Maxillary sinus floor elevation
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Maxillary sinus floor elevation
- 1. Sinus Floor Elevation Procedures Registrar: Dr Rakesh Chandran Supervisor: Dr Yusuf Jadwat
- 2. • ANATOMY OF THE MAXILLARY SINUS • MEDICATION • SINUS FLOOR ELEVATION PROCEDURES • POST SURGICAL INSTRUCTIONS • COMPLICATIONS • REVIEW OF THE LITERATURE PRESENTATION OUTLINE
- 3. ANATOMY OF THE MAXILLARY SINUS • Pyramidal in shape • Apex pointed towards the zygomatic bone • Volume in an adult ≈15ml (range 9ml to 20ml) BASE- lateral wall of nose • (≈33mm X 33mm) • Base to apex ≈ 23mm • Sinus ostium is placed high and is in an unfavourable position for gravity dependent drainage
- 4. ANATOMY OF THE MAXILLARY SINUS SUPERIOR WALL- floor of the orbit • Infraorbital nerves and vessels POSTERIOR WALL • internal maxillary artery, • pterygoid plexus, • sphenopalatine ganglion • greater palatine nerve FLOOR- alveolar process of the maxilla LATERAL WALL-facial surface of the maxilla • infraorbital foramen • thickness ranges from 0.5 to 2.5mm
- 5. • Also known as Underwood’s septa • Almost 30% of dentate maxilla have septa • 75% appearing in the premolar region. • Complete septa are very rare (1%) • Primary septa are developmental • Secondary septa are caused by irregular pneumatisation following loss of posterior teeth SEPTA
- 6. • Mucosal lining of the sinus • Pseudo-stratified columnar ciliated respiratory epithelium covering a thin layer of connective tissue • 0.45 to 1.40mm in thickness • Considered normal if less than 4mm Increased thickness associated with • thick gingival biotype • chronic sinus inflammation • smoking SCHNEIDERIAN MEMBRANE
- 7. VASCULAR SUPPLY Anastomosis • Infraorbital • posterior superior alveolar artery. • posterior lateral nasal (medial aspect of the sinus). The formation of the intraosseous and extraosseous anastomoses is termed the double arterial arcade.
- 8. Coronal sections The intraosseous branch of the posterior superior alveolar artery most frequently runs through a bony groove inside the lateral wall of the maxillary sinus. Rarely the artery may run within a bony canal. Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.
- 9. The courses of the intra osseous branch of the posterior superior alveolar artery Straight (78.1%) U-shaped (21.9%) Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.
- 10. Mean and range values of the height of the IObr of the PSAA from the CEJ in mm. The minimum mean height from the cervix to the IObr • 21.1mm in the first molar region • 26.9mm in the first premolar region More precautions should be taken at the first molar region than the first premolar region. Hur MS et al., 2009. Clinical implications of the topography and distribution of the posterior superior alveolar artery. J Craniofac Surg.
- 11. VENOUS DRAINAGE Anterior facial vein Pterygoid venous plexus LYMPHATIC DRAINAGE Submandibular lymph node NERVE SUPPLY Maxillary division of trigeminal nerve (V2)
- 12. ABSOLUTE LOCAL CONTRAINDICATIONS • local aggressive benign tumours • malignant tumours • large maxillary cysts • acute sinusitis • allergic rhinitis
- 13. RATIONALE FOR ANTIBIOTIC PROPHYLAXIS • Endoscopically normal sinuses were shown to be non sterile • Most common bacteria • Streptococcus viridans • Staphylococcus epidermidis • Streptococcus pneumonia • Sinus graft procedure often violate the sinus mucosa and bacteria may contaminate the graft site RATIONALE FOR ANTIBIOTIC IN THE GRAFT • the bone graft is a dead space prone to infection • systemic antibiotic drugs do not enter the area until revascularization
