See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/51439318

Consensus Statements and Recommended Clinical Procedures Regarding

Surgical Techniques

Article in The International journal of oral & maxillofacial implants · January 2009
Source: PubMed

CITATIONS READS

137 4,617

5 authors, including:

Stephen T Chen Jay R Beagle

University of Melbourne University of Kentucky
63 PUBLICATIONS 8,281 CITATIONS 25 PUBLICATIONS 860 CITATIONS

SEE PROFILE SEE PROFILE

Simon Storgård Jensen Matteo Chiapasco

University of Copenhagen University of Milan
84 PUBLICATIONS 4,302 CITATIONS 109 PUBLICATIONS 7,320 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Simon Storgård Jensen on 11 April 2014.

The user has requested enhancement of the downloaded file.

272_4e_Chen.qxd 9/15/09 12:41 PM Page 272

Group 4 Consensus Statements

Consensus Statements and Recommended Clinical

Procedures Regarding Surgical Techniques
Stephen T. Chen, BDS, MDSc, PhD1/Jay Beagle, DDS, MSD2/Simon Storgård Jensen, DDS3/
Matteo Chiapasco, MD4/Ivan Darby, BDS, PhD, FRACDS(Perio)5

INTRODUCTORY REMARKS review papers. At the conference, these review papers

were thoroughly critiqued by an international group
Techniques and biomaterials associated with the sur- of specialists in periodontics, oral and maxillofacial
gical placement of dental implants continue to surgery, and prosthodontics, each with particular clini-
develop and have facilitated the expansion of clinical cal expertise and research experience. First, the group
indications for implant therapy. However, the variety was asked to consider whether the review papers
of procedures and biomaterials available can create a were valid methodologically and whether the conclu-
confusing picture for the implant surgeon who has sions drawn were a fair reflection of the evidence
the responsibility for recommending the most appro- available. Second, additional contributions by group
priate surgical approach with the lowest risk of com- members were called for and the manuscripts were
plications and morbidity to the patient. The aim of amended if deemed appropriate. Third, preliminary
group 4 was to review the surgical techniques and consensus statements and clinical recommendations
biomaterials used in current practice, and to evaluate were drafted and presented to the plenum. Comments
the evidence supporting the use of these procedures. and recommendations were received from the
Fourteen months prior to the conference, four plenum, and a final set of consensus statements and
groups of researchers prepared comprehensive review clinical recommendations were prepared.
papers on four different topics: (1) clinical and esthetic
outcomes of implants placed in postextraction sites, Disclosure
(2) bone augmentation procedures in localized defects All the group members were asked to reveal any con-
in the alveolar ridge with different bone grafts and flicts of interest potentially influencing the outcomes of
bone substitute materials, (3) bone augmentation pro- the consensus work. No such conflicts were identified.
cedures in extended defects in the alveolar ridge, and
(4) ridge preservation techniques for implant therapy.
The reviewers were asked to review the literature in a IMPLANTS IN POSTEXTRACTION SITES
systematic manner, to consider all levels of evidence
except for expert opinion, and to prepare narrative The following consensus statements and clinical rec-
ommendations are derived from the review paper by
Chen and Buser, as well as that of Darby et al (on
1Senior Fellow, Periodontics, School of Dental Science, University ridge preservation techniques).
of Melbourne, Parkville, Victoria, Australia.
2Private Practice, Indianapolis, Indiana, USA.
Definition of Terms
3Consultant Oral and Maxillofacial Surgeon, Department of Oral
At the 3rd ITI Consensus Conference in 2003, it was
and Maxillofacial Surgery, Copenhagen University Hospital
Glostrup, Glostrup, Denmark.
recognized that descriptive terms for the time points
4Professor and Head, Unit of Oral Surgery, Department of Medi- for implant placement after tooth extraction encoun-
cine, Surgery, and Dentistry, San Paolo Hospital, University of tered in the dental literature were imprecise, and
Milan, Milan, Italy. therefore open to interpretation. A classification sys-
5Associate Professor, Periodontics, School of Dental Science,
tem for timing of implant placement after tooth
University of Melbourne, Parkville, Victoria, Australia.
extraction was therefore proposed, based on desired
Correspondence to: Dr Stephen Chen, 223 Whitehorse Road, clinical outcomes during healing rather than on
Balwyn, VIC 3103, Australia. Fax: +61 3 9817 6122. Email: descriptive terms or rigid time frames following
schen@balwynperio.com.au extraction.1 In this classification system, type 1 refers
These statements are part of the Proceedings of the Fourth ITI Con-
to the placement of an implant into a tooth socket
sensus Conference, sponsored by the International Team for Im- concurrently with the extraction; type 2 refers to the
plantology (ITI) and held August 26–28, 2008, in Stuttgart, Germany. placement of an implant after substantial soft tissue

