, and easy-touse system to determine implant stability and assess osseointegration. It provides accurate, consistent, and objective information needed to assess when implants may be loaded. (Courtesy of BioHorizons.) Note: I utilize Osstell technology primarily in delayed loading implant cases. This gives me a frame of reference at the time of implant placement compared to the time of loading. My goal is for an ISQ value of 65 or higher after an appropriate healing time. 4.

[Audio] Radiosurgery Device Fig 1-10 The Surgitron Dual 120 surgical device (Ellman International), utilized to cauterize blood vessels during surgery. Osstell IDx The value of the Osstell system is that it helps clinicians objectively determine implant stability and assess the progress of osseointegration6–12 (Fig 1-9), with many peer- reviewed research articles supporting its use. It is a fast, easy, and reliable way to provide accurate and objective information needed to proceed with implant loading. My cases are routinely tested for ISQ values to assess implant stability. ISQ values may potentially reduce treatment time, better manage risk, and offer an ability to better communicate findings with patients. The Osstell system allows for the quick and easy identification of which implants are ready for loading and which need additional healing time in an objective way, with hundreds of publications now supporting its use.6–14 Fig 1-11 Use of the Ellman Surgitron device to cauterize a blood vessel following flap elevation. Fully rectified waveform Radiosurgery Device Produces an incision with concurrent coagulation Allows increased visibility due to enhanced coagulation Partially rectified waveform Strictly a coagulating waveform Used in areas of bleeding or oozing Bipolar radiosurgery A radiosurgical energy source (Fig 1-10) delivers advanced radiowave technology and provides outstanding surgical control, precision, and versatility.15,16 Unlike lasers, the high frequency of the 4-MHz Surgitron Dual 120 surgical device minimizes heat dissipation, and thus cellular alteration, while cutting and coagulating soft tissues. Approximately 50 watts of power is utilized with the ability to micro-coagulate pinpoint locations. This favors minimal charring or tissue necrosis and is ideal for the oral maxillofacial region with critical anatomy. Advantages include reduced postoperative discomfort and minimal scar formation. Typical radiosurgery systems come with the following four waveforms. Fully rectified filtered waveform Used for performing deep surgical incisions. Waveform mimics the cut of a scalpel blade with only minimal coagulation. When used with a varied-tip straight-wire electrode, produces the most delicate of incisions. Bipolar electrodes coupled with a radiosurgical wave form. Higher radiofrequency of 4 MHz versus bipolar electrosurgical signal of 1.8 MHz. Research has shown that high-frequency radiosurgery produces less tissue alteration and lateral heat to the surrounding tissue than does the low-frequency electrosurgical signal (Fig 1-11). The bipolar componentry of radiosurgery is a must for clinicians involved with implant surgery. This is true because it allows for cauterization in the presence of body fluids (blood and saliva). 5.

[Audio] 1 : Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting Fig 1-12 Mectron's Piezosurgery device. Its patented technology allows for the precise cutting of alveolar bone while minimizing the risk of soft tissue injury. Insert tip Concentrator Resonator Generator Piezo-ceramic rings Fig 1-13 The Piezosurgery handpiece is a high-frequency electrical impulse from the console to the ceramic disks. The electricity induces mechanical deformations of the ceramic disks, which are transferred to the insert to generate a micrometric cutting action. The micrometric movement is approximately 80 µm in the horizontal amplitude and 5 µm in the vertical direction. 5 µm 80 µm Mechanical dipole Piezosurgery Device direction (Fig 1-13). The device comes with more than 100 different tips characterized by their ability to seamlessly and efficiently cut bone all while being capable of differentiating between hard and soft tissues. These features have been demonstrated to decrease the risk of damage to important anatomical structures such as nerves and membranes. Piezosurgery has been shown to clinically lower the rate of sinus membrane perforations and has also been frequently utilized during ridge split procedures and harvesting of bone blocks (Fig 1-14). The author utilizes piezosurgical technology on a daily basis for a variety of bone-based surgical procedures that include but are not limited to the following: sinus grafting, ridge splitting, harvesting autogenous bone blocks, and recipient site preparation for bone grafts. One of the most widely utilized new tools in implant dentistry over the past decade has been the Piezosurgery device (Fig 1-12). More specifically, Mectron's dual-wave technology has been frequently cited owing to its patented technology overcoming the limitations of single wave.17 Work pioneered by Professor Tomaso Vercellotti in Italy demonstrated that a primary wave between 24 and 36 kHz modulated by a secondary low-frequency wave from 30 to 60 Hz could be utilized to efficiently maximize bone cutting while preventing overheating and necrosis.18–21 The Piezosurgery handpiece is therefore a high-frequency electrical impulse unit with micrometric movement of approximately 80 µm in the horizontal amplitude and 5 µm in the vertical 6.