Adts Maxillary Sinus

Maxillary Sinus Augmentation: Fixed restorations in the compromised posterior maxilla A Peer-Reviewed Publication

Continuing Education Course 4 CEUs

The Academy of Dental Therapeutics and Stomatology is an ADA CERP Recognized Provider

Written By:

Stephen S. Wallace, DDS Associate Clinical Professor, New York University, Department of Implant Dentistry

This CE course is written for Dentists, Periodontists, Implantologists and Oral Surgeons The cost of this CE course is $55.00 for 4 CEUs Cancellation/Refund Policy - Any participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

This course was made possible by an unrestricted educational grant from

Educational Objectives This article will focus on the lateral window sinus elevation procedure. Its role as a preprosthetic surgical procedure will be discussed and the surgical technique presented. An evidencebased decision process will be presented so that appropriate decisions can be made that will lead to the most positive patient outcomes. After reading this article the clinician will be able to:

Figure 1. Posterior maxilla with pneumatized sinus and minimal crestal bone height. Crestal bone height in molar region is 3-4 mm.

Figure 2. Maxillary sinus grafted with Bio-Oss¤ xenograft prior to the placement of implants. Crestal bone height is now 15 mm.

1. Identify appropriate graft materials for sinus surgery. 2. Compare implant survival rates pertaining to membrane placement. 3. Select implants based on surface texture.

Introduction Implant dentistry has dramatically changed the way we approach our fully and partially edentulous patients. A technique that was introduced to specifically address the edentulous mandible has evolved to encompass therapy to the edentulous maxilla, the partially edentulous patient and finally, to the patient missing a single tooth.1 Bone loss following tooth extraction and/ or periodontal disease can complicate the placement of root-form implants due to a lack of sufficient height or width of residual bone. This can be overcome with ridge augmentation procedures that can restore the lost bone volume. The posterior maxilla may present an additional obstruction to implant placement due to pneumatization (increasing size) of the maxillary sinus. Some patients possess limited crestal bone height in the posterior maxilla even when teeth are present and it is not uncommon for the sinuses to pneumatize further after the extraction of the posterior teeth. Pneumatization alone, even without any additional loss of crestal bone due to periodontal disease, may be sufficient to prevent the uncomplicated placement of even short implants in the posterior maxilla without prior sinus elevation surgery. Figure 1 and Figure 2 give an example of the change in bone height that can be achieved with the lateral window sinus elevation technique. The surgical technique of maxillary sinus floor elevation was first published by Boyne in 1980.2 In the 25 years since that introduction a host of surgical procedures have been developed to correct

the bone deficiency created by sinus pneumatization. They are all forms of sinus elevation surgery and the techniques include variations of Boyne s lateral window antrostomy, the osteotome sinus floor elevation, crestal core elevation and the localized management of the sinus floor.3,4,5 Recent evidence-based literature reviews by Wallace, et al and Del Fabbro, et al have reported remarkable levels of success for all of these techniques.6,7 In light of the improved prosthetic options that maxillary posterior implant placement can make available to our patients, it is important for both surgical and restorative dentists to be aware of this therapeutic approach and know how best to maximize patient outcomes. This maximization will result from a decision-making process whereby the proper choices can lead to an increase in implant survival from the average sinus lift survival rate of 91.8% to a survival rate of 98.6%. This is an implant survival rate that is as good as one can expect with implant placement in the anterior mandible.

Surgical technique The lateral window technique begins with a full thickness mucoperiosteal flap to gain access to the lateral bony wall of the sinus. An antrostomy, or window, is made in the lateral wall with a diamond bur using either a surgical or a high speed hand piece. The bony window can then be rotated horizontally along with sinus membrane elevation or it can be completely removed. The Schneiderian (sinus) membrane is reflected across the sinus floor and then superiorly up the medial sinus wall. The elevated membrane thus becomes the superior and distal walls of a compartment in the lower 1/3 of the sinus that will receive the bone graft. Once the graft material is placed the lateral window should be covered with a biologic barrier membrane prior to suturing the flap back into position. The graft is allowed to mature, with the formation of new bone around the graft particles, prior to implant placement

simultaneously with grafting if sufficient crestal bone is present to stabilize them. The implants are given sufficient time to integrate in the grafted sinus and then restored with traditional implant prosthetic components. The surgical procedure is demonstrated in Figures 3-10.

