European Journal of Oral Surgery by Ariesdue srl

Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale Vol. 4 issue 3 DECember 2013 ISSN 2037-7525

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European journal of oral surgery Official journal of the SocietĂ Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

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Vol. 4 issue 3 decEMBER 2013

page 51

Sinus floor elevation with a transcrestal approach: review of the literature and presentation of a simplified surgical technique

page 57

Computer-aided flapless surgery for implant prosthodontic rehabilitation of edentulous patients: a clinical case report

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European journal of oral surgery Official journal of the Società Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

Editorial

Prof. Carlo Maiorana Editor-in-chief

Dear colleagues, we are moving to 2014 after going through a very tough year for the dental practitioners due to the delicate economic period involving a huge part of Europe. Once more, when difficult times are running, the recourse to excellence in the daily practice is the best weapon. We think that our journal has been contributing, even though in a small way, to update practioners by presenting case reports and original monographs with the support of many clinicians, both from the university and the private practice side. For this reason all of them and the members of the board of JOS deserve our appreciation for their invaluable job during the current year. I just want to remind you that next October 4th, 2014, the 3° Congress of the Society will take place in Milan, entitled “Timing in oral surgery”. The event, whose preliminary program is already visible on the website, will host prominent speakers from Italy and Switzerland: Rino Burkhardt, Marco Rosa, Mario Beretta, Jason Motta Jones, Alberto Fonzar and Carlo Ghezzi. I sincerely hope that many of you will attend the meeting in order to be upadted on some of the hottest topics in oral surgery. I take the opportunity of this editorial to wish all of you merry Christmas and a happy new year.

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Monograph

Sinus floor elevation with a transcrestal approach: review of the literature and presentation of a simplified surgical technique Mattia Pramstraller Roberto Farina Giovanni Franceschetti Leonardo Trombelli Research Centre for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, Ferrara, Italy

Aim

Conclusion

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The loss of maxillary posterior teeth leads to a dimensional reduction of the bone crest, which is partly due to the pneumatization of the maxillary sinus. Transcrestal sinus floor elevation (tSFE) is a bone augmentation procedure based on the creation of an access through the edentulous bone crest. To date, several techniques for tSFE have been proposed and validated. Recently, we proposed a simplified, minimally invasive technique for tSFE (namely, the Smart Lift technique) which is based on the use of specifically designed drills and osteotomes. The present paper describes the postextraction dimensional alterations of the alveolar crest in the maxillary posterior sextants focusing on the contribution of sinus pneumatization, illustrates the operative steps of the Smart Lift technique and presents available data on clinical and patient-centered outcomes of tSFE when performed with this specific technique. The Smart Lift technique represents a simplified, user-friendly option, since it allows for a substantial extent of sinus lift at limited operation times along with limited morbidity.

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Key words: Maxillary sinus; Sinus lift; Crestal approach; Minimally-invasive; Dental implant; Bone regeneration.

Trombelli L.

Introduction The maxillary sinus is a pyramid-shaped cavity with its base adjacent to the nasal wall and apex pointing to the zygoma. In adults, the average dimensions of the sinus are 2.5 to 3.5 cm in width, 3.6 to 4.5 cm in height, and 3.8 to 4.5 cm in depth (1). It has an estimated volume of approximately 12 to 15 cm3 (2). The maxillary sinus bone cavity is lined with the sinus membrane, also known as the Schneiderian membrane, which has a thickness of approximately 0.8 mm (3). The dimensions of the bone crest at maxillary posterior sextants is closely related to the presence (or absence) of the maxillary posterior teeth. In a recent study, ridge height was shown to be significantly lower at fully edentulous compared to fully dentate maxillary posterior sextants. The contribution of sinus pneumatization to the reduction in crest height following tooth loss ranged between 20% to 46% (4). Previous studies evaluated the morphology of the edentulous maxillary alveolar crest as well as its relationship with the maxillary sinus on panoramic radiographs (5-11) or by direct in vivo assessment (i.e. during surgery or on cadavers) (9, 12, 13). Our research group evaluated the dimensions of the bone crest at edentulous sites in the posterior maxilla on computerized tomography (CT) scans (14). Bone height showed a significant decrease from first premolar (13 mm) to molar sites (5.4 mm and 6.6 mm at first and second molar respectively), and was insufficient for the placement of implants of adequate length (≥ 8 mm) in more than 60% of molar sites and in 15-40% of premolar sites (14).

Transcrestal sinus floor techniques Maxillary sinus floor elevation represents a surgical procedure to vertically enhance the available bone, thus permitting the placement of implants with adequate length in the edentulous posterior maxilla. In the transcrestal (or transalveolar) sinus floor elevation (tSFE) the access to the sinus cavity is created through the edentulous bone crest (15-17). Tatum presented the transcrestal approach in 1977 (18) and then published it in 1986 (15). The technique consisted of preparing the implant site with a “socket former”, selected according to the implant size to be placed. A “green-stick fracture” of the sinus floor was performed by hand tapping the “socket former” in a vertical direction until a fracture of the sinus floor was obtained. Later, Summers modified this technique (16, 17), suggesting the use of a specific set of osteotomes for both preparing the implant site and elevating the sinus floor. In 2002 Fugazzotto (19) published a modification of these techniques with the use of a trephine bur. The rationale was to use the bone core created by the trephine drill during implant site preparation as a graft for sinus lift, after fracturing the sinus floor with osteotomes. Since then, many surgical techniques with specially designed instruments for tSFE were reported in the literature (2028). Currently available surgical techniques for tSFE are mainly based on either the fracture or the perforation

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of the sinus floor by means of osteotomes (21-23) or burs (24-28). However, both osteotome and bur-driven procedures present advantages and limitations. The use of osteotomes may increase the density of soft maxillary bone while elevating the sinus membrane by hydraulic pressure. On the other hand, when the alveolar bone is thick the osteotome technique requires extensive malleting trauma during sinus floor elevation. This may cause benign paroxysmal positional vertigo (BPPV), a benign syndrome characterized by short, recurrent episodes of vertigo, initiated by movements of head lateralization and extension toward the affected site (29-32). In addition, the use of excessive forces during osteotome malleting may result in unwanted penetrations of the instruments in the sinus cavity, increasing the risk of membrane perforation. The combined use of a trephine bur in close proximity to the sinus floor limits the need for repeated malleting. In addition, the use of burs with different working lengths provides a controlled perforation of the sinus floor, restraining the action of the cutting edge to the native bone and limiting the risk for perforation of the sinus membrane. The currently available drilling devices, however, tend not to preserve the residual native bone during implant-site preparation and sinus floor perforation. Therefore, the bur-driven procedures often call for the additional use of a graft for bone augmentation. Bone augmentation is generally provided by grafting the sinus cavity with autogenous bone, bone substitutes, or the combination of the two (33-38).