- 14. Systemic antibiotic prophylaxis No allergy to penicillin Augmentin 825mg/125mg. One tablet twice daily starting 1 day before/ 5 days after Non anaphylactic allergy to penicillin Cefuroxime axetil 500mg. (Cephalosporin) One tablet twice daily starting 1 day before/ 5 days after Anaphylactic reaction to penicillin Levofloxacin 500mg. (Fluoroquinolone) One tablet starting 1 day before/ 5 days after Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
- 15. Antibiotic in graft Cefazolin (1gm) dilute with 2ml saline (cephalosporin) 100mg add to collagen membrane 400mg add to graft material Clindamycin 150mg/1ml 30mg add to collagen membrane 120mg add to graft material Capsules and tablets should not be used as they contain fillers that are not conducive to osteogenesis. Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
- 16. Glucocorticoid medication Dexamethazone (4mg) Two tablets in the morning the day before and day of surgery One tablets in the morning for 2 days after surgery Decongestant medication Oxymetazoline 0.05% (Vicks) Analgesic medication Analgesic containing codeine as codeine is a potent antitussive. Cryotherapy Ice or cold dressings for the 24 to 48 hours Then heat applied to increase blood and lymph flow Misch CE. Contemporary Implant Dentistry 3rd Ed. 2008
- 17. SINUS FLOOR ELEVATION TECHNIQUES LATERAL WINDOW TRANSCRESTAL APPROACH
- 18. HISTORY 1980: Boyne and James reported on elevation of the maxillary sinus floor in patients with large, pneumatized sinus cavities as a preparation for the placement of blade implants. Boyne, P. J. & James, R. A. (1980) Grafting of the maxillary sinus floor with autogenous marrow and bone. Journal of Oral Surgery 38, 613–616. 1994: Summers described a crestal approach, using tapered osteotomes with increasing diameters. Summers, R. B. (1994) A new concept in maxillary implant surgery: the osteotome technique. Compendium 15, 152–154–156, 158 passim; quiz 162.
- 19. ATROPHIC POSTERIOR MAXILLA Favourable interarch relationship Insufficient bone height for standard implant Vertical bone height ≤6mm or oblique sinus floor Lateral window technique Vertical bone height >6mm and horizontal sinus floor Transcrestal TREATMENT GUIDELINES- INTERNATIONAL TEAM FOR IMPLANTOLOGY (ITI)
- 20. LATERAL WINDOW TECHNIQUES Modified Caldwell-Luc approach (Tatum) Ultrasonic ostectomy (Torella) Piezoelectric bony window osteotomy (Vercellotti et al) Trephine (Emtiaz) Antral membrane balloon elevation ( Soltan and Smiler) Other variations Hinge osteotomy Elevated osteotomy Crestal osteotomy TRANSCRESTAL APPROACH TECHNIQUES Osteotome technique (Summers) Modified osteotome technique (Davarpanah et al 1996) Hydraulic pressure- saline (Sotirakis and Gonshor) SINUS FLOOR ELEVATION TECHNIQUES
- 21. LATERAL WINDOW APPROACH Katsuyama H., Jensen SS. ITI Treatment Guide. Volume 5. 2011 Handling the cortical bone 1. fracture the cortical bony plate like a trap- door and use it as the new sinus floor, leaving it attached to the underlying mucosa. 2. removal of the cortical bone and use it as the new sinus floor- elevated osteotomy 3. removal of the bone by thinning it out. 4. remove the cortical bony plate and replace it on the lateral aspect of the graft at the end of the grafting procedure.
