Clinical Success

in

Bone Surgery with

Ultrasonic Devices

Marie Grace Poblete-Michel, DMD, MSc, DCD

Jean-François Michel, DDS, PhD, DCD

Paris, Berlin, Chicago, Tokyo, London, Milan, Barcelona, Istanbul,

Moscow, New Delhi, Prague, São Paulo and, Warsaw
ISBN 978-2-912550-64-4

© 2009 Quintessence International

Quintessence International
11 bis, rue d’Aguesseau
75008 Paris
France

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.

Design: STDI, Lassay-les-Châteaux, France

Printing and Binding: EMD, Lassay-les-Châteaux, France

Printed in France
Authors

Marie Grace Poblete-Michel, DMD, MSc, DCD

Former Assistant Professor in Periodontology
College of Dentistry
University of the East
Manila, Philippines

Jean-François Michel, DDS, PhD, DCD

Master of Lectures in Periodontology
Academic and Clinical Chair
Department of Periodontology
Faculty of Dentistry
University of Rennes I Rennes,
France

Coauthors
Solenn Hourdin, DDS
Former University Hospital Assistant in Periodontology
Faculty of Dentistry
University of Rennes I
Rennes, France

Nadine Brodala, DDS, MSc

Clinical Assistant Professor
Department of Periodontology
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina, USA

Gilles Gagnot, DDS, PhD

Former University Hospital Assistant in Periodontology
Faculty of Dentistry
University of Rennes I
Rennes, France
Acknowledgements

The authors wish to express their gratitude to:

Dr Jean-Marie Korbendau (Evreux, France) for sharing his vast scientific

knowledge and for his guidance and help in editing this book.

Professor Hessam Nowzari (Department of Periodontology, University of

Southern California, Los Angeles, CA, USA) for contributing his broad
scientific competence, his advice, and his objective and innovative approach
to periodontology that has guided our work through these years.

Drs Amir Aalam (Los Angeles, CA, USA) and Pascal Huet (Nantes, France)
for generously contributing clinical case photographs.

Mr Robert Grégoire and Ms Violaine Tureau (Acteon Group, France) for

their dedicated collaboration.

The Mectron, Esacrom, EMS, and NSK Companies (France) for their kind
participation.

Mr Joseph Lelannic (Center of Scanning Electron Microscopy and

Microanalysis, University of Rennes I, France) for working with us to create
quality SEM images.

Professor Jean-François Gaudy (Faculty of Medicine, University of Paris V,

France) and Mr Eric Berthon (Laboratory of Anatomy, University of Rennes
I, France) for the photographs of anatomic specimens.

Dr Nicolas Bedhet (Rennes, France) for his collaboration and the extraoral
grafts presented in this book.
Table of contents

Cover
Table of contents
Foreword
Introduction

1 Ultrasounds: Medical and surgical applications

Piezoelectricity
Different mechanisms of ultrasonic wave production
Advantages of ultrasound use in the practice of bone surgery

Indications and contraindications for bone surgery

2 in periodontology and implant dentistry
Indications
Contraindications

Ultrasonic-assisted bone surgery:

3 Devices and instrumentation
Objectives and characteristic requirements of an osteotome
Types of nonconventional osteotomes
Ultrasonic-assisted osteotomes
Advantages of ultrasonic-assisted osteotomes
Technology of current ultrasonic-assisted osteotomes
 Clinical applications in oral surgery

4 Preoperative evaluation and premedication

Preoperative evaluation
Premedication

Intraoral and extraoral donor sites in periodontal

5 and implant surgery
Intraoral donor sites
Extraoral donor sites

6 Techniques – Clinical cases

Treatment of periodontal and preimplant defects
Reconstruction of bone loss through the sinus cavity
Piezoperiotomy: Ultrasonic-assisted atraumatic tooth extraction
Conclusion
Foreword

I am delighted to be asked to write the foreword for this impressive book on

the use of ultrasonic devices for bone surgery. The authors are timely in
presenting this information for clinicians who are active in periodontal, oral
and maxillofacial, and implant surgery. The reader is thoughtfully instructed
in this new technology such that one quickly develops an appreciation of the
science behind the device and the possible clinical applications of the device.
What comes through loud and clear throughout this book is that piezosurgery
is a true advance in the surgical management of bony tissues. The book
nicely illustrates the many applications of piezosurgery in periodontal, oral,
and implant surgery. The book further helps the reader to examine and
treatment plan various clinical situations. The inclusion of contraindications
for piezosurgery should be useful to early learners of this technology and
ensure appropriate planning and use. The section on intraoral and extraoral
donor sites is a useful reminder for the experienced surgeon and an excellent
guide for the developing surgeon. Cases are well used to teach the reader the
nuances of piezosurgery techniques in a variety of clinical situations.

All in all, I view this book as a tremendous resource for surgeons, for
residents in graduate training, and for students. As an academician involved
in the day to day training of young dental students and residents, this book
will be a wonderful resource for me in educating these individuals in surgical
applications. As a practitioner, this book will teach me new techniques for
managing a variety of osseous and implant surgical situations. Recognizing
that the field of implant dentistry has exploded, it is timely to have surgical
technologies such as ultrasonic devices to accompany the placement of dental
implants. But recognizing that this area of dentistry is never content, I expect
the advances in osseous surgery detailed in this book to be quickly followed
by the next generation of ultrasonic devices. I look forward to the ever
emerging new possibilities for improved and advanced patient care utilizing
ultrasonic devices.

Ray C. Williams, DMD

Distinguished Professor and Chair,
Department of Periodontology
School of Dentistry
University of North Carolina
Chapel Hill, North Carolina, USA
Introduction

Managing the periodontal environment is a permanent challenge for the

periodontist. The periodontium is an entity wherein the superficial
periodontium is closely related to the deep periodontium. The alveolar bone
partially determines the stability of the periodontal attachment and thus
contributes to the periodontal health as far as esthetics and function are
concerned. Different techniques and surgical protocols have been proposed to
treat bone loss, be it during periodontal disease, after extractions, infections,
or trauma, or within the context of placing osseointegrated dental implants.
Most of these protocols involve bone surgery techniques.

Success in the practice of bone surgery requires the evaluation of more than
50 criteria (Misch 1987). The essential criteria are of course the long-term
stability of the tissues surrounding the implant(s), the absence of
inflammation or infection, and the prosthodontic needs and expectations of
the patient. The dental implant possibilities will then be subjected to the
anatomic criteria of the bone in the concerned area. When there is a pre-
existing bone defect, bone grafting should be considered. Bone resorption is a
natural physiologic phenomenon after the loss of teeth. Local or general
resorptions may be the result of pathologic processes such as the evolution of
untreated aggressive periodontitis or an endodontic or endoperiodontal
infection. In addidtion resorption may be of traumatic, tumoral, or iatrogenic
origin, and the alveolar bone can also be partially or totally destroyed at the
moment of the tooth extraction.

Studying the morphology of the bone defect is essential for selecting the
method of reconstruction (Mattout and Mattout 2003). If the volume of the
defect is significant, we need to use a technique that is osteoinductive (Misch
et al, 1992). The progress on alloplastic materials, allogenic materials (Deep
et al, 1989; Nique et al, 1987), and guided bone regeneration techniques
(Buser et al, 1993; Nyman et al, 1990) has reached a relatively high level of
predictability. However, compared with an autogenous bone graft, these
techniques lack the capacity of healing and the ability to provide a predictable
prognosis. From the biologic and immunologic points of view, autogenous
bone has demonstrated its superiority over all other materials.

The treatment success in oral surgery, periodontology, and implant dentistry

must take into account more precise biologic criteria. These criteria include:
using atraumatic surgical procedures; limiting risks to the surrounding tissue;
and improving visibility, hemostasis, and postoperative conditions. Most of
the instruments available so far have allowed rapid sampling but have not
met all of these criteria. As far as bone grafts are concerned, most of the
cutting instruments are modifications of instruments used decades ago in oral
and maxillofacial surgery, ie, manual and mechanical instruments like saws,
burs, and/or mallets and chisels.

Nowadays, it seems desirable to have at one’s disposal precision instruments

tailored to every aspect of periodontal and implant surgery of hard tissues.
Moreover, the narrow access to the sites of the oral cavity, efforts by the
practitioner, and trauma inflicted on the patient (immediate and mediate
postoperative conditions) are difficulties that at present cannot be ignored.
Piezosurgery is an innovative technical approach to hard tissue surgery that
was developed in the 1980s. It was derived from the basic principles of
“piezoelectricity,” which was discovered by Jacques and Pierre Curie in the
late 19th century. The idea of being able to cut through the bone using
ultrasounds has been published since the 1970s (Horton et al. 1975). This
surgical technique is assisted by an ultrasonic modulated frequency allowing
precise and safe cutting of hard tissue. The tip selectively cuts the
mineralized tissues without cutting the soft tissues. It therefore limits the risk
of damage to the bloodvessels and nerves during bone harvesting. Moreover,
visibility is increased, owing to physiologic saline solution irrigation that
flows at the working end of the tip. The piezoelectric surgery accordingly
offers comfort, safety, and precision to the surgeon during delicate
interventions. The surgical indications for powerful ultrasounds using a
piezoelectric device differ from all other bone surgery techniques (eg, rotary
instruments).

This more precise and less traumatic technique for the tissues has a learning
curve that requires prior training in order to understand the perfect balance
between the pressure exerted by the hand of the practitioner and the
movement of the tip.

This book presents the practical applications of powerful ultrasonic devices

through their technical and surgical aspects. It aims to inform practitioners on
the indications, effects, and limitations of this technique by including new
protocols. It also provides the guiding principles in using these devices for
optimal clinical application. Finally, it presents clinical cases illustrating the
proposed indications.

Bibliography
Buser D, Dula K, Belser U, Hort HP, Berthold H. Localized ridge
augmentation using guided bone regeneration. I. Surgical procedure in the
maxilla. Int J Periodontics Restorative Dent. 1993;13(1):29–45.
Deep ME, Hosny M, Sharawy M. Osteogenesis in composite grafts of
allogenic demineralised bone powder and porous hydroxyapatite. J Oral
Maxillofac Surg. 1989;47:50–56.
Horton JE, Tarpley TM, Wood LD. The healing of surgical defects in
alveolar bone produced with ultrasonic instrumentation, chisel, and rotary
bur. Oral Surg, Oral Med, Oral Patho, Oral Radio. 1975;39(4):536–546.
Mattout P, Mattout C. Les Thérapeutiques Parodontales et Implantaires.
Paris: Quintessence International.
Misch CE. Patient dental medical implant evaluation form. Misch Implant
Institute Dearborn, 1987.
Misch CM, Misch CE, Resnir RR, Ismail YH. Reconstruction of maxillary
alveolar defects with mandibular symphysis grafts for dental implants:
Preliminary procedural report. Int J Oral Maxillofac Impl. 1992;3(7):360–
366.
Nique T, Fonseca RJ, Upton LG, Scott R. Particulate allogenic bone grafts
into maxillary alveolar clefts in humans: A preliminary report. J Oral
 Maxillofac Surg. 1987;45:386–392.
Nyman S, Lang NP, Buser D, Brägger U. Bone regeneration adjacent to
titanium dental implants using guided tissue regeneration: A report of two
cases. Int J Oral Maxillofac Impl. 1990;13(1):29–45.
Ultrasounds:

Medical and surgical

applications
Piezoelectricity
Ultrasounds are waves with a frequency higher than 20,000 Hz (ie, cycles per
second). A large number of ultrasonic frequencies used in everyday life—
such as those used in car alarms and other antitheft systems—are not
perceptible to the human ear. Humans perceive frequencies between 20 and
20,000 Hz. Ultrasound is therefore inaudible to humans but audible to certain
animals such as dogs, bats, and dolphins. Developed in the 1950s, ultrasound
technology is now widely used in the fields of medicine, dentistry,
metallurgy, and aviation, and by the navy. It is also used for fishing, cleaning,
and remote controls (eg, automatic gates).

The ultrasonic wave displaces itself in a medium and transmits its energy to
the particles encountered. Ultrasonic vibrations are waves that are (1)
displaced in a longitudinal direction, (2) displaced in a medium, and (3)
reflected and absorbed at the interface of the different surfaces encountered
(Van Der Weijden 2007).

Different mechanisms of ultrasonic wave production

Three vibrational systems have been developed for the different ultrasonic
devices.

Magnetostrictive systems
A ferromagnetic bar and a copper spiral thread in the handpiece generate
vibrations ranging from 18,000 to 45,000 Hz. These devices produce an
elliptic movement of the tip resembling a hammering motion.

Sonic systems
An air turbine in the handpiece generates vibrations ranging from 2,500 to
16,000 Hz. These devices produce an elliptic or circular movement of the tip
resembling hammering and abrasion motions.

Piezoelectric systems
Piezoelectric instruments are widely used in dentistry, and their effects are
becoming better understood.

The physicists Pierre and Jacques Curie (younger and elder brother,
respectively), in collaboration with Gabriel Lippmann, discovered the
piezoelectric effect as early as 1890. According to these French researchers,
the application of compression forces on certain solids generates an electric
load. As a result, the term piezo, from the Greek verb piezein meaning
“compress” or “press,” was chosen. Solids with this property have a
crystalline structure, such as quartz, tourmaline, Seignette salt (also known as
potassium sodium tartrate), and barium titanate. Today, quartz crystals have
been abandoned, and most piezoelectric handpieces are made of ceramic
crystalline structures.

Advantages of ultrasound use in the practice of bone

surgery
Ultrasonic devices have six main properties (Gagnot and Poblete 2004).

1. Sweeping: Occurs when the tip is placed tangentially on the surface to be

treated.
2. Irrigation: Needed to cool the tip. It also may be used to deliver
antibacterial chemical substances into the periodontal pocket, which is
particularly useful during ultrasonic scaling.
3. Chipping: May be observed every time the dorsal surface of the tip is
placed against the surface to be treated.
4. Microcurrents: Generated by the vibration passing through the irrigation
liquid (eg, physiologic saline solution, antiseptics) or through the fluids
encountered during the intervention (eg, saliva, blood).
5. Cavitation: During the vibration, small depressions similar to bubbles are
produced at the end of the tip at sites of maximum vibration (ie, at the tip
extremity and 2 to 3 mm from the tip). These air bubbles vibrate with their
source, increase in size, and then explode. This phenomenon, which has
antibacterial properties, is called cavitation. It depends on the frequency, not
the amplitude, of the ultrasonic vibration.
6. Abrasion: Relates to the vibrational frequency and the surface of the tip
used (eg, stainless steel, diamond, or composite). It has a large effect on the
quality of surface obtained and the cutting effect.