The Smart Lift technique: description of the procedure The Smart Lift technique is a simplified, minimally invasive procedure for tSFE which was developed by the Research Center for the Study of Periodontal and Peri-implant Diseases, University of Ferrara, and the Department of Dentistry, Ospedale “Casa Sollievo della Sofferenza”, S. Giovanni Rotondo (38-48). The technique is characterized by a transcrestal access to the sinus cavity by means of specially-designed drills and osteotomes which are used in a pre-defined, standardized sequence. According to the prosthetic treatment planning, the location for implant placement is established, and the residual bone height at such location is first diagnosed by proper x-ray examination (Fig. 1, 2). The distance from the bone crest to the sinus floor as assessed radiographically will provide the “radiographic working length” (rWL). The preparation of the implant site is performed according to a standardized sequence of manual and rotating instruments. All instruments in the surgical set are characterized by laser marks at 4-5-6-7-8-9-10-11 mm with corresponding adjustable stop devices to allow for a precise control of the working length. The major novelty of the Smart Lift resides in the fact that all manual and rotating instruments are used with adjustable stop devices that restrict the working action of burs and osteotomes to the vertical amount of residual bone, thereby preventing the accidental penetration of instruments into the sinus cavity. The use of adjustable stop devices would dictate the extent of the working action of manual and rotating

Monograph instruments, thus minimizing the risk for membrane perforation and post-surgical infections. After the full-thikness flap elevation, the first drill (Locator Drill) is used to perforate the cortical bone to a depth of 3.5 mm at the site where the implant is to be placed. A second drill (Probe Drill), with a diameter of 1.2 mm and cutting only at the top edge, is used to define the position and orientation of the implant. In order to minimize the risk of sinus floor perforation, this bur is used with an adjustable stop device which is set at least 1 mm shorter than the rWL. Then, the “Probe Osteotome” (Ø 1.2 mm) is carefully inserted into the site prepared by the Probe Drill, and gently forced in an apical direction through the cancellous bone until the cortical bone resistance of the sinus floor is met (Fig. 3). Therefore, the Probe Osteotome will provide the “surgical working length” (sWL), which is the true anatomical distance from the bone crest to the sinus floor in the exact location where the implant should be placed (Fig. 3). Thus, the working action of all manual and rotating instruments that will be used in subsequent surgical steps will be now set at the sWL by using the proper adjustable stop device. A Radiographic Pin (Ø 1.2 mm) can also be used to check the angulation and depth of the prepared site by means

of a periapical x-ray. The Radiographic Pin handle has a diameter of 4.0 mm, thus permitting to evaluate the spatial relationship between the prepared site and the buccolingual as well as mesio-distal dimensions of the alveolar ridge. This will help the clinician to determine the diameter of the implant to be placed. Then, a “Guide Drill” diameter 3.2 mm (for implants with a diameter of 3.75 - 4.5 mm) or 4.0 mm (for implants with a diameter of 4.8 - 5.0 mm) is used. This drill follows the preparation of the Guide Drill and creates a crestal countersink, 2 mm deep, where the trephine bur (Smart Lift Drill) will be inserted. Such countersink enables to centre the working action of the trephine bur. The “Smart Lift Drill” (Ø 3.2 or 4.0), set at the sWL, produces a bone core up to the sinus floor (Fig. 4). After the removal of the trephine bur, the bone core is then condensed and malleted to fracture the sinus floor by means of a calibrated osteotome (Smart Lift Elevator, diameter of 3.2 or 4.0) that corresponds to the diameter of the trephine preparation (Fig. 5). The osteotome is used under gently malleting forces to implode the trephined bone core over the sinus floor. In relation to the extent of vertical bone augmentation to be achieved, a cortical bone particulate or a bone substitute can be further grafted and

fig. 1 Pre-surgery clinical situation of the right maxillary edentulous sextants

fig. 2 Pre-surgery radiograph of a first maxillary molar edentulous site.

fig. 3 The surgical working length, as assessed by the Probe Osteotome, amounts to 7 mm.

fig. 4 The Smart Lift Drill is inserted in the crestal countersink with the stop device adjusted at 7 mm, and creates a bone core.

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fig. 5 The bone core is condensed by malleting with the Smart Lift Elevator, with the stop device adjusted at 7 mm.

fig. 6 An implant is placed following sinus augmentation.

fig. 7 A transmucosal healing protocol is adopted.

fig. 8 Periapical radiograph as taken immediately after surgery.

The Smart Lift technique: state of the art During the last 5 years, several studies on the Smart Lift technique have been conducted by the Research Centre for Periodontal and Peri-implant Diseases, University of Ferrara, Italy (38-48). In this section, the current knowledge about the treatment outcomes, postoperative morbidity and patient-related outcomes of the Smart Lift technique is reported in a concise form.

EFFICACY OF THE PROCEDURE fig. 9 6-month radiograph.

condensed into the sinus by the osteotome. Again, the Smart Lift Elevator is used with the adjustable stop device at the sWL, thus preventing any unwanted penetration of the instruments into the sinus cavity. Provided that the residual bone may ensure an adequate primary stability, an implant can be inserted during the same surgical session (Fig. 6, 7) . Otherwise, a staged approach is recommended.

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q Implant placement in concomitance with the tSFE procedure: in all treated cases reported in pertinent studies, the Smart Lift technique allowed for the placement of an implant concomitant to tSFE (38, 43, 45-48). The mean implant length ranged between 9.5 and 10 mm among studies (43, 45, 46, 48). Only one implant failed to osseointegrate before the 6-month follow-up (46). q Vertical bone augmentation: the mean extent of sinus lift ranged between 6.5 to 7.7 mm (45-47). The mean height of the radiopaque area over the implant apex

Monograph (as evaluated as distance occupied by a radiopaque area between the implant apex and the sinus floor as assessed at the mid portion of the implant) as reported in different cohort and randomized controlled trials ranged between 2.0 and 3.0 mm (45-47).