Figure 10. Bio-Gide¤ resorbable collagen membrane in place over the graft

Figure 3. Full thickness flap elevated and lateral window outlined

The goals of the sinus elevation procedure are the creation of vital bone in the posterior maxilla, the osseointegration of the implants placed in that bone and the survival of those implants under occlusal load. Figure 4. Window outlined with #8 diamond bur

How successful we are in this endeavor will be affected by the decisions we make about graft material selection, membrane placement and implant surface selection Within the last year, two evidence-based reviews have been published on the sinus elevation technique (Wallace & Froum, Del Fabbro, Testori, et al).6,7

Figure 5. Outline completed with sinus membrane visible

Figure 6. Membrane elevation initiated with Hu-Friedy Kramer #3 curette

Evidence-based reviews are structured, unbiased compilations of the best evidence available. The data from similar studies is then combined to enlarge the database in order to achieve greater statistical power. This combined data is then subjected to meta-analysis so that the variables that affect the outcome of this procedure can be isolated and their affects quantified.

Evidence-Based Decision Making

Graft Materials Autogenous bone

Figure 7. Membrane elevation completed up the medial wall of the sinus

Figure 8. Bio-Oss¤ (an organic bovine xenograft) being placed in anterior compartment with a syringe

Figure 9. Bio-Oss¤ (a xenograft) has been placed to a height of 15 mm

Autogenous bone was the first graft material to be widely utilized as a sinus grafting material. Many early studies involved the harvesting of a block graft from the iliac crest and then stabilizing this graft with implants placed through the remaining crestal bone and into the graft. Autogenous bone grafts from the hip, knee and various intraoral sites have also been utilized in particulate form. The utilization of grafts of 100% autogenous bone has a number of disadvantages. Harvesting of this bone generally involves hospitalization (extraoral) or requires a second surgical site (intraoral), thus increasing the length of time of the surgery, the surgical risk and the morbidity of the procedure. Secondarily, clinicians have reported a more-than-average graft resorption when using iliac bone.8 A computerized tomographic study by Uchida, utilizing Sim/Plant diagnostic software, calculated that 5.47 cc of graft material would be required to graft a sinus for the placement of multiple 15 mm implants.9 The 11 cc of graft material required for a bilateral case would generally exceed that which could be harvested intraorally. For the above-mentioned reasons it has become practical to utilize bone replacement grafts alone, or in combination with autogenous bone, as a sinus grafting material.

Demineralized freeze-dried bone Demineralized freeze-dried bone (DFDBA) has also been utilized as a sinus graft material. While used successfully by some clinicians, the results published following the Academy of Osseointegration Sinus Consensus Conference showed both poor bone quality and a poor implant survival rate (85%). Furthermore, this demineralized graft is susceptible to slumping , or settling, with a concomitant loss of graft height. It has a volumetric resorption rate second only to that of autogenous bone.8

Figure 11. Osteoconduction. Bone deposition directly on the Bio-Oss¤ graft particles at 6 months. Stevenel s blue and picric acid fuchsin (Bio-Oss - yellow, osteoid — green, new bone — red) Original magnification x 20.

Xenografts Xenografts have been very well documented as a sinus grafting material. They have been used alone or as part of a composite graft combined with autogenous bone, venous blood or platelet-rich plasma. In the Wallace review, the survival rate for implants placed in xenografts was similar to that of implants placed in particulate autogenous bone grafts.6 The Del Fabbro review was even more specific in the documentation of the utilization of xenografts. Survival rates for implants placed in 100% xenograft, composite grafts, and 100% autogenous bone grafts were 96%, 94.9% and 87.7% respectively as seen in Table 1.

