Phần đầu của cuốn sách cung cấp cơ sở lý luận và nguyên tắc cơ bản của các kỹ thuật phẫu thuật được mô tả trong phần thứ hai, hoàn toàn dành cho các trường hợp lâm sàng. Với sự hợp tác của các đồng nghiệp tại Trường Giải phẫu của Đại học Bologna, chúng tôi đã mô tả những trở ngại giải phẫu chính đối với việc đặt implant. Sử dụng hộp sọ và tử thi khô, chúng tôi đã thực hiện và minh họa những sai lầm phẫu thuật phổ biến nhất có thể gây ra biến chứng hoặc thương tích nghiêm trọng cho bệnh nhân. Chúng tôi nghĩ rằng các kỹ thuật hiện tại cho phép phục hồi thành công hàm trên sau và chúng tôi đưa ra các khái niệm mới để nâng cao phương pháp phẫu thuật cho các thủ thuật nâng xoang được coi là trở ngại cho việc đặt implant. Do đó, chúng tôi đã bao gồm một chương dành riêng cho xoang hàm trên, được viết bởi hai bác sĩ tai mũi họng, họ đã xem xét sinh lý bệnh của vùng này có thể ảnh hưởng đến các lựa chọn điều trị lâm sàng. Việc đánh giá sức khỏe tổng quát và quản lý thuốc mê của bệnh nhân được trình bày chi tiết trong một chương do hai bác sĩ gây mê viết. Tình trạng sức khỏe của bệnh nhân và việc lựa chọn gây mê có thể ảnh hưởng mạnh đến can thiệp lâm sàng (phẫu thuật xâm lấn hoặc không xâm lấn) và các khả năng điều trị được khuyến nghị. Các trường hợp lâm sàng được trình bày trong cuốn sách minh họa cách vượt qua những trở ngại giải phẫu bằng nhiều kỹ thuật khác nhau, bao gồm phẫu thuật không vạt xâm lấn tối thiểu, phẫu thuật không mảnh ghép, sử dụng mô cấy nghiêng để tránh các cấu trúc giải phẫu quan trọng, và phẫu thuật ghép xương với các mảnh ghép lớn và nhỏ. Các trường hợp bệnh nhân ngoại trú cơ bản được ghi lại, cũng như các trường hợp phức tạp hơn cần gây mê toàn thân và nhập viện. Đối với mỗi trường hợp lâm sàng, chúng tôi cung cấp tình trạng bệnh hiện có và biểu hiện nội khoa, cân nhắc chẩn đoán trước phẫu thuật, quy trình phẫu thuật với các bước kỹ thuật phù hợp nhất, cân nhắc sau phẫu thuật và hình ảnh. Ngoài ra, các trường hợp lâm sàng được chỉ định đã được ghi lại toàn bộ trên video và bạn có thể tìm thấy trên trang web của cuốn sách tại www.rinaldidentalimplants.com. Chúng tôi hy vọng rằng bạn sẽ tìm thấy thông tin được cung cấp trong các chương khác nhau để kích thích tư duy và hữu ích cho việc thực hành hàng ngày của bạn. Chúng tôi chúc bạn đọc tốt và nâng cao tầm nhìn cho các trường hợp tương lai của bạn. Hãy nhớ rằng, như Tiến sĩ Ganz đã nói: “Có một mối nguy hiểm khi chúng ta bị ràng buộc bởi các khái niệm hai chiều khi rõ ràng chúng ta đang sống trong một thế giới ba chiều”.
COMPUTER-GUIDED APPLICATIONS for Dental Implants, Bone Grafting, and Reconstructive Surgery MARCO RINALDI, MD, DMD Private Practice Bologna, Italy SCOTT D GANZ, DMD Private Practice Fort Lee, New Jersey ANGELO MOTTOLA, MD, DMD Stomatological Institute A Beretta Maggiore Hospital Bologna, Italy Translation from the Italian by Dr Stefano Lauriola www.ajlobby.com 3251 Riverport Lane St Louis, Missouri 63043 COMPUTER-GUIDED APPLICATIONS FOR DENTAL IMPLANTS, BONE GRAFTING, AND RECONSTRUCTIVE SURGERY © 2009 Elsevier Srl – Tutti I diritti riservati © 2013 Edra Lswr SpA – Tutti i diritti riservati © 2016 Elsevier Inc All rights reserved ISBN: 978-0-323-27803-4 All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein This edition of Superamento degli ostacoli anatomici in chiurgia implantare by Rinaldi M, Mottola A, is published by arrangement with LSWR SRL Executive Content Strategist: Kathy Falk Content Development Manager: Jolynn Gower Senior Content Development Specialist: Brian Loehr Publishing Services Manager: Julie Eddy Project Manager: Jan Waters Designer: Margaret Reid Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 www.ajlobby.com To my wife Cristina, my son, Francesco, and to my daughter, Chiara Marco Rinaldi To my son, Giovanni Angelo Mottola For their endless support and understanding To my wife Sabrina, daughters Michelle, Samantha, Jacquelyn, and granddaughter, Jayden To my parents, Joseph and May Scott D Ganz www.ajlobby.com AUTHORS Marco Rinaldi Scott D Ganz Angelo Mottola vii www.ajlobby.com CONTRIBUTORS Luca Amorosa, MD Maggiore Hospital Bologna, Italy Luca Boriani, MD Rizzoli Orthopedic Institute Bologna, Italy Alessio Esposti Biomedical Engineer Materialise Leuven, Belgium Alessandro Gasbarrini, MD Rizzoli Orthopedic Institute Bologna, Italy Gino Latini, MD Medical Director Hospital of Fano Fano (PU), Italy Stefano Pagnutti, PhD Biologist Bioteck srl Vicenza, Italy Sandro Rosa, MD Private Practice Bologna, Italy Alessandra Ruggeri, DDS Professor of Anatomy University of Bologna Bologna, Italy Valter Teti, MD Sant Orsola-malpighi Hospital Bologna, Italy Giovanni Mazzotti†, MD, PhD Professor of Anatomy University of Bologna Bologna, Italy †Deceased ix www.ajlobby.com PREFACE When patients present for treatment of missing teeth, often clinicians are under the illusion that dental implants are always the best treatment option regardless of the amount of existing bone Imagine if your dental practice was set in the world of Lilliput and you had to treat oversized patients like Mr Gulliver You would immediately realize that it would be impossible to place implants because of the substantial anatomical obstacles The foundation and philosophy of this textbook is to provide clinicians with sound strategies and protocols for the diagnosis, assessment, and successful treatment of patients who present with minimal and major anatomical obstacles Clinical cases have been documented with sequential images and video footage to illustrate important concepts and the rationale for the prescribed treatment It is not the purpose of this book to underscore the merits of dental implants as a treatment modality, nor to mandate particular types, diameter, length, or number of implants required to complete each case, because this will ultimately be the decision of the clinician However, we have made every effort to explain the rationale and decision choices for the treatment rendered based on one underlying question that faces the clinician every day, “Is there enough bone?” Today, unlike in the past, the supply of dental implants varies greatly from very short to very long, very narrow to very wide diameters, and with many different physical characteristics that separate the myriad of manufacturers’ product lines Therefore the estimation of the bone quantity necessary to insert an implant has been long conditioned by the industry in that the volumes considered to be minimal or maximal were those able to accommodate the implants that were produced Nevertheless, even for the narrowest diameter implants, there are cases in which the bone volume is insufficient Therefore there are potential implant receptor sites that not offer sufficient bone volume to place an implant and represent an obstacle to treatment This scenario describes very common anatomical realities that can best be visualized using three-dimensional imaging modalities represented by computed tomography (CT) and the lower radiation dose cone beam CT (CBCT) devices Although the dental implant literature describes classifications of bone in a general sense, there often is no direct path from the diagnosis to the therapeutic choices to offer our patients When faced with the anatomical obstacle of insufficient bone, which would preclude the placement of dental implants, what treatment options remain for the patient? The purpose of this textbook will be to describe in detail two possible solutions to the problem: (1) “remove” the obstacle or (2) “avoid” the obstacle When there is insufficient bone volume, removing the obstacle requires rehabilitation of the receptor site by rebuilding the lost bone Various types of bone grafting modalities have been shown to be the most predictable reconstructive approach, offering the highest guarantee of success Minor defects often can be satisfactorily treated with particulate bone grafts and guided bone regeneration before or simultaneous with implant placement However, major volumetric defects present a challenge because of the availability of intraoral donor sites capable of providing the sufficient amount of bone required to rehabilitate the site(s) Therefore in many cases, it may be necessary to use extraoral donor sites that require general anesthesia, increase trauma and patient morbidity, and increase treatment duration and the costs of the procedures In addition, we must consider the risks and benefits of the suggested reconstructive therapy based on the age and general health of our patients Avoiding an anatomical obstacle can provide additional treatment alternatives that are less invasive and traumatic The dental implant literature has reported the successful use of endosseous implants that are placed off-angle or placed in particular locations to avoid vital anatomical structures such as the maxillary sinuses or the mental foramina These solutions include the pterygomaxillary implants performed by Jean F Tulasne (1992), the use of zygomatic fixtures designed by Brånemark and as suggested by Paul Tessier (1989), the remote anchorage reported by Parel (2001), and the use of tilted implants reported by Krekmanov (2000), Aparicio (2001), and Malo (2003) In clinical practice, we often encounter patients who, for various reasons, had to give up complex bone reconstructions, so the use of angled implants seemed to provide less traumatic, less expensive, and faster solutions However, placing tilted implants is anything but easy, especially when precision is required near vital anatomical structures It is difficult to plan an angled implant using standard diagnostic techniques Orthopantomography offers only an overview but does not allow precise measurements because of inherent distortion CT and CBCT dental scans reveal the third dimension through volumetric reconstructions, combined with the cross-sectional slices or vertical cuts, in a true, undistorted 1:1 ratio for accurate measurements We can superimpose an implant template on these images only if it is vertical with respect to the occlusal plane (parallel to the section) An angled implant involves more than one crosssection, and therefore it is difficult to fully appreciate the path of the proposed implant without advanced interactive software applications During the surgical procedure, using a fullthickness flap and direct vision still does not provide adequate assessment of deep structures Therefore, in our experience with a “freehand” approach of placing these implants, we determined that it was at best an “approximate surgery” and thus considered