The piezoelectric effect can be defined as either:

Direct: The electrical polarization (ie, displacement of positive and
negative charges) that occurs when certain materials (eg, quartz or
ceramic) with piezoelectric properties are subjected to mechanical
force.
Indirect: The deformation (eg, dilatation or contraction) that occurs
when these same materials with piezoelectric properties are subjected
to an electric field.

The electric current generates a distortion of the ceramic disks. These

movements create vibrations in the axis of the transducer. The amplifier,
bound to the tip, increases the combined vibratory displacements of the
ceramic disks. The tip vibrations come into resonance with the piezoelectric
disks, which increases their energy output and improves their efficiency.
Therefore, the tip vibrates on a longitudinal axis as shown in Fig 1-1.

1-1 Vibrational direction of the “saw” tip attached to a functioning piezoelectric handpiece.
 1-2 Handpiece meant for producing ultrasonic piezoelectric vibrations (Satelec).

The vibrational amplitude in the surgical mode is between 30 and 60 μm. The
countermass absorbs the vibrations rearward and optimizes the
electromechanical output.

These handpieces are submitted to an indirect or reverse effect (Fig 1-2). The
use of appropriate frequencies allows a cutting effect under constant
irrigation of the hard tissues, which makes these machines well suited for use
in bone surgery.

Bibliography
Gagnot G, Poblete MG. Du bon usage des ultrasons: La maîtrise des
vibrations. Rev Odont Stomat (Paris) 2004a;33:85–95.
Piezotome [clinical pamphlet]. Satelec Acteon, 2006.
Van Der Weijden F. The Power of Ultrasonics. Chicago: Quintessence, 2007.
Indications and
contraindications

for bone surgery

in periodontology
and implant dentistry
The extraction of teeth following trauma results in a loss of substance,
creating functional and esthetic consequences that are significant during oral
rehabilitations (Fig 2-1).

According to Harris (1997), bone resorption may have four main causes:
Pathologic (eg, periodontal diseases, cysts)
Surgical (eg, extraction of impacted cuspids, apicoectomy)
Congenital (eg, micrognathy, oligodontia, palatal clefts)
Physiologic (eg, tooth loss, age, pneumatization of the maxillary sinus)

The most frequent causes of the loss of bone substance are aggressive
periodontitis and postextraction trauma related to wearing an unadapted
removable prosthesis. The following clinical case shows the consequences of
these bone pathologies.

This radiographic example shows a 40-year-old woman in good general

health but with severe chronic periodontitis that has been stabilized for 2
years with conventional periodontal treatment (ie, initial nonsurgical
treatment, periodontal surgery, and replacement of tooth 16 with a
conventional fixed bridge) (Fig 2-2).

For the past 15 years, she has received regular maintenance every 4 months.
The periodontal situation after 15 years was acceptable. However, bone loss
evolved on the distal of tooth 15, which also showed signs of occlusal trauma
(Fig 2-3).

An occlusal adjustment was completed and maintenance care was reinforced.

The patient returned for follow-up after 2 years (1997) with a marked
mobility of her fixed prosthesis. The radiograph showed terminal bone loss
requiring the extraction of tooth 15 (Fig 2-4). A three-dimensional vertical
and horizontal loss of substance is inevitable after healing (Fig 2-5).

Healing conditions depend on three factors:

1. Size of the defect: Healing quality depends on the critical size of the bone
defect, which is specific to the type of bone. A defect above the critical size
cannot heal properly and will induce a loss of substance.
2. Number of walls: The number of bony walls determines the behavior of
the overlying soft tissues. If the remaining bony walls are reduced to one or
two walls, the unsupported soft tissues will collapse into the defect (Figs 2-6
and 2-7).

3. Type of defect: A close infrabony defect will heal more easily than an open
defect, as the filling of the defect is mechanically easier (Fig 2-8). When the
defect is open, it indicates the need for bone surgery. The correction of the
loss of substance has to be done with a bone block graft, a bone filling
material, or a membrane with or without bone chips. Through the use of
powerful ultrasonic devices and their wide range of tips mountable on a
handpiece, it is now possible to perform osteotomies, osteoplasties, and
separation of the soft and hard tissues to correct these losses of substance.

As with any oral surgery, bone surgical techniques (eg, manual,

mechanical, or ultrasonic) present indications and contraindications.

2-1 Loss of substance after tooth extraction making bone reconstruction compulsory prior to
dental implant placement (computed tomography [CT] scan slices 81–83).
2-2 View of stabilized severe chronic periodontitis in 1980, 2 years after periodontal surgery.

2-3 View in 1995: Bone loss on the distal part of tooth 15 presenting signs of occlusal
trauma.
2-4 View in 1997: Significant tooth mobility and bone loss, resulting in tooth extraction.

2-5 View after healing: Notice the important loss of substance.

 2-6 One-wall, open infrabony defect (absence of buccal bony wall) before tooth extraction.

2-7 One-wall infrabony defect after healing without correction of the loss of substance.

2-8 Close infrabony defect with correct bone healing. The bone loss can occur from the
neighboring bone.

Indications
There are relatively numerous indications for bone surgery in periodontology
and implant dentistry.
Indications

Horizontal ridge augmentation

Vertical ridge augmentation
Reconstruction of the loss of substance through the sinus cavity
Extractions of impacted and ankylosed teeth and excision of cysts

Horizontal ridge augmentation

Horizontal ridge augmentation is the characteristic indication for bone block
grafts and for the expansion of narrow edentulous crests.

Bone block grafts

The horizontal loss of substance often requires the harvesting of an
autogenous bone block from the chin, ramus, or retromolar area (Vercelloti et
al, 2005; Boioli et al, 2004) (Fig 2-9).

This technique may also be indicated for orthognathic surgery and cranial
bone sampling.

During the harvesting of autogenous bone blocks for onlay grafting, the
ultrasonic-assisted bone surgery fulfills the conditions necessary to obtain
good integration between the bone block graft and the recipient site (ie,
sampling, integration of the graft, and then precise adjustment) (Horton et al
1981).

Remodeling the onlay grafts is made easy by ultrasonic devices that smooth
angles and help to correct the gap between the graft and the recipient site.

Several authors have asserted that ultrasonic devices also demonstrate

excellent safety and precision in maxillofacial surgery (Giraud 1991; Giraud
et al 1991; Salami et al 2007; Eggers et al 2004).

Crest expansion technique

First described by Scipioni et al (1994), this technique allows the placement
of dental implants into originally narrow crests. With a cutting instrument
(eg, BS5 [Satelec] or OT2 [Mectron] saw tips), the clinician separates the
buccal from the lingual or palatal cortical bone. Crestal expansion is then
performed using bone compactors or expanders and immediate introduction
of the dental implant between the two cortical walls. After osteoplasty to
level the edge of the crest, the clinician may decide whether to place a bone
substitute biomaterial before suturing the surgical site.

Vertical ridge augmentation

In cases of vertical ridge augmentation, bone filling must be done in one of
the following four ways:
By providing a bone block graft.
By using bone chips or bone substitute biomaterials. The collection of
bone chips limits damage to donor sites by using only the surface of the
bone. This is known as the bone scrapping technique. In this way, we
obtain autogenous bone chips with osteoinductive properties (Fig 2-
10).
By using a membrane with or without bone chips.
By bone distraction that repositions the available apical bone coronally.

Reconstruction of the loss of substance through the sinus cavity

The sinus cavity has a natural tendency to increase over time, which is called
sinus pneumatization. Moreover, the extraction of the posterior maxillary
teeth leads to a loss of height of the alveolar bony crest.

Bone resorption rapidly makes the crest insufficient for the placement of
dental implants. This resorption occurs in both a vertical and a horizontal
direction. Cawood and Howell (1988) classified maxillary bone loss in six
categories (Fig 2-11). The placement of a dental implant in a bony defect
may induce a perforation of the Schneiderian membrane or make its
placement impossible due to the absence of primary stability.

The Schneiderian membrane is a kind of mucus membrane that plays a role in

immune defense and is in charge of maintaining the health of the maxillary
sinus. It can be beneficial to perform a sinus floor augmentation by lifting
this membrane and then placing autogenous bone chips, bone block, or even
bone substitute biomaterials.
This type of surgery is conducted under local anesthesia injected in the
buccal and palatal mucosa next to the edentulous alveolar crest. A localized
flap is elevated on the anterolateral wall of the maxillary sinus (Fig 2-12).

Various techniques can be practiced for sectioning the access window.

However, internal lifting of the sinus window by rotation or pressure
increases the risk of membrane perforation during crestal augmentation.
Therefore, it is best to detach the access window over its entire perimeter and
to separate the fragment (Figs 2-13 to 2-15).

Chapter 6 elaborates these techniques in detail by presenting clinical cases of

maxillary sinus floor augmentation.

2-9 Ramus harvesting with the Piezotome using a BS2L saw tip (Satelec).
 2-10 Harvesting of autogenous bone chips with the BS4 and BS6 saw tips (Satelec).

2-11 Classification of the loss of substance in the maxilla according to Cawood and Howell
(1988). Classes IV, V, and VI require sinus floor augmentation prior to dental implant
placement.
 2-12 A flap exposing the anterolateral wall of the maxillary sinus.

2-13 and 2-14 Caldwell-Luc technique followed by immediate dental implant placement.
 2-15 Follow-up of a Caldwell-Luc procedure after a year. The sinus floor augmentation was
elevated with a resorbable bone substitute biomaterial (Cerasorb® [Curasan]).

Extraction of impacted and ankylosed teeth and excision of cysts

The benefits of this type of intervention can be significant because the
volume of bone tissues may allow immediate placement of dental implants,
which would be impossible with a conventional technique (Siervo et al 2004;
Leclercq and Dohan 2004).

Ultrasonic tips such as the LC (Satelec) or ES009 (Esacrom) can be used to

perform delicate tooth extractions that respect the alveolar bony walls.

The table below summarizes the specified harvesting sites for each of these
indications.
 Indications

If access is difficult
If anatomic elements must be preserved
If tissue preservation is indispensable

Contraindications
For better operating conditions, it is important to check the general health of
the patient. The contraindications are the same as those for any oral surgical
procedure.
Contraindications

Electrical implants such as pacemakers, in either the patient or the

clinician.
Certain systemic diseases, such as cardiovascular diseases, diabetes,
and bone disease, or in patients undergoing radiotherapy, all of which
can hinder the dental implant surgery.
Alterations that may or may not be related to systemic diseases, bone
structure, and vascularization. Verifying the bone structure and the
healthy vascular condition of the patient are fundamental elements for
good integration and healing.
Behaviors such as smoking and excessive drinking.
These contraindications are detailed in chapter 6, which presents the different
surgical techniques.

Bibliography
Boioli LT, Vercellotti T, Tecucianu JF. La chirurgie piézoélectrique: Une
alternative aux techniques classiques de chirurgie osseuse. Inf Dent
2004;86(41):2887–2893.
Cawood JI, Howell RA. A classification of the edentulous jaws. Int J Oral
Maxillofac Surg 1988;17:232–236.
Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: An ultrasound device
for cutting bone and its use and limitations in maxillofacial surgery. Br J
Oral Maxillofac Surg 2004;42(5):451–453.
Giraud JY. Étude et mise en œuvre d’un ostéotomes assisté par ultrasons
[thesis]. Toulouse: Université Paul Sabatier, 1991.
Giraud JY, Villemin S, Darmana R, Cahuzac JP, Autefage A, Morucci JP.
Bone cutting. Clin Phys Physiol Meas 1991;12(1):1–19.
Harris D. Advanced surgical procedures: Bone augmentation. Dent Update
1997;24:332–337.
Horton JE, Tarpley TM Jr, Jacoway JR. Clinical applications of ultrasonic
instrumentation in the surgical removal of bone. Oral Surg Oral Med Oral
Pathol 1981;51(3):236–242.
Leclercq P, Dohan D. De l’intérêt du bistouri ultrasonore en implantologie:
Technologie, applications cliniques. Première partie: Technologie.
Implantodontie 2004;30:1–7.
Salami A, Vercellotti T, Mora R, Dellepiane M. Piezoelectric bone surgery in
otologic surgery. Otolaryngol Head Neck Surg 2007;136(3):484–485.
Scipioni A, Bruschi GB, Calesini G. The edentulous ridge expansion
technique: A five-year study. Int J Periodontics Restorative Dent
1994;14(5):451–459.
Siervo S, Ruggli-Milic S, Radici M, Siervo P, Jager K. Piezoelectric surgery.
An alternative method of minimally invasive surgery [in French, German].
Schweiz Monatsschr Zahnmed 2004;114(4):365–377.
Vercellotti T, Nevins ML, Kim DM, et al. Osseous response following
resective therapy with piezosurgery. Int J Periodontics Restorative Dent
2005;25(6):543–549.
Ultrasonic-assisted
bone surgery

Devices and
instrumentation
The osteotomes inspired by chisels, saws, and gouges from the timber
industry and used since the 17th and 18th centuries have given way to
modern conventional osteotomes.

The introduction of motorized cutting instruments has been the most

important technologic advance in oral surgery. These instruments both
increase the cutting speed and reduce the cutting effort exerted during
osteotomy, while taking into account the surgical parameters.

In odontostomatology, the continuous circular movement is primarily used

with three types of instruments: (1) drills for piercing, (2) trephines and saws
for making larger holes (eg, bone harvesting), and (3) stainless steel and
diamond-coated burs used with a micromotor, a handpiece, and constant
irrigation with physiologic saline solution. All these rotary instruments are
used at a speed of 40,000 to 50,000 rpm, with temperatures not exceeding
57°C. At 57°C, the bone proteins coagulate, resulting in irreversible tissue
damage.