Table 1. Implant Survival Rates with Various Grafting Materials Type of graft

# placed

# failed survival rate %

100% autogenous

3398

418

87.7%

composite graft

2011

103

94.9%

100% bone replacement

1120

45

96.0%

Studies by Hallman, Hising and Valentini all have shown a higher implant survival rate when using 100% Bio-Oss® as a bone replacement graft than when either 100% autogenous bone or composite grafts of Bio-Oss® and autogenous bone are utilized.10,11,12

Efficacy of Xenografts The efficacy of xenografts is likely due to a combination of factors: 1. Osteoconductivity. 2. Slow resorbability. 3. The residual graft material does not interfere with osseointegration. The most important factor that can be attributed to xenografts is their osteoconductivity. Osteoconductivity may be defined as the direct apposition of vital bone on the xenograft surface. This is very well demonstrated in Figure 11. This newly formed vital bone (red) is ultimately responsible for the osseointegration of the implant in the grafted site.

A second feature of the xenograft material is that it is slowly resorbable when placed in the maxillary sinus. This quality both prevents slumping (loss of graft height) and adds approximately 25% to the overall mineral content of the matured graft. An average taken from 8 published histological studies showed 25% vital bone formation, 25% residual xenograft and 50% marrow in the matured sinus graft. The resulting 50% total mineralized tissue (new bone + residual graft) makes the future implant receptor site equivalent in density to that of type 2 (dense) bone. The third feature is the repeated histological finding that implants placed in sinuses grafted with Bio-Oss® are never seen in direct contact with the graft material. This is evidence that the residual graft material, while providing support and density, does not interfere with osseointegration.13,14 Issues of safety are of paramount concern to us as dentists when placing graft material in the human body. A great amount of undue concern has been placed on xenogenic material due to the outbreak of bovine spongiform encephalopathy (BSE) in Europe. Regulations and testing of xenografts are quite extensive. The raw material for U.S. products is sourced from the long bones of U.S. cattle only. The material is processed by heat and chemicals to insure that it is sterile and prion-free. For Bio-Oss® the proof of deorganification is obtained through BioRad assay, SDS-PAGE testing and SDS-PAGE + Western blotting.15,16 To date, there has never been a reported case of disease transmission attributed to particulate xenografts.

Membranes Membrane placement is the second major variable evaluated in the sinus reviews. The Wallace review has shown that the utilization of a barrier membrane over the lateral window has a positive affect on implant survival.6 The three controlled trials listed in Table 2 all showed higher implant survival rates when a membrane was used.17,18,19 Further, twenty additional studies showed implant survival with a membrane to be 93.6% compared to 88.7% without a membrane.

Table 2. Membrane vs. No Membrane (intra-study comparison in controlled trials) Study Tarnow, et al17 Tawil, et al18 Froum, et al19

with membrane 28 implants - 100% 29 implants - 93.1% 133 implants - 99.2%

without membrane 27 implants - 92.6% 32 implants - 78.1% 82 implants - 96.3%

The advent of guided bone regeneration techniques in the early 1990 s improved our ability to repair compromised implant receptor sites. Sinus grafting may be considered as a form of guided bone regeneration within a cavity. Guided bone regeneration utilizes membranes to isolate the area of regeneration and exclude non-osteogenic connective tissue from the graft site. When a membrane is placed over a grafted bone defect, completely sealing the defect from the outside environment, the following characteristics are observed in the regenerated tissue beneath the membrane:

Table 3. Survival Rates for Rough vs. Machined Implants surface

std error

mean

machined

1.98

82.4

84.0

rough

2.82

95.2

91.6

Table 4. Distribution of Implants and Overall Survival Rate According to Implant Surface Texture. subgroup

1. Corticalization of the graft surface. 2. Contiguity of the graft particles. 3. Increased vascularity of the maturing graft.

# studies

Figure 12. Clinical appearance of lateral window area 8 months after sinus grafting. Lateral wall is completely restored.

