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Bone Augmentation in Implant Dentistry: A Step by Step Guide To Predictable Alveolar Ridge and Sinus Grafting 1st Edition Edition, (Ebook PDF
Bone Augmentation in Implant Dentistry: A Step by Step Guide To Predictable Alveolar Ridge and Sinus Grafting 1st Edition Edition, (Ebook PDF
PIKOS
MICHAEL A. PIKOS received his DDS from The Ohio State
|
University College of Dentistry, after which he completed an
internship at Miami Valley Hospital and residency training in
Augmentation
Montefiore Hospital. He is a Diplomate of the American
Board of Oral and Maxillofacial Surgery, the American Board
of Oral Implantology/Implant Dentistry, and the Interna-
tional Congress of Oral Implantologists and a Fellow of the
American College of Dentists. He is also an adjunct assistant
Implant
professor in the Department of Oral & Maxillofacial Sur-
gery at The Ohio State University College of Dentistry and
Nova Southeastern University College of Dental Medicine. Graft Window IN
Dr Pikos is on the editorial boards of several journals and
Dentistry
is a well-published author who has lectured extensively on
dental implants in North and South America, Europe, Asia,
and the Middle East. He is the founder and CEO of the Pikos
Institute. Since 1990, he has been teaching advanced bone
and soft tissue grafting courses with alumni that now number
more than 3,400 from all 50 states and 43 countries. Dr Pikos
MICHAEL A. PIKOS,
maintains a private practice limited exclusively to implant
surgery in Trinity, Florida (www.pikosinstitute.com). dds
with Richard J. Miron, dds, msc, phd
Sinus Augmentation
Extraction Site
ISBN 978-0-86715-825-0
90000>
9 780867 158250 A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting
97%
5 4 3 2 1
All rights reserved.This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.
Printed in China
Index 258
Preface
Implant dentistry has evolved tremendously over the past regeneration. Chapter 2 presents barrier membranes, bone
three decades and is rapidly progressing as new materials grafting materials, as well as growth factors utilized for bone
and protocols become available. While biomaterials and augmentation procedures and describes their biologic back-
clinical guidelines were once believed to turn over every ground and clinical use in implant dentistry.
3 to 5 years, new advancements are now being brought to Chapter 3 is the first surgical chapter and is dedicated to
our field every year. Today, implant dentistry is perhaps the extraction socket management. A brief overview of dimen-
most widely researched discipline in our field and mandates sional changes occurring postextraction is presented, and there-
that clinicians stay updated on current trends and protocols. after clinical guidelines with step-by-step protocols are covered.
With the number of advancements made in digitally based Discussion of the use of various biomaterials and their ability
media and marketing, it is imperative that the clinician be able to minimize dimensional changes postextraction in both the
to separate new trends from evidence-based protocols. It is esthetic and nonesthetic zones is provided. Furthermore, proto-
without question that the goal of every clinician is that each cols for ridge preservation in the absence of buccal/lingual
patient be treated with the best possible outcome in mind. As plates are included as well as an introduction to the concept
such, we should strive to implement rational evidence-based and clinical indication for “socket shield” therapy.
decisions grounded on available literature to allow us to make Chapter 4 covers the topic of alveolar ridge augmentation.
sound and predictable choices.The goal of this textbook is to Specific indications and a description of patient selection
share my clinical experiences, both successes and failures, with criteria, step-by-step surgical procedures, and aspects of
my colleagues to facilitate learning through documented cases postoperative treatment are presented. This chapter also
that I have performed over the past 35+ years. includes background information on guided bone regener-
To accomplish this, this textbook has been separated into six ation, intraoral bone harvesting techniques, horizontal and
core chapters. Each clinical case is supplemented with italicized vertical alveolar ridge augmentation procedures in maxil-
personal notes describing learned experiences from each case, lary/mandibular posterior and anterior regions, ridge split
clinical tips and pearls from that case, technical notes geared techniques, and vestibuloplasty. The numerous complica-
toward facilitating the reader’s clinical ability to perform simi- tions faced during any of the above-mentioned procedures
lar cases/techniques, as well as in-depth analysis and critical are also discussed with solutions to such encounters.