Because improvements in cutting instruments have aided the development of

osteotomy techniques, the study of the osteotomy itself and the action of the
instrument on the material remains of fundamental importance. These
considerations also lead to the definition of optimal geometric characteristics
of the cutting instruments, thereby minimizing the cutting effort as well as
reducing the temperature. The geometry of a saw’s teeth determines its mode
of action on a material (Giraud et al, 1991).

Objectives and characteristic requirements

of an osteotome
The practice of osteotomy has three major objectives:
1. Excision osteotomy: Ablation of a piece of bone
2. Reparation osteotomy: Anatomic correction
3. Access osteotomy: Sectioning bone that prevents access to the main
surgical site, which is then placed back in its original anatomic
position after surgery
In summary, osteotomes can resect, trephine, and smooth bone, thereby
bringing about osteotomies, osteoplasties, and osteosynthesis.

Characteristic requirements of an osteotome

Rapid cutting to minimize the duration of surgery

Reduced effort in cutting to give the surgeon total control of the
instrument
No bone loss or dispersion in the surgical field
No bone tissue destruction caused by burning
No delayed or restrained bone consolidation
No lesions in surrounding tissues
No undesirable biologic effects
Ergonomic design
Easy to sterilize
Capable of performing osteotomies in several planes
The instruments must be autoclavable, and the technical maintenance must be
simple. Deterioration and technical malfunctions of the devices must be
controllable by the user. Finally, the instruments must ensure their proper
cooling through irrigation in the sterile conditions necessitated by surgery.

Types of nonconventional osteotomes

Laser
Laser instruments are unsuitable for cutting bone because of the basic
interaction of laser beams with biologic material. In all cases, laser surgery
exceeds the threshold of thermal necrosis; thus, the healing and consolidation
process is delayed. Laser surgery is mainly indicated for excision and soft
tissue surgery and for dentin surface sterilization.

High-pressure water jet

This technique has not been sufficiently tested to determine whether it is
suitable for surgical applications.

Ultrasonic devices
This technique, called ultrasonic-assisted osteotomy, increases the capacity
of a sharp cutting tool. It superimposes the ultrasonic movement of the tip
with the manual cutting movement.

Ultrasonic-assisted osteotomes
Terminology
The term piezosurgery applies to devices employing the piezoelectric effect
to generate ultrasounds. This technique is relatively new and in continued
development due to advances made with the piezosurgery machine developed
by Vercelloti and the Mectron Company (Vercelloti et al 2001). Earlier
studies on the same topic were published by Horton et al (1981), who spoke
of ultrasonic instrumentation and by Sun et al (1997) who introduced the use
of ultrasonic devices and also spoke of ultrasonic surgical instruments.
Currently, we talk about ultrasonic scalpels, powerful ultrasonic devices
(Michel et al 2007), and ultrasonic-assisted osteotomes. In this book, we use
the term most commonly accepted in the literature: piezosurgery.

History
Catuna (1953) was the first to describe the cutting effects of ultrasound
devices on hard tissues.

Volkov and Shepeleva in 1974 used ultrasonic devices in orthopedic bone

surgery, which provided them with clinical experience that helped to simplify
orthopedic surgery. However, the technique of sectioning and preparing hard
tissues was first studied by Horton et al (1981) in the 1970s and 1980s in the
field of oral surgery. It was further developed by maxillofacial surgeons to
solve difficulties in their own practice. Stübinger et al (2005) insisted that
piezoelectric instruments have known a new impetus since the 1990s. Torella
et al (1998) and Vercellotti et al (2001) have gone so far as to state that the
method has been perfected and adapted to practical clinical needs.

Advantages of ultrasonic-assisted osteotomes

Ultrasonic devices offer five main advantages: selective cutting action,
precision and cutting safety, visibility, accessibility, and better postoperative
results.
Selective cutting action

Ultrasonic-assisted osteotomes are efficient at cutting mineralized tissues but

inefficient at cutting soft tissues. The instrument should have a frequency of
50 kHz to cut hard tissues. Nevertheless, no soft tissue should be found
between the tip and the hard tissue because it reduces the cutting effect on the
mineralized tissue. Consequently, any useless contact with the soft tissues
should be avoided.

There is great interest in the use of this technique during surgeries

performed close to sensitive anatomic structures, such as vascular-nervous
bundles, that must be protected at all costs.

It should be noted that the cutting action is less efficient at cutting Type IV
bone (Lekholm and Zarb 1985) than at cutting other types of bone.

Precision and cutting safety

The microvibrations of the microtip make a precise and controlled
submillimetric cut of the bone tissue. Unlike techniques that use a bur or saw,
the ultrasonic-assisted osteotome generates no macrovibrations and
macromovements that could affect the surgeon’s hand. In contrast, when
using a bur or saw, a clinician has to resist the movements induced by the
rotational torque of the instrument. As a result, a supplementary effort is
made to counteract these movements, which reduces the surgeon’s sensory
perception, particularly when structures of varying degrees of mineralization
are encountered (Giraud et al 1991).

The microvibrations modulated by ultrasounds create an osteotomy without

friction and macrovibrations. In addition, the width of the cut is much smaller
than that obtained with rotary instruments (Fig 3-1). This width also depends
on the size of the tip used.

Because ultrasonic-assisted osteotomes require less cutting effort, they make

complex surgeries easier.

The increased precision of the surgical procedures can be attributed to the

easy handling of the instrument, which is comparable to holding a pen.
Visibility
This technique ensures an operative field almost free from bleeding.
According to Boioli et al (2004), this feature seems to be a result of the
cavitational process, which is produced by the vibration of the tip through the
layer of cells in contact with the instrument. This layer liberates a protein
precipitate that reduces bleeding.

This characteristic is especially advantageous in areas with poor access and

reduced visibility.

The visibility is further enhanced by efficient drainage of the site. Water not
only disperses the heat transmitted by the vibrating tip but it also—through
the characteristic cavitational cloud of ultrasonic instruments—interrupts the
acoustic interaction between the point of the tip and the tissues to be cut.
Because of the pressure of the spray and the abrasive effect of the imploding
cavitational bubbles, the cavitational cloud is particularly efficient at rinsing
the surfaces and draining the debris.

Accessibility
Because of their cutting control and the shape of their tips, ultrasonic-assisted
osteotomes make it possible to work easily in areas with poor accessibility.

Better postoperative results

Vercellotti et al (2005) clearly demonstrated in an animal study the effects of
piezoelectric instrumentation on bone healing. These authors experimented
on dogs, conducting bone resections with the Piezosurgery system (Mectron),
a tungsten carbide bur (CB), and a diamond-coated bur (DB).

Histometry and histology of the gain or loss of the initial bone level were
used to evaluate healing after 14, 28, and 56 days. A notch made on the tooth
on the day of the bone resection indicated the bone gain or loss. As early as
the 14th day, the results showed a difference in the surgical sites treated with
CB or DB, which had lost bone, versus those treated with the Piezosurgery
system, which had gained bone. After 56 days, the CB and DB sites had lost
a minimum amount of bone, compared with the Pieozosurgery sites, which
had gained a significant amount of bone (mean = 0.43 mm).
Our group compared four different methods of harvesting autogenous fresh
bone from animal mandibles in vitro. A histomorphometric study was done
using scanning electron micrographs of the samples to compare surface
conditions created by the piezoelectric instruments with those created by
conventional rotary instruments using a round CB (Figs 3-2 to 3-4). The
piezoelectric instruments were judged superior to the conventional
instruments.

Technology of current ultrasonic-assisted osteotomes

Ultrasonic scalers are used daily by dentists. Most scalers use reverse
piezoelectricity, which means that they do not cut tissues, especially not hard
tissues.

Ultrasonic-assisted osteotomes are technically similar in aspect to

piezoelectric ultrasonic scalers distributed in the market. They consist of the
following components:
A handpiece
A tip screwed into the handpiece

3-1 Details of animal mandibular bone sections using the (a) BS1 saw tip (Satelec), (b) SL1
diamond-coated tip (DB) (Satelec), (c) piezoperiotomy LC tip (Satelec) and (d) a tungsten
carbide bur (CB).
3-2 Scanning electron microscopic (SEM) view of the animal bone section in Fig 3-1a using
the BS1 tip (original magnification ×50).

3-3 SEM view of the animal bone section in Fig 3-1b using the SL1 tip (b) (original
magnification ×50).
 3-4 SEM view of the animal bone section in Fig 3-1d using a CB (d) (original magnification
×50).

An alternative current (AC) generator of average frequency

A power control
An adjustable external irrigation system
Four parameters make ultrasonic scalers different from conventional scalers:
(1) frequencies of the generator, (2) mass, (3) shape, and (4) hardness of the
tips.

The following section presents the main systems available on the market.
1. The Piezosurgery system (Fig 3-5): Has three-dimensional ultrasonic
vibrations controlled for osteotomy, osteoplasty, and extractions in
implantology, periodontology, endodontics, and surgical orthodontics. The
tips have been specially developed to cut bone and to minimize trauma to the
soft tissues. The high frequency oscillates from 22 to 29.5 kHz, and the low
frequency is modulated from 10 to 60 kHz, which allows efficient use and
improves tissue healing.
2. The Piezotome system (Satelec) (Fig 3-6): Equipped with a new ultrasonic
generator, the SP Newtron module integrates three systems of instrument
control.
Automatic frequency regulation: ranges from 28 to 36 kHz according
to the acoustic response of the tip
 “Push-pull” system: constant amplitude control of the insert vibrations,
aimed at preserving fragile tissues, soft tissues in particular
Feedback principle: constant and immediate adaptation of the power
depending on the resistance encountered by the tip
These three systems constitute the “cruise-control system,” or frequency
regulator, which allows the clinician to master the surgical technique with
maximum safeguards in place (Fig 3-7).

3. The Surgysonic II system (Esacrom) (Fig 3-8): Has a frequency ranging

from 24 to 32 kHz with a power shift of 50 to 70 W. Its major advantages are
precision and delicate cutting. The action is controlled, powerful, and very
effective during noninvasive interventions. There is constant monitoring of
the length and the depth of the cut. Its selective cut respects soft tissues. The
parameters are power, vibration, and irrigation. The Surgysonic II system
allows bone surgeries to be performed with a safe and precise technique.

4. The Piezo Master Surgery system (EMS) (Fig 3-9): Uses micrometric
precision (60 to 200 μm) to ensure efficient and optimum safeguards in high-
precision atraumatic osteotomies. It has a unique touch screen technology.
The main advantage during surgery is that the oscillations are perfectly linear
(ie, back and forth, up and down). The vibrations have a high frequency of 24
to 32 kHz. The sectioning of hard tissue is optimal without damage to soft
tissues. There is permanent cooling of the tissues and thus no thermal
alteration. Bleeding is limited.

5. The VarioSurg system (NSK) (Fig 3-10): Has a frequency of 27 to 34.5

kHz and presents many advantages, such as its strong and precise cutting
capacity. Not only does it make use of the cavitational process, but it also has
a light-emitting handpiece that increases visibility in the surgical field. This
approach to ultrasonic surgery reduces the production of heat, thus
minimizing the risk of osteonecrosis and limiting damage to the surrounding
soft tissues. The VarioSurg system selectively cuts the mineralized structures,
even in the event of accidental contact with soft tissue.

6. The UBS system (Italia Medica): Has a frequency of 20 to 32 kHz and

characteristics similar to the other machines, but it has the ability to cut soft
tissues using special spear-shaped titanium alloy tips. Since this book is
devoted to hard-tissue surgeries, the characteristics of this system are not
discussed.

Clinical applications in oral surgery

Through the use of several types of tips mounted on the handpiece,
ultrasonic-assisted osteotomes make it possible to perform osteotomies,
osteoplasties, separation of soft tissues and bone, and bone sectioning.

For example, they can be used during periodontal surgeries for bone removal
or soft tissue surgery, dental implant surgery (eg, tooth extraction followed
by immediate dental implant placement), autogenous bone block harvesting
from the chin or ramus, expansion of narrow ridges, bone distraction, and
maxillary sinus floor augmentation.

3-5 Ultrasonic device and tips for bone surgery (Mectron Company).
 3-6 Ultrasonic device and tips for bone surgery (Satelec Company).

3-7 Handpiece designed to produce an ultrasonic piezoelectric vibration in “Newtron”

nonsurgical mode and in “Piezo” surgical mode (Satelec).
3-8 Ultrasonic device and tips for bone surgery (Esacrom Company).

3-9 Ultrasonic device and tips for bone surgery (EMS Company).
3-10 Ultrasonic device and tips for bone surgery (NSK Company).
The other applications relating to oral surgery are (1) the extraction of
impacted teeth, particularly those in close contact with the inferior alveolar
nerve; (2) the removal of ankylosed teeth; (3) the excision of cysts; and (4)
the removal of osseointegrated dental implants due to mechanical problems.

Finally, there are also applications in maxillofacial surgery: (1) orthognathic

surgery, (2) cranial bone harvesting, and (3) nerve repositioning in the
alveolar canal.

Clinical procedures involving ultrasonic-assisted osteotomes display more

precision and safety in eliminating granulation tissue and bone tissue
remodeling than do procedures performed with conventional tools. Two
major advantages are bone preservation and the possibility of harvesting bone
chips.

The use of ultrasound devices improves the success rate for the removal of
dental implants, chin bone block grafts, ramus bone block grafts, and the
repositioning of the alveolar nerve (Horton et al 1981).

During the harvesting of autogenous bone blocks for onlay grafting,

respecting the surgical rules gives better chances for bone integration
between the bone block and the recipient site (ie, at the cutting phase in order
to respect the integrity and for optimal remodeling of the graft).

Piezosurgery makes remodeling the autogenous onlay bone grafts to smooth

the angles and to better fill gaps between the graft and the recipient site easy.
Emphasis should be placed on the patient’s comfort. During piezosurgery, we
must avoid subjecting the patient to the use of conventional surgical hand
chisels in cleaving the graft during sampling.

During maxillofacial surgery, many authors emphasize the safety and

precision of the technique. According to Eggers et al (2004), the use of
piezoelectric devices may be limited to sectioning thick bone in areas where
access is difficult.