As in guided bone regeneration, the first membranes widely utilized in sinus grafting were non-resorbable e-PTFE (Gore-Tex®) membranes. To be effective, these membranes had to be fixated by tacking them to the bone surface. Removal of the membrane required the flap reflection at the time of implant placement surgery to be as extensive as it was for the lateral window surgery. If bioabsorbable barrier membranes could be utilized over the lateral window, and achieve the same results, this latter surgery could be less extensive and therefore less traumatic. A recent study has compared the results utilizing either absorbable (Bio-Gide®) or non-absorbable barrier membranes (e-PTFE, Gore-Tex®) over the lateral window. The results show both a similar vital bone formation (17.6% and 16.9% respectively) and a similar implant survival rate (97.6% and 97.8% respectively) for the two types of membranes.20

Implants A third variable that affects implant survival in sinus grafts is the surface texture of the implants that are placed in the graft. Both the Wallace (Table 3) and Del Fabbro (Table 4) reviews show a dramatic difference in implant survival when comparing rough to machined implants.6,7

# # % tot. of implant survival patients implants implants failures rate %

turned

19

726

2827

40.44%

406 85.64%

rough

18

882

2939

42.05%

115 96.09%

445

1224

17.51%

67

2053

6990

100.00%

588

not classified

Histological studies of sinus grafts by Tarnow, et al and Froum, et al both show these changes as well as a dramatic increase in vital bone content when a membrane is utilized compared to cases where it is not used (25% and 11.8% respectively in the Tarnow study).17,19 Figure 12 shows a completely regenerated lateral window area eight months after sinus grafting with Bio-Oss® and placing a Bio-Gide® membrane over the window.

least sq. mean

total

5

The large differences observed in implant survival are most likely a result of the known differences in implant bone contact achieved by the rough and smooth surfaces. Studies utilizing special implants that have both surfaces on the same implant show a large difference in implant bone contact between the surfaces. By having both surfaces on the same implant, these studies rule out the variable of comparing implants that were placed in different sites. The study by Lazzara showed bone implant contact for Osseotite® and machined surfaces to be 79.7% and 46.5% respectively in good quality bone but only 51.7% and 8.1% respectively in poor quality bone.21 Trisi, in a similar study, has shown that the bone-implant contact with machined implants is usually less than you would expect given the bone quality of the receptor site.22 On the contrary, the Osseotite® surface always had better than expected bone contact. Davies has shown that the textured Osseotite® surface is better able to stabilize the blood clot on the surface, allowing for bone formation directly on the surface (contact osteogenesis).23 The inability of the machined surface to stabilize the blood clot leads to retraction of the clot and bone formation away from the implant surface (distance osteogenesis). A recent study at the New York University Department of Implant Dentistry has shown that machine-surfaced implants are much more likely to fail than implants with textured surfaces when placed in sinus grafted cases with reduced residual crestal bone height.24 This is yet another clinical deficiency resulting from the poor bone implant contact that is established with a machined surface.

Conclusions One result of the Wallace evidence-based review was the publication of the following statement by the American Academy of Periodontology: 6 There is evidence to indicate that the lateral window technique for the sinus bone augmentation procedure is successful at regenerating sufficient bone for implant placement. The implant survival rate is greater

than 90% which is similar to implants placed in native bone. The evidence-based reviews further identified some of the important variables that affect the outcome of this procedure. These variables are listed as follows: 1. Particulate bone grafts result in a higher survival rate than block grafts. 2. Bone replacement grafts result in a higher implant survival rate than autogenous bone or composite grafts 3. Rough surface implants result in a higher survival rate than machine-surfaced implants. 4. Membrane placement over the lateral window results in a higher implant survival rate than if a membrane is not used. Additional studies were presented in the present paper showing that the xenograft Bio-Oss® achieves its predictable success through a combination of its osteoconductivity, its characteristic slow resorbability and its lack of interference with the process of osseointegration. Evidence was also presented to show that, with regard to bone formation and implant survival, comparable positive affects are achieved with the bioabsorbable Bio-Gide® and the nonabsorbabe Gore-Tex® e-PTFE barrier mebranes. A clinician can utilize an evidence-based decision-making process to dramatically improve implant survival rates in the grafted maxillary sinus. In the Wallace evidence-based review the average implant survival for the lateral window procedure was 91.8%. By making the two decisions to utilize rough surfaced implants and particulate bone grafts the implant survival rate became 94.5%. By making a third decision to place a membrane over the lateral window, the implant survival rate became 98.6%. The ability to place implants in the compromised posterior maxilla with a very high predictability will allow us, as clinicians, to more predictably treat our patients with more favorable treatment plans. Certainly, patient function and comfort will be improved if we choose to place fixed restorations instead of removable dentures in our partially and completely edentulous patients.