Post surgery morbidity

q Duration of the surgical procedure : the mean duration of the sinus floor elevation procedure (as the time elapsed from cortical perforation with the Locator Drill to the completion of the grafting procedure, immediately before implant placement) as reported in different cohort and randomized controlled trials ranged between 19 and 25 minutes (38, 43, 45, 47, 48). q Pain and discomfort: immediately after surgery, the mean scores for discomfort and pain (as assessed on a 0-100 Visual Analogue Scale, VAS) (49) ranged between 0 and 17 (43, 45) and between 2 and 9 (43, 45) respectively. The 7-day mean VAS score for pain ranged between 1 and 2.1, depending on the study (38, 43, 45, 47). The low scores for pain and discomfort were further corroborated by the results of a recent study, where 33 over 38 patients manifested no problem to repeat the same type of surgery if needed (48). q Intra- and post-surgical complications: five studies reported data on the intra- and post-surgical complications associated with the use of the Smart Lift technique (43, 45-48). Membrane perforation was the most frequent complication, and ranged from 0% (43) to 13% of cases (48). In all cases, the perforation was managed with the insertion of a surgical haemostatic dressing (Gingistat®; GABA Vebas, S. Giuliano Milanese, Milan, Italy) through the crestal access. Then, the grafting procedure was completed and the implant was inserted. At 6 months following implant placement, 4 studies reported an implant survival rate of 100% and the finalization of the prosthetic rehabilitation in all treated cases (43, 45, 47, 48), while one study reported one case of failed osseointegration over a total of 45 implants (46). Rarely, other types of complications, i.e. paresthesia in the suborbital area (1 case) (46), tinnitus (1 case) (46), and BPPV (1 case) (48) occurred. All these complications spontaneously subsided within the first week following surgery.

Determinants q Type of bone substitute: in the Smart Lift technique, the vertical bone augmentation is obtained by pushing the trephined bone core in an apical direction. Several studies, however, evaluated the clinical effectiveness of the Smart Lift technique when used in conjunction with graft materials (43, 45, 48). In a case series, autogenous bone particulate, collagen-enriched or magnesiumenriched synthetic hydroxyapatite (S-HA and Mg-HA, respectively), or deproteinized bovine bone mineral (DBBM) were successfully used in combination with the Smart Lift technique (43). When the performance of the Smart Lift technique in conjunction with DBBM or a S-HA was evaluated in a randomized controlled trial, both DBBM and S-HA treated sites showed substantial extent of sinus lift and amount of radiopaque material apical to the implant apex immediately after surgery, which were maintained at 6 months (45). Better

outcomes were observed in S-HA group compared with DBBM group at 6 months post-surgery. (45). The results of another RCT showed that both DBBM and ß–tricalcium phosphate (ß-TCP) may safely support tSFE when performed with the Smart Lift technique. At 6 months, a significant reduction in the radiopaque area apical to the implant apex as well as in the extent of sinus lift was observed with respect to post-surgery values in the ß-TCP group (48). q Influence of smoking status: a recent study showed that tSFE performed with the Smart Lift technique may similarly result in a substantial 6-month vertical augmentation along with a limited incidence of complications in smoker and non-smoker patients (46). q Influence of the operator experience: recently, a study was designed to evaluate the influence of the operator’s experience in implant surgery and tSFE procedures on the outcomes of the Smart Lift technique (47). Sixty patients were treated with the Smart Lift technique by three operators with different levels of experience in implant surgery (expert, moderately experienced and low experienced, as assessed in terms of years of clinical activity, number of implants placed prior to their participation in the trial, and previous experience in tSFE procedures) and inexperienced with respect to the Smart Lift technique. All treatment groups showed substantial extent of sinus lift in a limited operation time, along with minimal incidence of membrane perforation and postoperative assumption of anti-inflammatory drugs, thus suggesting that the Smart Lift technique may be considered as a user-friendly option for tSFE. The outcomes of the procedure, however, were found to be influenced by the operator level of experience in implant surgery (47).

Conclusion The vertical reduction of crest dimensions following tooth loss in the posterior maxilla is partly due to the pneumatization of the maxillary sinus. In the edentulous, maxillary posterior sextants, the vertical dimension of the residual bone crest may frequently call for bone augmentation procedures to allow for the placement of implants with adequate length and width. Among the techniques for tSFE which have been proposed in the literature, the Smart Lift technique represents a simplified, user-friendly option, since it allows for a substantial extent of sinus lift at limited operation times along with limited morbidity.

References 1. Th1. Van den Bergh JPA, ten Bruggenkate CM, Disch FJ, Tuinzing DB. Anatomical aspects of sinus floor elevations. Clin Oral Implants Res. 2000;11:256-265. 2. Chanavaz M. Maxillary sinus: anatomy, physiology, surgery and bone grafting related to implantology. Eleven years of surgical experience (1979–1990). Journal of Oral Implantology. 1990;16:199-209. 3. Beretta M. Current trends in sinus lift procedures. European Journal of Oral Surgery. 2010;1:8-20. 4. Farina R, Pramstraller M, Franceschetti G, Pramstraller C, Trombelli L. Alveolar ridge