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alternative aux techniques classiques de chirurgie osseuse. Inf Dent
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Catuna MC. Sonic energy. A possible dental application. Preliminary report
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Eggers G, Klein J, Blank J, Hassfeld S. Piezosurgery: An ultrasound device
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Giraud JY, Villemin S, Darmana R, Cahuzac JP, Autefage A, Morucci JP.
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Harris D. Advanced surgical procedures: Bone augmentation. Dent Update
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Preoperative
evaluation

and
premedication
Preoperative evaluation
The preoperative evaluation is done to ensure the absence of absolute or
relative contraindications to bone surgery and/or local anesthesia.

It also allows for evaluation of patient risk factors, either systemic (eg,
osteoporosis, infections, immune deficiency) or behavioral (eg, tobacco
consumption, high risk behavior, poor hygiene).

Systemic examination
A systemic examination is compulsory for a maxillary sinus floor
augmentation procedure and must be done in close collaboration with the
treating physician.

Local examination
The required bone volume determines the choice of the donor site. When a
large volume of bone is needed, it is routinely harvested from an extraoral
site, such as the cranium or iliac, with the patient’s consent.
Extraoral harvesting has specific constraints that must be presented to
the patient. These include the requirement for general anesthesia,
postoperative conditions, and the integration of bone of a different
embryologic origin (eg, iliac bone). Fortunately, intraoral harvesting is
possible in most cases and solves the problems related to the loss of
substance.
Any oral infection must be eliminated before the intervention.
– Infectious dental niches should be identified and treated by
orthograde or retrograde techniques.
– Periodontal disease is not an absolute contraindication, but it should
be treated before an intervention so that tissues are healthy.
– Before a sinus floor augmentation is performed, a maxillofacial or
otolaryngologic surgeon should treat any sinus disorder.

A simplified preoperative hemostatic evaluation is needed to determine

hemorrhagic risk during and after the surgery. This evaluation should include
such factors as bleeding time (BT), platelet count, international normalized
ratio (INR), and activated cephalin time (ACT). Eventually, a dose of
fibrinogen can also be added.

Premedication
The prescribed medications are to be taken the day before the intervention to
limit postoperative side effects and to prevent infection and inflammation.
Preoperative prescription
Prophylactic antibiotics are to be started the day before the surgery.
According to international recommendations, their use should be
continued for 6 to 10 days, until the site has completely healed.

Level 2 analgesics are to be taken 1 hour before the surgery and again
following the intervention.

For optimum patient cooperation during the 2 hours of intervention, a

sedative can be prescribed.

Short-term corticoids limit edema related to the elevation of the

buccinator and masseter muscles.

The use of a mouth per style sheet rinse after surgery helps to
compensate for the suspension of toothbrushing on the surgical site.

Example of pharmacologic prescription for an onlay bone graft harvested

from the ramus:

• Amoxicillin: 1 g, 3 boxes
– Take 1 capsule the morning of the intervention. After the surgery, take 2
capsules twice a day (morning and evening) for 10 days.
• Betamethasone: 2 mg, 1 box
– Take 2 capsules the morning of the intervention, then 2 capsules once a
day (morning) after the surgery for a maximum of 4 days.
• Hydroxyzine: 25 mg, 1 box
– Take 2 to 3 capsules 2 hours before the intervention.
 – This medication can cause drowsiness. Driving is strictly discouraged, so
the patient should be accompanied on the day of the intervention.
• Dextropropoxyphene: 65 mg, combined with paracetamol 650 mg; 2
boxes
– Take 1 capsule an hour before the intervention. Continue regularly every
4 hours for 2 days. Do not exceed 6 capsules per day. In case of
persistent pain, continue with the same dosage.
• Chlorhexidine: 200 mL, 1 bottle
– Rinse mouth twice a day for 1 minute, starting the day of the
intervention.
• Soft-bristle toothbrush
– On the sixth day following surgery, slightly brush the surgical site twice
a day (morning and evening).

Informed consent
Prior to the surgery, clinicians must inform patients of the objectives of the
surgery, the stages of the treatment, its advantages and disadvantages, and
alternative solutions, and obtain their written consent. The informed consent
document should be given to the patient in duplicate for signature. The
patient keeps one copy and returns the other copy to the clinician on the day
of intervention to be kept with the patient’s records.

An example of an informed consent document for an autogenous onlay bone

graft and placement of dental implant(s) follows.

Practitioner’s letterhead
Date_____________
Patient:________________
After performing a preoperative evaluation and clinical examination as
requested by your general practitioner Dr ............................, please find
attached an estimate of the proposed onlay bone graft harvested on the
................................... (donor site region).
After 3 to 5 months of normal healing, this technique is followed by an
endosseous implant surgery with the placement of .......................................
dental implants. These dental implants will then receive prosthetic
reconstruction to be done by Dr ....................................
In your case, prior to dental implant placement, a bone graft and additional
examinations are required such as an occlusal evaluation mounted on a
dental articulator and a computed tomography (CT) scan.
If these dental implants can be placed, you should be informed of the
following points:
– Alternative solutions to this surgery, such as prosthodontic reconstruction
(eg, removable partial dentures), are available.
– This technique has an excellent long-term prognosis, but your systemic
health greatly influences the results. Therefore, a long-term prognosis is
difficult to make. Studies show an average success rate of 95%.
The surgery will be conducted in two phases:
– Phase 1: Harvesting the bone graft followed by graft fixation using
microscrews. This graft is covered by the gingiva for 3 to 4 months. No
occlusal forces should be exerted on the site during healing.
– Phase 2: Unscrewing of the fixation screws followed by immediate
placement of the dental implants.
Additional interventions may include the placement of gingival grafts (free
or embedded) to create keratinized gingiva. You will be informed if the
need for additional interventions arises. Both the temporary and the
permanent implant-supported prosthesis will be placed by your general
practitioner or, with the consent of the latter, by the practitioner delegated to
place the dental implants.
To ensure optimum long-term results, several factors must be maintained:
– high level of oral hygiene
– strength of your immune system
– quality of the prosthesis
Short-term side effects of the surgery are minimal. However, the following
symptoms may develop in the hours after surgery:
– localized pain
– slight edema
– hyposensitivity of the skin and mucosa around the surgical site
The total cost, excluding the prosthesis to be done by your general
practitioner, is indicated in the attached statement.
Please read the above information carefully, and return a signed copy of this
consent form.

Patient signature
Intraoral and
extraoral
donor sites

in periodontal
and implant surgery
Intraoral donor sites
The available intraoral donor sites are found primarily in the mandible and, in
the maxilla (eg, maxillary tuberosity). However, only the mandibular sites
commonly provide a sufficient volume of bone.

Two mandibular regions are most frequently used as donor sites: (1) the
anterior region (mental symphysis) and (2) the posterior laterodistal region of
the mandibular body and the ramus.

Chin graft

Anatomy of the chin region

In the chin, the harvesting zone is limited distally by the mental foramina,
superiorly by the dental root apices, and inferiorly by the inferior border of
the mandible. It is recommended that the central part of the chin not be
harvested to avoid making a depression and altering its form. However,
harvesting of the chin is possible provided that the inferior border of the
mandible is left intact (Fig 5-1).

When harvesting in this region, the clinician must be careful to avoid the
vasculonervous pedicles of the chin as well as the incisors and canines. This
area is described as a loop located anterior to the foramina and must be
identified on a preoperative computed tomography (CT) scan. The apices of
the incisors and canines follow a topography median to the cortical plate. In
spite of this position, the vasculonervous pedicles can be torn during deep
corticocancellous bone grafting.

At the opening of the mental foramen, the nerve divides into three or four
branches. One descends toward the chin; the others move toward the anterior
vestibule and toward the mucus and cutaneous sides of the lips.

The size of the grafts in this site range from 45 to 50 mm (6 to 13 mm long

by 6 to 9 mm wide). There is easy access to the site, and the harvesting is
done under local anesthesia. The bone obtained is of excellent quality (ie,
essentially cortical with a little cancellous bone).
A preoperative profile teleradiogram and CT scan are essential to know how
much bone thickness is available and to correctly determine whether the graft
is corticocancellous (Fig 5-2).

Surgical approach
The initial approach can be sulcular at the level of the incisor-canine group,
thus leaving an invisible scar on the vestibular area. But when the flap is of a
significant size, raising the flap to the basal border with releasing incisions
may leave scars that can annoy the patient. In 2004, Tuslane and Andréani
proposed that an inverted V-shaped incision be used on the labial mucosa.
This incision is convenient and, according to these authors, allows the
harvesting of fairly large grafts.

We recommend making an incision on the mucogingival line (Fig 5-3). This

protects the anatomy, makes releasing incisions unnecessary, and allows easy
access to the harvest site. Moreover, this incision protects the marginal
periodontium, and careful suturing of this region does not leave a visible scar.

In all cases, the procedure is performed using a full-thickness flap (Fig 5-4).
Preservation of the periostium contributes to the healing process, but it must
be pushed aside so as not to obstruct the incision of the ultrasonic tip. After
raising the flap and exposing the site, the clinician can control the desired
surface and thickness of the graft, which must be previously verified on the
preoperative CT scan.

Sectioning is most often done with a graduated straight saw tip (eg, BS1
[Satelec] or OT6 [Mectron]), which allows continuous control of the depth of
the tip’s incision relative to the internal cortical plate (Fig 5-5). As a general
rule, the incision lines must be placed 3 mm below the tooth apices and at
least 5 mm from the basal border of the mandible (Fig 5-6). Laterally, a safe
distance of 5 mm from the mental foramen is required. This is particularly
important when the CT scan reveals an extension of the mental nerve’s
anterior loop from the foramen.

Since a chin graft is situated on a one-dimensional plane, its elevation is more

delicate than that of the ramus graft. Harvesting without difficulty is possible
if the cortical graft lies on spongy tissue (Fig 5-7). Otherwise, it is essential
to make one or two small lateral surface cuts on the graft to allow an
osteotome to be placed cortically and to progressively dislodge the graft. In
some cases, the graft can be removed with the aide of a surgical mallet (Fig
5-8). The harvested graft is often corticocancellous (Fig 5-9).

Protecting the internal cortical plate is vital to avoid hemorrhagic risk or

hematoma of the buccal floor.

Compression and a resorbable collagen sponge or Surgicel (Johnson and

Johnson) ensures hemostasis. The suture is carried out in a single plane if the
incision has been done on the mucogingival line, which is another advantage
of this choice of incision. Postoperative edema and hematoma formation can
be minimized or even prevented by the simple application of compression
and the immediate application of an ice pack. Nonetheless, the patient must
be informed of the short-term risk of an unesthetic postoperative ecchymosis.

The intervention is technically made easy by the use of ultrasonic

instruments; nevertheless, it involves risks that should not be underestimated.
1. Vascular: Particularly in case of rupture or harvesting of the internal
cortical plate.
2. Nervous: Lesion of the incisive-canine pedicle is frequent and estimated to
occur in 2% to 25% of cases according to the authors. The consequences may
be hypo- or hyper-esthetics.
3. Osseous: Risk of fracture of the basal bony border if the graft is harvested
too close to the border.
4. Esthetics: Asymetric contracture of chin muscles is mentioned in the
literature. It rarely occurs if the incision has been made on the mucogingival
line.
5. Dental: Devitalization of incisors or canines is possible if the apex is
traumatized during harvesting. The risk is assessed in the literature to be from
3% to 10%. Secondary devitalization may also originate from periapical
lesions.
5-1 Cortical bone harvesting of the chin (clinical case courtesy of Dr A. Aalam).

5-2 Profile teleradiogram showing the chin area.

 5-3 Incision on the mucogingival line.

5-4 Full-thickness flap preparation exposing the bone to be harvested.

5-5 Exposed donor site.

 5-6 Control of the depth during harvesting using the BS1 tip (Satelec).

5-7 Anatomic zone of the chin graft.

5-8 and 5-9 Corticocancellous bone graft.

Ramus graft

Piezosurgery allows maximum intraoperative precision during intraoral

grafting and protects the soft tissues (Horton et al 1975).

The advent of ultrasonic-based surgeries and their instrumentation warrants

the ramus zone for autogenous grafting (Veis et al 2004). The major
advantages of harvesting this zone are the mildness of the technique, the
favorable postoperative conditions, and the quantity of available bone. They
are most often associated with autogenous onlay bone grafts. This technique
is indicated for preimplant reconstruction of moderate vertical and horizontal
bone defects. It has a very high success rate when used to increase the
thickness of the crest and a less predictable success rate when used to
increase the height of the crest. The mastery of this technique helps to rebuild
bone volume compatible with the esthetic and functional integration of the
dental implant restorations.

Anatomy of the ramus region

Posterior to the mental protuberance, the lateral surface of the mandibular
body and the anterior part of the coronoid process can be easily accessed.
This region consists essentially of cortical bone. The structures that must not
be damaged are the molar roots, the inferior alveolar nerve, the lingual nerve,
and the buccal nerve, which innervates the buccal mucosa. The dental roots
lie increasingly vestibular as they approach the emergence of the mental
nerve. Harvesting is therefore less risky when it is in line with the first,
second, and third molars. It is compulsory to perform a preoperative CT scan
for such grafts.

The use of ultrasonic tips has several major advantages:

Absence of major vasculonervous risks since these tips do not cut soft
tissues
Limited risk of lesions in cases of slippage
Visibility due to constant irrigation
Control of the depth of incisions because of the graduations marked on
the tip

Harvesting includes the external oblique line or the buccinator crest (Figs 5-
10 to 5-12) at the level of or posterior to the third mandibular molar. It
requires prior elevation of the mandibular buccinator muscle bundle (Gaudy
2006).
Anatomic structures at risk in the ramus region
Because ultrasonic surgery has very little or no effect on the soft tissues
(Boioli et al 2005; Salami et al 2007), the practitioner is better able to focus
on the surgery itself.

The two anatomic risks in the ramus region are the facial artery and vein as
well as the inferior alveolar nerve.

Facial artery and vein

The facial artery and vein arise within the inferior surface of the mandibular
body. A depression positioned inferiorly in front of the mandibular angle
allows it to be located by simple palpation. Within the soft tissues, the facial
artery and vein pass anterior to the masseter muscle and continue on the
lateral surface of the buccinator muscle. The presence of these vessels makes
it imperative to protect the adjacent soft tissues during bone harvesting to
avoid a hemorrhagic accident (Fig 5-13).