Author Profile Stephen S. Wallace, DDS Dr. Wallace is an Associate Professor at the New York University Department of Implant Dentistry. He is a Diplomat of the International College of Oral Implantologists and a Fellow of the Academy of Osseointegration. He maintains a private practice in periodontics in Waterbury, CT. Dr Wallace is a national and international speaker on topics relating to implant dentistry. He has published numerous articles on sinus elevation surgery and the effects of biologic width around implants. He is an editor of a maxillary sinus surgery text (Italian) and has authored chapters in sinus texts in the USA. Dr. Wallace has recently published an evidence-based review on sinus elevation surgery. If you have any questions or comments for the author(s) of this CE course please e-mail [email protected]. Please reference course title & author.

Disclaimer This course has been made possible through an unrestricted educational grant by Osteohealth. Dr. Wallace has been paid an honorarium by Osteohealth to author this course.

References 1. Branemark 10 or 20 year data article 2. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg 1980;38:613- 616. 3. Summers RB. The osteotome technique: Part 3 — Less invasive methods of elevating the sinus floor. Compend Contin Educ Dent 1994;15(6):698-708. 4. Toffler M. Site development in the posterior maxilla using osteocompression and apical alveolar displacement. Compend Contin Educ Dent 2001;22:775-790. 5. Bruschi GB, Scipioni A, Calesini G, Bruschi E. Localized management of the sinus floor with simultaneous implant placement: A clinical report. Int J Oral Maxillofac Implants 1998;13:219-226. 6. Wallace SS, Froum SJ. Effect of maxillary sinus augmentation on the survival of endosseous dental implants. A systematic review. Ann Periodontol 2003;8:328-343. 7. Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic review of survival rates for implants placed in the grafted maxillary sinus. Int J Periodontics Restorative Dent 2004;24:565-578. 8. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the sinus consensus of 1996. J Oral Maxillofac Implants 1998;13(supplement). 9. Uchida Y, Goto M, Katsuki T, Soejima Y. Measurement of maxillary sinus volume using computerized tomographic images. Int J Oral Maxillofac Implants 1998;13:811-818. 10. Hallman M, Sennerby L, Lundgren S. A clinical and histologic evaluation of implant integration in the posterior maxilla after sinus floor augmentation with autogenous bone, bovine hydroxyapatite, or a 20:80 mixture. Int J Oral Maxillofac Implants 2002;17:635-643. 11. Hising P, Bolin A, Branting C. Reconstruction of severely resorbed alveolar crests with dental implants using a bovine mineral for augmentation. Int J Oral Maxillofac Implants 2001;16:90-97. 12. Valentini P, Abensur D. Maxillary sinus floor elevation for implant placement with demineralized freeze-dried bone and bovine bone (Bio-Oss): A clinical study of 20 patients. Int J Periodont

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Rest Dent 1997;17:233-241. 13. Scarano A, Pecora G, Piatelli M, Piatelli A. Osseointegration in a sinus augmented with bovine porous bone mineral: Histological results in an implant retrieved 4 years after case insertion. A case report. J Periodontol 2004;75:1161-1166. 14. Valentini P, Abensur D, Densari D, Graziani JN, H mmerle CHF. Histological evaluation of Bio-Oss¤ in a 2-stage sinus floor elevation and implantation procedure. A human case report. Clin Oral Implants Res 1998;9:59-64. 15. Benke D, Olah A, M hler. Protein-chemical analysis of Bio-Oss bone substitute and evidence on its carbonate content. Biomaterials 2001;22:1005-1012. 16. Wenz B, Oesch B, Horst M. Analysis of the risk of transmitting bovine spongiform encephalopathy through bone grafts derived from bovine bone. Biomaterials 2001;22:1599-1606.