272 Volume 24, Supplement, 2009

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 273

Group 4: Consensus Statements

Table 1 Advantages and Disadvantages of the Various Time Points for Implant Placement After Tooth Extraction
Classification Advantages Disadvantages

Type 1 • Extraction and implant placement are combined in the same surgical procedure • Morphology of the site may increase the difficulty of placing
• Reduced overall treatment time compared to types 2, 3, and 4 an implant in an ideal position
• Peri-implant defects often present as two- or three-walled defects, which • Morphology of the site may compromise initial implant stability
are favorable for simultaneous bone augmentation procedures • Lack of soft tissue volume makes attainment of tension-free
primary closure more difficult
• Increased risk of marginal mucosal recession
• Inability to predict bone modeling may compromise outcomes
Type 2 • Reduced treatment time • Two surgical procedures are required
• Additional soft tissue volume allows for easier attainment of tension-free closure • Morphology of the site may compromise initial implant stability
• Additional soft tissue volume may enhance soft tissue esthetic outcomes
• Flattening of facial bone contours facilitates grafting of the facial
surface of the bone
• Peri-implant defects often present as two- or three-walled defects, which
are favorable for simultaneous bone augmentation procedures
• Allows for resolution of pathology associated with the extracted tooth
Type 3 • Partial bone healing usually allows implant stability to be more readily attained • Two surgical procedures are required
• Additional soft tissue volume allows for easier attainment of tension-free closure • Extended treatment time as compared to type 1 and
• Additional soft tissue volume may enhance soft tissue-esthetic outcomes type 2 placement
• Peri-implant defects often present as two- or three-walled defects, which are • Socket walls exhibit varying amounts of resorption
favorable for simultaneous bone augmentation procedures • Increased horizontal bone resorption may limit the volume of
• Flattening of facial bone contours facilitates grafting of the facial surface bone for implant placement
of the bone
• Allows for resolution of pathology associated with the extracted tooth
Type 4 • Bone healing usually allows implant stability to be readily attained • Two surgical procedures are required
• Additional soft tissue volume allows for easier attainment of tension-free closure • Extended treatment time compared to type 1, type 2,
• Additional soft tissue volume may enhance soft tissue esthetic outcomes and type 3 placement
• Allows for resolution of pathology associated with the extracted tooth • Socket walls exhibit greatest amounts of resorption
• Greatest chance of increased bone resorption limiting the
volume of bone for implant placement

healing has taken place, but before any clinically sig- Healing and Regenerative Outcomes
nificant bone fill occurs within the socket; type 3 is Modeling of the ridge after extraction continues to
placement of an implant following significant clinical occur following implant placement. Bone augmenta-
and/or radiographic bone fill of the socket; and type 4 tion procedures are effective in promoting bone
is placement of the implant into a fully healed site. regeneration with immediate and early implant
In spite of this new classification system, descrip- placement. Bone augmentation procedures may
tive terms have remained in use since 2003. There- compensate for modeling changes and may improve
fore, to avoid ambiguity and misinterpretation of the ridge contours. Bone augmentation procedures are
various time points for implant placement after tooth more successful with immediate and early implant
extraction, the descriptive terminology in the ITI placement than with late placement.
Treatment Guide, Volume 3, as described above (see
also Table 1 in the review by Chen and Buser) was Survival Outcomes
adopted for this Consensus Conference.2 The survival rates of postextraction implants are high
The following additional terms were defined: and comparable to those of implants placed in
healed sites.
• Postextraction implant placement: Used to collec-
tively describe type 1, type 2, and type 3 implant Esthetic Outcomes
placements. Immediate implant placement is associated with risk
• Early implant placement: Used to collectively of mucosal recession. Risk indicators include thin tis-
describe type 2 and type 3 implant placements. sue biotype, thin facial bone, dehiscence of the facial
• Peri-implant defect: The space between the bone, and malposition of the implant.
exposed implant surface and the inner surface of Based on esthetic indices, 80% of immediate
the walls of a fresh or healing extraction socket. implant sites demonstrate satisfactory outcomes.
• Ridge preservation: A procedure to minimize verti-
cal and horizontal ridge alterations in postextrac-
tion sites.