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Trombelli L. dimensions in maxillary posterior sextants: a retrospective comparative study of dentate and edentulous sites using computerized tomography data. Clin Oral Implants Res. 2011 Oct;22(10):1138-44. 5. Wehrbein H. & Diedrich P. The initial morphological state in the basally pneumatized maxillary sinus – a radiological-histological study in man. Fortschritte der Kieferorthopa ̈die. 1992;53:254-262 (article in German). 6. Xie Q., Na ̈rhi T.O., Nevalainen J.M., Wolf J. & Ainamo, A. Oral status and prosthetic factors related to residual ridge resorption in elderly subjects. Acta Odontologica Scandinavica. 1997;55:306-313. 7. Ohba T., Langlais R.P., Morimoto Y., Tanaka T. & Hashimoto K. Maxillary sinus floor in edentulous and dentate patients. Indian Journal of Dental Research. 2001;12:121-125. 8. Sag ̆lam A.A. The vertical heights of maxillary and mandibular bones in panoramic radiographs of dentate and edentulous subjects. Quintessence International 2002;33:433– 438. 9. Juodzbalys G. & Raustia A.M. Accuracy of clinical and radiological classification of the jaw-bone anatomy for implantation-survey of 374 patients. Journal of Oral Implantology 2004:30:30–39. 10. Güler A.U., Sumer M., Sumer P. & Bic ̧er I. The evaluation of vertical heights of maxillary and mandibular bones and the location of anatomic landmarks in panoramic radiographs of edentulous patients for implant dentistry. Journal of Oral Rehabilitation 2005;32:741-746. 11. Sharan A. & Madjar D. Maxillary sinus pneumatization following extractions: a radiographic study. The International Journal of Oral & Maxillofacial Implants 2008;23:48–56. 12. Ulm C.W., Solar P., Gsellmann B., Matejka M. & Watzek G. The edentulous maxillary alveolar process in the region of the maxillary sinus-study of physical dimension. The International Journal of Oral and Maxillofacial Surgery 1995;24:279–282. 13. Eufinger H., König S., Eufinger A. & Machtens E. Significance of the height and width of the alveolar ridge in implantology in the edentulous maxilla. Analysis of 95 cadaver jaws and 24 consecutive patients. Mund-, Kiefer- und Gesichtschirurgie 1999;3(Suppl. 1):S14–18 (article in German). 14. Pramstraller M, Farina R, Franceschetti G, Pramstraller C, Trombelli L. Ridge dimensions of the edentulous posterior maxilla: a retrospective analysis of a cohort of 127 patients using computerized tomography data. Clin Oral Implants Res. 2011 Jan;22(1):54-61. 15. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207229. 16. Summers RB. A new concept in maxillary implant surgery: The osteotome technique. Compendium 1994;15:152, 154-156, 158 passim; quiz 162. 17. Summers RB. The osteotome technique: Part 3 – Less invasive methods of elevating the sinus floor. Compendium 1994;15:698, 700, 702-704 passim;quiz 710. 18. Tatum OH. Lecture presented to Alabama Implant Study Group. 1977. 19. Fugazzotto PA. Immediate implant placement following a modified trephine/osteotome approach: Success rates of 116 implants to 4 years in function. Int J Oral Maxillofac Implants 2002;17:113-120. 20. Summers RB. The osteotome technique: Part 4–Future site development. Compend Contin Educ Dent. 1995;16:1080,1092 passim; quiz 1099. 21. Coatoam GW. Indirect sinus augmentation procedures using one-stage anatomically shaped root-form implants. J Oral Implantol 1997;23:25-42. 22. Bruschi GB, Scipioni A, Calesini G, Bruschi E. Localized management of sinus floor with simultaneous implant placement: a clinical report. Int J Oral Maxillofac Implants 1998;13:219-226. 23. Deporter D, Todescan R, Caudry S. Simplifying management of the posterior maxilla using short, porous-surfaced dental implants and simultaneous indirect sinus elevation. Int J Periodontics Restorative Dent 2000;20:476-485. 24. Cosci F, Luccioli M. A new sinus lift technique in conjunction with placement of 265 implants: a 6-year retrospective study. Implant Dent 2000;9:363-368. 25. Soltan M, Smiler DG. Trephine bone core sinus elevation graft. Implant Dent 2004;13:148152. 26. Le Gall MG. Localized sinus elevation and osteocompression with single-stage tapered dental implants: technical note. Int J Oral Maxillofac Implants 2004;19:431-437. 27. Vitkov L, Gellrich NC, Hannig M. Sinus floor elevation via hydraulic detachment and elevation of the Schneiderian membrane. Clin Oral Implants Res 2005;16:615-621. 28. Chen L, Cha J. An 8-year retrospective study: 1,100 patients receiving 1,557 implants using the minimally invasive hydraulic sinus condensing technique. J Periodontol 2005;76:482491. 29. Galli M, Petracca T, Minozzi F, Gallottini L. Complications in implant surgery by Summers’