18. Tawil G, Mawla M. Sinus floor elevation using a bovine bone mineral (Bio-Oss) with or without the concomitant use of a bilayered collagen barrier (Bio-Gide): A clinical report of immediate and delayed implant placement. Int J Oral Maxillofac Implants 2001;16:713-721. 19. Froum SJ, Tarnow DP, Wallace SS, Rohrer MD, Cho S-C. Sinus floor elevation using anorganic bovine bone matrix (OsteoGraf/N) with and without Autogenous bone: A clinical, histologic, radiographic, and histomorphometric analysis — Part 2 of an ongoing prospective study. Int J Periodont Rest Dent 1998;18:529-543.

2. Sinus elevation surgery has been used for how many years? a. 1 b. 5 c. 15 d. 25

4. Implant survival in the grafted maxillary sinus is: a. generally poor. b. generally favorable. c. as high as implant placement in non-grafted bone. d. much lower than that seen in non-grafted bone. 5. Surgical technique for the lateral window procedure a. utilizes flapless surgery. b. involves split thickness flap techniques. c. involves full thickness flap entry. d. involves bone surgery only.

20. Wallace SS, Froum SJ, Tarnow DP, Cho S-C. Sinus augmentation using anorganic bovine bone (Bio-Oss¤) with bioabsorbable and non-absorbable membranes. Int J Periodontics Restorative Dent 2005;25: accepted for publication. 21. Lazzara RJ, Testori T, Trisi P, Porter S, Weinstein RL. A human histologic analysis of Osseotite and machined surfaces using implants with 2 opposing surfaces. Int J Periodontics Restorative Dent 1999;19:117-129. 22. Trisi P, Lazzara RJ, Rao W, Rebaudi A. Bone — implant contact and bone quality: Evaluation of expected and actual bone contact on machined and Osseotite implants. Int J Periodontics Restorative Dent 2003;23:535-546. 23. Dziedzic DM, Davies JE, et al. Proceedings of the 5th Biomaterials conference.University of Toronto Press 1996:124. 24. Wallace SS, Elian N, Kim MG, Kim BS, Zaky J, Cho SC, Froum SJ, Tarnow DP. The relationship between residual crestal bone height and the implant survival rate in the augmented maxillary sinus. Submitted for publication Jan 2005.

Registered Trademarks Bio-Oss® and Bio-Gide® are registered trademarks of Ed. Geistlich S ehne Ag Fuer Chemiche Industrie, licensed by Osteohealth Company.

Gore-Tex® is a registered trademark of W.L. Gore & Associates, Inc.

1. Inadequate crestal bone height for implant placement may result from a. periodontal bone loss. b. pueumatization of the sinus. c. both of the above. d. none of the above.

3. Variations in sinus elevation surgery include: a. lateral window antrostomy. b. osteotome sinus elevation. c. crestal core elevation. d. all of the above.

17. Tarnow DP, Wallace SS, Froum SJ. Histologic and clinical comparison of bilateral sinus floor elevations with and without barrier membrane placement in 12 patients: Part 3 of an ongoing prospective study. Int J Periodontics Restorative Dent 2000;20:116-125.

Osseotite® is a registered trademark of Implant Innovations, Inc.

Course Questions

6. Exposing the sinus membrane is accomplished a. with bone chisels. b. with osteotomes. c. with burs. d. with all of the above. 7. Once outlined, the bony window in the lateral wall a. is hinged superiorly. b. is removed. c. both a and b above. d. neither a or b above. 8. The goals of sinus elevation are a. the creation of bone in the maxillary sinus. b. integration of implants in the grafted sinus. c. having the placed implants function under load. d. all of the above. 9. The best information that we have for achieving predictable results with the sinus elevation procedure are a. expert opinions. b. evidence-based reviews. c. commercial advertising brochures. d. hands-on courses. 10. Evidence-based reviews are good sources of information because they a. are unbiased. b. consider the best available evidence. c. gain statistical power by combining like data. d. all of the above. 11. Three important variables discussed in the evidence-based reviews are a. type of graft material, use of a membrane, sterile surgical technique. b. method of flap entry, handling of the bone window, use of membrane. c. type of graft material, use of a membrane, type of implant surface. d. handling of the bone window, sterile surgical technique, use of membrane.

pg. 13

12. The first graft material to be utilized extensively in sinus grafting was a. autogenous bone. b. demineralized freeze-dried bone. c. composite grafts. d. xenografts.