evaluation on how I would perform each case today (many Chapter 5 focuses on sinus grafting. First, the history of
of the cases were performed 10+ years ago).Two chapters are sinus grafting is presented with an overview of anatomical
dedicated to biomaterials and instruments utilized for bone considerations. Clinical and radiographic assessment is then
augmentation protocols and form the basis for the bioma- considered with detailed discussion of the lateral window
terials and surgical instrumentation utilized throughout the versus crestal protocol utilized for specific clinical indica-
surgical chapters. It is clear that the number of changes made tions. Emphasis in this chapter includes instrumentation for
in material design/instrumentation has facilitated (and in many sinus grafting, incision design and flap management, graft
cases improved) the ability of clinicians to perform surgical selection and placement, the use of osseodensification tech-
procedures. Parallel to this and equally as important, a great nology, as well as protocols for sinus membrane repair. Both
deal of advancement has been made in biomaterial sciences. one- and two-stage protocols are discussed with cases shown
While biomaterials were once considered to act as a passive for single-tooth, multiple-tooth, and fully edentulous arches.
structural material aimed at filling voids, today they act as bioac- The final section of this chapter covers numerous potential
tive molecules responsible for rapidly stimulating new tissue complications faced during sinus grafting and their resolution.
vi
Lastly, chapter 6 covers full-arch reconstruction utilizing remains difficult to assess and scientifically critique many of
conventional conversion protocols and newer fully guided these newer protocols without proper long-term follow-up.
immediate-reconstruction protocols in a detailed step-by- Having practiced implant dentistry for more than 35 years,
step manner utilizing the nSequence patented technology. I consider follow-up times of 1 year, 5 years, and 10 years to
My hope is that through the numerous cases presented be immeasurably important. This book focuses exclusively
throughout this textbook, clinicians will be better able to on the protocols that have been developed over numerous
implement evidence-based clinical decisions that will lead years with established long-term follow-ups to provide the
to predictable bone augmentation results and long-term reader with a set of surgical guidelines and principles with
success.We live in an age where information can be obtained predictable long-term documented outcomes. Furthermore,
through social media at an ever-increasing speed. Clinicians an online video series available at www.pikosonline.com will
are now free to post cases directly to social media following supplement the book to further guide the clinician with
surgery and obtain nearly live feedback on their work. This surgical demonstrations provided within our online teaching
provides the clinician and reader with direct responses to library. I sincerely hope that these videos in conjunction with
their surgical work; however, with the number of new tech- the content of this book will provide an enjoyable learning
niques and protocols being utilized and promoted online, it experience, and I look forward to your future feedback.
Acknowledgments My fellow clinicians and staff whom I have had the honor
of working with during my 36 years of private practice.
Although the acknowledgments are typically found in the The thousands of clinicians whom I have had the honor
first pages of a book, they are usually the last piece to be and privilege to meet both at my Institute and from main
written. And for good reason, as they allow the author to podium lectures throughout the world.
reflect on those individuals who have contributed in one The thousands of patients for entrusting me with their
way or another to its completion. implant surgical care over all these years.
For the development and production of this book, I owe Rick Miron, an awesome, highly intelligent, yet so humble
a deep sense of gratitude to the following people: colleague and friend without whose help this book would
My incredible and selfless wife Diane, daughter Lindsey, and definitely not be possible.
son Tony for sacrificing our time together and for their uncon- The entire team at Quintessence Publishing, including
ditional love, support, and encouragement during all these years. Leah Huffman (Senior Editor), Angelina Schmelter (Digital
My beloved mother Mary, and to the joyous memory & Print Production Specialist), Bryn Grisham (Director of
of my father Anthony, both of whom provided for me a Book Publications), and especially William Hartman (Execu-
sound spiritual-based and loving environment with solid tiveVice President & Director).This book certainly has been
core values from which to grow. improved many times over, and I thank each of you for your
The many teachers and mentors who have so impacted dedication, patience, and helpfulness leading to its completion.
my life and career, with special thanks to Carl Misch, Tom And Almighty God for blessing me with a profession that
Golec, Leonard Linkow, Hilt Tatum, P.D. Miller, and Pat Allen. I have had such great passion for, and more importantly for
My Institute team—Alison Thiede, Kali Kampmann, giving me the skill sets necessary to help transform people’s
Mark Robinson, and Roger Hemond—for their uncon- lives on a daily basis.