- 22. LATERAL WINDOW APPROACH Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008 Removal of cortical bone 1. Round bur 2. Ultrasonic instruments 3. Piezoelectric 4. Trephine
- 23. LATERAL WINDOW APPROACH- ANTRAL MEMBRANE BALLOON ELEVATION Soltan M., Smiler DG. Antral membrane balloon elevation. Journal of oral Implantology. 2005
- 24. TRANSCRESTAL APPROACH- SUMMERS TECHNIQUE Pjetursson BE., Lang NP. Clinical Periodontology and implant Dentistry. 2008 X Larger diameter osteotomes
- 25. TRANSCRESTAL APPROACH- MODIFIED SUMMERS TECHNIQUE Davarpanah M et al., 2011. The Modified Osteotome Technique. Int J Periodont Rest Dent
- 26. TRANSCRESTAL APPROACH- HYDRAULIC PRESSURE- SALINE
- 27. Do not blow your nose Do not use tobacco Do not drink with a straw Do not lift or pull up the lip to look at the sutures Sneeze with the mouth open Notify the office if • you feel granules in your nose POSTOPERATIVE INSTRUCTIONS
- 28. INTRA-OPERATIVE COMPLICATIONS 1. Sinus membrane perforation (10 to 20%) 2. Excessive bleeding (bony window/ sinus membrane/wound dehiscences) 3. Injury of the infraorbital neurovascular bundle 4. Implant migration 5. Hematoma 6. Adjacent tooth sensitivity POST-OPERATIVE COMPLICATIONS 1. Infection of the grafted sinus (3-7 days post-op) (3%). 2. Sinusitis COMPLICATIONS
- 29. Confounding factors Study design Patient factors (age, gender, health, SES, hygiene….. Operator factors (experience, techniques….. Regenerative material properties Follow up period Implant properties LITERATURE REVIEW Up to 1996?? Currently used
- 30. 4th ITI Consensus conference on Sinus Floor Elevation Procedures, 2008 ITI Treatment Guide (Volume 5) Review published 2011 with updated literature Jensen SS. LITERATURE REVIEW
- 31. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Technique Study characteristics Implant survival Lateral window technique 85 studies, 4807 patients, 14944 implants, after 12 to 107 months loading Machined implant surfaces: 61.2% to 100% Rough surface implants: 88.6% to 100% Transcrestal technique 18 studies, 1096 patients, 1744 implants, after 12 to 64 months loading 83% to 100%
- 32. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Lateral window technique Study characteristics Implant survival Bone substitute only 19 studies,740 patients, 2481 implants, after 12 to 107 months loading 82% to 100% Excluding smooth surface 88.6% to 100% Autograft only or combined with bone substitute 36 studies,1210 patients, 4218 implants, after 12 to 107 months of loading 61.2% to 100% Excluding smooth surface 96% to 100%
- 33. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Lateral window technique Implant survival Deproteinised bovine bone mineral (DBBM) 85% to 100% Deproteinised bovine bone mineral (DBBM) and autograft 89% to 100% Autologous block grafts (iliac crest)- simultaneous 61.2% to 92.2% Autologous block grafts (iliac crest)- staged 76.9% to 94.4% Hydroxyapatite (alloplast) 96% to 100% Demineralized Freeze Dried Bone allograft and DBBM 82.1% to 96.8% Without grafting material* 97.7% to 100% * Three case series, implants acted as tent poles allowing the coagulum to occupy the space
- 34. LITERATURE REVIEW Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Lateral window technique Implant survival Implant survival Excluding smooth surface Membrane over the lateral window 92% to 100% 92% to 100% Without the use of a membrane 61.2% to 100% 93% to 100%
- 35. LITERATURE - TRANSCRESTAL TECHNIQUE Jensen SS. 4th ITI Consensus conference: Sinus Floor Elevation Procedures, 2008 in ITI Treatment Guide 2011 Transcrestal technique Study characteristics Implant survival Without grafting material 8 studies, 249 patients, 443 implants after 12 to 36 months of loading 91.4% to 100% Deproteinised bovine bone mineral (DBBM) 4 studies, 122 patients, 195 implants after 12 to 45 months of loading 95% to 100% Autologous bone 2 studies?, 489 patients, 771 implants after 20 to 54 months of loading 93.8% to 97.8%
- 36. • Maxillary sinus elevation is a predictable technique. • Autogenous bone grafts were considered the gold standard – now allografts with particulate autografts are associated with better implant survival rates (Esposito et al., 2006). • Rough surface implants have more favourable clinical outcomes. • Simultaneous and delayed give equivalent results. CONCLUSION Jensen SS., Katsuyama H., 2011. ITI Treatment guide. Volume 5. Sinus floor elevation procedures. Testori T et al., 2009. maxillary sinus surgery and alternatives in treatment.
- 37. Thank you
Editor's Notes
- The distance of the intraosseous posterior superior artery to the alveolar crest is 16 to 19mm
- The distance of the intraosseous posterior superior artery to the alveolar crest is 16 to 19mm Found in the body of the maxilla, this sinus has three recesses: an alveolar recess pointed inferiorly, bounded by the alveolar process of the maxilla; a zygomatic recess pointed laterally, bounded by the zygomatic bone; and an infraorbital recess pointed superiorly, bounded by the inferior orbital surface of the maxilla.