23. When compared to bioabsorbable barrier membranes, non-absorbable (e-PTFE) barrier membranes placed over the window a. give better results. b. are easier to place. c. are easier to remove. d. none of the above.

13. Disadvantages when using autogenous bone may include a. need for hospitalization. b. need for a second surgical site. c. re-pneumatization of the sinus following grafting. d. all of the above.

24. In a study comparing the bioabsorbable Bio-Gide® membrane to the non-absorbable e-PTFE membrane, use of the Bio-Gide® membrane resulted in a. the same bone quality. b. the same implant survival rate. c. less invasive implant placement surgery. d. all of the above.

14. Harvesting autogenous bone a. increases surgical time. b. increases morbidity. c. increases surgical risk. d. all of the above.

25. Use of a membrane over the lateral window results in the following: a. increase in vital bone percentage in the matured graft. b. increase in implant survival on implants placed in the grafted sinus. c. both a and b above. d. neither a or b above.

15. Demineralized freeze-dried bone as a graft material a. cannot be utilized successfully due to lack of mineral. b. maintains its volume after grafting. c. appears to have a lower success rate than other graft materials. d. must be used as a composite graft.

26. With regard to implant surface micromorphology, both the Wallace and Del Fabbro reviews have shown6,7 a. higher implant survival with textured than machined surfaces. b. higher implant survival with machined than textured surfaces. c. similar implant survival with both surfaces. d. no comparisons could be made due to insufficient data.

16. Xenografts for sinus grafting have been used a. alone. b. mixed with blood. c. as composite grafts with autogenous bone. d. all of the above. 17. Xenografts like Bio-Oss® are successful because they a. are osteoconductive. b. are slowly resorbable. c. do not interfere with osseointegration. d. all of the above.

27. The difference in implant survival between the rough and machined surfaced implants were said be due to which of the following a. better primary stability with the rough surface. b. better clot retention on the rough surfaced implants. c. better implant to bone interface on the rough surfaced implants. d. b and c above.

18. The most important factor in the success of Bio-Oss® as a graft material is its a. slow resorbability. b. osteoconduction. c. non-interference with osseointegration. d. ready availability.

28. The better implant to bone interface on the rough surface is due to a. greater primary stability achieved with the rough surfaced implants. b. contact osteogenesis. c. distance osteogenesis. d. the use of implants with 2 surfaces.

19. Bio-Oss® bone replacement graft material a. is provided sterile. b. is prion-free. c. has a 100% safety record as a graft material. d. all of the above.

29. According to a recent NYU study, the increased failure rates when implants are placed into minimal crestal bone may be due to a. a general lack of primary stability. b. the micro-motion resulting from inadequate primary stability. c. the poor implant to bone contact achieved with the machined surface. d. all of the above.

20. A bone replacement graft may be considered osteoconductive if a. vital bone forms directly on its surface. b. it is slowly resorbed. c. it has a high mineral content. d. it is safe and readily available. 21. Studies on implant survival with various grafting materials show highest implant survival rates when which of the following is utilized a. 100% autogenous bone. b. composite grafts that include autogenous bone. c. 100% bone replacement grafts. d. all of the above. 22. One of the following results is not seen when a membrane is placed over the lateral window a. corticalization of the graft surface. b. fixation of the graft to the membrane surface. c. contiguity of the graft particles. d. increased vascularity of the maturing graft.

30. The high implant survival rates that can be achieved with maxillary sinus grafting allow clinicians to a. predictably treat patients with a compromised posterior maxilla. b. utilize fixed as opposed to removable appliances. c. successfully place implants in the compromised posterior maxilla. d. all of the above.

pg. 14

ANSWER SHEET

Maxillary Sinus Augmentation: This course is intended for dentists, dental hygienists, and dental assistants.