ditional commitment to excellence.
vii
Instrumentation
for
Alveolar Ridge
Augmentation and
Sinus Grafting
CBCT
In the last decade, the use of 3D CBCT has dramatically
increased.1,2 When computed tomography was first intro-
duced (mainly in implantology), its use was limited to a small
number of specialists, due primarily to its limited indications,
high costs, and elevated dose of radiation. In the late 1990s,
a new technology using a “cone beam” and a reciprocat-
ing detector, which rotates around the patient 360 degrees,
entered the dental implant field, making high-definition 3D
scans easily accessible to dentists and their patients. b
By 2005, I began utilizing CBCT technology in my own
private practice and teaching institution. Because my prac- dentoalveolar structures led to its more frequent use owing
tice has been limited to implant reconstruction for the past to its higher safety standards. Today, all patients within my
25 years, I require ALL of my patients to have a CBCT scan, practice requiring implant dentistry or bone augmenta-
as this 3D technology plays an integral role in overall diag- tion procedures must have a CBCT image taken prior to
nosis and treatment planning. CBCT has seen widespread implant therapy, bone augmentation, or sinus augmentation
use in all fields of dentistry, including implantology, oral in order to fully characterize anatomical features/abnor-
surgery, endodontics, and orthodontics.1,2 malities and diagnose potential pathology. Furthermore,
One of the major breakthroughs in CBCT technology the use of CBCT for postgraft evaluation prior to implant
was the ability to use significantly smaller doses of radia- placement has become routine.
tion when compared to conventional films.1,2 The estab- Carestream Dental provides a high-quality CBCT system
lishment of sensitive radiographic techniques for assessing with state-of-the-art features3 (Fig 1-1). Advantages of the
system include the ability to perform all necessary exam- the leaders in the field, and together we have codeveloped
inations with one system (CS 9600 family). Image reso- many specific trays for implant surgery (Fig 1-3), soft tissue
lution can reach up to 75 μm (sizes up to 16 × 17 cm), grafting (Fig 1-4), block grafting (Fig 1-5), and sinus grafting
ideal for a wide range of applications from implantology to (Fig 1-6). Each kit contains various useful instruments that
oral surgery, orthodontics, and endodontics (Fig 1-2).These have assisted our team in surgery.
features will only further improve over time. Low-dose Nevertheless, each instrument must be chosen according
imaging modes are also possible with 3D image quality, to the treating surgeon’s preference. For example, one instru-
utilizing lower doses of radiation when compared to tradi- ment used specifically when dealing with full-arch cases is
tional panoramic radiographs. Box 1-1 provides a list of the right-angle torque wrench (Salvin AccessTorq Right
relevant features of the system. AngleVariable Torque Driver), with adjustable Ncm features
from 10 to 35 Ncm (Fig 1-7). This instrument is valuable
for hard-to-reach areas. Another tool frequently utilized in
large bone augmentation procedures is the Pro-fix Preci-
Hand Instruments sion Fixation System (Osteogenics).4,5 This system includes
self-drilling membrane fixation screws, self-drilling tent-
Hand instruments are widely utilized within any dental office, ing screws, and self-tapping bone fixation screws (Fig 1-8),
with various companies now promoting sales of their indi- shown in a number of bone augmentation procedures in
vidual items. Salvin Dental has been recognized as one of chapter 4.