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technique: Benign paroxysmal positional vertigo (BPPV). Minerva Stomatol 2004;53:535541. 30. Rodrıguez Gutierrez C, Rodr ́ıguez Go ́ mez E. Positional vertigo afterwards maxillary dental implant surgery with bone regeneration. Med Oral Patol Oral Cir Bucal 2007;12:E151-E153. 31. Pen ̃arrocha-Diago M, Rambla-Ferrer J, Perez V, Pe ́rez- Garrigues H. Benign paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: A study of 4 cases. Int J Oral Maxillofac Implants 2008;23:129-132. 32. Sammartino, G; Mariniello, M; Scaravilli, MS (2011). Benign paroxysmal positional vertigo following closed sinus floor elevation procedure: Mallet osteotomes vs. Screwable osteotomes. A triple blind randomized controlled trial. Clinical oral implants research 22(6):669-72. 33. Tong DC, Rioux K, Drangsholt M, Beirne OR. A review of survival rates for implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral Maxillofac Implants 1998;13:175182. 34. 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. 35. Emmerich D, Att W, Stappert C. Sinus floor elevation using osteotomes: A systematic review and meta-analysis. J Periodontol 2005;76:1237-1251. 36. Pjetursson BE, Tan WC, Zwahlen M, Lang NP. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Part I: Lateral approach. J Clin Periodontol 2008;35(Suppl.8) 216-240. 37. Tan WC, Lang NP, Zwahlen M, Pjetursson BE. A systematic review of the success of sinus floor elevation and survival of implants inserted in combination with sinus floor elevation. Part II: Transalveolar technique. J Clin Periodontol 2008;35(Suppl.8): 241-254. 38. Trombelli L, Franceschetti G, Farina R, Itro A. Smart-lift technique used in association with a hydroxyapatite-based biomaterial. Clinical outcomes and postoperative morbidity. European J. Oral Surg 2010;2(1):47-55. 39. Trombelli L, Minenna P, Franceschetti G, Farina R, Minenna L. Smart-Lift technique for the elevation of the maxillary sinus floor with a transcrestal approach. Implantologia 2008;6:9-18. 40. Trombelli L, Minenna P, Franceschetti G, Farina R, Minenna L. Smart-Lift: A new minimallyinvasive procedure for sinus floor elevation. Dent Cadmos 2008;76:71-83. 41. Trombelli L, MInenna P, Franceschetti G, Farina R, Minenna L. Smart Lift ed elevazione mini invasive del seno mascellare. Dental Clinics 2010;4(2):1-10. 42. Trombelli, L., Minenna, P., Franceschetti, G., Minenna, L., Itro, A. & Farina, R. A Minimally Invasive Approach for Transcrestal Sinus Floor Elevation: a Case Report. Quintessence International 2010:41:363-369. 43. Trombelli, L., Minenna, P., Franceschetti, G., Minenna, L. & Farina, R. Transcrestal SinusFloor Elevation with a Minimally Invasive Technique. A Case Series. Journal of Periodontology 2010;81:158-166. 44. Franceschetti G, Minenna P, Farina R, Trombelli L. Smart Lift Technique for Minimally Invasive Transcrestal Sinus Floor Elevation. Implant Tribune 2012:24-27. 45. Trombelli L, Franceschetti G, Rizzi A, Minenna P Minenna L, Farina R. Minimally invasive transcrestal sinus ﬂoor elevation with graft biomaterials. A randomized clinical trial. Clin Oral Implants Res. 2012;23:424-32. 46. Franceschetti G, Farina R, Stacchi C, Di Lenarda R, Di Raimondo R, Trombelli L. Radiographic outcomes of transcrestal sinus floor elevation performed with a minimally invasive technique in smoker and non-smoker patients. Clin Oral Implants Res. 2013 May 8. doi: 10.1111/clr.12188. [Epub ahead of print]. 47. Franceschetti G, Farina R, Minenna L, Franceschetti G, Trombelli L. Learning curve of a minimally-invasive technique for transcrestal sinus floor elevation: a split-group analysis in a prospective case series with multiple operators. Clin Oral Implants Res 2013: Submitted 48. Trombelli L, Franceschetti G, Stacchi C, Minenna L, Riccardi O, Di Raimondo R, Rizzi A, Farina R. Minimally-invasive transcrestal sinus floor elevation with deproteinized bovine bone or ß-tricalcium phosphate: a multicenter, double-blind, randomized, controlled clinical trial. J Clin Periodontol 2013: Submitted 49. McCormack HM, Horne DJ, Sheather S. Clinical applications of visual analogue scales: a critical review. Psychol Med 1988;18:1007-19.

Case report

Computer-aided flapless surgery for implant prosthodontic rehabilitation of edentulous patients: a clinical case report Mario Beretta1, Pier Paolo Poli2, Paolo Maridati3, Gianluca Bassi4, Carlo Maiorana5 DDS, PhD. Clinical Assistant Professor, Department of Dental Implants U. O. C. Maxillofacial Surgery & Dentistry, Fondazione IRCCS Cà Granda. University of Milan, Milan, Italy 2 DDS. Department of Dental Implants. U. O. C. Maxillofacial Surgery & Dentistry, Fondazione IRCCS Cà Granda. University of Milan, Milan, Italy 3 DDS, PhD. Department of Dental Implants. U. O. C. Maxillofacial Surgery & Dentistry, Fondazione IRCCS Cà Granda. University of Milan, Milan, Italy 4 DDS. Department of Dental Implants. U. O. C. Maxillofacial Surgery & Dentistry, Fondazione IRCCS Cà Granda. University of Milan, Milan, Italy 5 MD, DDS. Professor and Chairman, Oral Surgery and Department of Dental Implants U. O. C. Maxillofacial Surgery & Dentistry, Fondazione IRCCS Cà Granda. University of Milan, Milan, Italy 1

Background

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The current guidelines for oral implantology aim to minimize surgical and prosthetic timing procedures and patient discomfort while preserving at the same time both quality and quantity of hard and soft tissues. A new surgical protocol, based on the concept of computer-aided flapless implant placement, has been recently presented, which complies to the abovementioned purposes. Implant position is pre-operatorily virtually planned through threedimensional planning software based on functional and aesthetic demands related to the final prosthesis. The development of modern CT scan associated with CAD/CAM technology let the clinicians to transfer the virtual plan into the surgical environment. Surgical guides obtained with a rapid prototyping process allow the surgeon to perform a flapless surgery and an ideal implant placement in the planned position. Following this procedure, the present case-report shows an implant prosthodontic rehabilitation of an upper edentulous jaw, obtained using a computeraided template-guided flapless implant placement followed by immediate loading. Computer-aided flapless implant surgery seems to provide several advantages to the clinicians, however a minimum safety distance from the limiting anatomical structures of at least 2 mm is recommended.

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Key words: Computer-aided Implantology; Dental implants immediate loading; Flapless; Oral surgery.

Beretta M. et al.

Introduction The rehabilitation of totally and partially edentulous jaws by means of dental implants has become a predictable treatment. In the past, the residual bone anatomy was determinant in assessing implants positions; such approach took less consideration to the prosthetic demands often leading to unsatisfactory functional and aesthetic results without respecting at the same time the biomechanics principles (1-3). Several bone augmentation techniques (4-8) were proposed to overcome the prosthetic limitations related to an implant malposition due to a severe alveolar ridge atrophy, allowing clinicians to develop the recent philosophy of prosthetic-driven implant placement, combining biomechanical, functional and aesthetic concepts. This procedure enables to define preoperatively the ideal position of the implant based on diagnostic casts and wax-up of the final prosthodontic restoration using a dedicated software. Subsequently, the virtual setting is transferred to the surgical field through customized radiographic and surgical templates (9-12). This approach was made possible by the use of computed tomography (CT) scans integrated with three-dimensional (3D) virtual planning software, and computeraided design/computer-assisted manufacture (CAD/CAM) technology. In the present case report, the virtually planned implant position is transferred to the patient by the support of a guided template provided with drill guides processed by stereolithographic rapid prototyping (13-17). Possible advantages of computer-aided template-guided oral implant placement include: flapless surgery with consequent decrease of surgical time and patient morbidity; preservation of soft tissue structure and hard tissue volume in the surgical site; integration of the restorative needs into the surgical planning, resulting in a more aesthetic, functional and predictable prosthetic outcome; simplification of the technique-sensitive and operatordependent surgical procedure (18). However this technique was not free of drawbacks, some of these included: the surgeonâ&#x20AC;&#x2122;s inability to visualize anatomic structures; the increased risk for axis and depth

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deviations during implant placement; a decreased ability to contour the jawbone topography when needed for prosthetic purposes (19).