undesirable for the precision that we required We therefore sought a solution using the diagnostic capabilities offered through CT and CBCT combined with advanced interactive treatment planning software xi www.ajlobby.com xii PREFACE applications that would allow precise simulated placement of the implants Today, it is possible to perform virtual surgery on the computer and then transfer this plan to clinical reality through the fabrication of stereolithographic resin models and a series of surgical guides, produced by specialized manufacturers Computer-guided surgery can provide accurate and predictable solutions to our many cases through advanced diagnostic software and planning tools and incorporation of physical templates, specialized drills, and associated surgical instrumentation Although most applications of this technology have been limited to implant placement, it was our desire to use these advanced tools for improved control of our bone grafting procedures The new digital workflow was incorporated into the variety of bone-grafting reconstructions through the use of stereolithographic models and surgical guides We developed protocols for assessment of receptor and donor graft sites, including sinus augmentation procedures and the use of surgical guides to assist in the process, increasing accuracy and reducing patient morbidity Presently, all surgical procedures are planned on the resin biological model of the maxilla or mandible, fabricated from the CT scan data, before touching the scalpel to the patient We cannot imagine performing surgery without these technologically advanced aids We strongly believe that computer-aided surgery is highly beneficial for cases in which we need to avoid anatomical obstacles and for cases in which we want to reconstruct deficient bone anatomy It is also our opinion that computerguided surgery, among the topics related to implant surgery, is the one most oriented to the future of our profession through these innovative applications of rapid prototyping techniques These technologies are already in use in neurosurgery, used for cranioplasties, and in orthopedics for the fabrication of three-dimensional prototypes of missing bone structures The potential application to reconstructive dental implantology through three-dimensional stereolithography and threedimensional printing to produce replicas of the jaws will greatly improve diagnostic and therapeutic procedures Perhaps one aspect of computer-guided surgical procedures is use of the diagnostic information to inform our patients of their treatment alternatives and as a communication tool for all members of the implant team Often, following a single diagnosis, different treatment plans may be proposed to a patient that may be difficult to comprehend Bone grafting is advised only to create a foundation for later or simultaneous implant placement and prosthetic reconstruction The three-dimensional images shown on the computer screen allow a clear depiction of the patient’s individual anatomy and the recommended treatment in a simulated visual environment that is easier for the patient to understand Additionally, it is therefore possible to help plan both the surgical intervention and the prosthetic outcome, providing for true “restoratively driven” implant reconstruction The educated patient can then have an indisputably central role in the choice of the treatment Therefore the three-dimensional views and the simulations with computer-generated images have an important communicative and medical-legal function, allowing for a positive doctor– patient relationship The first part of the book provides the basic rationale and principles of surgical techniques that are depicted in the second part, entirely devoted to clinical cases In cooperation with the colleagues of the Anatomical School of the University of Bologna, we described the main anatomical obstacles to implant placement Using dry skulls and cadavers, we performed and illustrated the most common surgical mistakes that can cause complications or serious injury to the patient We think current techniques allow for the successful rehabilitation of the posterior maxilla, and we offer new concepts to enhance the surgical approach for sinus augmentation procedures considered obstacles for implant placement Therefore we have included a chapter dedicated to the maxillary sinus, written by two otolaryngologists, who reviewed the pathophysiology of this region that can affect clinical treatment alternatives The evaluation of general health and the anesthetic management of patients are detailed in a chapter written by two anesthetists The patient’s state of health and the choice of anesthesia can strongly influence the clinical intervention (invasive or noninvasive surgery) and recommended therapeutic possibilities The clinical cases presented in the book illustrate how to overcome the anatomical obstacles using a variety of different techniques, including minimally invasive flapless surgery, graftless surgery, use of tilted implants to avoid vital anatomical structures, and bone graft surgery with small and large grafts Basic outpatient cases are documented, as well as more complex cases that necessitated general anesthesia and hospitalization For each clinical case, we provided the preexisting medical condition and intraoral presentation, preoperative diagnostic considerations, surgical procedures with the most relevant technical steps, postoperative considerations, and photographs In addition, designated clinical cases have been documented in entirety on video and can be found on the book’s website at www.rinaldidentalimplants.com We hope that you will find the information provided within the various chapters to be thought provoking, and useful to your everyday practice We wish you good reading and an enhanced vision for your future cases Remember, as Dr Ganz states: “There is a danger when we are bound by two-dimensional concepts when clearly we live in a three-dimensional world.” Marco Rinaldi Scott D Ganz Angelo Mottola www.ajlobby.com CHAPTER Anatomical Obstacles to the Insertion of Implants Giovanni Mazzotti† and Alessandra Ruggeri PLASTICITY OF BONE Successful dental implantology implies specific knowledge of the maxillomandibular complex, combined with essential surgical and restorative skills The diagnostic phase first requires appreciation of the patient’s unique vital anatomical structures, which include blood vessels, nerves, and facial and muscle planes Second, each potential implant receptor site must be evaluated based on the existing structure of the cortical and cancellous bone The ability to assess individual bony anatomy has increased exponentially with the advent of three-dimensional imaging modalities, computed tomography (CT), cone beam CT (CBCT), the increase in power of today’s personal desktop and laptop computers, and sophisticated interactive treatment planning software These software applications allow the clinician to perform in-depth diagnostic analysis and evaluation of highly accurate three-dimensional images processed in all planes of space quickly and cost effectively However, to fully appreciate the diagnostic findings it is important to understand the nature of bone Bone is one of the most plastic tissues in human body Its shape and structure can change in relation to numerous parameters such as load, age, physical activity, hormonal metabolism, diet, and environmental factors As early as the second half of the seventeenth century, Galileo Galilei described the correlation between body weight and characteristics of bone size or how mechanical load affects bone biology These observations were developed over the years by various authors who sought to further correlate changes in shape or structure with specific determinants Clinical and experimental evidence has shown that pressure is a critical factor affecting the compactness of bone tissue From a mechanical perspective, muscle contraction is the main determinant for the pressure stimulus, even in bones subjected to loading In the upright position, for example, mechanical load of body weight on the hip joint is increased by muscle contraction of a factor up to six times higher in more intensive efforts The opposite was observed in space flights, in which, in total absence of gravity, even after a few days, a significant decrease occurs in bone tissue, of both bone matrix and mineral component This decrease was more prominent in bones of the lower limbs and the trunk These conditions are only partially reversible after return to Earth if †Deceased the period spent in the absence of gravity is greater than months The mechanism of action that allows bone remodeling in relation to mechanical load and the work of the muscular component is not yet fully understood Currently, the most accredited hypothesis refers to the ability of bone tissue, and particularly of the organic matrix, to generate electrical signals under load In a bone subjected to mechanical loading, the part under the compressive effect becomes negatively charged and bone deposition occurs, whereas the part subjected to tensile stress becomes positively charged and bone resorption is observed.Experimental models also support this hypothesis, showing that, under the application of an electric current, bone deposition is observed at the cathode and resorption at the anode These processes interact with the constant dynamic of bone tissue remodelling, in which the destruction and reconstruction of osteons occurs systematically and continuously at all stages of life On the other hand, it is not possible to predetermine the density of bone in different areas without instrumental analysis Bone density, in fact, can vary not only for metabolic or dietary factors, as previously mentioned, but also for the occlusal load and the tone of the masticatory muscles, occlusion, and posture In dental implantology these concepts can be applied to the biology of the bone– implant interface and to its response to masticatory loads For any designated implant receptor site an accurate evaluation of bone tissue must be performed Many classifications of bone density have been described since the dawn of modern implantology, such as that by Linkow (1970), who defined three bone structures based on the shape of the trabecular pattern and the size of the bone lacunae The classification by Lekholm, Zarb, and Albrektsson (1985) distinguished among four bone types based on the proportion of cortical and cancellous components