Inferior alveolar nerve

Oftentimes, the inferior alveolar nerve borders the lingual cortical plate of the
ramus apically, and its position dictates the size of the graft. The inactivity of
ultrasonic devices on soft tissues coupled with their cutting precision make
these instruments very important in protecting this nerve during oral surgery
(Fig 5-14).
5-10 External oblique line.

5-11 Bone harvesting zone.

 5-12 Bone harvesting including the external oblique line.

5-13 Passage of the artery anterior to the facial vein (photo Dr J-F Gaudy).
 5-14 Posterior section of the ramus showing the anatomy and position of the inferior alveolar
nerve. This area allows the harvesting sufficient quantity of bone compatible with most of the
dental implant indications (photo Mr E. Berthon).

Advantages of the ramus graft compared with the chin graft

In contrast to the symphysis region (Fig 5-15), the ramus bone, because of its
structure, allows three-dimensional sectioning: (1) longitudinal, (2) horizontal
transversal, and (3) vertical transversal (Fig 5-16). These three incisions
allow the bone block to be dislodged with care and finesse, and they make the
use of a surgical mallet unnecessary. The volume of available bone allows
harvesting of bone blocks and chips in sufficient quantity to restore two to
three teeth and satisfies major esthetic and functional indications.

When the bone deficit exceeds three teeth, the iliac crest or the cranial bone
may be harvested, but not without risks and postoperative side effects. A
maxillofacial surgeon performs these extraoral grafts.

Advantages of using ultrasound tips

Unlike conventional rotary instruments, the form and orientation of ultrasonic
tips are compatible with the sectioning of the ramus block. They allow easy
access to narrow and distant zones without risk of injury to the anatomic
barriers.

Because clinicians do not have to focus on these anatomic risks, they can
fully concentrate on the intervention.
Intervention preparation—CT scan analysis
The need for a bone graft is confirmed by CT scan analysis of the slices
passing through the harvesting zone (Figs 5-17 and 5-18). The course of the
inferior alveolar nerve must be followed from its entry at the Spix spine to
the second molar (ie, its lingual and apical position is checked some
millimeters after the second molar). Finally, the available bone is measured
from the external oblique line, keeping a safety margin of 2 mm from this
anatomic structure (Fig 5-19).

The bone volume requirements for dental implant placement may challenge
practitioner ability and can make it difficult for patients to qualify for
treatment, even if the biologic and human principles are often neglected in
such surgeries. The marketing of various bone substitutes sometimes makes
us forget the biologic value of human bone. Autogenous bone remains the
gold standard for bone graft materials (Jensen et al 2006; Khoury et al 2007;
McAllister and Haghighat 2007), because of the presence of natural growth
factors (Khan et al 2000; Gerber and Ferrara 2000) and stem cells (Owen
1988; Bianco et al 2001), which make it capable of osteoinduction.

Advantages of the ramus graft with ultrasonic-assisted surgery

Protection of soft tissues and anatomic structures

Use of autogenous bone instead of bone substitute biomaterials
Easy access to the graft, contrary to chin harvesting
Limited postoperative complications
Ultrasonic precision in bone sectioning and bone block remodeling,
unlike rotary instrumentation
Sectioning time is the only shortcoming of this technique, but it can be
overcome by learning the proper manipulation of the ultrasonic instruments.
Because of better postoperative results, supplementary follow-up
appointments are no longer necessary.
5-15 The symphysis area only allows bone sectioning in a single plane; therefore, dislodging
the bone block becomes more complicated.

5-16 The anatomy of the ramus area allows sectioning in three planes, which makes for
gentler removal of the bone block.
5-17 CT scan slices of the zone to be restored when bone volume augmentation is indicated.

5-18 Axial CT slice.

 5-19 Coronal oblique slice of the ramus identifying the position of the inferior alveolar nerve
and the bone volume available for harvesting.

Extraoral donor sites

Extraoral donor sites include cranial and iliac bone. Tibia bone grafts are no
longer performed, owing to pain and risk of fracture (Fig 5-20).

Cranial bone
The cranial bone graft is parietal and has many advantages, including (1)
minimal postoperative pain, (2) an invisible scar, (3) good bone quantity, and
(4) high bone density (Figs 5-21 and 5-22).

A preoperative CT scan and a standard profile and facial teleradiogram are

indispensable. However, this type of bone harvesting also has many
disadvantages such as (1) neurologic risks, (2) weakening of the cranial vault,
and (3) the need for general anesthesia. Because clinicians are not authorized
to perform this technique, it is not discussed further in this book.

Iliac bone
The iliac bone is widely used in bone surgery. It provides a voluminous graft
that is particularly useful when there is a significant loss of bone. Clinicians
are not authorized to perform this type of extraoral harvesting, so a
maxillofacial surgeon must do the harvesting.

The harvesting zone comprises the anterior part of the iliac crest, posterior to
the anterosuperior iliac spine (Fig 5-23). Abundant cancellous bone is
obtained with large quantities of primarily cortical bone. Risks include:
Neurologic complications at the harvested site (eg, femorocutaneous
nerve lesion). Nevertheless, this risk is less than that associated with a
cranial graft.
High resorbability, particularly in onlay grafts.
Although the harvesting of iliac bone is considered a delicate technique,
stable long-term results can be obtained in certain cases, and it enables the
dental implant to be placed after 4.5 months (Figs 5-24 to 5-26).

5-20 Harvesting zone for the tibia.

 5-21 Harvesting zone for the cranial bone.

5-22a Cranial bone harvesting (photo courtesy of Dr P. Huet).

5-22b Cranial bone harvesting showing the lifting of the graft using a bone chisel (photo
courtesy of Dr P. Huet).

5-23 Harvesting zone for the iliac bone.

5-24 Aspect of an oral reconstruction: implantsupported prosthesis after iliac bone graft.
Result after 3 years (bone graft by Dr N. Bedhet).

5-25 CT scan horizontal slice showing the position of the implants on the iliac graft.
 5-26 View of the second quadrant showing the integration of the dental implants (SLA
[Straumann]) in the iliac graft.

Bibliography
Bianco P, Riminucci M, Gronthos S, Robey PG. Bone marrow stromal stem
cells: Nature, biology, and potential applications. Stem Cells 2001;19:180–
192.
Boioli LT, Etrillard P, Vercellotti T, Jecucianu JF. Piézochirurgie et
aménagement osseux péri-implantaire. Implant 2005;11(4):261–264.
Gaudy JF. Atlas d’Anatomie Implantaire. Issy les Moulineaux: Masson,
2006.
Gerber HP, Ferrara N. Angiogenesis and bone growth. Trends Cardiovasc
Med 2000;10:223–228.
Horton JE, Tarpley TM Jr, Wood LD. The healing of surgical defects in
alveolar bone produced with ultrasonic instrumentation, chisel, and rotary
bur. Oral Surg Oral Med Oral Pathol 1975;39:536–546.
Jensen SS, Broggini N, Hjørting-Hansen E, Schenk R, Buser D. Bone healing
and graft resorption of autograft, anorganic bovine bone and beta-
tricalcium phosphate. A histologic and histomorphometric study in the
mandibles of minipigs. Clin Oral Implants Res 2006;17(3):237–243.
Khan SN, Bostrom MP, Lane JM. Bone growth factors. Orthop Clin North
Am 2000;31:375–388.
Khoury F, Antoun H, Missika P. Bone Augmentation in Oral Implantology.
Chicago: Quintessence, 2007.
McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol
2007;78:377–396.
Owen M. Marrow stromal stem cells. J Cell Sci Suppl 1988;10:63–76.
Salami A, Vercellotti T, Mora R, Dellepiane M. Piezoelectric bone surgery in
otologic surgery. Otolaryngol Head Neck Surg 2007;136:484–485.
Tulasne JF, Andréani JF. Les greffes osseuses en implantologie. Paris:
Quintessence International, 2004:117.
Veis A, Tsirlis A, Parisis N. Effect of autogenous harvest site location on the
outcome of ridge augmentation for implant dehiscences. Int J Periodontics
Restorative Dent 2004;24:155–163.
Techniques

Clinical
cases
The techniques presented in this chapter are performed to treat periodontal
and preimplant defects as well as sinus augmentation procedures prior to
dental implant placement.

Treatment of periodontal and preimplant defects

Horizontal ridge augmentation
Bone healing after tooth extraction reduces the size of the alveolar crest (Fig
6-1), thereby compromising dental implant placement. Performing a bone
graft yields the necessary volume needed to reconstitute the loss of substance.

The graft must be securely transfixed with microscrews or micropins that

anchor it to the recipient site. The junction between the graft and the donor
site must be remodeled and improved by introducing bone chips or bone
chips mixed with resorbable substitute biomaterial.

Clinical case

A maxillary central incisor (tooth 11) previously restored with a fixed

prosthesis using a coronoradicular anchorage was extracted because of root
fracture (Fig 6-2). The chronic infection provoked bone resorption (Fig 6-3).
Owing to the vertical and horizontal defect, an esthetic and functional dental
implant restoration could not be performed.

Figures 6-4 to 6-6 show the computed tomography (CT) scan analysis of the
restored zone. Figure 6-7 shows the coronal oblique slices of the ramus distal
to tooth 47 and the harvest zone. Figures 6-8 to 6-25 show the detailed steps
of the intervention.

Surgical protocol
Autogenous bone graft harvested from the ramus using the Piezotome and the
BS (Bone Surgery) tips (Satelec).
1. Disinfection of intraoral and extraoral tissues: Use povidone-iodine (eg,
Betadine, Purdue Pharma), or chlorhexidine for patients who are allergic to
iodine or its derivatives.

2. Local anesthesia at the recipient and donor sites: Additional anesthesia is

given on the buccal and lingual nerves passing through the ramus and on the
nasopalatine nerve for the maxillary recipient site.

Regional nerve block anesthesia is not recommended for two reasons:

Local anesthesia is sufficient. Unlike teeth, bone structures are rarely
resistant to anesthesia.
The absence of regional anesthesia helps to keep complete control over
the instruments used in close proximity to the inferior alveolar nerve.

3. Preparation of the recipient site (Fig 6-8):

Large incisions extending on the lingual or palatal area expose the
grafted bone.
A full-thickness flap is elevated.
The defect is measured.

6-1 Coronal oblique reconstruction showing the loss of crestal width after healing.

6-2 Extraction of tooth 11 due to root fracture.

6-3 Occlusal view of the loss of substance.
 6-4 to 6-6 CT scans of the zone to be restored.

4. Harvesting of the ramus bone:

The external oblique line is palpated.
Incisions must be similar to the surgical removal of impacted third
molars (ie, sulcular then along the ascending branch, slightly oblique
 toward the exterior). An additional mesial releasing incision allows
better surgical comfort.
Wide elevation avoids excessive tension on the tissues (Fig 6-9).
Osteotomy:
– Longitudinal cut with the BS1 tip. The depth into the bone tissue is easily
determined because of the markings (every 3 mm) indicated on the tip
6-10).
– Two lateral transversal cuts with the BS1 tip (Fig 6-11).
– An apical cut with the BS2 tip. The major advantage of the piezoultrasonic
tips is their safety when used in proximity to soft tissues (Fig 6-12).
– The corners of the block to be isolated are cut.
– Using a flat Palti osteotome (Hu-Friedy), the bone block is dislodged
without excessive force (Fig 6-13). The previous cuts must be deepened in
case of difficulty in lifting the bone graft. In the ramus area, the removal of
the piece of bone does not require the use of surgical chisels. Once the
block is detached (Fig 6-14), it is then checked and directly submerged in
physiologic saline solution.
– A bone trap is installed and bone chips harvested using a BS4 tip. The BS6
tip allows harvesting of thin slices of bone, which help to fill the residual
spaces between the graft and the recipient site.
– Hermetic O-type suturing with a 3/0 slow resorbable suture (Fig 6-15).
5. Adaption and fixing the graft at the recipient site: A delicate but essential
step for the graft’s integration (De Carvalho et al 2000).
The use of ultrasonic-based surgery facilitates precision remodeling and
recovery of bone chips.
Fitting the bone block: the graft must be in close contact with the
recipient site surface (Fig 6-16).
The graft and the recipient site are adjusted with the BS1 tip (Figs 6-17
and 6-18).
Graft fixation with osteosynthesis microscrews. The placement of two
microscrews prevents rotational movement. The graft perforations are
initially done on sterile gauze saturated with physiologic saline solution
(Fig 6-19); then the block is adapted and screwed onto the recipient
site (see Fig 6-20). It is also possible to make the initial hole in the
gauze. Once the first microscrew is fixed on the site, the second
 perforation can then be made (Fig 6-21). Graft fixation can also be
done with the aid of a cortical bone block clamp. Finally, remodeling
of the graft is done using a BS4 tip (Fig 6-22), and bone chips are
placed between the graft and the recipient site (Figs 6-23 and 6-24).
An apical periosteal incision and partial thickness flap elevation allow
complete coverage of the bone volume.
Hermetic mattress suturing with a 4/0 silk nonresorbale suture (Fig 6-
25). The provisional tooth is adjusted out of occlusion.
Please note: A splinted provisional tooth is preferred over a removable
prosthesis during the 4-month healing period. A splinted provisional
prosthesis limits the transfer of forces on the bone graft, which can
provoke fibrosis between the bone structures.

The ultrasonic device and its tips are inseparable for this technique. The BS
tips are indicated and perfectly adapted for this type of surgery. The BS1 tip
is marked every 3 mm, allowing perfect control of the osteotomy. The BS2
tip permits the famous apical cut that is so difficult to perform with a rotary
instrument. Using this tip helps in preserving the integrity of the surrounding
soft tissues. The BS4 is the tip of choice for rapid retrieval of bone chips and
for adapting and remodeling the graft.

6-7 Coronal oblique section of the harvesting site on the ramus.

6-8 Preparation of the recipient site for a ramus bone block graft. Note the divergent
releasing incisions that favor the flap vascularization.

6-9 A large flap elevation of the donor site prevents tissue tension.
6-10 Longitudinal slice with the BS1 (Satelec) tip. The depth can be controlled because of
the tip markings every 3 mm. In this case, the depth is 7 mm.