Fig 1-3 The Pikos implant surgical kit: Quinn Type Periosteal Elevator, 2 Fig 1-4 The Pikos soft tissue grafting instrumentation kit: UNC Perio Probe,
Minnesota Retractors, Jacobson Long Castroviejo Needle Holder, Seldin Frazier 3mm Surgical Aspirator, Siegel Round Scalpel Handle, Handle For
Retractor, Dean Scissor, Siegel Round Scalpel Handle, Adson 1×2 Tissue Bendable Micro Blades, Bendable Micro Blades–Nordland #69 (Box of 6),
Forceps, Adson Serrated Tissue Forceps, Gerald Micro Surgical Tissue Quinn Type Periosteal Elevator, Adson 1×2 Tissue Forceps, Adson Serrated
Forceps–Serrated, Gerald Micro Surgical Tissue Forceps–1×2, Kelly Curved Tissue Forceps, Gerald Micro Surgical Tissue Forceps–Serrated, Gerald
Hemostat, Crile-Wood Needle Holder, Castroviejo Micro Scissors–Curved, Micro Surgical Tissue Forceps–1×2, Rhodes Chisel, Gracey 11/12 Curette,
Periotome Straight, Molt Mouth Gag, Weider Tongue Retractor, Castroviejo Kelly Curved Hemostat, Corn Plier, Crile-Wood Needle Holder, Dean
Caliper, Friedman Rongeur, 10×6 Instrument Cassette, 10×6 Instrument Scissor, Micro Needle Holder, Castroviejo Micro Scissors, 10×6 Instrument
Deep Cassette. (Courtesy of Salvin Dental.) Cassette, 10×6 Instrument Deep Cassette. (Courtesy of Salvin Dental.)
Fig 1-5 The Pikos bone block grafting instrumentation kit: Tatum “D” Fig 1-6 The Pikos sinus elevation kit: Set of 5 Sinus Curettes (#1, #5, Freer,
Shaped Spreader #3,Tatum “D” Shaped Spreader #4, 6mm Cottle Curved Pikos #7, Pikos #8), Graft Material Packer–Double Ended, Bone Spoon /
Chisel, 6mm Sheehan Straight Chisel, Pikos Ramus Retractor, Quinn Type 4mm Graft Packer Combination, Stainless Steel Organizing Cassette. (Cour-
Periosteal Elevator, Siegel Round Scalpel Handle, Castroviejo Caliper–Short, tesy of Salvin Dental.)
Pikos Block Grafting Bur Kit, 1.5mm Wire Passing Bur, Stainless Steel Orga-
nizing Cassette. (Courtesy of Salvin Dental.)
Osstell IDx
The value of the Osstell system is that it helps clinicians
objectively determine implant stability and assess the
progress of osseointegration6–12 (Fig 1-9), with many peer-
reviewed research articles supporting its use. It is a fast, easy,
and reliable way to provide accurate and objective informa-
tion needed to proceed with implant loading. My cases are
routinely tested for ISQ values to assess implant stability. ISQ
values may potentially reduce treatment time, better manage
risk, and offer an ability to better communicate findings
with patients. The Osstell system allows for the quick and
easy identification of which implants are ready for loading
and which need additional healing time in an objective way,
with hundreds of publications now supporting its use.6–14 Fig 1-11 Use of the Ellman Surgitron device to cauterize a blood vessel
following flap elevation.
Piezosurgery Device direction (Fig 1-13).The device comes with more than 100
different tips characterized by their ability to seamlessly and
One of the most widely utilized new tools in implant efficiently cut bone all while being capable of differentiat-
dentistry over the past decade has been the Piezosurgery ing between hard and soft tissues.These features have been
device (Fig 1-12). More specifically, Mectron’s dual-wave demonstrated to decrease the risk of damage to important
technology has been frequently cited owing to its patented anatomical structures such as nerves and membranes. Piezo-
technology overcoming the limitations of single wave.17 surgery has been shown to clinically lower the rate of sinus
Work pioneered by Professor Tomaso Vercellotti in Italy membrane perforations and has also been frequently utilized
demonstrated that a primary wave between 24 and 36 kHz during ridge split procedures and harvesting of bone blocks
modulated by a secondary low-frequency wave from 30 to (Fig 1-14). The author utilizes piezosurgical technology on
60 Hz could be utilized to efficiently maximize bone cutting a daily basis for a variety of bone-based surgical procedures
while preventing overheating and necrosis.18–21 The Piezo- that include but are not limited to the following: sinus graft-
surgery handpiece is therefore a high-frequency electrical ing, ridge splitting, harvesting autogenous bone blocks, and
impulse unit with micrometric movement of approximately recipient site preparation for bone grafts.
80 µm in the horizontal amplitude and 5 µm in the vertical
a b
Fig 1-14 (a and b) Use of a Piezosurgery device to harvest a symphysis bone block.