The International Journal of Oral & Maxillofacial Implants 273

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 274

Chen et al

Ridge Preservation changes of the ridge. As there is minimal bone regen-

Ridge preservation procedures following tooth eration within the socket at this time point, peri-
extraction result in a greater orofacial dimension of implant defects are usually still present. However, the
bone than when no ridge preservation procedures defects usually present with two or three intact walls,
are performed. which are amenable to simultaneous bone augmen-
tation techniques. The lack of bone regeneration
Advantages and Disadvantages of Implant within the socket may increase the difficulty of attain-
Placement Times ing initial stability of the implant. This approach
There are advantages and disadvantages for each of allows pathology associated with the extracted tooth
the time points for implant placement following tooth to resolve prior to implant placement.
extraction that should be carefully considered. These For early implant placement (type 3), partial bone
are described below and summarized in Table 1. healing in the socket usually allows implant stability to
With immediate implant placement (type 1), com- be more readily attained compared to type 1 and type
bining tooth extraction and implant placement 2 placement. The soft tissues are usually fully healed,
reduces the number of surgical procedures that the allowing tension-free closure of the site. The increased
patient needs to undergo. The peri-implant defect volume of soft tissue may enhance soft tissue esthetic
usually presents as a two- or three-walled defect, outcomes. However, it should be noted that modeling
which is amenable to simultaneous bone augmenta- of the bone is more advanced than with type 2
tion techniques. In addition, there is an opportunity to implant placement. The socket walls exhibit varying
attach a provisional restoration to the implant soon degrees of resorption that may limit the volume avail-
after placement so that the patient avoids the need able for implant placement. Peri-implant defects may
for an interim removable prosthesis. However, these still be present, but they are usually reduced in orofa-
advantages are counteracted by the increased techni- cial dimension. Two- and three-walled defects are
cal difficulty of preparing the osteotomy to allow the amenable to simultaneous bone augmentation proce-
implant to be placed with initial stability and in a dures. Flattening of the facial bone facilitates grafting
good prosthetic position. There is also an increased of the facial surface with bone substitutes, a procedure
risk of mucosal recession, which may compromise soft usually necessary for augmentation of ridge contour.
tissue esthetic outcomes. Additional hard and soft tis- With Type 3 placement, the increased time from tooth
sue augmentation procedures are usually required to extraction allows healing of extended pathological
overcome this risk, further increasing the technical defects to take place.
demands of the procedure. Although grafting of the In late implant placement (type 4), the socket walls
peri-implant defect with particulate bone or bone exhibit the greatest amount of resorption. Although
substitutes is readily achieved, grafting of the external the soft tissues are fully healed and manipulation of
surface of the facial bone is more demanding due to the surgical flaps is facilitated, ongoing modeling and
the convexity of the bone wall. If primary soft tissue horizontal resorption increases the risk of there being
closure is required, the lack of soft tissue increases the insufficient bone volume to place the implant. Addi-
difficulty of attaining tension-free closure. Flap tionally, there is a greater risk that peri-implant
advancement may alter the mucogingival line. Clini- defects will present as no- or one-wall defects, com-
cians should be mindful of the fact that bone model- pared to immediate and early implant placement.
ing following tooth extraction is unpredictable. This
may potentially lead to suboptimal bone regenerative Clinical Recommendations
outcomes and unpredictable dimensional changes. • The clinician has the option of placing implants
With early implant placement (type 2), healing of immediately, early, or late following tooth extrac-
the soft tissues increases the volume of mucosa at the tion. The advantages and disadvantages of each
site. This facilitates manipulation of the surgical flaps approach need to be carefully considered in order
and allows flap advancement for partial submergence to reduce the risk of complications. Therefore, to
of the implant or primary closure to be more readily ensure optimum outcomes, a proper risk assess-
achieved. In areas of high esthetic importance, the ment of the patient and site should be under-
increased volume of soft tissue may enhance soft tis- taken. This includes an esthetic risk assessment3 in
sue esthetic outcomes. In the 4- to 8-week period fol- areas of esthetic importance.
lowing tooth extraction, slight flattening of the facial • Whenever implants are placed in postextraction
bone wall is commonly observed. This facilitates graft- sites, the need for regenerative therapy must
ing of the facial surface of the bone with bone substi- always be assessed. Bone augmentation is recom-
tutes possessing low rates of substitution. These mended to compensate for bone modeling, and to
grafts may serve to limit long-term dimensional optimize functional and esthetic outcomes. In all