Aim Purpose of this case report was to illustrate the implant prosthetic rehabilitation of an upper edentulous jaw, obtained using a computeraided template-guided flapless surgical approach and followed by an immediate loading of the restoration.

Case report A 63 years old male patient requiring a fixed rehabilitation due to functional and aesthetic problems related to the upper jaw, was selected to be treated with computer-aided template-guided oral implant placement. The remaining teeth were considered useless for a rehabilitation of the whole jaw and were therefore extracted 3 months prior to implant surgery, resulting in a fully edentulous maxilla (Fig. 1). The posterior areas required major surgery procedures due to the severe atrophy and the pneumatization of the sinus, however the patient refused to undergo such treatment. The final prosthetic rehabilitation proposed was an implant-supported prosthesis (Toronto bridge) with four implants inserted in position 1.5, 1.2, 2.2, 2.5 in the upper maxilla. The patient enjoied good systemic health, reported no previous irradiation to the head or neck region, neither alcohol, tobacco or drug abuse nor psychological disorders, and had no parafunctional bad habits. The possibility to perform the implants insertion without any graft procedures was confirmed by CT scans and a panoramic exam. The 3DiagnosysÂŽ

data software (3Diemme, Como, Italy) was used to plan the correct implant position and to transfer the project to the surgical environment, allowing the correct realization of a surgical stent. The treatment protocol required the following steps. 1. Wax-up models. 2. Radiological diagnostic template. 3. CT scan wearing the temporary prosthesis and optical scan of the latter. 4. Matching of the two scans within the software and CT-based virtual implant planning. 5. Surgical stent. 6. Implant surgery. 7. Prosthetic phase

Analysis of wax-up models First we evaluated the models by articulator and realization of a preliminary prosthetic wax-up to check occlusion, articulation, and vertical dimension, corresponding to the exact replica of the existing denture accepted by the patient, integrated with aesthetic and functional principles.

The template A radiological diagnostic template based on the preliminary prosthetic wax-up, as a duplication of the final prosthesis was fabricated. The radiological stent was equipped with an extraoral radiopaque 3D marker, required for the subsequent scans overlapping.

CT scan and temporary prosthesis scan CT scan of the edentulous jaw was taken while the patient was wearing the temporary radiopaque appliance to integrate the anatomic data with the functional and aesthetic parameters, and optical scan of the prosthesis

fig. 1 Pre-operative view.

Case report itself, as needed by the 3Diagnosys® data software.

matching of scans The two scans were matched within the software and CT-based tridimensional virtual implant planning with the 3Diagnosys® data software according to the jawbone anatomy and the prosthetic design was performed (Fig. 2). This was made possible by processing the data obtained from the CT device in a Digital Imaging and COmmunications in Medicine (DICOM) format which allows the simultaneous visualization of axial, three-dimensional, panoramic and cross-sectional images on the computer monitor.

SURGICAL GUIDE The virtual project was transferred on a 1:1 scale model (RealPATIENT™) (Fig. 3) with a rapid prototyping technique, and subsequently a surgical stent was obtained according to the CT-scans and pre-operatory chalk models by means of of stereolithography (Fig. 4). The calibrated stent is mandatory in cases in which a temporary prosthesis has to be inserted immediately after the implant procedure.

Implant surgery Computer-aided template-guided flapless implant placement (Fig. 5-7) was performed on an outpatient basis. The surgical guide had been previously prepared with chemical sterilization. An antibiotic prophylaxis consisting of 2g of Amoxicillin was administered one hour before surgery. After a bacterial decontamination with a 0.2% chlorhexidine rinsing solution, local anaesthesia infiltration was performed with carbocaine 2% with epinephrine 1:50.000. The surgical stent was then ensured in the proper position with a guided insertion of three surgical pins on the buccal side of the alveolar process, according to the virtual planning, as to preserve the anatomic structures. The surgical stent allowed the use of calibrated burs, switching the metallic cylinders contained in the stents itself. More accuracy in the implant placement with a low risk of incorrect insertion is obtained in this way. A circular mucosal operculectomy was performed with a surgical mucotome to remove the gingival plug in the implant site, then serial osteotomies with an internal cooling pre-drill and

subsequent internal cooling formdrills were made until reaching the programmed depth. It was then possible to place two Camlog® implants (ø 3.8 mm x L 11 mm Screw-line Camlog® Guide, Camlog Biotechnologies, Basel, CH) in position 1.2, 2.2 and two Camlog® implants (ø 3.8 mm x L 13 mm Screw-line Camlog® Guide) with a 30° angulation in position 1.5, 2.5 according to Malo et al. all-on-four protocol (20). After the removal of the pins and the surgical template, 4mg/ ml dexamethasone sodium phosphate were injected intramuscularly to reduce the post-operative oedema and 100 mg oral Nimesulide were administered for pain control. As the primary stability during the insertion was more than 40 N/cm, the four implants were considered suitable for an immediate prosthetic loading.

Prosthetic phase Four Vario SR® (Camlog Biotechnologies, Basel, CH) definitive abutments were screwed to the implants (Fig. 8-15). The temporary prosthesiswas then relined and connected to the temporary abutments fixed to the definitive ones.

fig. 3 Real model with implant analogs placed in the virtually planned position. fig. 2 Virtual planning: four implants in the upper jaw

fig. 4 Surgical stent.

fig. 5 Pre-surgical view.

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fig. 6 Implant sites preparation.

fig. 7 Implant placement.

fig. 9 Temporary abutments screwed onto definitive VarioÂŽ abutments. fig. 8 VarioÂŽ definitive abutments.

fig. 10, 11 Denture relining with self curing resin.

fig. 12 Post-operative X-rays control.