- The distance of the intraosseous posterior superior artery to the alveolar crest is 16 to 19mm Found in the body of the maxilla, this sinus has three recesses: an alveolar recess pointed inferiorly, bounded by the alveolar process of the maxilla; a zygomatic recess pointed laterally, bounded by the zygomatic bone; and an infraorbital recess pointed superiorly, bounded by the inferior orbital surface of the maxilla. Within the anterior wall and ≈6-7 mm (up to 14mm) from the orbital rim is the infraorbital foramen. The infraorbital nerve runs along the superior wall of the sinus and exits through the foramen. The infraorbital blood vessels and nerves lie directly on the superior wall of the interior and within the sinus mucosa. Located in the superior aspect of the medial wall is the maxillary or primary ostium through which the sinus drains its secretions (ciliary action) via the ethmoid infundibulum through the hiatus semilunaris into the middle meatus of the nasal cavity. The lateral wall maybe less than a mm in edentulous patients. The thickness ranges from 0.5 to 2.5mm and is thicker in males. The lateral wall houses an endosseous anastomosis of the infraorbital and the posterior superior alveolar artery. The inferior wall is ≈ at the level of the nasal floor in dentate patients but often 1cm lower in the edentulous posterior maxilla.
- Considered normal if less than 4mm Cakur, Sumbullu 2011
- A posterior lateral nasal artery (a branch of the sphenopalatine artery that also rises from the maxillary artery) also supplies the region from the medial aspect of the sinus
- B-buccal aspect P-palatal aspect MS-maxillary sinus NC-nasal cavity.
- Tid three times daily Qd- once Bid twice
- Tid three times daily Qd- once Bid twice
- Tid three times daily Qd- once Bid twice There are three main classifications of anaphylaxis. Anaphylactic shock is associated with systemic vasodilation that causes low blood pressure which is by definition 30% lower than the person's baseline or below standard values.[7] Biphasic anaphylaxis is the recurrence of symptoms within 1–72 hours with no further exposure to the allergen.[3] Reports of incidence vary, with some studies claiming as many as 20% of cases.[24] The recurrence typically occurs within 8 hours.[10] It is managed in the same manner as anaphylaxis.[5]Pseudoanaphylaxis or anaphylactoid reactions are a type of anaphylaxis that does not involve an allergic reaction but is due to direct mast cell degranulation.[10][25] Non-immune anaphylaxis is the current term use by the World Allergy Organization[25] with some recommending that the old terminology no longer be used.[10]
- ANCEF INJ USES Cefazolin is an antibiotic used to treat a wide variety of bacterial infections. It may also be used before and during certain surgeries to help prevent infection. Thismedication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria. How to use Ancef injDepending on your specific product, this medication is given by injection into a vein or into a muscle. Use this product exactly as directed by your doctor. The dosage is based on your medical condition and response to treatment. If you are giving this medication to yourself at home, learn all preparation and usage instructions from your health care professional. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and discard medical supplies safely. Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, use this drug at evenly spaced intervals. Continue to use this medication until the full prescribed treatment period is finished, even if symptoms disappear after a few days. Stopping the medication too early may result in a return of the infection The antibiotic concentration within a blood clot depends on the systemic blood titer. After the clot stabilizes,.