274 Volume 24, Supplement, 2009

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 275

Group 4: Consensus Statements

four placement protocols the ability to attain pri- General Statements

mary stability in the appropriate restorative posi- There are a variety of augmentation materials avail-
tion is a requirement. Presence of an acute able with different biologic and mechanical proper-
infection is an absolute contraindication. ties, ranging from particulate alloplastic materials to
• Immediate implant placement (type 1) may be intraorally harvested block grafts.
considered in patients and sites with a low esthetic There are a variety of defect situations with increas-
risk profile.3 This includes single-tooth sites with ing complexity, ranging from fenestrations to dehis-
thick tissue biotypes and with thick and intact cences to lateral deficiencies to vertical deficiencies
facial bone walls. including combinations of these.
• Early implant placement with soft tissue healing Survival rates of implants placed in regenerated
(type 2) may be considered in the majority of sites bone after treatment of localized defects in the alveo-
due to an increased volume of soft tissue available. lar ridge are comparable to survival rates of implants
Early implant placement with partial bone healing placed in native bone. It was not possible to demon-
(type 3) may be considered if primary stability of strate the superiority of one augmentation technique
the implant in the correct restorative position can- over another based on implant survival rates.
not be achieved with type 2 placement.
• In sites where extensive bone modeling is antici- Dehiscence and Fenestration-type Defects
pated, late implant placement (type 4) is the least Augmentation of dehiscence and fenestration-type
desirable option. When Type 4 implant placement defects is effective in reducing the amount of
is indicated, ridge preservation procedures using exposed implant surface. Complete resolution of
low-substitution–rate graft materials and mem- dehiscence and fenestration-type defects cannot be
branes are recommended. Such indications predictably accomplished, regardless of which graft-
include the growing patient, where primary stabil- ing protocol is employed.
ity cannot be achieved with type 1, 2, or 3 place- Increased defect fill was observed when the aug-
ments due to anatomical restrictions, or when a mentation procedure included the use of a barrier
delay in implant treatment is anticipated. membrane.
Survival rates of implants placed simultaneously
with augmentation of dehiscence or fenestration-
BONE AUGMENTATION PROCEDURES IN type defects are high.
LOCALIZED ALVEOLAR RIDGE DEFECTS
Horizontal Ridge Augmentation
The following consensus statements and clinical rec- Techniques are available to effectively and predictably
ommendations are derived from the review paper by increase the width of the alveolar ridge. Augmenta-
Jensen and Terheyden. Aspects of this paper dealing tion utilizing autogenous bone blocks with or with-
with sinus floor grafting have been incorporated into out membranes results in higher gains in ridge width
the next section of these consensus statements. and lower complication rates than use of particulate
materials with or without a membrane. Survival rates
Definition of Terms of implants placed in horizontally augmented alveo-
The following definitions were adopted from the lar ridges are high.
Glossary of Oral and Maxillofacial Implants4:
Vertical Ridge Augmentation
• Autograft (synonymous with autogenous graft): Tis- Techniques are available to increase the height of the
sue transferred from one location to another alveolar ridge. However, the predictability is substan-
within the same individual. tially lower and the complication rate substantially
• Allograft: A graft between genetically dissimilar higher than with horizontal ridge augmentation
members of the same species. procedures.
• Xenograft: A graft taken from a donor of another Augmentation utilizing autogenous bone blocks
species. with or without membranes results in higher gains in
• Alloplast: Inorganic, synthetic, or inert foreign ridge height than use of particulate materials with or
material implanted into tissue. without a membrane.
• Dehiscence: A buccal or lingual bone defect in the Survival rates of implants placed in vertically aug-
crestal area extending apically at an implant. mented alveolar ridges are high.
• Fenestration: A buccal or lingual window defect of
either bone or soft tissue, occurring over a root,
implant, or alveolar ridge.