The Misch-Judy classification also distinguished four classes (D1-D4) of bone density (and a fifth class, relating to immature bone) Refinement of these four classifications in four points also has been proposed as follows: Solely or mainly compact bone Thick layer of compact bone surrounding a central region, with structural trabecular mesh very tight Thin layer of compact bone surrounding the middle, with trabeculae still very dense Thin cortical layer of compact bone enclosing a central portion with sparse trabeculae and large mesh (de Oliveira 2008) www.ajlobby.com CHAPTER 1 Anatomical Obstacles to the Insertion of Implants With the advent of CT imaging, technology helped define bone density based on relative values of the grayscale values within each CT scan The units of measurement that determine bone density using medical grade CT has been termed Hounsfield units Therefore an additional parameter of bone classification has been described in the literature (Norton, 2001) DISTRIBUTION OF MASTICATORY LOADS IN THE SKULL Forces of mastication are distributed within the skull along specific directions The mandible is a separate and movable bone that transmits load to the maxilla, which is a fixed part of the skull Observed from the front, the maxilla has two processes: one medial to the frontal process and one lateral to the zygomatic process The zygomatic bone is small in size, but structurally it is extremely robust because of its characteristic function and consists entirely of compact bone From a functional point of view, it is a real keystone for the distribution of loads It connects the maxillary bones superiorly with the frontal bone, medially with the sphenoid greater wing, and posteriorly with the zygomatic process of the temporal bone Forces are distributed along specific planes (Fig 1.1)—a frontal plane through which the forces, on each side, medially through the frontal process of maxilla and laterally through the zygomatic process with the zygomatic bone and frontal process, close together around the orbital arch (see Fig 1.1a) The orbital contour is composed of the supraorbital margin of the frontal bone, the infraorbital edge of the maxilla, medially the maxillary frontal process, and laterally the zygomatic bone Indeed, the whole anterior orbital circumference is the first area of force distribution The zygomatic bone meets the zygomatic process of the temporal bone posteriorly, forming the zygomatic arch Two distinct roots can be identified in the zygomatic process of temporal bone: a transverse root represented by the articular tubercle, which is part of the temporomandibular joint, and a longitudinal one posteriorly.The longitudinal root first goes posteriorly to the squame surface, slightly prominent like a delicate bas-relief Once reaching the anterior surface of the mastoid process, the relief appearance continues with the inferior temporal line of the parietal bone Temporal lines give insertion to most of the temporal muscle; in particular, the inferior line provides insertion to the posterosuperior muscle bundles, and the upper provides insertion to the temporal fascia Anteriorly, the temporal lines of the parietal bone converge toward the temporal line, the sturdy vertical pillar that separates the anterior surface of the frontal bone from its lateral aspect, where it takes part in forming the temporal fossa On the lateral surface of the skull is an elliptical region that, starting from the zygomatic bone, continues with the zygomatic process and extends to the squama of the temporal bone This, in turn, is connected with the temporal lines of the parietal bone, which converge on the orbital process of frontal bone The latter, articulating with the upper corner a b c Figure 1.1 Distribution of masticatory loads in the skull (a) Skull in the frontal plane The lines of force, through the maxillary frontal process and zygomatic bone, end, as indicated by the arrows, on the anterior margin of the orbital cavity (b) Skull, lateral aspect Laterally, the lines of force form an ellipse; starting from the zygomatic bone they go upward and posteriorly to the zygomatic arch, ending on the temporal lines of the parietal bone, thus delimiting the insertion area of the temporal muscle (dotted line) (c) Skull in the frontal plane Posteromedially, on the lateral wall of the orbital cavity, the zygomatic bone articulates with the anterior margin of the great wing of the sphenoid, transmitting the lines of force, as indicated by the arrows, to the skull base www.ajlobby.com 538 Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol) INTRODUCTION Zygomatic implants represent a real alternative to large reconstructions with bone grafts in cases of advanced atrophy of the maxillary bone Computer-guided implant surgery is generally considered not suitable for the placement of zygomatic implants The average angular error of computer-guided surgery reported by the literature2 is of 3.81° (ranging from 0° to 24.9°), and because zygomatic implants are particularly long (from 30 to 50 mm), an angular error could lead drills to dangerous anatomical locations, causing serious injuries to the patient The flapless approach is not indicated, due to the impossibility to visually check the anatomical structures For these reasons, the initial computer-guided approaches to the zygomatic surgery have been gradually abandoned, although the constant protocol improvements could make the computer-guided surgery safely applicable in this field in the future However, the authors are convinced that the contribution in terms of surgical and prosthetic planning offered by three-dimensional technologies can be also used for zygomatic implants Therefore, the authors tried to identify the weak points of the bone-supported computer-guided technique applicable to the zygomatic implants and made the following considerations: • The bone-supported surgical guides may be affected by any irregularity of the support base on the alveolar crest • The surface of the alveolar bone crest, which provides support to the guide, is rather limited for ensuring stability to the guide • The surgical guides might lean while using the long drills, often used from extraoral positions, and are necessary for the zygomatic implants • The surgical guides could hamper the necessary intrasinusal control of the drill’s path • The planning with the software is not simple, especially in threedimensional images The authors tried to improve these points by requiring the manufacturer (SimPlant, Hasselt, Belgium) to make the following changes to the standard procedures They constitute our protocol and will be described hereinafter ACTION FLOW Examination of CT/CBCT Images • The analysis of the CT/CBCT images is an essential step for case planning • A treatment plan using zygomatic implants and possible alternative solutions can be created through computerized planning • In addition, the x-ray images demonstrate the available bone volumes and the presence of possible sinus pathologies (Fig A.61) Analysis of the STL Model • The STL model of the maxillary bone allows direct assessment of the position of the zygomatic implants (Fig A.62) in relation to the various anatomical situations Surgery Simulation on the Model • The zygomatic implant sites are prepared directly on the STL model (Fig A.63), using the same techniques that would be used during the surgery For this type of implant, the authors consider this approach more realistic and easier with respect to the computer planning • The surgical simulation first involves making an opening on the lateral wall of the maxillary sinus, which will allow for the elevation of the sinus membrane and to check the drill’s direction • When the implant sites are satisfactory (Fig A.64), training implants are positioned in the stereolithographic model (Fig A.65) • In summary, it is recommended that a surgical simulation is completed on the STL model and the position of the two zygomatic implants, or four implants used with the “quad” technique • The simulation on the model allows for the evaluation of the implant placement in relation to the anatomical structures as well as to precisely define the implants’ entrance and exit points and assess their intrasinusal and extrasinusual path (Fig A.66) • For these evaluations, the clinician can choose to refer to the original protocol or to more recent ones.3 In any case, the simulation on the model allows for any clinical consideration before performing the surgery www.ajlobby.com Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies 539 PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Figure A.61 Computer Planning (SimPlant Dentsply Implants) of two zygomatic implants Figure A.62 The stereolithographic model (SimPlant Dentsply Implants) allows a direct evaluation of the patient’s anatomy Figure A.64 On the model it is possible to estimate, with special instruments, the length of the implants It is also possible to see the sinus fenestration, rectangular, oriented along the zygomatic process of the maxillary bone, immediately anterior to the infra-zygomatic crest The clinician can draw directly on the model the outline of the surgical guide Figure A.63 Surgical simulation on the stereolithographic model, providing the preparation of the sites for the zygomatic implants Figure A.65 A traning zygomatic implant is inserted in the stereolithographic model Continued www.ajlobby.com 540 Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Construction of Sinus Lifting Guide • Similar to what proposed in the previous protocol for sinus augmentation, the authors use a “sinus lifting guide,” modified for this use • The guide will be used for the preparation of the sinus fenestration (Fig A.67) In this case, it will be necessary to create a rectangular opening of 1.5/2.0 mm times 0.5/1.0 mm • The opening in the sinus lateral wall should be wide enough to allow the detachment of the sinus membrane and oriented along the axis of the zygomatic implant immediately before the infrazygomatic crest This step can be carried out before or after the implant placement (Step 3), because the STL model is transparent and allows for the visual confirmation of the drill’s path Drawing of the Zygomatic Surgical Guide Outline • Directly on the STL model (after placing the implants), the authors identify an area of support that will contribute to the surgical guide stability • By drawing the guide outline, the clinician can indicate how the guide can be carried out in order to fit