Fig 1-15 Group of 12 OD burs (Versah) utilized during crestal sinus augmentation procedures to compact bone.
Versah Burs Bone has long been considered an ideal tissue in the
body because it is flexible, changing shape via deformation
The use of OD burs has also substantially improved our (without necessarily breaking/cracking), can withstand and
ability to obtain primary stability in low-density bone (Fig widen during compression, and is able to lengthen during
1-15).The biomechanical stability of implants has typically tension.23
been dependent on several factors, including implant macro Bone is typically prepared prior to implant placement
and micro design as well as the quality and quantity of utilizing standard drill burs. Because fresh, hydrated trabecu-
surrounding bone.22 Several protocols have been identified lar bone is a ductile material, it has a good capacity for plastic
to increase implant primary stability over the years: deformation. Osseodensification is essentially a burnishing
process that redistributes bone material on the bony surface
• Drilling protocol: underpreparation of osteotomy through plastic deformation.The counterclockwise rotation
• Implant type: macrotexture and microtexture of OD burs causes the lands of the bur to slide across the
• Longer implants providing greater bone-to-implant surface of the bone via low plastic deformation; these burs
contact (BIC) are purposefully designed with a compressive force less than
• Techniques for osseocondensation of bone the ultimate strength of bone. As a result, OD burs have
SD ED OD
several reported advantages. First, they create live, real-time laterally compresses bone during the continuously rotating
haptic feedback that informs the surgeon if more or less and concurrently advancing bur. This facilitates “compaction
force is needed, allowing the surgeon to make instanta- autografting” or “osseodensification.” During this process,
neous adjustments to the advancing force depending on the bone debris is redistributed up the flutes and is pressed into
given bone density.These burs rotate in a counterclockwise the trabecular walls of the osteotomy24 (Fig 1-16).The auto-
direction and do not “cut” as expected with conventional grafting supplements the basic bone compression, and the
burs. They therefore densify bone (D3, D4) by rotating in condensation effect acts to further densify the inner walls
the noncutting direction (counterclockwise at 800–1,200 of the osteotomy.25 Trisi et al were one of the first to study
rotations per minute). It has been recommended by the the OD technique in an animal model.25 It was found that
manufacturer that copious amounts of irrigation fluid be OD burs increased the percentage of bone density/BIC
used during this procedure to provide lubrication between values around dental implants inserted in low-density bone
the bur and bone surfaces and to eliminate overheating. compared with conventional implant drilling techniques25
OD burs have been shown to produce compression waves, (Fig 1-17).These burs are highlighted primarily in chapter
where a large negative rake applies outward pressure that 5 under sinus augmentation procedures.
Conclusion 7. Shin SY, Shin SI, Kye SB, et al.The effects of defect type and depth, and
measurement direction on the implant stability quotient (ISQ) value. J
Oral Implantol 2015;41:652–656.
The use of novel instruments has facilitated the ability of 8. Yoon HG, Heo SJ, Koak JY, Kim SK, Lee SY. Effect of bone quality and
the clinician to perform more predictable and accurate bone implant surgical technique on implant stability quotient (ISQ) value. J
augmentation and sinus grafting.Today, the use of CBCT has Adv Prosthodont 2011;3:10–15.
9. Baldi D, Lombardi T, Colombo J, et al. Correlation between insertion
been shown to markedly improve diagnostics and treatment torque and implant stability quotient in tapered implants with knife-
planning in implant dentistry, and it is something I consider edge thread design. Biomed Res Int 2018;2018:7201093.
a necessity and standard for the field. In addition to hand 10. Bruno V, Berti C, Barausse C, et al. Clinical relevance of bone density
instruments that have been utilized and further refined over values from CT related to dental implant stability:A retrospective study.