The International Journal of Oral & Maxillofacial Implants 275

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 276

Chen et al

Maxillary Sinus Floor Elevation Using the a screw. The origin may be an autograft, allograft,
Transalveolar Approach alloplast, or xenograft.
Maxillary sinus floor elevation using the transalveolar • Maxillary sinus floor elevation: An augmentation
approach is predictable for augmenting bone in the procedure for the placement of implants in the
posterior maxilla. A variety of grafting materials can posterior maxilla where pnuematization of the
be safely and predictably used, alone or in combina- maxillary sinus and/or vertical loss of alveolar
tion. These materials include autografts, allografts, bone has occurred.
xenografts, and alloplastic materials. At present, it is • Split-ridge technique: An augmentation procedure
not clear whether the introduction of a grafting to increase the width of a narrow residual ridge by
material improves the prognosis. surgically splitting it or expanding it with a series
of osteotomes of increasing diameter.
Clinical Recommendations • Distraction osteogenesis: A surgical process for
• Dehiscence and fenestration-type defects may be reconstruction of skeletal deformities that involves
successfully managed using a particulate autograft, gradual controlled displacement of surgically cre-
allograft, or xenograft covered with a membrane. ated fractures to simultaneously expand soft tis-
• Horizontal ridge augmentations often require the sue and bone volume.
use of an autogenous block graft, which may be
combined with a membrane and/or a particulate
autograft, allograft, or xenograft. General Statements
• Vertical ridge augmentations most often require Several surgical procedures are available and effec-
the use of an autogenous block graft, which may tive for the augmentation of deficient edentulous
be combined with a membrane and/or a particu- ridges, allowing implants to be placed. However,
late autograft, allograft, or xenograft. Despite the most of the studies are retrospective in nature, with
use of an autogenous block graft, elevated rates of small sample sizes and short follow-up periods.
complications and a need for additional grafting Therefore, direct comparisons between studies
have to be anticipated. Even localized vertical bone should not be made and definitive conclusions can-
deficiencies may require advanced surgical proce- not be drawn.
dures like distraction osteogenesis, interpositional
grafts, or onlay grafts from extraoral donor sites. Onlay Bone Grafting of Severely Resorbed
• The clinician should be aware that the obtainable Edentulous Ridges
defect fill decreases and complication rates and Autogenous onlay bone grafting procedures are
need for additional grafting procedures increase effective and predictable for the correction of
with more demanding defect types. The augmen- severely resorbed edentulous ridges to allow implant
tation material should be selected according to placement. Uneventful healing/consolidation of
the biologic and mechanical characteristics grafts taken from intra- and/or extraoral donor sites
needed in the specific clinical situation. occurs in the majority of cases.
• The use of a membrane is indicated whenever a Acceptable survival rates of implants placed in
particulate material is applied. maxillae and mandibles reconstructed with autoge-
nous onlay bone grafts are reported. The survival
rates are slightly lower than those of implants placed
BONE AUGMENTATION PROCEDURES IN in native bone.
EXTENDED ALVEOLAR RIDGE DEFECTS
Maxillary Sinus Floor Elevation Using the
The following consensus statements and clinical rec- Lateral Approach
ommendations are derived from the review paper by Maxillary sinus floor elevation procedures are pre-
Chiapasco et al. These statements also incorporate dictable for augmentation of bone in the posterior
aspects of the review paper by Jensen and Terheyden maxilla. A variety of grafting materials can be safely
that deal with sinus floor grafting. and predictably used, alone or in combination. These
materials include autografts, allografts, xenografts, and
Definition of Terms alloplastic materials. The use of autografts does not
The following definitions were adopted from the influence survival rates of rough-surfaced implants but
Glossary of Oral and Maxillofacial Implants4: may reduce healing times.
The quantity and quality of bone in the residual
• Onlay graft: A graft used in block form and fixed maxilla influence survival rates of implants indepen-
upon the cortical surface of the recipient bed with dently from the type of grafting procedure.