the specificity of each clinical case • The authors recommend extending the support area on the bone buccal surface up to the base of the zygomatic body and almost embracing the zygomatic alveolar crest In this way, much more extensive support is created Thus, the guide stability is increased, which will be supported by both the alveolar ridge and the vestibular bone portion • At the level of the sinus fenestration, an opening must be created to control the passage of the drills during the preparation of the implant sites The rectangular opening resembles the one carried out with the “sinus lifting guide” (Step 4) In this way, the zygomatic surgical guide give us the exact entrance point and the intermediate control of the drills up to the zygomatic body (see Figs A.64 to A.66) • The authors recommend the construction of two separate guides, one for each side (right and left) A single guide could create an obstacle in the use of the drills, which (due to their length) are used from the opposite side, often from the extraoral position Optical Scan Model of the STL Model • The STL model, with implants inserted, undergoes optical scanning (3D Imetric SA, Courgenay, Swizerland) • The image obtained is imported into the software (SimPlant Dentsply Implants) and constitutes our digital planning as if it was designed with the software • Surgical planning will be used (Fig A.68) for the stereolithographic construction of the surgical guide (Figs A.69, A.70) Construction of the Zygomatic Surgical Guide • The surgical guides, constructed following the clinician’s instructions, provide a precise entrance point for the drills, allowing them to follow their intermediate path, both intrasinusal and extrasinusal, checking the implant’s Figure A.66 Two zygomatic implants were inserted in the model Figure A.68 The stereolithographic model with implants inserted is scanned (Imetric 3D SA, Courgenay, Swizerland) and the image is imported in the SimPlant (SimPlant Dentsply Implants) Figure A.67 Sinus Lifting Guides modified for the zygomatic surgery The fenestration is rectangular and is oriented upward following the implant direction along the zygomatic process of the maxillary bone Figure A.69 Preview of the surgical guides The borders of the guides match those drawn by the clinician on the STL model www.ajlobby.com Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies 541 PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Figure A.70 Preview of surgical guide in right lateral view The guide extends from the entrance point on the occlusal plane, following the intrasinusal implant course up to the base of the zygomatic body, and resting on it next to the implant exit point Figure A.71 Zygomatic surgical guide made with stereolithographic technique The guide finds support on the alveolar ridge, embraces the zygomatic process of the maxillary bone, and rests on the base of the zygomatic body This extended shape guarantees a better stability of the guide In addition, the lateral opening allows us to control the drill intermediate path, intra- and extra-sinusal The guide can then follow the drills very close to the exit point, reducing the problems of angular deviation preparation up to the exit point at the level of the zygomatic body (Fig A.71) • The surgical guide can be also used, through specific PEEK adapters, with piezosurgical inserts, specially designed for the zygomatic implant surgery (ES052XZT, ES3, 5ZT, Esacrom, Imola, Bologna, Italy) (Fig A.72) Sinus Window Using Sinus Lifting Guide • The “sinus lifting guide,” placed on the bone surface, guides the osteotomies for the rectangular sinus fenestrations (Figs.A.73, A.74) Figure A.72 The two zygomatic surgical guide can also be used with piezosurgical inserts The insert positioned in the left zygomatic bone (ES052XZT) is pointed and is used first, the one on the right (ES3, 5ZT) is used for the final preparation These inserts, specially designed for zygomatic surgery (Esacrom, Imola, Italy) can help to improve the safety and accuracy during the preparation of implant sites To use these piezosurgical inserts with the surgical guides specific PEEK adapters were utilized the specific adapter in PEEK Figure A.73 The Sinus Lifting Guide is used for the preparation, with a piezoelectric insert, of the sinus fenestration • Through the fenestration, you can detach the sinus membrane (Fig A.75) and check the course of the drills during the preparation of implant sites Bone Support of Zygomatic Surgical Guide • The zygomatic surgical guide, placed on the alveolar bone crest, also finds support on the antral bone surface, ending at the base of the zygomatic body and remaining adherent to the process of the zygomatic maxillary bone (Fig A.76) It will guide the tools for the preparation of the implant sites 10 Zygomatic Implant Site Preparation • For the preparation of the zygomatic implant sites, the authors recommend using drills or piezosurgical inserts (Figs A.77, A.78) Continued www.ajlobby.com 542 Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Figure A.74 Quadrilateral osteotomy, made immediately anterior to Figure A.76 The zygomatic surgical guide in place The guide is open laterally to allow the checking of the drill’s path through the the zygomatic alveolar crest fenestration sinus Figure A.75 Elevation of the sinus membrane The bone flap is Figure A.77 Implant site preparation with piezosurgical insert The buccal opening of the guide allows us to easily control the tool’s path pushed into of the sinus cavity • The tools enter the guide’s sleeve at the level of the entrance point and cross the maxillary sinus, remaining visible through the bony window up to the exit point on the zygomatic body (Fig A.79) 11 Zygomatic Implant Placement • The zygomatic implants are inserted freehand in the implant sites, prepared through the guide (Fig A.80) • While screwing the implants, their intermediate path (frequently intrasinusal) can be constantly checked (Fig A.81), up to the exit point on the zygomatic body • At this level, make sure that the implants not protrude too far from the surface of the zygomatic body (Fig A.82) 12 Postoperative CT/CBCT Control • A postoperative radiographic control is generally not necessary, but it can be performed at any time • Through a postoperative CT/CBCT scan, it is possible to evaluate the surgical precision by superimposition, with the O&O software (SimPlant, Hasselt, Belgium), of the preoperative and the postoperative images By using this software, it is possible to obtain linear and angular measurements in all planes of space and calculate the average error made with respect to the planning4 (Figs A.83, A.84) www.ajlobby.com Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies 543 PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Figure A.78 Control of the tool through the sinus opening Figure A.80 Placement of the zygomatic implant Figure A.79 Continuation of the implant site preparation with long piezosurgical inserts Figure A.81 From the entrance point, the zygomatic implant, placed at the level of the alveolar crest, goes through the sinus cavity up to the exit point on the anterior surface of the zygomatic process Figure A.82 Two zygomatic implants were placed through the zygomatic surgical guides Continued www.ajlobby.com 544 Appendix Bone Grafting Surgical Protocols Using Three-Dimensional Technologies PROTOCOL 6 Zygomatic Implants (Ganz-Rinaldi Zygomatic Implants Protocol)—cont’d Figure A.83 The superimposition of the preoperative CT scan with the postoperative one allows us to evaluate, with a good approximation, the correspondence between the planning and the execution (O&O Software, SimPlant, Hasselt, Belgium) Figure A.84 It is possible to eliminate virtually all the bone in order to evaluate the different position between the planned implants and those actually placed Using this software it is possible to measure the axial and angular discrepancies and calculate the average REFERENCES Gentile L, Mottola A, Rinaldi M VI International Symposium SimPlant Academy: Innovative Solutions in Guided Implantology October 26th and 27th Bologna, Italy: Medimond International Proceedings; 2012 151–152 Van Assche N, Vercruyssen M, Coucke W, Teughels W, Jacobs R, Quirynen M Accuracy of computer-aided implant placement Clin Oral Implants Res 2012;23(Suppl 6):112–123 3 Aparicio C A proposed classification for zygomatic implant patient based on the zygoma anatomy guided approach (ZAGA): a cross-sectional survey Eur J Oral Implantol 2011;4(3):269–275 Autumn Piccinini personal communication; 2011 www.ajlobby.com INDEX A Absolute indications, for bone grafting, 17 Acquisition protocols, for computer-assisted implant surgery, 106–111, 110f Acute sinusitis, medical treatment of, 132–133 Age advanced, computer implant surgery for partial edentulism and, 157 mandibular edentulism and, computer implant surgery for, 165 maxillary edentulism and, computer implant surgery using tilted implants for, 191 Agenesis, of maxillary right lateral incisor, and implant prosthetic replacement of tooth, 161–162 considerations for, 161, 162f–163f medical and clinical picture of, 161, 162f postoperative considerations for, 162 prosthetic procedures of, 161–162, 164f surgical procedure of, 161, 163f–164f Alkaline phosphatase, 22 Alveolar nerve course of, 14f inferior, 13–14, 14f superficialization of computer implant surgery for mandibular edentulism with, 165 in computer implant surgery using tilted implants for mandibular edentulism, 177 Alveolar plexus, Alveolar process, 13 Analgesia, 136 Anesthesia, risk of, 135, 135t Angiogenesis, in bone regeneration, 21–22, 21f–22f Angled implants, 105–106, 108f–110f Antibiotic therapy, for chronic sinusitis, 133 Antrum of Higmore, 124 Anxiolysis, 135 Arteries, of maxillary sinus, 126 Ascending ramus, harvesting bone from, for bone defects in thickness and height, 381–382 Atrophy, maxillary bone, zygomatic implants in, 509–519 medical and clinical situation of, 509 postoperative considerations in, 510, 528f–531f preoperative considerations in, 509, 521f–523f surgical procedures in, 509–510, 523f–528f B Benzodiazepines, 137 Bilateral sinus augmentation bone harvest from posterior superior iliac spine in, 423 medical and clinical situation of, 423, 424f preoperative considerations for, 423–424, 425f–427f, 433f–436f Bilateral sinus augmentation (Continued) surgical procedures for, 423–424, 427f–433f computer implant surgery for, 483 implant placement in, 483–484, 493f–495f medical and clinical