Biomed Res Int 2018;2018:6758245.
the years, new instrumentation has become available. This 11. Buyukguclu G, Ozkurt-Kayahan Z, Kazazoglu E. Reliability of the
includes but is not limited to radiosurgery, Piezosurgery, Osstell implant stability quotient and Penguin resonance frequency
Osstell ISQ implant stability devices, and OD burs, all of analysis to evaluate implant stability. Implant Dent 2018;27:429–433.
which can be utilized on a routine basis for alveolar ridge 12. Nakashima D, Ishii K, Matsumoto M, Nakamura M, Nagura T. A study
on the use of the Osstell apparatus to evaluate pedicle screw stability:An
augmentation and sinus grafting in implant dentistry.While in-vitro study using micro-CT. PLoS One 2018;13:e0199362.
their introduction was brief in this chapter, their use is 13. Balleri P, Cozzolino A, Ghelli L, Momicchioli G, Varriale A. Stability
further highlighted in the clinical chapters of this textbook. measurements of osseointegrated implants using Osstell in partially
edentulous jaws after 1 year of loading:A pilot study. Clin Implant Dent
Furthermore, as the field continues to advance rapidly,
Relat Res 2002;4:128–132.
new devices will certainly be brought to market in the 14. Sim CP, Lang NP. Factors influencing resonance frequency analysis
coming years. For a current list of the tools and instruments assessed by Osstell™ mentor during implant tissue integration: I. In-
utilized for alveolar ridge augmentation in my practice and strument positioning, bone structure, implant length. Clin Oral Implants
Res 2010;21:598–604.
guidelines for their use, a detailed and up-to-date description 15. Sherman JA. Oral Radiosurgery: An Illustrated Clinical Guide, ed 2.
is provided at www.pikosonline.com. London: Martin Dunitz, 1997.
16. Sharma S, Gambhir R, Singh S, Singh G, Sharma V. Radiosurgery in
dentistry: A brief review. Ann Dent Res 2014;2:8–21.
17. Vercellotti T, Nevins ML, Kim DM, et al. Osseous response following
References
resective therapy with Piezosurgery. Int J Periodontics Restorative Dent
2005;25:543–549.
18. Vercellotti T, De Paoli S, Nevins M.The piezoelectric bony window
1. Scarfe WC,Angelopoulos C (eds). Maxillofacial Cone Beam Computed osteotomy and sinus membrane elevation: Introduction of a new tech-
Tomography: Principles, Techniques and Clinical Applications. New nique for simplification of the sinus augmentation procedure. Int J
York: Springer, 2018. Periodontics Restorative Dent 2001;21:561–567.
2. Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed 19. Vercellotti T. Piezoelectric surgery in implantology: A case report—A
tomography in implant dentistry: The International Congress of Oral new piezoelectric ridge expansion technique. Int J Periodontics Re-
Implantologists consensus report. Implant Dent 2012;21:78–86. storative Dent 2000;20:358–365.
3. Ludlow J,Timothy R,Walker C, et al. Effective dose of dental CBCT—A 20. Vercellotti T, Nevins ML, Kim DM, et al. Osseous response following
meta analysis of published data and additional data for nine CBCT units. resective therapy with piezosurgery. Int J Periodontics Restorative Dent
Dentomaxillofac Radiol 2014;44:20140197. 2005;25:543–549.
4. Urban I, Jovanovic SA, Buser D, Bornstein MM. Partial lateralization of 21. Vercellotti T, Pollack AS. A new bone surgery device: Sinus grafting and
the nasopalatine nerve at the incisive foramen for ridge augmentation in periodontal surgery. Compend Contin Educ Dent 2006;27:319–325.
the anterior maxilla prior to placement of dental implants: A retrospec- 22. Meyer U,Vollmer D, Runte C, Bourauel C, Joos U. Bone loading pat-
tive case series evaluating self-reported data and neurosensory testing. tern around implants in average and atrophic edentulous maxillae: A
Int J Periodontics Restorative Dent 2015;35:169–177. finite-element analysis. J Craniomaxillofac Surg 2001;29:100–105.
5. Chan HL, Benavides E,Tsai CY,Wang HL.A titanium mesh and partic- 23. Seeman E. Bone quality: The material and structural basis of bone
ulate allograft for vertical ridge augmentation in the posterior mandible: strength. J Bone Miner Metab 2008;26:1–8.
A pilot study. Int J Periodontics Restorative Dent 2015;35:515–522. 24. Huwais S, Meyer EG.A novel osseous densification approach in implant
6. Herrero-Climent M, Santos-García R, Jaramillo-Santos R, et al. osteotomy preparation to increase biomechanical primary stability, bone
Assessment of Osstell ISQ’s reliability for implant stability measure- mineral density, and bone-to-implant contact. Int J Oral Maxillofac
ment: A cross-sectional clinical study. Med Oral Patol Oral Cir Bucal Implants 2017;32:27–36.