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After reading instructions: 1)Complete all information above. 2) Complete answer sheets with either a pen or a pencil. 3)Mark only one answer for each question. 4)When test is completed, enclose the completed answer sheet. Successful completion of this course will earn you 4 CEUs. 5) A blank duplicate answer sheet may be copied for additional course participants. For faster processing, courses can be faxed MAILTO ACADEMY OF DENTAL THERAPEUTICS AND STOMATOLOGY with credit card payment to (216)398-7922.

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1. Were the objectives and educational methods appropriate?

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Course Evaluation

5

4

3

2

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0

Exp. Date__________________________________

2. Were the course objectives accomplished? 5

4

3

2

1

0

1

0

3. Please rate the course content. 5

4

3

2

4. Please rate the instructor’s effectiveness. 5

4

3

2

1

0

5. Was the overall administration of the course effective? 5

4

3

2

1

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6. How do you rate the author’s grasp of the topic? 5

4

3

2

1

0

7. Do you feel that the references were adequate?

1 Yes

2

No

8. Do you feel that the educational objectives were met? 1 Yes

2

No

9. If any of the continuing education questions were unclear or ambiguous, please list them: ________________________________________________________ 10. Was there any subject matter you were unclear on? Please describe. ________________________________________________________ 11. Would you participate in a program similar to this one in the future on a different topic of interest: 1 Yes 2 No 12. What additional continuing dental education topics would you like to see? _______________________________________________________ AUTHOR(S) Stephen S. Wallace, DDS

AUTHOR(S) DISCLAIMER Dr. Wallace has been paid an honorarium by Osteohealth to author this course.

EDUCATIONAL OBJECTIVES This article will focus on the lateral window sinus elevation procedure. Its role as a preprosthetic surgical procedure will be discussed and the surgical technique presented. An evidence-based decision process will be presented so that appropriate decisions can be made that will lead to the most positive patient outcomes. After reading this article the clinician will be able to:

1. Identify appropriate graft materials for sinus surgery.

2. Compare implant survival rates pertaining to membrane placement. 3. Select implants based on surface texture.

INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive verification of passing by mail within two weeks after taking an examination.

1. A B C D E 2. A B C D E 3. A B C D E 4. A B C D E 5. A B C D E 6. A B C D E 7. A B C D E 8. A B C D E 9. A B C D E 10. A B C D E 11. A B C D E 12. A B C D E 13. A B C D E 14. A B C D E 15. A B C D E

SPONSOR/PROVIDER The Academy of Dental Therapeutics and Stomatology, Inc. (ADTS) is the only sponsor/provider. This course was made possible through an unrestricted educational grant from Osteohealth. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed and the opinions of clinicians. Please direct all questions pertaining to the ADTS or the administration of this course to the Program Director, P. O. Box 116, Chesterland, OH 44026 or [email protected].

COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive verification of 4 CEUs. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. For current term of acceptance please contact the ADTS. “DANB Approval” indicates that a continuing education course appears to meet certain specifications as described in the DANB Recertification Guidelines. DANB does not, however, endorse or recommend any particular continuing education course and is not responsible for the quality of any course content. Participants are urged to contact their state dental boards for continuing education requirements. The cost of this course is $55.00. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the courses and do not

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16. A B C D E 17. A B C D E 18. A B C D E 19. A B C D E 20. A B C D E 21. A B C D E 22. A B C D E 23. A B C D E 24. A B C D E 25. A B C D E 26. A B C D E 27. A B C D E 28. A B C D E 29. A B C D E 30. A B C D E

necessarily reflect those of the ADTS. Completing a single continuing education course does not provide enough information to make the participant an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. PARTICIPANT FEEDBACK Please e-mail all questions to [email protected], or fax (216)398-7922.

RECORD KEEPING The ADTS maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt of your request; a report fee of $25 will be billed to you.

CANCELLATION / REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting the Academy of Dental Therapeutics and Stomatology in writing.

COURSE EVALUATION We encourage participant feedback pertaining to all courses. Please be sure to complete the attached survey included with the answer sheet. © 2005 The Academy of Dental Therapeutics and Stomatology