situation of, 483 postoperative considerations and implant placement for, 483, 492f–493f preoperative considerations of, 483, 484f–487f surgical procedures of, 483, 487f–491f Bilateral sinus grafts, for partial edentulism with subsinusal defects in height, 446 Bispectral index (BIS), 136, 136t Bleeding tendency, in computer implant surgery for mandibular edentulism, 165 Blood clot, protection of, 17, 18f Bone availability distally to mental foramen, in computer implant surgery using tilted implants for mandibular edentulism, 171 plasticity of, 2–3 residual quantity of, 15 Bone autograft, from iliac crest, 43–47, 43f complications of, 43–44 surgical technique for anterolateral, 44–45, 44f–46f posterior superior iliac spine, 46–47 Bone crests, separation and expansion of, 53–54, 54f–57f Bone defects bone grafting for, 17–18, 18f–20f computer implant surgery for partial edentulism with, 146 edentulous maxilla with, computer implant surgery for, 320, 321f–322f harvesting bone from mandibular body and ascending ramus for, 381–382 bone grafting in, 381–382 implant placement in, 382 medical and clinical picture of, 381 preoperative considerations in, 381–382, 382f–384f, 387f–388f surgical procedures in, 381–382, 384f–390f mandibular distal, in computer implant surgery using tilted implants for mandibular edentulism, 181 mandibular edentulism with, computer implant surgery for, 351 using tilted implants, 198 maxillary edentulism with computer implant surgery for, 301, 302f–304f, 306f, 327, 329f, 351 computer implant surgery using tilted implants for, 198 sub-sinusal, 279, 281f in thickness and height, 279, 281f–282f severe maxillary, bone grafting and sinus augmentation for, 263–264 thick, in piezoelectric surgery for partial edentulism, 408 Bone density, in Hounsfield units, 111–112, 113f Bone grafting, 391, 397 bone block, removal of, 392f in computer implant surgery for edentulous maxilla, 320 determination of, 397, 399f fixation of graft, 392f flaps, everting suture of, 393f freeze-dried homologous bone, positioning of, 393f harvest, delimitation of, 392f harvesting of bone, 397, 400f–401f homologous bone, placement of, 397, 402f indication for, 397, 398f insertion fibers, isolation and incision of, 392f integration of graft, 395f for maxillary edentulism with massive cyst and sinusitis, 292, 296f–300f for severe maxillary bone defects, 263–264, 265f, 267f–270f, 274f–275f Bone grafts, 17–95 adverse clinical signs and complications of, 89–91, 90f bone remodeling in, 25 extraoral modeling of, 50–51, 50f–51f fixation of, 51, 51f–53f flap adaptation in, 85, 86f indications for, 17–18, 18f–20f for mandibular edentulism with bone defects in thickness and height, computer implant surgery for, 351 for maxillary edentulism with bone defects, 279–280, 284f–287f, 301, 306f–309f, 311f, 315f, 351 computer implant surgery for, 327 with subsinusal defects in thickness and height, 341, 370, 375f–376f photofunctionalization and customized bone in, 88, 88f–89f in piezoelectric surgery for partial edentulism, 408, 410f–411f preparation of recipient bed for, 50, 50f STL models and surgical guides for, 63–68 cross-sectional visualization, 64–66, 64f–66f screw-retained versus cement-retained prosthetic design, 66–68, 67f–69f three-dimensional imaging, 63–64, 64f surgical protocols for, using three-dimensional technologies, 76–81, 77f–85f time of healing with, 87, 87f Bone regeneration angiogenesis in, 21–22, 21f–22f clinical and applicative considerations in, 25 creeping substitution in, 25 elements of biology of, 18–26 events of, 21–25 future for, 25–26 morphogenesis in, 22 Page numbers followed by f indicate figures; t, tables; b, boxes 545 www.ajlobby.com 546 Index Bone regeneration (Continued) osteoclastic resorption in, 24, 24f, 26f osteogenesis in, 22–24, 23f regenerative potential of grafted site in, 25 remodeling and, 25 tissue triad in, 19–21, 20f Bone remodeling, 25 Bone-supported guides, indications for, 115, 116f Bone-supported SurgiGuide, in computer implant surgery using tilted implants for maxillary edentulism, 187f–188f Bone suture technique, in mental symphysis, 33, 37f Buccal, C Canine fossa, Cawood and Howell classification, 15, 15t CBCT-aided guided surgery, 63 Cellular elements, in tissue triad, 19–20 Cement-retained prosthetic design, screwretained prosthetic design versus, 66–68, 67f–69f Chisels, for bone harvesting, 33, 34f Chronic sinusitis medical treatment of, 133 in sinus graft with heterologous bone block for maxillary edentulism, 412 surgical therapy for, 133 Classification of Lekholm and Zarb, 15, 15t Classification of Misch, 15, 15t Collagen fibers, 23–24, 23f Computed tomography in computer implant surgery for mandibular edentulism with bone defects in thickness and height, 353f–354f for mandibular edentulism with superficialization of alveolar nerve and bleeding tendency, 165 for maxillary edentulism with bone and subsinusal defects, 327, 329f for maxillary edentulism with bone defects in thickness and height, 358f for single edentulism with minimal invasiveness, 152, 152f–153f using tilted implants for maxillary and mandibular edentulism with bone and subsinusal defects, 198, 199f–200f, 202f using tilted implants for maxillary edentulism, 184, 185f–187f in maxillary edentulism, with subsinusal defects in height and thickness, bone grafts, sinus grafts and tilted implants for, 342f–343f Computer-aided design and computer-aided design (CAD-CAD) abutment, 161–162 Computer-aided design and computer-aided manufacture (CAD-CAM) customized abutment, 161–162, 164f technique, prosthesis made from, 350f Computer-guided surgery, 226, 391 bone supported surgical guide, 226, 228f digital cast, 228f implant planning, three-dimensional view of, 227f–228f Computer-guided surgery (Continued) implant planning in, 393f–394f planning, 227f prosthetic framework fabricated by, 232f–233f three-dimensional views in, 394f–395f treatment planning software, 226 Computer implant surgery, 96–123, 209–210, 211f, 221, 397 acquisition protocols and scan prosthesis, 106–111, 110f–111f radiographic templates of, 110–111, 111f–112f for bilateral sinus augmentation, 483 clinical indications of, 105–106, 108f–110f for edentulous maxilla, bone grafting in, 320 features and performance of, 111–114, 113f software features of, 112–114 views of, 112, 114f implant planning software and stereolithographic models in, 96–105 presurgical planning software, 96, 96f stereolithography and powder sintering, 98–99, 98f–101f three-dimensional simulation, 97–98, 97f–98f tools for transfer of simulations to clinical practice, 99–105, 102f–107f for mandibular edentulism with bone defects in thickness and height, 351, 362f–363f with superficialization of alveolar nerve and bleeding tendency, 165 for maxillary edentulism, 279–280 with bone and subsinusal defects, 327 with bone defects in thickness and height, 301, 351, 359f–360f with massive cyst and sinusitis, 292 with subsinusal defects in thickness and height, 370 modeling in, 397, 406f–407f for partial edentulism with advanced age, 157–158 with bone defects in thickness, 146 with normal sinus morphology, 140 planning in, 211f–213f, 215f, 222f, 397, 400f, 403f preparation of implant sites, 117f–118f, 118 for single edentulism with minimal invasiveness, 152 for sinus augmentation, bone harvest from posterior superior iliac spine in, 437 for sinus elevation, stereolithographic model in, 459 implant planning in, 459, 463f medical and clinical presentation of, 459 postoperative considerations for, 459, 463f, 465f preoperative considerations for, 459, 460f–462f prosthesis in, 460, 465f–466f surgical procedures in, 459, 462f–465f for sinus floor augmentation, stereolithographic sinus lift guide in, 475 three-dimensional views, 213f–214f, 216f, 223f–224f www.ajlobby.com Computer implant surgery (Continued) types of surgical guides, 114–118, 114f bone-supported guides, 115, 116f mucosal-supported guides, 115 tooth-supported guides, 115 using tilted implants for mandibular edentulism, bone availability distally to mental foramen in, 171 for mandibular edentulism with defects in height and superficialization of alveolar nerve, 177 for mandibular edentulism with distal bone defects, 181 for maxillary and mandibular edentulism with bone and subsinusal defects, 198–199 for maxillary edentulism, maxillary sinuses in, 184–185 for maxillary edentulism with sinus disease and subsinusal bone defects, 191 Cone beam computed tomography, 240 Conscious sedation, 136 Crestal access technique, in sinus grafting, 57–59, 77 Crestal osteotomy technique, in sinus grafting, 59 Cross-sectional visualization, 64–66, 64f–66f Customized bone, for bone grafts, 88, 89f Cutting depth, in osteotomy, 30 Cyst, massive, in maxillary edentulism, 292, 293f–294f, 297f Cystectomy, for maxillary edentulism with massive cyst and sinusitis, 292, 297f D Deep sedation/analgesia, 136 Demineralized bone matrix, in bone regeneration, 26 Density, of bone, Desktop three-dimensional printers, 98 Diagnostic free-hand, 69, 70f Diagnostic prosthesis, 103, 104f–106f Diamond discs, for osteotomy, 30 Digital cast, 226, 228f Digital Imaging and Communications in Medicine (DICOM), 63 Double scan protocol, 226 “Drill-on-sleeve” concept, 71, 72f Drugs, for pharmacologic management of patients, 137 E Ear, nose, and throat specialist, role of, in management of patients undergoing sinus grafts and implant surgery, 127–134 Edentulism anatomical problems and consequences of, 4–14 in infratemporal fossa, 4–5 in mandible, 9–14, 10f–11f, 13f–14f in maxillary sinus, 7–9, 8f–9f in mental foramen, 13–14, 14f in mylohyoid line, 9–13, 10f–11f in pterygopalatine fossa, 4f, 5–7, 6f Index Edentulism (Continued) mandibular see also Mandibular edentulism with bone and subsinusal defects, computer implant surgery using tilted implants for, 198–199 computer implant surgery using tilted implants for, bone availability distally to mental foramen in, 171 with defects in height and superficialization of alveolar nerve, computer implant surgery using tilted implants for, 177 with distal bone defects, computer implant surgery using tilted implants for, 181 with superficialization of alveolar nerve and bleeding tendency, computer implant surgery for, 165 maxillary see also Maxillary edentulism with bone and subsinusal defects, computer implant surgery for, 327 with bone and subsinusal defects, computer implant surgery using tilted implants for, 198–199 with bone defects, computer implant surgery for, 279–280 with bone defects in thickness and height, computer