2013;18:e877–e882. 25. Trisi P, Berardini M, Falco A, PodaliriVulpiani M. New osseodensification
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bone: In vivo evaluation in sheep. Implant Dent 2016;25:24–31.
Membranes,
Grafting Materials,
and
Growth
Factors
11
Nonresorbable membranes
Space-making Compatibility
Nonresorbable membranes include expanded (ePTFE),
high-density (dPTFE), and titanium-reinforced (PTFE-TR)
membranes and titanium meshes (Ti mesh).39 A number of
animal studies involving various defect configurations as well
as histologic data from both animal and human studies have
Mechanical Cell demonstrated higher tissue regeneration with their use.40
strength occlusivity Nonresorbable membranes have several advantages
and disadvantages. Their main advantage is their superior
rigidity over resorbable collagen-based membranes. Their
main disadvantage is the requirement for a second surgical
Degradability
timeline intervention to remove the barrier after implantation,41
which bears the potential for re-injuring and/or compro-
mising the obtained regenerated tissue. However, clinical
indications presented later in this textbook demonstrate
Fig 2-2 The ideal barrier membrane for GBR procedures needs to fulfill
the following criteria: biocompatibility, space-making ability, cell occlusivity
various applications where their use is pivotal because of
to prevent epithelial tissue downgrowth, ideal mechanical strength, and their superior strength.41 In general, more recent nonre-
optimal degradation properties. sorbable membranes are effectively biocompatible and
offer the added ability to maintain sufficient space in the
membrane for longer periods when compared to resorbable
membranes. They have a more predictable profile during
the healing process because of their better mechanical
Requirements of barrier membranes strength, and their handling has been made easier over
for GBR the years.42
While the first successful barrier membrane was a cellulose PTFE membranes
acetate laboratory filter by Millipore,12 since then a wide PTFE membranes were first introduced to dentistry in 1984.
range of new membranes have been designed with better Prior to that, these membranes were utilized clinically for simi-
biocompatibility for various clinical applications. Each of lar applications in general medicine as a vascular graft mate-
these membrane classes possesses distinct advantages and rial for hernia repair.43,44 Each side of the porous structure of
disadvantages. As a medical application in dentistry, barrier ePTFE has its own features45: On one side, an open micro-
membranes should fulfill some fundamental requirements structure collar 1 mm thick and with 90% porosity retards
(Fig 2-2): the growth of the epithelium during the early wound healing
phase; on the other side, a 0.15-mm-thick and 30% porous
• Biocompatibility: The interaction between membranes and membrane provides space for new bone growth and acts to
host tissue should not induce a foreign body response. prevent fibrous ingrowth.The average healing period after in
• Space-making: The ability to maintain a space for cells vivo implantation is approximately 3 to 9 months depending
from surrounding bone tissue for a specific time duration. on the clinical application.
• Cell occlusivity: Prevents fibrous tissue that delays bone The advantages of dPTFE membranes (Fig 2-3), which
formation from invading the defect site. feature 0.2-µm pores, are that they do not require primary
• Mechanical strength: Proper physical properties to allow closure and have been widely utilized for ridge preservation
and protect the healing process, including protection of therapies following extraction16 (Fig 2-4). Compared with
the underlying blood clot. the conventional ePTFE, dPTFE membranes demonstrate
• Degradability: Adequate degradation time matching the lower rates of infection and are easily removed. dPTFE
regeneration rate of bone tissue, avoiding a secondary membranes may also be reinforced with titanium (Fig 2-5).