- ANCEF INJ USES Cefazolin is an antibiotic used to treat a wide variety of bacterial infections. It may also be used before and during certain surgeries to help prevent infection. Thismedication is known as a cephalosporin antibiotic. It works by stopping the growth of bacteria. How to use Ancef injDepending on your specific product, this medication is given by injection into a vein or into a muscle. Use this product exactly as directed by your doctor. The dosage is based on your medical condition and response to treatment. If you are giving this medication to yourself at home, learn all preparation and usage instructions from your health care professional. Before using, check this product visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and discard medical supplies safely. Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, use this drug at evenly spaced intervals. Continue to use this medication until the full prescribed treatment period is finished, even if symptoms disappear after a few days. Stopping the medication too early may result in a return of the infection
- Management of the Posterior Maxilla With Sinus Lift: Review of Techniques Sunitha V. Raja, Other than the instruments used for performing theosteotomy, 3 other variations have been described.The first is the hinge osteotomy, where a hinge bony rectangle is created in the lateral wall of the maxilla,approximating the malar buttress. This bony rectangleis then pushed inward, along with the schneiderianmembrane, to function as a new sinus floor,reinforced with graft material.8,14 The range of motionof the bone flap is limited in this case because itcan be moved inward only until the height of thehinge.However, in cases of compromised anatomy of thelateral wall of the maxilla, the use of the elevatedosteotomy is advocated. In the elevated osteotomy anuninterrupted bone cut replaces the hinge along thesuperior horizontal aspect of the quadrilateral. In thistechnique the bone and schneiderian membrane canbe elevated higher than the aperture from which theywere cut. In cases of advanced alveolar resorption, the malarbuttress may approximate the alveolar crest. In suchcases the complete osteotomy technique can be used.A quadrilateral cut is first made; a molt curette is thenused to peel the schneiderian membrane carefullyfrom the entire surface of the bone window. Once thebone segment is removed, it is placed in saline solutionand safeguarded for subsequent repositioning. The final variation is the crestal osteotomy, inwhich a rectangular-shaped osteotomy is prepared on the crest of the alveolar ridge. The detached window is then elevated apically while the sinus membrane is simultaneously reflected. As in the hinge osteotomy technique, the rectangular bony segment will act as the new sinus floor. This technique can only be used when less than 2 mm of bone is evident between the floor of the sinus and crest of the residual ridge
- Management of the Posterior Maxilla With Sinus Lift: Review of Techniques Sunitha V. Raja, Other than the instruments used for performing theosteotomy, 3 other variations have been described.The first is the hinge osteotomy, where a hinge bony rectangle is created in the lateral wall of the maxilla,approximating the malar buttress. This bony rectangleis then pushed inward, along with the schneiderianmembrane, to function as a new sinus floor,reinforced with graft material.8,14 The range of motionof the bone flap is limited in this case because itcan be moved inward only until the height of thehinge.However, in cases of compromised anatomy of thelateral wall of the maxilla, the use of the elevatedosteotomy is advocated. In the elevated osteotomy anuninterrupted bone cut replaces the hinge along thesuperior horizontal aspect of the quadrilateral. In thistechnique the bone and schneiderian membrane canbe elevated higher than the aperture from which theywere cut. In cases of advanced alveolar resorption, the malarbuttress may approximate the alveolar crest. In suchcases the complete osteotomy technique can be used.A quadrilateral cut is first made; a molt curette is thenused to peel the schneiderian membrane carefullyfrom the entire surface of the bone window. Once thebone segment is removed, it is placed in saline solutionand safeguarded for subsequent repositioning. The final variation is the crestal osteotomy, inwhich a rectangular-shaped osteotomy is prepared on the crest of the alveolar ridge. The detached window is then elevated apically while the sinus membrane is simultaneously reflected. As in the hinge osteotomy technique, the rectangular bony segment will act as the new sinus floor. This technique can only be used when less than 2 mm of bone is evident between the floor of the sinus and crest of the residual ridge
- The outline of the lateral window has been marked with a round bur The buccal bony plate is trimmed to a paper-thin lamella with a fi ne grit round diamond bur, avoiding the perforation of the sinus membrane. Before elevating the sinus membrane the entire buccal bone is removed to gain access to the membrane. Two implants have been installed after fi lling the medial part of the sinus compartment. The sinus membrane is carefully elevated using a blunt instrument. To avoid penetration, it is essential to keep contact with the underlying bone at all time during this procedure. The sinus compartment has been fi lled with a loosely packed 1 : 1 mixture of particulate autogenous bone and a xenograft. The lateral window has been covered with single or double layer of resorbable barrier membrane.