implant surgery for, 301 maxillary sinuses in computer implant surgery using tilted implants for, 184–185 with sinus disease and subsinusal bone defects, computer implant surgery using tilted implants for, 191 with subsinusal defects in height and thickness, bone grafts, sinus grafts and tilted implants for, 341 partial see also Partial edentulism with advanced age, computer implant surgery for, 157–158 with bone defects in thickness, computer implant surgery for, 146 bone graft in piezoelectric surgery for, 408 with normal sinus morphology, computer implant surgery for, 140 with subsinusal defects in height, bilateral sinus grafts for, 446 single, with minimal invasiveness, computer implant surgery for, 152 Edentulous maxilla, bone grafting in computer implant surgery for, 320 medical and clinical picture of, 320, 321f postoperative considerations and implants insertion for, 320, 323f–326f preoperative considerations for, 320, 321f surgical procedure for, 320, 321f–323f “Endoscopic anatomy”, 124 Endoscopy, for chronic sinusitis, 133 F Facial artery, 12–13 FESS see Functional endoscopic sinus surgery (FESS) Fissure burs, for osteotomy, 30, 33f Flap, adaptation of, 85, 86f Flapless surgery, 115 in computer implant surgery for mandibular edentulism with superficialization of alveolar nerve and bleeding tendency, 165 systems, 157 Flapless technique, for computer implant surgery for bilateral sinus augmentation, 483–484, 493f Fracture, from iliac harvest, 43–44 Freeze-dried bone graft, 18f Full template guidance, for implant surgery, 70–76, 71f–76f Functional endoscopic sinus surgery (FESS), 124 G Ganz-Rinaldi classification of guided implant surgery protocols, 69 General anesthesia, inpatient, 135 Graft resorption, 89, 90f Graftless surgery, 114–115 Growth factors, for bone regeneration, 20–21, 20f Guided implant surgery protocols, Ganz-Rinaldi classification of, 69 H Hard palate, 7f Hemimaxillectomy, zygomatic and pterygomaxillary implants in, 496–497 medical and clinical situation of, 496, 497f–498f postoperative considerations in, 497, 506f–508f preliminary remarks in, 496 preoperative considerations in, 496, 498f–502f surgical procedures in, 496–497, 502f–506f Hounsfield units, bone density in, 111–112, 113f Hydraulic Subantral Membrane Elevator, 348f I Iliac crest, bone autograft from, 43–47, 43f complications of, 43–44 surgical technique for anterolateral, 44–45, 44f–46f posterior superior iliac spine, 46–47 Iliac spine, posterior superior, bone harvest from in bilateral sinus augmentation, 423, 427f–428f in computer implant surgery for sinus augmentation, 437, 439f–441f Immediate loading, 209–210, 234–235 Implant(s) immediate, for maxillary edentulism with massive cyst and sinusitis, 292, 299f–300f inclined see Inclined implants tilted see Tilted implants zygomatic and pterygomaxillary, in hemimaxillectomy, 496–497 medical and clinical situation of, 496, 497f–498f postoperative considerations in, 497, 506f–508f preliminary remarks in, 496 preoperative considerations in, 496, 498f–502f surgical procedures in, 496–497, 502f–506f www.ajlobby.com 547 Implant insertion, anatomical obstacles to, 1–16 bone plasticity in, 2–3 edentulism in, 4–14 infratemporal fossa in, 4–5 jaw bones in, postextraction atrophy of, 14–15 mandible in, 9–13, 10f–11f canal of, 13–14, 13f–14f masticatory load distribution in, 3–4 maxillary sinus in, 7–9, 8f–9f mental foramen in, 13–14, 14f mylohyoid line in, 9–13, 10f–11f pterygopalatine fossa in, 4f, 5–7, 6f residual bone quantity in, 15 Implant placement, computer-guided, in sinus augmentation, 467, 473f planning of, 468f–469f Implant planning software, 96–105 features of, 112–114 home page, 172f Implant surgery, role of ear, nose, and throat specialist in management of patients undergoing, 127–134 Incisor, maxillary right lateral, agenesis of, and implant prosthetic replacement of tooth, 161–162 Inclined implants, 209–210, 211f, 215f–216f clipping function at, 214f insertion of, 214f–215f, 218f–219f planning of, 211f–213f, 215f position of, 209 after removal of guides, 219f Inferior alveolar artery, 5, 13 Inferior alveolar canal, 13 Infraorbital canal, Infraorbital groove, Infratemporal fossa, dental implants and, 4–5 Infundibulum, 125 Innervation, of maxillary sinus, 126 Internal maxillary artery, Intraoral bone harvest, 26–41 from mandibular body and ramus, 39–41 access in, 40 anesthesia in, 40 donor site in, 39–41, 39f osteotomy and bone removal in, 40–41, 40f–42f treatment of donor site and suture in, 41, 42f–43f from mental symphysis, 29–33 access in, 29–30, 31f anesthetic technique in, 29 donor site in, 29–33, 29f–31f osteotomies and, 30–33, 31f–37f treatment of donor site and suture in, 33, 37f–38f minor, 26, 26f–28f J Jaw bones, postextraction atrophy of, 14–15 K Ketamine, 137 Ketanest see Ketamine 548 Index L L-shaped graft, 35f Large sinus elevation, 77 Lateral access technique, in sinus grafting, 57–59, 77 Lateral femoral cutaneous nerve, 44 Lateral incisors, congenital agenesis of, 397 medical and clinical picture, 397, 398f postoperative considerations, and implant placement in, 397 abutments, in place, 407f computer modeling of abutments, 397, 406f–407f control orthopantomographic scan in, 397, 405f healing screw, placement of, 406f implant sites, preparation of, 397, 404f implants, placement of, 397, 404f–405f impression in, 397, 406f osteosynthesis screws, removal of, 397, 404f patient, smile of, 407f placement of surgical guide, 397, 404f planning of, 397, 403f removal of surgical guide, 397, 405f screw-retained temporary crowns, placement of, 397, 406f surgical guide in, 397, 404f sutures in, 397, 405f preoperative considerations in, 397 determination of bone grafts, 397, 399f donor site in, 397, 399f harvest guide for, 397, 400f harvest site, position of, 397, 400f indication for bone graft, 397, 398f scan-prosthesis in, 397, 398f stereolithographic models in, 397, 399f surgical procedures in, 397 bone, harvesting of, 397, 400f–401f flap, elevation of, 397, 401f grafts, preparation of, 401f gum tissue, suturing of, 397, 401f harvest guide, placement of, 397, 400f homologous bone, placement of, 397, 402f osteosynthesis screws, placement of, 397, 402f recipient site, preparation of, 397, 401f suture in, 397, 402f Level of consciousness according to Observer’s Assessment of Alertness/Sedation Scale, 136t according to Ramsey, 136t Lingual artery, 12–13 Lingual frenulum, 10 Lingula, of mandible, 13, 13f “Lip-lift” technique, 67–68, 68f Local anesthesia, 135–137 Localization guides, for bone grafting, 79–81, 80f–82f M Mandible, in implant planning, 9–13, 10f–11f canal of, 13–14, 13f–14f Mandibular atrophy, severe, bone grafting and sinus augmentation for final prosthesis for, 249, 261f–262f first intervention for, 247–248 surgical procedures in, 247–248, 252f–255f Mandibular atrophy, severe, bone grafting and sinus augmentation for (Continued) medical and clinical picture of, 247 preoperative considerations in, 247, 249f–252f second intervention for, 248 preoperative considerations in, 248, 256f–258f surgical procedures in, 248, 258f–260f third intervention for, 248 preoperative considerations and surgical procedures in, 248, 260f–261f Mandibular body, bone harvest from, 39–41 access in, 40 anesthesia in, 40 for bone defects in thickness and height, 381–382 donor site in, 39–41, 39f osteotomy and bone removal in, 40–41, 40f–42f treatment of donor site and suture in, 41, 42f–43f Mandibular canal, implant insertion and, 13–14, 13f–14f Mandibular distal bone defects, in computer implant surgery using tilted implants for mandibular edentulism, 181 Mandibular edentulism with bone and subsinusal defects, computer implant surgery using tilted implants for, 198–199 medical and clinical picture of, 198 postoperative considerations for, 199 preoperative considerations for, 198, 199f–205f surgical procedure for, 198–199, 205f–208f with bone defects in thickness and height, computer implant surgery for, 351 first intervention in, 351, 353f–354f medical and clinical picture in, 351 postoperative considerations in, 351–352, 358f, 369f second intervention in, 361f–364f surgical procedure for, 352, 366f–368f computer implant surgery using inclined implants for, 209–210 medical and clinical picture, 209 postoperative considerations in, 210, 220f preoperative considerations in, 209–210, 211f–212f, 217f surgical procedure for, 210, 217f–220f computer implant surgery using tilted implants for, bone availability distally to mental foramen in, 171 medical and clinical picture of, 171 postoperative considerations for, 171, 175f–176f preoperative considerations for, 171, 172f–174f surgical procedure for, 171, 174f–175f with defects in height and superficialization of alveolar nerve, computer implant surgery using tilted implants for, 177 medical and clinical picture of, 177 postoperative considerations for, 177 preoperative considerations for, 177, 177f–179f surgical procedure for, 177, 180f www.ajlobby.com Mandibular edentulism (Continued) with distal bone defects, computer implant surgery using tilted implants for, 181 medical and clinical picture of, 181 postoperative considerations for, 181, 183f preoperative considerations for, 181, 181f–182f surgical procedure for, 181, 182f–183f with superficialization of alveolar nerve and bleeding tendency, computer implant surgery for, 165 medical and clinical picture of, 165, 166f postoperative considerations for, 165, 170f preoperative considerations for, 165, 166f–169f surgical procedure of, 165, 169f–170f Mandibular nerve, Masticatory loads, distribution of, in skull, 3–4, 3f Maxilla, edentulous, bone grafting in computer implant surgery for, 320 Maxillary artery, 6–7, 6f Maxillary atrophy, severe, bone grafting and sinus augmentation for final prosthesis for, 249, 261f–262f first intervention for, 247–248 surgical procedures in, 247–248, 252f–255f medical and clinical picture of, 247 preoperative considerations in, 247, 249f–252f second intervention for, 248 preoperative considerations in, 248, 256f–258f surgical procedures in, 248, 258f–260f third intervention for, 248 preoperative considerations and surgical procedures in, 248, 260f–261f Maxillary bone defects, severe, bone grafting and sinus augmentation for, 263–264 final prosthesis for, 264, 277f–278f first intervention for preoperative considerations in, 263, 264f–266f reconstructive surgery in, 263, 266f–270f medical and clinical picture of, 263 preliminary remarks for, 263 second intervention for implant placement in, 264, 275f–277f preoperative considerations