6-11 Outline of the transverse vertical sections.

6-12 Apical section respecting the soft tissues close to the cutting zone using the BS2 tip
(Satelec).

6-13 Dislodging the bone block without excessive force with a flat Palti osteotome (Hu-
Friedy).
6-14 The bone block is checked then immersed in physiologic saline solution.

6-15 Hermetic O-type suturing using a slow resorbable 3/0 suture.

 6-16 Graft adaptation and intimate contact with the recipient site.

6-17 and 6-18 Remodeling of the graft using a BS1 tip before adaptation to the recipient site.
 6-19 Drilling through the graft is performed on sterile gauze saturated with physiologic
saline solution.

6-20 Graft fixation is considered a difficult step in the surgical procedure, but it is necessary
for the success of the graft. Fixing it with two microscrews prevents rotational movement.
6-21 It is also possible to make the initial hole on the sterile gauze. After screwing the first
microscrew onto the recipient site, the second perforation can then be made.

6-22 Remodeling the graft with the BS4 tip (Satelec).

 6-23 Bone chips harvested on the donor site after 4 minutes of bone scrapping.

6-24 The bone chips are placed between the graft and the recipient site. An inlay/onlay
position allows an increase in height and width.
6-25 Hermetic matress suturing with a nonresorbable 4/0 silk suture. A temporary tooth is
splinted with no occlusal contact.

6-26 Healing of the mucosa of the donor site after 2 weeks.

 6-27 to 6-31 CT slices of the donor (28) and recipient sites (29, 30, and 31) before placement
of the dental implant.

6-32 Osteosynthesis microscrews become visible under the mucosa after 3 to 4 months.

The only disadvantage in using these devices could be the extended duration
needed to complete the cutting. The time it takes depends on the quality of
bone that is encountered and is reduced when the operator is correctly trained
in the proper manipulation of these ultrasonic tips. However, the extended
surgical period is made up for by an uncomplicated postoperative result.
For 2 hours of surgical intervention, 15 to 20 minutes are devoted to
osteotomy of the bone block and 5 to 8 minutes to harvesting bone chips.
This estimated time frame depends on the bone quality.

Postoperative results
Surgical side effects occur less frequently in the area of the ramus than in the
area of the chin (Clavero and Lundgren 2003). The postoperative results are
significantly improved when using piezosurgery compared with those
achieved using conventional instruments (Gruber et al 2005) (Fig 6-26).

The results can be compared with the postextraction conditions of an

impacted third molar because of a similar flap elevation. Therefore, the
postoperative conditions are not complicated, and the same postoperative
instructions are prescribed to the patient. Our clinical experience, however,
shows that the symptoms are significantly reduced, and the sutures can be
removed after only 15 days. An example of a postoperative prescription
follows. This prescription may also apply for interventions such as sinus floor
elevation or piezoperiotomy, which are described later in this chapter.

Postoperative instructions
• To limit bleeding:
− Take lots of rest. During the 3 days following surgery, avoid sports and
all other activities that accelerate the heartbeat.
− Do not drink hot liquids. Eat warm and soft foods.
− Avoid sucking and exploring the surgical zone with your tongue.
− In case of bleeding, lie down and put pressure on the surgical site with
your fingers and clean gauze for at least 20 minutes.
• To limit pain:
− Follow the analgesic drug prescription. Begin an hour before the
intervention, then continue regularly for 48 hours without waiting for the
pain to recur.
− In case of pain, continue with the same dosage.
− Avoid smoking within the week following surgery.
 − Chew on the side opposite to the surgical site.
− The pain varies from person to person and depends on the type of
intervention.
• To limit the swelling:
− Place a cold compress (eg, ice pack wrapped with a towel) on the facial
area next to the site of the operation.
− Follow the anti-inflammatory drug prescription.
• Regarding oral hygiene:
− The teeth at a distance from the operated area may be brushed as usual.
− Toothbrushing on the surgical site must not be done until the 15th day
after surgery. It should be done gently and gradually with the prescribed
soft bristle toothbrush and recommended technique.
− A mouth rinse compensates for this limited brushing.
• To enable optimum healing:
− Do not stimulate the treated zone in any way. Pay attention to what
you eat, to strong pressures, to wearing compressive removable
prosthesis, and to any other stimuli.
− This zone must remain nonfunctional for a month.
• In case of emergency:
− It is normal to develop a hematoma and feel a dull pain on the bone
harvest site. Call us in case of severe and throbbing pain, inflammation
that makes swallowing difficult, persistent bleeding, or other alarming
concerns.
• The sutures will be removed after 15 days.

Healing

This new ultrasonic technology in surgery promotes bone healing (Horton et

al 1975; Vercellotti et al 2005) essential for the future success of dental
implant treatment. The most likely hypothesis for this observation is better
control of the temperature while using the Piezotome (Tuffreau and Garbarini
2006). However, further biologic studies are needed to explain the
acceleration of the healing process clinically observed with this
instrumentation.

Two phenomena compete during the healing stage:

1. Bone apposition: Helps to join the bone graft with the recipient site
(Figs 6-27 to 6-31) by osteoconduction, osteogenesis, and
osteoinduction.
2. Bone resorption: Explained by the absence of mechanical stress of
the attached bone tissue. The osteosynthesis screws become apparent
3 to 4 months after the surgery. The literature describes this
phenomenon as “tent-like.” These figures show the type of
remodeling and the volume that we can obtain after 4 months of
healing (Figs 6-32 and 6-33).

If we refer to the biologic principles of healing after dental extraction, 3

months are necessary to replace the bony table and the socket with new bone
(Atwood 1979). From clinical experience, a period of 4 months seems to
strike a satisfying compromise between the time needed for apposition and
too much time, leading to resorption. Minor resorption is often observed,
which at this period is insignificant for the placement of the dental implant
(Fig 6-34). Note that the screws were removed when the dental implant was
placed.

At this stage, a submerged connective tissue graft was added. The objective
was to accentuate the buccal prominence and to optimize the level of the
papilla.

Figure 6-35 shows the completed restoration 6 months later. The

gingivoplasty resulted in a regular gingival surface and good integration of
the restoration in the esthetic zone.

Vertical ridge augmentation

A vertical defect of the alveolar crest is more difficult to correct. In the
mandible, it is often possible to just place a membrane or to insert bone chips
stabilized by the placement of a resorbable or nonresorbable membrane.
These bone chips can be conveniently harvested in the ramus area.
 6-33 Bone resorption around the osteosynthesis screws.

6-34 Dental implant placement after unscrewing the osteosynthesis screws.

6-35 Definitive restoration 6 months later.

 Clinical case 1
The following clinical case illustrates this technique (Figs 6-36 to 6-41).

Two inlay/onlay block grafts can be done for clinical situations that exibit a
significant loss of substance. The bone is harvested either from the ramus or
the chin. The surgical protocol is identical to the case previously described.

Reconstruction of bone loss through the sinus cavity

The rehabilitation of the partially or completely edentulous posterior maxilla
with dental implants has shown very predictable long-term results
(Albrektsson et al 1986; Adell et al 1990; Lekholm et al 1994; Lindquist et al
1996; Buser et al 1997; Weber et al 2000). However, some patients present
unfavorable conditions in this particular zone of the dental arch. Often, these
patients have either been edentulous for a long period of time, and/or they
have experienced some form of trauma that has led to the loss of hard tissues.
These circumstances may manifest as maxillary sinus pneumatization and/or
alveolar ridge resorption, both of which compromise the vertical bone
dimensions that are critical for dental implant placement in that location (Fig
6-42).

6-36 and 6-37 Preoperative CT scan of the bone loss after extraction of tooth 37 as a result
of improper healing.
 6-38 Placement of a WN dental implant (Straumann) on the alveolar bone grafted with bone
chips from the ramus and covered by a resorbable membrane.

6-39 Tissues surrounding the healing abutment after 12 weeks.

6-40 and 6-41 Clinical aspect and periapical view a year later.

Every time the resorption is related to the alveolar crest, the restoration is
preferably done on the crest site after a bone graft or placement of a
membrane (Fig 6-43). If resorption is related to the sinus cavity, the
Schneiderian membrane can be elevated. In addition, the posterior maxilla
most frequently has the poorest bone quality, which in turn could
compromise the final results of dental implant therapy.

To overcome these problems, bone grafting of the maxillary sinus has

become a very popular and predictable procedure.

To perform a successful sinus floor augmentation, it is important to

understand the maxillary sinus function and how it could be affected by the
surgical intervention. The maxillary sinus (Fig 6-44) is lined with flattened,
pseudostratified, ciliated epithelium. It is composed of basal cells, goblet
cells that synthesize and discharge glycoprotein-containing mucus,
seromucinous glands, and ciliated columnar cells. The ciliated epithelium
clears sinus fluid that is removed by antigravitational movement. The natural
ostium facilitates drainage of sinus fluid through the middle meatus of the
nose, which is located cranially. In a healthy sinus, mucociliary clearance
spreads from the sinus floor in a starlike pattern, ascends the sinus walls, and
passes through the ostium (Takahashi 1984; Stammberger 1989; Kennedy
and Zinreich 1991).

A sinus floor elevation generally does not interfere with sinus function when
it is performed on a healthy sinus (Regev et al 1995; Timmenga et al 1997;
Zimbler et al 1998; Watelet and Van Cauwenberge 1999; Peleg et al 1999;
Van den Bergh et al 2000). On the other hand, the same procedure performed
on an unhealthy sinus can contribute to fluid stagnation and bacterial
overgrowth, leading to exacerbated sinusitis. Local preexisting conditions
(eg, polyps that present an obstacle for the elevation of the sinus mucosa)
require appropriate management prior to sinus floor elevation to avoid
unexpected complications.

Thus, not only is the evaluation of the intraoral conditions important in

identifying potential complicating factors but also the overall medical status
of any patient who is planning to undergo this procedure. This presurgical
evaluation may reveal potential contraindications, whether local or systemic.

Finally, to identify potential local contraindications, patients must undergo a

thorough radiographic evaluation is necessary to identify any underlying
sinus pathology and anatomic disturbances.

The CT scan is superior to conventional radiography in visualizing certain

tumors, forms of rhinosinusitis, and sinusitis (eg, of odontologic origin).

For any of these diagnoses, the recommended treatment modalities (eg,

endoscopic surgery, root canal therapy to alleviate sinusitis due to necrotic
pulp) should be performed. Further diagnostics can then confirm the
resolution of the given problem prior to the sinus floor elevation.

There are important anatomic obstacles (Fig 6-45) that might be

contraindications to surgery when lifting the membrane (ie, elevation of the
membrane must be large enough to allow placement of autogenous bone or a
substitute material but not so large as to destroy a certain tension of the
membrane). The frequency of membrane tearing depends on its thickness, the
presence of obstacles (eg, crests, depressions), and skillful manipulation
when opening and lifting the sinus. Ultrasonic instruments make the work
easier and reduce the risk of tearing the membrane, as they do not cut soft
tissues. Tearing is not rare and does not seem to be in direct relation to
postoperative complications. However, the tears have to be sutured with
Vicryl 4/0 or 5/0 to prevent exposure of the graft in the sinus cavity and to
restore the integrity of the mucosa. Last but not least, the permeability of the
membrane should be checked before the surgery.

6-42 Preoperative CT scan of the alveolar resorption requiring bone reconstruction before
placement of dental implants in sites 24 and 25.
6-43 View of a graft and two Euroteknika dental implants (threaded and smooth) after 6
years.

6-44 Horizontal CT scan of the cranium showing the maxillary sinus.

 6-45 Example of a compartmentalized maxillary sinus. This makes the lifting of the sinus
floor difficult or even impossible.

Absolute contraindications to sinus floor augmentation

Severe deformities of the maxillary sinus

Radiotherapy of the head and neck area
Sarcoidosis
Benign but aggressive tumors and malignant tumors
Inadequate oral hygiene
Untreated periodontal disease
Mucosal diseases (eg, erosive lichen planus)

Certainly, there are also specific general medical conditions that could
represent contraindications not only for sinus floor augmentation but also for
any oral surgical intervention.

General medical contraindications to oral surgery

Uncontrolled diabetes mellitus
Uncontrolled hypertension
 Anticoagulant therapy
Long-term prescription of bisphosphonates
Steroid treatment at the time of the sinus graft procedure
Metabolic bone disease
Compromised immune system
Chronic liver and renal disease
Pregnancy
Chemotherapy and radiotherapy
Drug abuse
Heavy smoking
Noncompliance

Ideally, a CT scan should be obtained during the planning phase for a sinus
floor augmentation, as this gathered information will enable the clinician to
detect any anatomic structures that would potentially require a modification
of the intended window preparation. However, in many clinical situations, a
standardized panoramic radiograph will suffice for the surgical planning of
sinus floor augmentation.

The radiographic analysis is also pertinent to evaluate the existing alveolar

bone height (ie, distance from the alveolar crest to the bony sinus floor). This
dimension is very important in choosing the appropriate surgical technique to
be selected for that site. The common notion describes 4 to 5 mm of vertical
bone height in the prospective implant site as the “cutoff” dimension (Fig 6-
46). If there is more than 5 mm of bone height available, the surgeon can
proceed with the conventional osteotome sinus lift (Summers 1994a, 1994b,
1994c, 1995).

However, in a situation of lesser bone height, the surgeon should instead

consider the Caldwell-Luc or Tatum technique to address the sinus floor
augmentation. The common practice for these procedures is to wait at least 4
to 6 months after the grafting procedure before placing dental implant(s).
 6-46 Indications for sinus augmentation (SA3 and SA4) by Misch, 1987 (Introduction).

In certain situations the dental implant(s) can be placed at the time of sinus
floor augmentation depending on several variables. It is beyond the
objectives of this chapter to discuss these variables. Therefore, only the
different surgical techniques are discussed.

Summers technique
Initially, the osteotome technique was introduced to compress very soft
maxillary bone classified as Type III and IV bone (Summers 1994a). This
compression improved the initial stability of implants, which is the key factor
for osseointegration.

The instruments developed for this bone compression have a tapered shape
and a concave extremity. This design allows for conservation of bone by
displacing it laterally to create a dense bony wall.