surgical procedure to remove the membrane. These membranes are excellent choices for large GBR
12
Commercial name
Type (manufacturer) Material Properties Comments
Good space maintainer; easy
GORE-TEX (W. L. Gore) ePTFE Longest clinical experience13,14
to handle
Titanium should not be ex-
Most stable space maintainer;
GORE-TEX-TI (W. L. Gore) ePTFE-TR posed; commonly used
filler material unnecessary
in ridge augmentation15
High-density GORE-TEX
dPTFE 0.2-μm pores Avoid a secondary surgery16
(W. L. Gore)
Cytoplast Primary closure
dPTFE 0.3-μm pores
(Osteogenics) unnecessary17
TefGen-FD
Non- dPTFE 0.2- to 0.3-μm pores Easy to detach18
(Lifecore Biomedical)
resorbable
membranes Nonresorbable ACE
dPTFE < 0.2-μm pores; 0.2 mm thick Limited cell proliferation19
(ACE Surgical Supply)
Titanium Augmentation
Micro Mesh (ACE Surgical Titanium mesh 1,700-µm pores; 0.1 mm thick Ideal long-term survival rate20
Supply)
Tocksystem Mesh 0.1- to 6.5-µm pore; Minimal resorption and
Titanium mesh
(Tocksystem) 0.1 mm thick inflammation21
Frios BoneShields
Titanium mesh 0.03-mm pores; 0.1 mm thick Sufficient bone to regenerate21
(Dentsply Friadent)
OSSIX (OraPharma) Porcine 1 Resorption: 16–24 weeks Increases the woven bone37
ePTFE-TR, titanium-reinforced ePTFE; dPTFE, dense PTFE; M-TAM, micro titanium augmentation mesh. (Reprinted with permission from
Miron and Zhang.38)
13
a b
a b
Fig 2-4 Use of a dPTFE membrane for socket grafting. Fig 2-5 A dPTFE membrane reinforced with titanium (Cytoplast Titanium-
Reinforced) for improved mechanical strength in single-tooth cases with a facial plate.
14
a b
Fig 2-7 (a and b) Titanium meshes are adapted according to the defect morphology. Typically two 5-mm Pro-fix screws (Osteogenics) are utilized for
both facial and lingual fixation.
a b
Fig 2-8 (a and b) Type 1 crosslinked bovine collagen membrane (Mem-Lok Pliable, BioHorizons). The prime advantage of collagen membranes is their
superior biocompatibility.
to close lateral windows (Fig 2-9). The main disadvantage formation.25 A list of clinically available membranes as well
of resorbable membranes are their varied and sometimes as their resorption times is presented in Table 2-1.
unpredictable resorption rates, which directly affect bone
15
a b
c d
Fig 2-10 SEM analysis of a collagen barrier membrane at three magnifications. (a and b) Membrane surface reveals many collagen fibrils that are inter-
twined with one another with various diameters and directions (original magnification ×50 and ×200, respectively). (c) High-resolution SEM demonstrating
collagen fibrils ranging in diameter from 1 to 5 μm (original magnification ×1,600). (d) Cross-sectional view of a collagen barrier membrane at approximately
300 μm (original magnification ×100). (Reprinted with permission from Miron et al.51)
Synthetic resorbable membranes cycle. For these reasons, synthetic resorbable membranes
A series of resorbable membranes mainly consisting of poly- generally cause a higher inflammatory response, and their
esters—eg, polyglycolic acid (PGA), polylactic acid (PLA), use has not been widespread in alveolar bone reconstruc-
and poly-ε-caprolactone (PCL)—and their copolymers are tion procedures.
also available.46 Aliphatic polyesters, such as polyglycolide
or polylactide, are derived from a variety of origins and can Membranes based on natural materials
be made in large quantities with a wide spectrum, offer- The highest number of reported clinical studies involves
ing different physical, chemical, and mechanical properties. the use of biodegradable resorbable membranes from natu-
Interestingly, the resorption of various membranes occurs ral collagen (see Table 2-1). Membranes based on natural
via different pathways. In a review paper on this subject,47 collagen are typically derived from human skin, bovine
Tatakis et al demonstrated that a large majority of collagen achilles tendon, or porcine skin and can be characterized
membranes are resorbed by enzymatic activity of infiltrat- by their excellent cell affinity and biocompatibility.48,49 The
ing macrophages and polymorphonuclear leukocytes, while main drawbacks of these membranes are their potential
polymers are typically degraded through hydrolysis, and the for losing their space-maintenance ability under physio-
degradation products are metabolized through the citric acid logic conditions, higher cost, and potential introduction of
16
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.