in, 263–264, 270f–274f Maxillary edentulism, 221 with bone and subsinusal defects, computer implant surgery for, 327 medical and clinical picture of, 327 postoperative considerations and implant placement for, 328, 334f–340f preoperative considerations for, 327, 329f–331f surgical procedure for, 327–328, 331f–334f with bone and subsinusal defects, computer implant surgery using tilted implants for, 198–199 medical and clinical picture of, 198 postoperative considerations for, 199 preoperative considerations for, 198, 199f–205f surgical procedure for, 198–199, 205f–208f Index Maxillary edentulism (Continued) with bone defects, computer implant surgery for, 279–280 first intervention for, 279, 282f–283f medical and clinical picture of, 279, 281f–282f postoperative considerations for, 280, 291f second intervention for, 280, 287f–289f surgical procedures for, 279–280, 283f–286f, 289f–291f with bone defects in thickness and height, computer implant surgery for, 301, 351 first intervention in, 301, 302f–304f, 351, 353f–354f medical and clinical picture of, 301, 302f, 351 postoperative considerations and final prosthesis for, 302, 318f–319f postoperative considerations for, 301, 309f, 351–352, 358f, 369f second intervention in, 351–352, 358f–361f second surgery (implant placement) for, 301–302, 310f–315f surgical procedure for, 301–302, 304f– 309f, 315f–317f, 351–352, 355f–357f, 364f–366f complete, 226 medical and clinical picture, 226 preoperative considerations in, 226, 228f–229f surgical procedures for, 226, 229f–232f computer implant surgery using inclined implants for, 209–210 medical and clinical picture, 209 postoperative considerations in, 210, 220f preoperative considerations in, 209–210, 211f–212f, 217f surgical procedure for, 210, 217f–220f with massive cyst and sinusitis, computer implant surgery for, 292 medical and clinical picture of, 292, 293f postoperative considerations in, 293, 299f–300f preoperative considerations in, 292, 293f–297f surgical procedures for, 292, 297f–299f maxillary sinuses in computer implant surgery using tilted implants for, 184–185 medical and clinical picture of, 184 postoperative considerations for, 185, 189f–190f preoperative considerations for, 184, 185f–188f surgical procedure of, 184–185, 188f–189f medical and clinical picture, 221 postoperative considerations in, 221 healing abutments, connection of, 225f orthopantomograph, 225f preoperative considerations in, 221 advanced maxillary atrophy, 221 with sinus disease and subsinusal bone defects, computer implant surgery using tilted implants for, 191 medical and clinical picture of, 191, 192f postoperative considerations for, 191, 197f Maxillary edentulism (Continued) preoperative considerations for, 191, 192f–195f surgical procedure for, 191, 195f–197f with subsinusal bone defect, sinus graft with heterologous bone block for, 412 medical and clinical picture of, 412 postoperative considerations for, 413, 419f preimplant considerations for, 413, 419f–420f preoperative considerations for, 412, 413f–416f prosthetic result in, 413, 422f surgical procedures in, 412–413, 416f–419f, 421f–422f with subsinusal defects in height and thickness, bone grafts, sinus grafts and tilted implants for, 341 medical and clinical picture of, 341 postoperative considerations in, 342, 350f preoperative considerations in, 341, 342f–347f surgical procedure for, 341–342, 347f–350f surgical procedure in, 221, 224f implant site, preparation of, from palatal side, 225f Maxillary nerve, 6–7 Maxillary right canine and central incisor, lack of space between, 161 Maxillary right lateral incisor, agenesis of, and implant prosthetic replacement of tooth, 161–162 considerations for, 161, 162f–163f medical and clinical picture of, 161, 162f postoperative considerations for, 162 prosthetic procedures of, 161–162, 164f surgical procedure of, 161, 163f–164f Maxillary sinus(es) clinical anatomy of, 124–127, 124t anterior wall, 125 inferior wall, 125–126 lateral wall, 125 medial wall, 125 posterior wall, 125 superior wall, 125 vascularization and innervation of, 126 in computer implant surgery using tilted implants for maxillary edentulism, 184 dental implants and, 7–9, 8f apex of, walls of, 9, 9f historical background, 124 role of otolaryngologist, 124–134 Maxillary sinus lift contraindications to, 129 ear, nose, and throat therapy before, 129–134 presurgical ear, nose, and throat diagnosis in, 127–129, 128f–132f recognition and treatment of ear, nose, and throat complications after, 133–134 Mental foramen bone availability distally to, in computer implant surgery using tilted implants for mandibular edentulism, 171 implant insertion and, 13–14, 14f Mental nerve anesthesia, 29 www.ajlobby.com 549 Mental symphysis, bone harvest from, 29–33 access in, 29–30, 31f anesthetic technique in, 29 donor site in, 29–33, 29f–31f osteotomies and, 30–33, 31f–37f treatment of donor site and suture in, 33, 37f–38f Mild sedation/anxiolysis, 135 Minimal invasiveness, single edentulism with, computer implant surgery for, 152 “Minimally invasive surgery”, 115 Moderate sedation/analgesia/conscious sedation, 136 Morphogenesis, in bone regeneration, 22 Mucociliary transport, of sinus, 127 Mucosal-supported guides, indications for, 115 Mylohyoid line, in implant planning, 9–13, 10f–11f Mylohyoideus muscle, 12 N Navigator system, 221 preparation of implant sites with, 224f simulation of surgery with, 224f Necrosis, of bone graft, 89, 90f Nitrous oxide, 137 Nondistorted imaging, 111–112 O Opioids, 137 Orbital contour, Orthopantomography in computer-guided implant placement for sinus augmentation, 474f in computer implant surgery for edentulous maxilla, 320, 321f using stereolithographic sinus lift guide for sinus floor augmentation, 475, 476f, 482f in maxillary complete edentulism, 232f Osteoblast, 22, 23f Osteoclasts, resorption of, in bone regeneration, 24, 24f, 26f Osteocytes, 23–24 Osteogenesis, in bone regeneration, 22–24, 23f Osteotomy(ies), 234–235, 238f bone harvesting and in mandibular body and ramus, 40–41, 40f–42f in mental symphysis, 30–33, 31f–37f crestal, 234, 236f, 238f medical and clinical picture, 234 with piezosurgical instrument, 234–235, 237f postoperative considerations, 235 preoperative considerations, 234 jaw, undercut in, 235f vertical bone height loss in, 234 preparation of implant sites, guides for, 237f software simulation, 236f and stereolithographic model, 237f surgical procedures, 234–235, 237f gingival flaps, suturing of, 239f guides for implant sites, 237f implant, freehand insertion of, 238f preparation of implant sites, 238f prosthetic abutments, positioning of, 239f tilted implant, placement of, 239f Toronto-type prosthesis, provision of, 239f 550 Index Ostium-meatal complex, 125 clinical anatomy of, 124–127 Outpatient sedation, 135–137 Overdenture reconstruction, 17, 18f P Palatine artery, Palatine foramen, 7f Paranasal sinuses, physiology of, 126–127 Partial edentulism with advanced age, computer implant surgery for, 157–158 medical and clinical picture of, 157, 158f postoperative considerations for, 158 preoperative considerations for, 157, 158f–159f surgical procedure of, 157–158, 159f–160f with bone defects in thickness, computer implant surgery for, 146 medical and clinical picture of, 146 postoperative considerations for, 146, 150f–151f preoperative considerations for, 146, 147f–150f surgical procedure of, 146, 149f–150f bone graft in piezoelectric surgery for, 408 medical and clinical picture of, 408 postoperative considerations for, 408 preoperative considerations for, 408, 408f–410f surgical procedure of, 408, 410f–411f with normal sinus morphology, computer implant surgery for, 140 medical and clinical picture of, 140, 140f postoperative considerations for, 140, 145f preoperative considerations for, 140, 141f–143f surgical procedure of, 140, 143f–144f with subsinusal defects in height, bilateral sinus grafts for, 446 medical and clinical picture of, 446 postoperative considerations and implants insertion for, 447, 456f–458f preoperative considerations for, 446, 448f–452f surgical procedure in, 446–447, 452f–456f PDGF see Platelet-derived growth factor (PDGF) Pharmacologic management, of patients, 135–138 drugs in, 137 inpatient general anesthesia, 135 outpatient sedation and local anesthesia, 135–137 risk of anesthesia, 135t Photofunctionalization, in bone grafts, 88, 88f Piezoelectric instruments, in computerguided implant placement for sinus augmentation, 471f Piezoelectric surgery, for partial edentulism, 408 medical and clinical picture of, 408 postoperative considerations for, 408 preoperative considerations for, 408, 408f–410f surgical procedure, 408, 410f–411f Plaster cast, 103–104, 107f Plastics, categories of, 98 Platelet-derived growth factor (PDGF), in angiogenesis, 21–22 Pneumatization, 76–77 Posterior fontanelle, 125 Posterior mandibular bone defects, 391 medical and clinical picture, 391 preoperative considerations for, 391 donor site of, 391, 392f guide for, 391, 392f implant, placement of, 391, 393f–395f morphology of, 391, 391f surgical procedures, 391 bone grafting, 391, 392f–393f implant placement, 391, 395f–396f Posterior superior iliac spine (PSIS), bone harvest from, 46–47 access in, 46–47, 47f–48f anesthetic technique in, 46–47, 46f–47f in bilateral sinus augmentation, 423, 427f–428f donor site in, 46 osteotoinoes and, 47, 48f post-operative treatment of, 47, 49f treatment of donor site & suture, 47, 49f Postextraction implant placement, 234–235, 235f Powder sintering, 98–99, 101f Pressure, in compactness of bone, Presurgical planning software, 96, 96f, 113f Propofol, 137 Prosthetic abutments, 112–114 PSIS see Posterior superior iliac spine (PSIS) Pterygoid canal, Pterygoid fossa, Pterygoid plexus, Pterygoid process, of sphenoid bone, Pterygopalatine fossa, 4f, 5–7, 6f Pterygopalatine ganglion, 6–7 “Pyramid of bone”, 65–66 R Radiographic templates, of computer-assisted implant surgery, 110–111, 111f Ramus bone harvest from, 39–41 access in, 40 anesthesia in, 40 donor site in, 39–41, 39f osteotomy and bone removal in, 40–41, 40f–42f treatment of donor site and suture in, 41, 42f–43f mandibular, 13 Rapid prototyping models, in computer-assisted implant surgery, 99–105 Reciprocating saws, for osteotomy, 30, 32f Reduction guide, 234–235, 236f–237f and stereolithographic model, 237f uses of, 235 Regenerative potential, of grafted site, 25 Relative indications, for bone grafting, 17 Resin blocks, for graft simulation, 77–88, 78f–79f Resins, used in stereolithography, 98 Resorption, graft, 89, 90f