276 Volume 24, Supplement, 2009

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 277

Group 4: Consensus Statements

Survival rates of rough-surfaced implants placed in • Both intraoral donor sites (including the mental
augmented maxillary sinuses are similar to those of symphysis, the mandibular body and ramus, and
implants inserted in native bone. the maxillary tuberosity) and extraoral donor sites
(including the iliac crest and the calvarium) can be
Split-Ridge/Ridge-Expansion Techniques with used for collecting autogenous bone.
Simultaneous Implant Placement • The choice between intraoral and extraoral sites is
Split-ridge and expansion techniques are effective for mainly related to the quantity of bone necessary to
the correction of moderately resorbed edentulous reconstruct the deficient alveolar ridge. Preference
ridges in selected cases. Survival rates of implants should be given to donor sites where the cortical
placed at sites augmented using split-ridge/ridge- component is more prevalent, in order to reduce
expansion techniques are similar to those of implants the risk of early or late resorption of the graft.
inserted in native bone. • Bone harvesting from the mental symphysis is
associated with relevant morbidity, and the quan-
Split-Ridge Technique with Interpositional tity of available bone is frequently limited. Neural
Bone Grafts damage to the incisal nerve occurs frequently.
There is a lack of evidence concerning the split-ridge Therefore, the mental symphysis should not be the
technique with interpositional bone graft and first choice for harvesting.
delayed implant placement. • Bone harvesting from the maxillary tuberosity is
followed by low morbidity but is not well docu-
Vertical Distraction Osteogenesis mented. The quality and quantity of available bone
Alveolar distraction osteogenesis can be used to aug- is often poor. Indications are limited to reconstruc-
ment vertically deficient alveolar ridges in selected tion of small defects.
cases. It has a high rate of complications, which • Bone harvesting from the mandibular ramus offers
include change of the distracting vector, incomplete good quality and quantity of available bone, due
distraction, fracture of the distracting device, and par- to the possibility of harvesting from both sides.
tial relapse of the initial bone gain. • Bone harvesting from the iliac crest offers high
Survival rates of implants placed at sites aug- quantities of bone. However, the cancellous bone
mented using distraction osteogenesis are similar to component is dominant and may lead to a higher
those of implants inserted in native bone. risk of unpredictable bone resorption. When bone
is harvested from the anterior iliac crest there may
Le Fort I Osteotomy with Interpositional be associated gait disturbances.
Autogenous Bone Grafts • Bone harvesting from the calvarium offers greater
Le Fort I osteotomy with interpositional autogenous quantities of highly corticalized bone and is asso-
bone grafting can be used successfully to treat ciated with low morbidity.
extreme atrophy of the maxilla associated with • Accurate modeling and stabilization of the graft
severe intermaxillary discrepancy. This procedure is with screws, and tension-free primary closure of
technically demanding and is associated with consid- the overlying flaps, are fundamental for the suc-
erable postoperative morbidity. cess of the procedure. Overcorrection of the defect
Survival rates of implants placed after Le Fort I is recommended to compensate for the potential
osteotomy with interpositional autogenous bone risk of bone resorption. Coverage of the bone
graft are lower than those reported for implants grafts with a low-resorption–rate xenograft/allo-
placed in native bone. plastic material, with or without a membrane, may
be indicated to reduce bone resorption.
Clinical Recommendations • The economic and biologic costs of bone trans-
• Bone augmentation procedures should always plantation must be carefully weighed. In selected
follow a prosthetically driven plan to allow ideal clinical situations short and/or reduced-diameter
three-dimensional implant positioning.The concept implants may be considered instead.
of “prosthetically driven bone augmentation” • The severely atrophic edentulous maxilla frequently
should be taken into consideration whenever needs onlay bone grafts due to poor quality of the
possible. residual bone and the presence of pneumatized
Autogenous Onlay Bone Grafting of Severely cavities, including the maxillary sinus and the nose.
Resorbed Edentulous Ridges: • Both implant placement in conjunction with bone
• Onlay bone grafting is a technique-sensitive pro- grafting and delayed implant placement have
cedure and is recommended only for well-trained been proposed. Delayed implant placement is
clinicians. recommended.