- with light malleting, the osteotome is pushed towards the compact bone of the sinus floor larger diameter osteotomes are used to increase the fracture area of the sinus floor grafting material is placed through the osteotomy site if required. The fi rst osteotome used in the implant site is a small diameter tapered osteotome (Fig. 50-32). With light malleting, the osteotome is pushed towards the compact bone of the sinus fl oor (Fig. 50-31b). After reaching the sinus fl oor, the osteotome is pushed about 1 mm further with light malleting in order to create a “greenstick” fracture on the compact bone of the sinus fl oor. A tapered osteotome with small diameter is chosen to minimize the force needed to fracture the compact bone. • The second tapered osteotome, with a diameter slightly larger then the fi rst one, is used to increase the fracture area of the sinus fl oor (Fig. 50-33). The second osteotome is applied to the same length as the fi rst one. • The third osteotome used is a straight osteotome with a diameter about 1–1.5 mm smaller than the implant to be placed (Fig. 50-34).
- After preparation of the site with PIEZOSURGERY®, the CS1 elevator is introduced, and the tube connected to a syringe containing 3 ml of physiological saline solution is then inserted in the CS1. With the sinus physiolift® protocol, it is possible to elevate the schneiderian membrane safely, controlling the pressure of the liquid by means of the attached physiolifter device.
- Infection of the grafted sinus (3-7 days post-op). Can spread to the orbit or even brain so aggressive treatment- removal of graft and antibiotics
- Jensen 2011 is ITI guide 6 literature review Rough surface: plasma sprayed, acid etched and/ or sandblasted titanium or HA coated Smooth and machined are almost the same and should be actually called turned surfaces (Misch page 602) Int J Oral Maxillofac Implants. 2009 Nov-Dec;24(6):1113-8. A retrospective study of the survival of smooth- and rough-surface dental implants. Balshe AA1, Assad DA, Eckert SE, Koka S, Weaver AL. Author information Abstract PURPOSE: To compare the time-dependent cumulative survival rates of smooth- and rough-surface dental implants. MATERIALS AND METHODS: A retrospective chart review was conducted for two time periods: January 1, 1991, through December 31, 1996, during which smooth-surface implants were used, and January 1, 2001, through December 31, 2005, during which rough-surface implants were used. This study included all implants placed and restored in one institution during the two time frames. Data were collected relative to patient age, gender, implant diameter, implant length, and anatomic location of implants. To facilitate the comparison, implants from the first and second time periods were followed through mid-1998 and mid-2007, respectively. Associations of patient/implant characteristics with implant survival were evaluated using marginal Cox proportional hazards models (adjusted for age and gender) and summarized with hazard ratios and corresponding 95% confidence intervals. RESULTS: A total of 593 patients (322 women and 271 men; mean age, 51.3 +/- 18.5 years) received 2,182 smooth-surface implants between 1991 and 1996, while 905 patients (539 women and 366 men; mean age, 48.2 +/- 17.8 years) received 2,425 rough-surface implants between 2001 and 2005. At 5 years after implant placement, survival rates were 94.0% and 94.5%, respectively, for smooth- and rough-surface implants (difference not significant). Among the smooth implants, implant length <or= 10 mm and anatomic location were identified as significantly associated with implant failure. In contrast, among the rough implants, implant length <or= 10 mm and anatomic location were not identified as risk factors for implant failure. CONCLUSIONS: Based on this retrospective study of two groups of patients with different implant surfaces and more than 2,000 implants in each group, there was no significant difference in the survival rates of smooth- and rough-surface dental implants. Anatomic location and implant length <or= 10 mm were associated with failures of the smooth-surface implants only.
- Jensen 2011 is ITI guide 6 literature review Rough surface: plasma sprayed, acid etched and/ or sandblasted titanium or HA coated
- In staged mean healing time between grafting and implant placement 6.0 months mean healing time between implant placement and loading 6.3 months
- In staged mean healing time between grafting and implant placement 6.0 months mean healing time between implant placement and loading 6.3 months
- In staged mean healing time between grafting and implant placement 6.0 months mean healing time between implant placement and loading 6.3 months
- In staged mean healing time between grafting and implant placement 6.0 months mean healing time between implant placement and loading 6.3 months
- 42- 60 months of loading for the last two sentences
- Autogenous bone grafts were considered the gold standard – Pjetursson et al, systematic review of lateral approach j clin perio 2008
- Autogenous bone grafts were considered the gold standard – Pjetursson et al, systematic review of lateral approach j clin perio 2008