Rhinosinusitis, medical therapy for treatment of, 132 Ridge expansion, 54 www.ajlobby.com S SAFE system, 165, 168f Sagittal saws, for osteotomy, 30, 32f Scaffold, in tissue triad, 19–20, 20f Scan prosthesis, 103, 103f, 106–111 construction of, 110–111, 112f Schneiderian membrane, 348f elevation of, 472f Schneider’s membrane, 125 Screw-retained prosthetic design, versus cement-retained prosthetic design, 66–68, 67f–69f Sedation Rating Scale, 136t Segmentation, 106–110, 111f Selective transparency, 73, 74f, 111–112 Silicone bite registration, 105 Simulation, three-dimensional, 97–98, 97f–98f Single edentulism, with minimal invasiveness, computer implant surgery for, 152 medical and clinical picture of, 152 postoperative considerations for, 152, 156f preoperative considerations for, 152, 152f–154f surgical procedure of, 152, 154f–156f Sinus(es) maxillary clinical anatomy of, 124–127, 124t in computer implant surgery using tilted implants for maxillary edentulism, 184 dental implants and, 7–9, 8f with normal morphology, computer implant surgery for partial edentulism with, 140 Sinus augmentation bone harvest from posterior superior iliac spine in bilateral, 423 medical and clinical situation of, 423, 424f preoperative considerations for, 423–424, 425f–427f, 433f–436f surgical procedures for, 423–424, 427f–433f bone harvest from posterior superior iliac spine in computer implant surgery for, 437 medical and clinical situation of, 437 postoperative considerations for, 438, 444f–445f preoperative considerations for, 437, 438f–443f surgical procedures of, 437–438, 443f–444f computer-guided implant placement in, 467 medical and clinical situation of, 467 preoperative considerations for, 467, 468f–470f surgical procedures for, 467, 470f–474f computer implant surgery for bilateral, 483, 487f–491f for severe maxillary bone defects, 263–264 Sinus disease, maxillary edentulism with, computer implant surgery using tilted implants for, 191 Sinus elevation, computer implant surgery for, stereolithographic model in, 459 implant planning in, 459, 463f medical and clinical presentation of, 459 postoperative considerations for, 459, 463f, 465f Index Sinus elevation, computer implant surgery for, stereolithographic model in (Continued) preoperative considerations for, 459, 460f–462f prosthesis in, 460, 465f–466f surgical procedures in, 459, 462f–465f Sinus floor augmentation, computer implant surgery with stereolithographic sinus lift guide for, 475 medical and clinical situation of, 475, 476f postoperative considerations and implant placement for, 475 preliminary remarks for, 475 preoperative considerations for, 475, 476f–478f surgical procedures for, 475, 479f–482f Sinus grafting, 57–63, 57f–62f classification of, 61 Sinus grafts bilateral, for partial edentulism with subsinusal defects in height, 446 in computer implant surgery for maxillary edentulism, 327 with subsinusal defects in thickness and height, 370, 375f–376f with heterologous bone block, for maxillary edentulism with subsinusal bone defect, 412 medical and clinical picture of, 412 postoperative considerations for, 413, 419f preimplant considerations for, 413, 419f–420f preoperative considerations for, 412, 413f–416f prosthetic result in, 413, 422f surgical procedures in, 412–413, 416f–419f, 421f–422f for maxillary edentulism with bone defects, 279–280, 287f–289f with subsinusal defects in height and thickness, 341, 349f role of ear, nose, and throat specialist in management of patients undergoing, 127–134 Sinus lifting guide, 79–81, 82f–85f in bone grafting and sinus augmentation for severe maxillary bone defects, 263, 265f–267f Sinus margins, localization of, 347f Sinus septa, in computer implant surgery for sinus augmentation, 437, 438f–439f Sinusitis acute, medical treatment of, 132–133 chronic medical treatment of, 133 in sinus graft with heterologous bone block for maxillary edentulism, 412 surgical therapy for, 133 maxillary, 8–9 maxillary edentulism and, 292 Small sinus elevation, 77 Sphenopalatine foramen, Sphenopalatine incisure, Sphenopalatine Meckel ganglion, 6–7 Spix spine, 13, 13f Split crest, 53–54, 54f Stem cells, in bone regeneration, 26 Stereolithographic sinus lift guide, in computer implant surgery for sinus floor augmentation, 475, 478f–479f Stereolithographic (STL) model in bilateral sinus augmentation using bone harvest from posterior superior iliac spine, 423, 426f–427f, 429f, 431f–432f in bilateral sinus grafts for partial edentulism, 446–447, 450f–452f in computer-guided implant placement for sinus augmentation, 469f–470f in computer implant surgery for maxillary edentulism with bone defects in thickness and height, 360f–361f for sinus augmentation, 437, 439f–440f for sinus elevation, 459, 461f–462f for sinus floor augmentation, 475, 478f using tilted implants for mandibular edentulism, 171, 174f for harvests and grafts, 63–68 in maxillary edentulism with subsinusal defects in height and thickness, 343f–344f, 347f in piezoelectric surgery for partial edentulism, 408, 409f sinus graft with heterologous bone block preformed on, for maxillary edentulism with subsinusal bone defect, 412, 416f, 420f and surgical guides, 209, 214f, 217f implant placement, simulation of, 209 removal of, 218f stability, checking of, 217f surgery on, simulation of, 217f Stereolithography, 98–99, 98f–100f guide principles of, 101–103 models of, 96–105 physical principle of, 98 Sub-sinusal bone defects, in maxillary edentulism, 279, 281f Sublingual artery, 12–13 Sublingual lodge, 10 Submandibular duct, 12–13 Submandibular gland, 12 Submandibular lodge, 12, 12f Subsinusal defects bone, maxillary edentulism with computer implant surgery using tilted implants for, 191 sinus graft with heterologous bone block for, 412 in height, in bilateral sinus grafts for partial edentulism, 446 in mandibular edentulism, computer implant surgery using tilted implants for, 198 in maxillary edentulism, computer implant surgery for, 327, 329f, 370 medical and clinical picture of, 370, 371f postoperative considerations and implants insertion for, 370–371, 376f–380f preoperative considerations for, 370, 371f–373f surgical procedure of, 370, 374f–376f using tilted implants, 198 in thickness and height computer implant surgery for maxillary edentulism with, 370 www.ajlobby.com 551 Subsinusal defects (Continued) maxillary edentulism with, bone grafts, sinus grafts and tilted implants for, 341, 344f–346f Sulfur bridges, 98 Suprahyoid fascia, 12 Suprahyoid region, 12, 12f Surgical guides, 99–105, 107f examples of, 102f for harvests and grafts, 63–68 indications for, 115 and stereolithographic bone model, 221, 224f recheck on, 225f stability position of, 224f types of, 102f, 114–118, 114f Surgical therapy, for chronic sinusitis, 133 T Template-assisted protocol, for implant surgery, 69–76, 70f–71f Temporal lines, Thermoplastics, 98 Thermosetting, 98 Three-dimensional CT/CBCT diagnostic imaging, 77 Three-dimensional imaging, for harvests and grafts, 63–64, 64f Three-dimensional planning, in extraction of impacted supernumerary teeth, 240–241 postoperative considerations in, 241 preoperative considerations for area of safety in, 240, 243f–244f location guides in, 244f mandibular impacted teeth, position of, 240, 241f–243f stereolithographic model in, 243f, 245f treatment planning software in, 240 surgical procedures for area of safety in, 240, 244f bone flap, removal of, 240, 245f interrupted stitches in, 240, 245f medical and clinical picture, 240 piezosurgical instrument in, 240, 244f–245f preliminary remarks, 240 preoperative considerations for, 240 supernumerary impacted tooth, removal of, 245f–246f surgical fissure bur, use of, 240, 245f Three-dimensional simulation, 97–98, 97f–98f Tilted implants, 221, 222f–223f in computer implant surgery for mandibular edentulism, 171, 172f–175f in computer implant surgery for mandibular edentulism with defects in height and superficialization of alveolar nerve, 177, 178f–179f in computer implant surgery for mandibular edentulism with distal bone defects, 181 in computer implant surgery for maxillary and mandibular edentulism with bone and subsinusal defects, 198–199, 200f, 202f–203f, 206f–207f in computer implant surgery for maxillary edentulism, 184–185, 186f, 189f 552 Index Tilted implants (Continued) in computer implant surgery for maxillary edentulism with sinus disease and subsinusal bone defects, 191, 192f–194f, 196f exposure of, 225f insertion of, 225f for maxillary edentulism with subsinusal defects in height and thickness, 341 detail of, 349f insertion of, 346f–349f preparation of, 348f Time, as obstacle in computer implant surgery for maxillary edentulism with massive cyst and sinusitis, 292 Tissue punch guide, 157, 159f Tissue triad, in bone regeneration, 19–21, 20f Tools, for osteotomies, 30, 32f Tooth-supported guides indications for, 115 surgical, 158 Tooth-supported SurgiGuides, in computer implant surgery with stereolithographic sinus lift guide for sinus floor augmentation, 478f Transparent template, 97–98 Transverse root, of zygomatic process, “Triangle of bone”, 65–66, 66f Triangular graft, 36f Two-dimensional panoramic radiography (OPT), implant assessment using, 97 V Vascular endothelial growth factor (VEGF), in angiogenesis, 21–22 Vascularization, of maxillary sinus, 126 VEGF see Vascular endothelial growth factor (VEGF) Veins, of maxillary sinus, 126 Venous plexuses, of infratemporal fossa, Ventilation, of sinus, 126 Vidian canal, Virtual navigation systems, 99–101 www.ajlobby.com W Wedge grafts, from iliac crest, 45 Z Zygoma anatomy-guided approach (ZAGA) classification, of zygomatic implants, 509 Zygomatic arch, Zygomatic bone, in distribution of masticatory loads in skull, Zygomatic implants, in maxillary bone atrophy, 509–519 medical and clinical situation of, 509 postoperative considerations in, 510, 528f–531f preoperative considerations in, 509, 521f–523f surgical procedures in, 509–510, 523f–528f Zygomatic nerve, .. .COMPUTER-GUIDED APPLICATIONS for Dental Implants, Bone Grafting, and Reconstructive Surgery MARCO RINALDI, MD, DMD Private Practice Bologna, Italy SCOTT D GANZ, DMD Private Practice Fort... www.ajlobby.com 3251 Riverport Lane St Louis, Missouri 63043 COMPUTER-GUIDED APPLICATIONS FOR DENTAL IMPLANTS, BONE GRAFTING, AND RECONSTRUCTIVE SURGERY © 2009 Elsevier Srl – Tutti I diritti riservati... local anatomy and avoid the perforation of the lingual cortical bone Mandibular Canal and Mental Foramen The mandible, or lower jaw, is a median bone of the skull situated at the lower and frontal