The International Journal of Oral & Maxillofacial Implants 277

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
272_4e_Chen.qxd 9/15/09 12:41 PM Page 278

Chen et al

Split-Ridge/Ridge-Expansion Techniques: ancy is present, an onlay bone augmentation may

• Split-ridge/ridge-expansion techniques are indi- be considered to create both sufficient bone vol-
cated in selected situations where atrophy of the ume and proper intermaxillary relationships, to
edentulous ridge has developed horizontally and optimize implant placement and related pros-
cancellous bone is present between the oral and thetic restoration.
facial cortical plates, and adequate residual height • Data related to the initial clinical situation should
exists. be reported, and defects classified according to
• Excessive facial inclination of the alveolar ridge well-defined criteria.
may contraindicate this procedure, as it may • If the initial bone height allows primary implant
worsen the initial situation from a prosthetic point stability, simultaneous implant placement (one-
of view. staged) can be recommended. In situations where
• The presence of undercuts may increase the risk of primary stability cannot be achieved, the elevation
bone fracture. of the sinus floor should be performed in a sepa-
• This technique is mainly indicated in the maxilla. rate surgical procedure followed by delayed
Ridge expansion in the mandible is frequently dif- implant insertion (two-staged).
ficult due to the rigidity of the bone. • Rough-surfaced implants should be utilized. Cov-
Vertical Distraction Osteogenesis: erage of the access window with a membrane may
• Vertical distraction osteogenesis is a technique- be considered.
sensitive procedure and is recommended only for Sinus Floor Elevation Using the Transalveolar
well-trained clinicians. Approach:
• Indications of this technique should be limited to • Sinus floor elevation using the transalveolar
vertically deficient ridges with adequate residual approach can be recommended in sites with suffi-
width. As the segment to be distracted has to be at cient alveolar crest width, initial bone height of 5
least 3 mm in height, severely deficient mandibles mm or more, and relatively flat sinus floor anatomy.
are not good candidates due to the risk of neural • The main disadvantage of this technique is possi-
damage and/or mandibular fracture. ble perforation of the sinus membrane, which is
• The presence of maxillary sinus and/or nasal cavi- difficult to manage. Therefore, the transalveolar
ties may be contraindications. technique should only be performed by clinicians
• The rigidity of the palatal mucosa may negatively with experience in performing sinus floor eleva-
influence the distraction vector. tion via the lateral approach.
Le Fort I Osteotomy with Interpositional Autoge- • A prerequisite for using this technique is that pri-
nous Bone Grafts: mary implant stability is achieved.
• Le Fort I osteotomy with interpositional autogenous
bone grafts is indicated in cases of extremely severe
resorption, and where there is an unfavorable hori- REFERENCES
zontal and vertical intermaxillary relationship.
• This procedure is technique-sensitive and is rec- 1. Hämmerle CH, Chen ST, Wilson TG Jr. Consensus statements
and recommended clinical procedures regarding the place-
ommended only for well-trained clinicians.
ment of implants in extraction sockets. Int J Oral Maxillofac
Sinus Floor Elevation Using the Lateral Approach: Implants 2004;19(suppl):26–28.
• In sites with limited initial bone height not allow- 2. Chen S, Buser D. Implants in post-extraction sites: A literature
ing insertion of the desired implant length, sinus update. In: Buser D, Belser U, Wismeijer D (eds). ITI Treatment
floor elevation via the lateral approach can be Guide, vol 3: Implants in Extraction Sockets. Berlin: Quintes-
sence, 2008:9–15.
used to increase the bone height.
3. Martin WC, Morton D, Buser D. Diagnostic factors for esthetic
• As atrophy of the maxilla occurs three-dimension- risk assessment. In: Buser D, Belser U, Wismeijer D (eds). ITI
ally, the edentulous posterior maxilla should not Treatment Guide, vol 1: Implant Therapy in the Esthetic
only be evaluated in terms of initial bone height Zone—Single-Tooth Replacements. Berlin: Quintessence,
below the maxillary sinus but also in relation to 2007:11–20.
4. Laney WR (ed). Glossary of Oral and Maxillofacial Implants.
any vertical and horizontal ridge deficiencies. If rel-
Berlin: Quintessence, 2007.
evant vertical/horizontal intermaxillary discrep-

278 Volume 24, Supplement, 2009

© 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE
MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

View publication stats