In this case the old denture used by the patient before the surgery and after the extractions, was modified in

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order to reduce expenses A rubber dam was used during the prosthesis relining, in order to avoid the infiltration

of the liquid resin in the underlying tissues. The temporary prosthesis was then modified and transformed in a temporary Toronto bridge with a metal framework used to reduce the flexibility of the structure. Six hours after surgery the temporary prosthesis was applied, balanced in the correct occlusion and polished. The patient left the clinic with correct masticatory function and good aesthetics. Implant position and implant connections to the prosthesis are showed in the postâ&#x20AC;&#x201C;operative panoramic exam (Fig. 17-18). The final prosthesis (Toronto bridge) reinforced with a titanium framework and composite, was inserted four months

Case report

fig. 13-14 Intraoral view of the temporary restoration.

fig. 15 Titanium definitive framework.

fig. 16 Final restoration.

fig. 17, 18 CT scan control of the definitive restoration.

after surgery (Fig. 16). Radiographic and clinical evaluations showed a good implant osteointegration and healing of soft tissues six months after surgery.

Discussion In the first guidelines proposed by BrĂĽnemark et al. at the end of the last century, a submerged healing period after dental implants insertion was considered mandatory in order to obtain a proper osseointegration. The prosthetic rehabilitation had to be accordingly postponed 4 â&#x20AC;&#x201C; 6 months after the surgical procedure. This initial protocol underwent numerous changing, with the aim to reduce

treatment time, minimizing at the same time intra- and post-operative patient discomfort and avoiding removable dentures during the healing process (21, 22, 23). Recently, computer-aided flapless surgery possibly associated with an immediate loading protocol, has become a reliable alternative procedure in order to overcome those limitations. The advantages of this surgical technique compared to traditional ones are many, owing to the development of new and more accurate softwares for CT Scan analysis and three-dimensional virtual planning that contributed to the advancing of this type of surgery and a one-stage implant immediate rehabilitation. The multiplanar reformatting technology associated with computer-aided

design (CAD) planning software allows the clinicians to virtually plan location, angle, depth and diameter of virtual implants on the basis of the diagnostic casts and wax-up as an exact replica of the final prosthesis. The present case, treated with a flapless approach, showed some possible advantages, namely a reduction of patient swelling and pain, intraoperative bleeding and surgical time without the need for suturing, preserving at the same time soft tissues architecture and hard tissue volume at the site, maintaining a correct peri-implant blood supply and allowing the patient to perform normal oral hygiene procedures immediately after (24). Some disadvantages were otherwise reported using a flapless surgery procedure. The lack of vol. 4 n. 3 2013

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Beretta M. et al. control in the determination of bone support and implant placement was considered one of the major ones. This aspect could lead to a high risk of complications in case of incorrect pre-surgical planning. Another disadvantage is represented by the unavailability to perform this procedure in all clinical situations. A conventional procedure is indicated in those cases in which a graft procedure is mandatory due to an insufficient bone support. According to Sclar (25), the method is indicated for patients with sufficient alveolar bone height, volume, and density and with an adequate or augmentable attached gingiva (the correct soft tissues thickness at the buccal and lingual aspect of each implant is about 2.5–3 mm, as reported in many studies) (26, 27) preferably keratinized, circumferentially adapted to the transmucosal implant structures. In the present case, adherence to these inclusion criteria allowed a prosthetically driven implant placement which considered the aesthetic soft tissues demands. The difficulty in screwing the abutment in the correct position, represented a practical disadvantage due to the unavailability to directly watch the implant connection. The oral surgeon should be very careful during the insertion of the abutments. X- rays are therefore often requested to check the correct position of these components. The reduction of surggical time with less morbidity is another advantage of this approach. Timing reduction was made possible by an accurate pre-surgical three-dimensional virtual planning using CT Scan Software, followed by the fabrication of an extremely precise surgical guide. The stereolithographic surgical template, fixed in the proper position by means of three transcortical anchor pins, allowed the surgeon to easily find the correct position for implant placement, as previously virtually determined. Immediate implant loading has been proven to be a viable treatment method for selected cases. This procedure was made possible with the evolution of modern scanning techniques and appropriate three-dimensional virtual planning software. Provisional prosthesis can be immediately inserted thanks to pre-surgical planning and the possibility to know the exact position of the abutments before the implant placement. It should be mentioned that immediate loading could be provided

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when implants achieve a primary stability of at least 30 N/cm (28, 29). Delivering a provisional prosthesis immediately after implant placement undoubtedly contributes to decrease patient discomfort, providing good esthetics and masticatory function.

Conclusion The authors want to support the flapless procedures in cases in which there is an appropriate bone support and graft procedures are not needed. In those cases, the advantages the surgeon can get are much more then the disadvantages and possible complications. Although this technique was developed to reduce the risks involved during the standard implant procedures providing an higher control of the system, the problem of deviation between the planned and placed implant position is still present (13, 19). Even with the use of a stereolithographic surgical guide, it is advisable to observe a minimum safety distance from the limiting anatomical structures during the planning phase of at least 2 mm.

References 1. Rangert B, Krogh PH, Langer B, et al. Bending overload and implant fracture: a retrospective clinical analysis. Int J Oral Maxillofac Implants. 1995;10:326–334. 2. Hobkirk JA, Havthoulas TK. The influence of mandibular deformation, implant numbers, and loading position on detected forces in abutments supporting fixed implant superstructures. J Prosthet Dent. 1998;80:169–174. 3. Stanford CM. Biomechanical and functional behavior of implants. Adv Dent Res. 1999;13:88–92. 4. Schwartz-Arad D, Levin L. Intraoral autogenous block onlay bone grafting for extensive reconstruction of atrophic maxillary alveolar ridges. J Periodontol. 2005;76:636–41. 5. Maiorana C, Santoro F. Maxillary and mandibular bone reconstruction with hip grafts and implants using Frialit-2 implants. Int J Periodontics Restorative Dent. 2002;22:221–229. 6. Simion M, Trisi P, Piattelli A. Vertical ridge augmentation using a membrane technique associated with osseointegrated implants. Int. J Periodontics Restorative Dent. 1994;14:497-511 7. Chiapasco M, Lang NP, Bosshardt DD. Quality and quantity of bone following alveolar distraction osteogenesis in the human mandible. Clin Oral Implants Res. 2006;17:394–402. 8. Engelke WG, Diederichs CG, Jacobs HG, et al:

Alveolar reconstruction with splitting osteotomy and microfixation of implants. Int J Oral Maxillofac Implants. 1997;12:310-8 9. ecker CM, Kaiser DA. Surgical guide for dental implant placement. J Prosthet Dent. 2000;83:248–251. 10. Almog DM, Torrado E, Meitner SW. Fabrication of imaging and surgical guides for dental implants. J Prosthet Dent. 2001;85:504–508. 11. Garber DA. The esthetic dental implant: letting restoration be the guide. J Oral Implantol. 1996;22:45– 50. 12. Pesun IJ, Gardner FM. Fabrication of a guide for radiographic evaluation and surgical placement of implants. J Prosthet Dent. 1995;73:548–552. 13. Di Giacomo GA, Cury PR, de Araujo NS, et al. Clinical application of stereolithographic surgical guides for implant placement: preliminary results. J Periodontol. 2005;76:503–507. 14. Sarment DP, Al-Shammari K, Kazor CE. Stereolithographic surgical templates for placement of dental implants in complex cases. Int J Periodontics Restorative Dent. 2003;23:287–295. 15. van Steenberghe D, Naert I, Andersson M, et al. A custom template and definitive prosthesis allowing immediate implant loading in the maxilla: a clinical report. Int J Oral Maxillofac Implants. 2002;17:663– 670. 16. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants. 2003; 18:571– 577. 17. Van Assche N, van Steenberghe D, Guerrero ME, et al. Accuracy of implant placement based on pre-surgical planning of three-dimensional cone beam images: a pilot study. J Clin Periodontol. 2007;34:816–821. 18. Valente F, Schiroli G, Sbrenna A. Accuracy of computeraided oral implant surgery: a clinical and radiographic study. Int J Oral Maxillofac Implants. 2009;24:234-42. 19. Ersoy AE, Turkyilmaz I, Ozan O, et al. Reliability of implant placement with stereolithographic surgical guides generated from computed tomography: clinical data from 94 implants. J Periodontol. 2008;79:133945. 20. Maló P, de Araújo Nobre M, Lopes A, Francischone C, Rigolizzo M. “All-on-4” immediate-function concept for completely edentulous maxillae: a clinical report on the medium (3 years) and long-term (5 years) outcomes. Clin Implant Dent Relat Res. 2012;14 Suppl 1. 21. Bedu A, Michalakis KX, Mariani EJ, Zourdos DM. Immediately Loaded Maxillary and Mandibular Dental Implants with Fixed CAD/CAM Prostheses Using a Flapless Surgical Approach: A Clinical Report; Journal of Prosthodontics 2011;20: 319–325. 22. Albrektsson T. A multicenter report on the osseointegrated oral implants. J Prosthet Dent 1988;60:75-84. 23. Jemt T, Lekholm U, Adell R. Osseointegrated implants in the treatment of partially edentulous patients: a preliminary study on 876 consecutively placed fixtures. Int J Oral Maxillofac Implants 1989;4:211-217. 24. Brodala N. Flapless surgery and its effect on dental implant outcomes. Int J Oral Maxillofac Implants. 2009;24:18-25. 25. Sclar AG. Guidelines for flapless surgery. J Oral Maxillofac

Case report Surg. 2007;65:20-32. 26. Oh TJ, Shotwell J, Billy J et al. Flapless implant surgery in the esthetic region: advantages and precautions. Int J Periodontics Restorative Dent 2007;27:27-33. 27. Bashutski JD, Wang HL. Common implant esthetic complications. Implant Dent 2007;16:340-348. 28. Drago CJ, Lazzara RJ. Immediate occlusal loading of Osseotite implants in the mandibular edentulous patients: a prospective observational report with 18-month data. J Prosthodont 2006;15:187-194. 29. Esposito M, Grusovin MG, Willings M et al. The effectiveness of immediate, early, and conventional loading of dental implants: a Cochrane systematic review of randomized controlled clinical trials. Int J Oral Maxillofac Implants 2007;22:893-904.

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ECM IN ACCREDITAMENTO

III° Convegno S.I.S.C.O.O.

PROGRAMMA PRELIMINARE DEL CONVEGNO

Società Italiana Specializzati in Chirurgia Odontostomatologica ed Orale

IL TIMING IN CHIRURGIA ORALE

MILANO 4 Ottobre 2014 Hotel dei Cavalieri Sala Carmagnola

08.30 - 09.00

Registrazione partecipanti

09.00 - 09.15

Saluto del Presidente Presentazione SISCOO

I Sessione 09.15 - 10.00

Il timing per l’implantologia in area estetica Rino Burkhardt

10.00 - 10.45

Il timing nel trattamento ortodontico implantologico delle agenesie Marco Rosa

10.45 - 11.15

Coffee Break

11.15 - 12.00

Il timing nella implantologia computer assistita Mario Beretta

12.00 - 12.45

Il timing nel trattamento delle neoformazioni benigne dei mascellari Jason Motta Jones

12.45 - 13.00

Discussione

13.00 - 14.15

Lunch

P.zza Missori, 1—Milano

ISCRIZIONI:

SEGRETERIA SISCOO Tel-Fax: 02 55032815 E-mail: segretria@siscoo.eu Web: www.siscoo.eu

Socio Fondatore Socio Attivo Socio Ordinario Socio Aggregato Specializzando in Chir. Odontost. Studente Partecipante

II Sessione

Gratuito Gratuito Gratuito Gratuito Gratuito Gratuito 200 €

14.15 - 15.00

Il timing chirurgico protesico nel paziente parodontalmente compromesso Alberto Fonzar

15.00 - 15.45

Il timing chirurgico conservativo nei pazienti con difetti dei tessuti molli parodontali Carlo Ghezzi

COMITATO SCIENTIFICO E ORGANIZZATORE Prof. Carlo MAIORANA Dott. Umberto GARAGIOLA Dott. Davide FARRONATO

Presidente Segretario Tesoriere

European Journal of Oral Surgery www.ejos.eu ORGANO UFFICIALE DI SISCOO