R. B. Summers first described this technique in 1993. Over the subsequent 2

years he published several articles on the use of osteotome instruments in the
field of implant dentistry (Summers 1994a, 1994b, 1994c, 1995).

This technique can be applied to a sinus floor augmentation using osteotomes

(Fig 6-47). Most dental implant manufacturers have embraced this technique
and have an osteotome kit available that corresponds with the drills used for
their dental implant systems. In general, the first or first few drills of the
dental implant system are used to prepare an initial osteotomy site. The
preoperative planning for this procedure is very important, as the initial
drilling sequence should be 2 mm short of the bony sinus floor. The use of
the osteotome instrument applies the principle of repositioning bone particles
and trapped fluids to create a hydraulic effect, thus eventually moving the
sinus floor and the membrane upward without entering the sinus cavity itself.
After creating a Greenstick fracture in the sinus floor, the osteotome is
inserted with a mallet to the desired depth.

Sequentially, multiple loads of bone grafting material are inserted into the
osteotome site. The osteotome instrument is then used again to tap the
membrane further upward.

The implant functions as the final osteotome, pushing the grafting material
and the Schneiderian membrane to their final height (Summers 1994b). The
literature has shown that there is no difference in using, for example,
autogenous bone chips versus a xenograft bone grafting material (Moy et al
1993). Thus, the patient does not require a second surgical site for this
procedure.

As mentioned earlier, about 4 to 5 mm of bony ridge height is required for

this procedure, which allows simultaneous placement of dental implant(s) at
the time of the sinus floor manipulation.

The crestal approach (eg, Summers technique) makes the protocol simpler
and reduces postoperative complications. However, the lifting of the
membrane should be done with round osteotomes. It is almost impossible
to control the integrity of the mucosa with this technique. Unlike the
alveolar graft, this kind of graft does not resorb, or does so very little.
Consequently, it is possible to obtain stable results without an excess of
bone filling.
 6-47 Sinus floor augmentation: Summers technique (1994) or crestal approach.

Tatum technique (crestal approach)

This technique for a sinus lift augmentation with delayed implant placement
was initially described by Tatum (1977) at the annual meeting of the
Alabama Implant Study Group. Several years later it was further described by
Summers (Summers 1994c). For this technique, a larger-sized trephine is
used to a depth of about 2 mm short of the bony sinus floor. Then, a large-
sized osteotome is used to fracture the bony floor. As in the previously
described technique, sequential loads of bone grafting material are placed
into the osteotomy site to further displace the Schneiderian membrane. This
technique is recommended in sites where the ridge height is less than 4-mm.
It is an alternative technique to the lateral window approach, or Caldwell-Luc
Technique (described later), as a less traumatic procedure. This approach
creates a “socket” that heals fairly quickly (3 to 4 months). The osteotomy
site is covered with a resorbable membrane for a better clinical outcome.

Caldwell-Luc technique

If the clinician encounters a situation in which the vertical bone height

dimensions are less than the dimensions recommended by Summers for an
osteotome sinus lift (< 5mm in bone height), clinicians should consider a
lateral approach for sinus elevation. Under these circumstances the radiologic
examination reveals significant pneumatization of the maxillary sinus cavity.

In 1893 in the United States, Caldwell initially described sinus surgery via
the canine fossa (Caldwell 1893) with the goal of treating sinus disorders.
Some 4 years later, in France, Luc described a similar technique (Luc 1897).
Later, this sinus surgery became known worldwide as the Caldwell-Luc
procedure. In this procedure, an incision is made several millimeters superior
to the maxillary mucogingival junction and extended from the canine to the
first molar. A full-thickness flap is elevated, and an opening into the sinus is
created in the area of the canine fossa. Often, a larger oroantral window was
created in the lateral wall of the sinus for postoperative irrigation, drainage,
and inspection of the antrum. Most current surgical techniques for sinus
elevation are modifications of the Caldwell-Luc technique (Jensen et al
1998).

Boyne and James (1980) presented the first report of sinus elevation for
implant placement. In this report they suggested a horizontal incision in the
mucosa starting from the canine fossa and extending posteriorly at a level 6
mm superior to the attached gingiva. According to this technique, a 1-cm
diameter antrostomy is made in the lateral sinus wall, and an autogenous
bone graft is used to elevate and hold the sinus membrane superiorly.

Another surgical technique features a lateral rectangular osteotomy with a

superior border that is scored and left intact, creating a trapdoor effect (Tatum
1986). This technique is frequently referred to as the modified Caldwell-Luc
technique for sinus elevation. Several variations of this technique have been
described in the literature.

In general, after the reflection of a facial flap, access to the antrum is created
at a low position along the anterior surface of the maxilla, very close to the
level of the existing alveolar bone (Wallace and Froum 2003). The bony
window is created with either diamond burs or diamond-coated tips, such as
the SL1 (Satelec) or SG6D (NSK) (Fig 6-48). Next, the Schneiderian
membrane is detached to create a space superior to the previous sinus floor
without entering into the sinus itself (Fig 6-49). SL3, SL4, and SL5 tips
(Satelec) make this lifting of the membrane possible according to the
different angles of the sinus floor with the window allowing access to the
sinus (Figs 6-50 and 6-51). The space is later filled with grafting material,
with or without immediate placement of dental implant(s) (Fig 6-52).
Furthermore, a resorbable membrane is placed over the access site prior to
replacing the soft tissue flap in its initial position (Fig 6-53). In most
situations, it is recommended to wait at least 6 months after the sinus lift
before proceeding with the implant placement. The major complication of
this approach is the risk of membrane perforation using diamond burs to
create the access and “blind” use of the conventional sinus lift elevators. If
these perforations appear to be fairly small (ie, only a few millimeters in
diameter), they can be managed by using a resorbable barrier membrane over
the accidental perforation.

6-48 Access to the sinus cavity via the lateral bony window.

6-49 Detaching the Schneiderian membrane using the SL3 tip (Satelec).
 6-50 and 6-51 Detaching the Schneiderian membrane using the SL4 and SL5 tips (Satelec).

6-52 Dental implant placement followed by filling the cavity with autogenous bone chips
and/or bone substitute biomaterial.

6-53 Suturing of the flap.

Piezosurgery and sinus floor augmentation

The advantage of using a piezosurgery device for sinus antrostomy is that its
unique modality of function, as described in chapter 2, allows the selective
cutting of mineralized tissues without disturbing the Schneiderian membrane.
Therefore, the surgical site is relatively bloodless, especially when compared
with the classic technique using rotary and hand instruments.

The microvibration fractures only the mineral apatite away from collagenous
material with excellent micrometric precision. There is no friction generated,
and it requires only light manual pressure. Several morphologic and
histomorphometric studies have shown that hard and soft tissues respond
more favorably to piezosurgery than to the conventional rotary bur
(Vercellotti et al 2001, 2005). All the general concepts of piezosurgery
present significant advantages when applied to sinus bone grafting
procedures. Thus, the lack of macrovibrations allows better handle control,
which ensures safer access even in difficult anatomic areas. The precision of
the bone cut is also remarkable, especially when compared with the approach
using rotary instruments.
The use of physiologic saline solution as a cooling irrigant with these devices
keeps the surgical area cool and free of blood. Thus, the tissues do not show
overheating, and the clinician has optimal intraoperative visibility.

For example, the sinus lift kit for the Piezotome contains two different “bone
scalpels” for the maxillary sinus antrostomy. The diamond-coated cutting
SL1 tip is designed to outline the lateral bony window and is run at power
settings of 2 or 3. In addition, the SL1 tip can be used to smooth sharp edges
at the periphery of the window. The SL2 tip is diamond coated, with a
diameter of 1.5 mm. This tip also cuts and smooths sharp edges. Some
practitioners use it for the entire outline of the window preparation, as it
creates a similar outline to that created with a rotary diamond bur. The
settings used for his tip are the same as those used for the SL1 tip, which
allows hard tissues to be cut.

In addition to these cutting tips, three noncutting tips are included in the kit.
These tips are used for the separation and elevation of the membrane. They
are used at a setting of 3 or 4, which allows the appropriate manipulation of
nonmineralized tissues, such as the Schneiderian membrane.

The SL3 tip is a flat-ended tip that helps the clinician to detach the
Schneiderian membrane from the window edges. The SL4 is a right-angled
tip, and the SL5 tip—with a 120-degree angle—allows for access in areas
that the SL4 might not reach. Both of these tips are recommended for the
further detachment and elevation of the membrane.

In general, the lateral approach to the sinus cavity is used (Tatum 1977;
Boyne and James 1980; Jensen et al 1998); however, a crestal approach
(Tatum 1986) from the inside of the implant osteotomy site can also be a
feasible option (Summers 1994a, 1994c; Bruschi et al 1998; Fugazzotto
2002).

In the course of the lateral approach, the clinician can either opt to remove
the lateral bony wall of the osteotomy window or to preserve and raise the
lateral wall coronally into the cavity.

Sinus antrostomy
Surgical protocol
1. Intraoral and extraoral disinfection
2. Local anesthesia: injected on the buccal and palatal musoca next to
the edentulous alveolar crest.
3. Access flap:
− Large incisions expose the lateral bony wall.
− A full-thickness flap is elevated.

Osteoplasty of lateral bony window (Caldwell-Luc)

The lateral window approach involves the gradual thinning of the bony wall
to slowly expose the endosteal surface of the sinus membrane. The proximity
to the membrane usually coincides with the appearance of a bluish hue in the
bony outline of the window. As mentioned earlier, this part of the osteoplasty
can be achieved with the use of the SL1 and SL2 (Satelec) or SG6D and
SG7D (NSK) tips. In the presence of septa dividing the sinus cavity, two
separate bony windows are created (mesially and distally), and the sinus
membrane can be elevated in two separate graft areas. If needed, an
incomplete septum can even be resected to allow complete membrane
elevation.

The SL3 or EL1 (Mectron) tip will ensure the safe detachment of the
membrane from the surrounding bone. The SL4 and SL5 tips or the ES003a
and ES003b tips (Esacrom) will detach and elevate the membrane for the
creation of the voided area within the bony sinus cavity. In general, if only
one window is created, the bony window will present the “new” bony floor of
the sinus if the membrane has been elevated sufficiently and passively.

After the placement of bone grafting material into the cavity, a resorbable
membrane is placed onto the grafted site, which is completed by the
positioning of the soft tissue, full-thickness mucogingival flap with
nonresorbable sutures (eg, Gore-Tex sutures), which can be removed after
about 2 weeks of initial healing.

Membrane elevation via the crestal approach (Tatum)

The conventional osteotome technique described previously for sinus
membrane elevation requires a sensitive tactile approach to avoid perforation
of the sinus membrane. Especially when the bone quality is very good (Type
I or II), a conventional manual osteotome can be fairly traumatic for a
conscious patient.

In this technique, the piezoultrasonic devices can facilitate the osteotomy via
a crestal approach. The SL2 tip can be used to prepare the osteotomy site to
the planned depth. New Intralift tips (Satelec) used with the Piezotome (Fig
6-54) are available. These tips are recommended for the crestal approach.
They have a cylindroconical shape and are named TKW1 to TKW4. After
using a pilot drill and strong irrigation (80 mL/min), they enable the
preparation of the dental implant socket. The “trumpet” tip (TKW5) is then
used with more moderate irrigation (40 mL/min). The membrane is lifted
using water pressure. Figure 6-55 shows these tips positioned during a sinus
lift.

After the insertion of the grafting material, for instance a xenograft (eg, Bio-
Oss [Osteohealth]), the same tip can be used to compact the grafting material
beneath the sinus membrane. Additional grafting material is placed into the
osteotomy site to complete the elevation using manual osteotomes with
concave extremities or using the TKW5 tip with a very low irrigation. The
dental implant is placed immediately, then the flap is repositioned and
sutured. If the primary fixation of the dental implant is insufficient, the flap is
repositioned and sutured, and the dental implant is placed after complete
bone healing. This technique gives favorable postoperative results and could
therefore replace the use of conventional instruments.

6-54 (a to e) Intralift® tips (Satelec) for sinus floor augmentation procedure via the crestal
approach: a) TKW1, b) TKW2, c) TKW3, d) TKW4, e) TKW5.
 6-55 (a to e) Clinical protocol for sinus floor augmentation procedure via the crestal
approach using the Intralift® tips (Satelec): a) TKW1, b) TKW2, c) TKW3, d) TKW4, e)
TKW5.

Clinical case 2

Figures 6-56 to 6-65 show a clinical case using the Caldwell-Luc technique
performed on the second quadrant and the clinical result after 3 weeks (Fig 6-
66).
 6-56 Preoperative occlusal aspect of the second quadrant edentulous crest.

6-57 Elevation of a full-thickness flap exposing the maxillary sinus lateral wall.
6-58 Horizontal slice using a diamond-coated SL1 tip (Satelec).

6-59 Clearly outlined lateral bony window.

6-60 The SL3 tip is used to initially detach the Schneiderian membrane; then, the bony
window is pushed upward into the sinus cavity.

6-61 The membrane is further detached with an SL4 tip.

 6-62 Completely detached and elevated lateral bony window. Note the bluish hue of the
Schneiderian membrane.

6-63 The bone substitute biomaterial is packed into the sinus cavity between the lifted lateral
bony window and the sinus floor.
6-64 A resorbable membrane covers the lateral window to contain the biomaterial.

6-65 A Gore-Tex suture repositions the flap and ensures its hermetic seal.

6-66 Postoperative healing after 3 weeks.

 Clinical case 3

Figures 6-67 to 6-77 show a clinical case using the Caldwell-Luc technique
performed on the first quadrant and the postoperative clinical result after 3
weeks (Fig 6-78).

Piezosurgery is a simple, precise, and safe method that can be used to

improve the conventional techniques for sinus floor augmentation,
particularly in allowing precise surgical access with minimum risk to the
maxillary sinus membrane.

The enhanced preoperative visibility is a result of irrigation with physiologic

saline solution, which reduces traumatic hemorrhaging from the bony wound
margins. This technique employs a very predictable surgical approach in
sinus augmentation and brings significant technical and possibly biologic
improvements compared with the conventional technique using rotary burs.

Postoperative conditions
The sutures are not to be removed before 15 days. Postoperative conditions
are clearly better after using piezosurgery versus conventional instruments.
Postoperative complications are rare. The most frequent complications that
do occur are:
Perforation of the Schneiderian membrane, which is observed in 6% of
dental implant cases. This complication is more difficult to diagnose
when a crestal approach is performed. A too-small lateral bony window
is a frequent cause of perforation as well as errors in the operator’s
technique (eg, wrong measurements or anterior interventions that can
damage the Schneiderian membrane).
Starting with a short residual bone height also results in an
unpredictable prognosis for dental implant survival.
Migration of dental implants into the subsinus space, whose causes are
controversial. It is imperative to remove the dental implant(s) through a
bony window in the canine fossa.

Aside from the postoperative prescriptions mentioned earlier in the chapter,

additional instructions are given to the patient after a sinus floor
augmentation to avoid complications.

Postoperative instructions following a sinus floor augmentation

• Do not blow the nose or sneeze while holding the nose for the next 4
weeks. Sneeze with the mouth open.
• Do not drink with straws, and do not spit forcefully. Avoid “bearing
down” as when lifting heavy objects, playing musical instruments that
require a blowing action, or any activity that increases nasal or oral pressure
during the duration of the healing process.
• Scuba diving and flying in pressurized aircraft may also increase sinus
pressure and must be avoided for at least a week following the intervention.

Healing
This new ultrasonic-based surgery seems to stimulate bone healing at both
sinus and ramus sites (Horton et al 1975; Vercellotti et al 2005), owing to
minimum temperature elevation and precise surgical technique. More
biologic studies are needed to explain why the healing processes are
clinically enhanced with these instruments.

6-67 Preoperative occlusal aspect of the first quadrant edentulous crest.

 6-68 Preoperative buccal aspect of the first quadrant edentulous crest.

6-69 Full-thickness flap elevation exposing the maxillary sinus lateral wall.
 6-70 Lateral window outlined using a diamond-coated SL2 tip (Satelec).

6-71 Clearly outlined lateral bony window. The membrane is detached, and the bony
window is pushed upward into the sinus cavity using an SL4 tip.
 6-72 Detached lateral bony window.

6-73 The bone substitute biomaterial (Bio-Oss [Osteohealth]) is packed into the sinus cavity
between the lifted lateral bony window and the sinus floor.
6-74 Two dental implants (Friadent) placed in the prepared implant sites. The bone substitute
biomaterial was further compacted by the placement of these dental implants.

6-75 Additional bone substitute biomaterial placed around the implants.

6-76 Occlusal view of sutured surgical site and temporary bridge.

6-77 Buccal view of sutured surgical site and temporary bridge.

6-78 Postoperative healing after 3 weeks.

During the healing stage, bone apposition and resorption remodel the grafted
material. The Dental implants can be placed from 3 to 4.5 months after sinus
floor augmentation. This leads to bone consolidation and sufficient
osteointegration. Placement of the dental implants should not be overly
delayed to avoid the risk of resorption due to the absence of function.

Piezoperiotomy: Ultrasonic-assisted atraumatic tooth

extraction
With the increasing popularity of immediate placement of dental implants,
more care should be taken in the extraction of teeth planned for dental
implant placement principally those in the anterior maxilla where esthetics
are essential. Care must be taken to preserve as much bony support as
possible (especially the buccal cortical plate) to keep the soft tissue at a good
biologic and esthetic level and to prevent the collapse of the bony socket.
Atraumatic tooth extraction preserves the remaining alveolar bone and
surrounding tissues, specifically the periosteum, which is the layer of
connective tissue that supplies the majority of vascularity to the bone tissue.

Tooth removal that does not compromise the extraction site is the ideal
precondition for a predictable immediate dental implant placement and a
successful nonloaded temporization (Testori and Bianchi 2003). Various
traditional techniques using rotary instruments are routinely used to drill
away surrounding bone during a complex extraction. However, without
proper irrigation, this practice causes third-degree burns to the bone, which
results in postoperative pain and accelerated bone loss as the body eliminates
the damaged bone structure. Violating the tissue rapidly accelerates bone loss
and often necessitates augmentation of the bone through grafting prior to
dental implant placement. If the tissue is treated with respect during the
extraction process, a dental implant can often be placed immediately allowing
the entire extraction/implant placement to be accomplished in the same visit.
In addition, postoperative discomfort such as swelling is greatly reduced.

Other common extraction instruments are the elevator and the periotome.
These manual instruments are wedged between the tooth and the periosteum.
They are supposed to luxate the tooth coronally and laterally using a lever or
a wedge. However, a tremendous amount of pressure is needed to loosen the
tooth from its socket. The thin buccal cortical plates may break when using
these instruments.

With the advent of new powerful piezoultrasonic devices in oral surgery, the
authors propose a new technique known as a piezoperiotomy. This technique
allows for the removal of fractured teeth, root fragments, or ankylosed teeth
without damaging alveolar bone and the surrounding tissues in preparation
for immediate or delayed placement of implants.

Definition
The piezoperiotomy technique is the atraumatic surgical widening or slitting
of the periosteum using a piezoelectric-driven tip attached to a high-powered
piezosurgery device.

The vibrating tip is gently guided apically, working down the root with a
rocking hand movement until the root can be lifted out of the socket. In the
absence of this space, such as in tooth ankylosis, the tip is placed at the
cervical part of the bone-cementum junction, and with a gentle downward
movement, the tip chisels away the fused joint and liberates the tooth. The
ultrasonic micro-oscillations permit the resection of the alveolar bony
housing without affecting the peripheral tissues. In addition, because of the
irrigation accompanied by cavitation, the piezoelectric generator has a
hemostatic effect on the tissues and avoids the temperature rise produced by
friction, which can provoke hard and soft tissue degradation (Torella et al
1998).
The ultrasonic micro-oscillations permit the resection of the alveolar bony
housing without affecting the peripheral tissues. In addition due to the
irrigation accompanied by cavitation, the piezoelectric generator has a
hemostatic effect on the tissues and avoids the temperature rise friction. It is
gently guided in an apical direction, working down alongside the root with a
rocking hand movement until the root can be lifted out of the socket. In the
absence of this space, such as in tooth ankylosis, the tip is placed at the
cervical part of the bone-cementum junction with a gentle downward
movement; the tip chisels away the fused joint and liberates the tooth.

Contrary to conventional instruments that laterally stretch and then tear the
ligament, the piezoperiotome enlarges the ligament space, allowing the teeth
to be immediately removed from the socket at its axis with minimal trauma to
the alveolar bone.

Widening of the periodontal ligament space must permit easy extraction of

fractured or nonfractured roots without decreasing the height of the alveolar
crest in order to reconstruct the papilla and preserve the alveolar bone.

Description
The insert used for this technique is an angulated blade-like tip (eg, LC
[Satelec] or EX1 [Mectron]) with its cutting edge vibrating parallel to the axis
of the handpiece (Fig 6-79).

With the piezoperiotomy technique, only one tip is needed to treat the entire
dentition.
Objectives

Widen the periodontal ligament space

Make root extractions easier
Prevent fractures of the buccal bony wall and preserve the crestal
bone volume

Indications

Avulsion of embedded roots

Extraction followed by immediate dental implant placement
Extraction of ankylosed teeth
Extraction of impacted teeth
Avulsion of root fragments (apical third of root)
Root extrusions

Surgical protocol
1. Intraoral and extraoral disinfection

2. Local anesthesia
6-79 LC tip (Satelec): Arrows indicate the tip’s vibrational direction parallel to the axis of
the handpiece.

6-80 Tip placed in the vibrating mode before contact with the tooth.
 6-81 Working end of the tip is in tangential contact with the tooth, parallel to the root
surface, and used with minimum lateral pressure.

6-82 The tip is “walked” around the circumference of the root with a back-and-forth rocking
movement in an apical direction. This movement prevents trauma to the bone. The tip should
constantly be irrigated.
 6-83 An extraction forceps or a root elevator can be used to finish the extraction.

3. Access flap (when necessary):

− Intrasulcular incision with internal bevel extended to each
side of the adjacent teeth
− Mucoperiosteal full-thickness flap on the buccal and
lingual (or palatal) surfaces
− Meticulous removal of the granulation tissue with
periodontal curettes

4. Device setting: Power mode 1 or 2, abundant irrigation (45 to 50 mL/min).

As with all piezoelectric tips, the power generator must be switched on in
the vibrating mode before the tip is placed in contact with the tooth or hard
tissue (Fig 6-80). This precaution prevents tip breakage and tissue damage.

5. Tip position: The working end must be tangential to the tooth, parallel to
the root, and used with minimum lateral pressure (Fig 6-81). A back-and-
forth rocking movement in an apical direction may be needed to “walk”
the tip around the circumference of the root to prevent trauma to the bone
(Fig 6-82). Once a third of the root has been loosened, an extraction
forceps or a root elevator can be used to finish the extraction (Fig 6-83),
thus preserving the extremely thin bony walls.
 Clinical case 4

Piezoperiotomy using the Piezotome and LC (Ligament Cutting) tip:

A 52-year-old man presented a vertical root fracture on tooth 11 (Figs 6-84

and 6-85). The cause of the fracture was unknown. The tooth had undergone
prior endodontic therapy and was asymptomatic. It had been restored with a
porcelain crown and a post and core.

Radiographic evidence showed that the root had a vertical fracture (Fig 6-86)
at the level of the cementoenamel junction, leading to demonstrated mobility.
Periodontal health was stable, with apparent cervical abrasions on both
anterior and posterior teeth. The patient was healthy, had no history of
smoking, and had no systemic contraindications for intraoral surgery and
dental implant placement. Tooth extraction using the piezoperiotomy
technique and immediate dental implant placement was proposed in the
treatment plan.

Local anesthesia was used to block the anterior alveolar nerve, and it was
then applied locally at the papilla to control bleeding at the surgical site.
Intrasulcular incisions were made buccally and palatally, mesial to the
maxillary left central incisor up to the mesial sulcus of the maxillary left
canine (Fig 6-87). Vertical releasing incisions were unnecessary. A
conservative reflection of the soft tissue was accomplished with a periosteal
elevator. Care was given to avoid tearing the tissue. The flap was elevated
and sutured for better visibility and access to the underlying alveolar bone
and tooth to be extracted (Fig 6-88). The Piezotome power setting was
adjusted to mode 2 with irrigation at 50 mL/min. An LC tip was then gently
inserted into the periodontal ligament space around the circumference of the
root (Figs 6-89 to 6-91). A back-and-forth rocking movement in an apical
direction was continued until a neat separation between the bony wall and the
root was obtained (Fig 6-92). Superfluous pressure that could block the
vibration of the tip was avoided. A No. 150 extraction forceps was used at the
final phase of the extraction. The porcelain crown with the post was removed
first, followed by the fractured root (Fig 6-93), which was readily removed in
one piece without compromising the extraction site (Fig 6-94). The extraction
was done atraumatically without provoking the unwarranted loss of the
osseous scaffold. It was then immediately followed by the recommended
sequence of dental implant placement with primary fixation toward the
palatal bone (Fig 6-95). Recovered bone chips from the drilling were placed
over the dental implant and the alveolar bone (Fig 6-96). An esthetic
restoration using a temporary crown fabricated and luted with temporary
cement was placed (Fig 6-97) and verified radiographically (Fig 6-98).

6-84 Preoperative buccal view of tooth 11.

6-85 Preoperative occlusal view of tooth 11.

6-86 Fracture line (arrow) on the root.

6-87 Buccal and palatal incisions.

6-88 The flap is sutured to keep it away from the working area. Note the fracture line on the
distal root surface of tooth 11.

6-89 to 6-91 LC tip (Satelec) inserted into periodontal ligament space and “walked” around
the circumference of the root.
6-92 Distinct separation between the root and the surrounding alveolar bone.

6-93 Atraumatic extraction finished with a No. 150 extraction forceps.

 6-94 Intact surrounding alveolar bone.

6-95 Placement of an RN dental implant (Straumann). Primary implant fixation on the

palatal wall.
6-96 Recovered bone chips from the drilling are placed over the dental implant and the
alveolar bone.

6-97 Sutured extraction site and temporary crown.

 6-98 Postoperative periapical view.

Healing
The healing process must be supervised and the patient’s oral hygiene
reinforced at every dental appointment.

Minimizing bone loss after extractions enables a dental implant to be placed

in an ideal orientation surrounded by bone, thereby increasing its esthetic and
biologic prognosis (Horowitz 2005).

The key to the process of immediate tooth replacement is to protect the

potential site during tooth extraction. The extraction should be done as
atraumatically as possible by taking precautions to retain the essential form of
the soft tissue profiles and to prevent the loss of bone support. Problems arise
when the compromised tooth is severely fractured, showing little or no
coronal structure beyond the height of the gingiva (Garber et al 2000).

The continuing development of the dental profession is a result of newer

 and safer techniques with the aid of modern technology. Current
technologies such as piezoelectricity used in oral surgery have allowed
clinicians to work with more precision, resulting in an increase in patient
comfort. This powerful ultrasonic device belongs to a category of
motorized instruments with a frequency ranging from 28 to 36 kHz. Its
objective is to respond to the drawbacks encountered with traditional
manual and rotary instruments. Using specialized tips, clinicians can
perform not only preimplant surgical procedures but also uncomplicated
tooth extractions (eg, root fragment, impacted or ankylosed teeth, and
extractions prior to an immediate dental implant placement).

Conclusion
The generalized practice of dental implant procedures and the advancing
precision in periodontal bone surgical techniques is revolutionizing bone
surgery into a group of routine dental techniques.

Most cases involving minimum bone loss can simply be corrected under local
anesthesia using autogenous bone with or without the association of bone
substitutes. However, these interventions, as simple as they may appear,
present some risks related to:
Anatomy
Access
The intervention (eg, bleeding, nerve lesions, infectious complications)
The instrument (eg, risk of slipping, incorrect control of the depth of
cutting)
Using powerful ultrasonic devices considerably reduces these risks. There is
a learning curve to these techniques, so further training is compulsory to learn
the correct manipulation of these instruments.
Performing piezosurgery gives optimal conditions of security when managing
the one and only biologic osteoinductive material: autogenous bone. This
technique increases the indications of dental implant surgery, making them
more accessible to trained clinicians.

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