Purpose: To establish consensus-driven guidelines that could support the clinical decision-making process for implant-supported rehabilitation of the posterior atrophic maxilla and ultimately improve long-term treatment outcomes and patient satisfaction. Materials and methods: A total of 33 participants were enrolled (18 active members of the Italian Academy of Osseointegration and 15 international experts). Based on the available evidence, the development group discussed and proposed an initial list of 20 statements, which were later evalu-ated by all participants. After the forms were completed, the responses were sent for blinded ana-lysis. In most cases, when a consensus was not reached, the statements were rephrased and sent to the participants for another round of evaluation. Three rounds were planned. Results: After the first round of voting, participants came close to reaching a consensus on six statements, but no consensus was achieved for the other fourteen. Following this, nineteen statements were rephrased and sent to participants again for the second round of voting, after which a consensus was reached for six statements and almost reached for three statements, but no consensus was achieved for the other ten. All 13 statements upon which no consensus was reached were rephrased and included in the third round. After this round, a consensus was achieved for an additional nine statements and almost achieved for three statements, but no consensus was reached for the remaining statement. Conclusion: This Delphi consensus highlights the importance of accurate preoperative planning, taking into consideration the maxillomandibular relationship to meet the functional and aesthetic requirements of the final restoration. Emphasis is placed on the role played by the sinus bony walls and floor in providing essential elements for bone formation, and on evaluation of bucco-palatal sinus width for choosing between lateral and transcrestal sinus floor elevation. Tilted and trans-sinus implants are considered viable options, whereas caution is advised when placing pterygoid implants. Zygomatic implants are seen as a potential option in specific cases, such as for completely edentulous elderly or oncological patients, for whom conventional alternatives are unsuitable. Schlagwörter: diagnostic procedure, implant dentistry, lateral window technique, pterygoid implants, sinus floor elevation, transcrestal sinus floor elevation, zygomatic implants The authors report no conflicts of interest relating to this study.

In den letzten Jahrzehnten wurden unterschiedliche Techniken zur Deckung parodontaler Rezessionen beschrieben. Ein Großteil davon ist nicht zur Deckung multipler tiefer benachbarter Cairo-Klasse-I-Rezessionen, sondern eher zur Korrektur multipler flacher bzw. einer tiefen mit mehreren benachbarten flachen Rezessionen geeignet. Der vorliegende Fallbericht beschreibt eine neue modifizierte Operationsmethode: den mehrfach gestielten koronal verschobenen Lappen, kombiniert mit Schmelz-Matrix-Proteinen und Bindegewebetransplantaten. Mithilfe dieser operativen Technik ist es möglich, selbst weit über die mukogingivale Grenze hinausgehende benachbarte Rezessionen mit einer hohen Wahrscheinlichkeit zu decken. Ein 25-jähriger Patient wurde eigenen Angaben zufolge wegen progredienter tiefer Cairo-Klasse-I-Rezessionen zur Therapie überwiesen. Die Wurzeldeckung erfolgte durch einen modifizierten mehrfach gestielten koronal verschobenen Lappen in Kombination mit einem aus dem Gaumen entnommenen Bindegewebetransplantat und einem Schmelzmatrixderivat. Die Evaluation des Ergebnisses erfolgte nach 6 Monaten. Hierbei zeigte sich eine Abdeckung von über 80 % der zuvor freiliegenden Wurzeloberflächen. Der mehrfach gestielte koronal verschobene Lappen ist eine nützliche Methode zur Deckung tiefer benachbarter parodontaler Rezessionen, die den Erhalt vorhandener respektive die Verbreiterung keratiniserter Gingiva ermöglicht und die Bildung von sichtbarem Narbengewebe auf ein geringes Ausmaß reduziert. Manuskripteingang: 22.03.2022, Annahme: 26.09.2022 Schlagwörter: Schmelzmatrixproteine, Gingivarezession, koronal verschobener Lappen, lateral verschobener Lappen, Zahnwurzel, Wurzeldeckung, Bindegewebetransplantat

During bone augmentation procedures, primary wound healing determines the bone augmentation result. After a crestal incision in the maxilla, the palatal flap might not be an adequate length to correctly couple to the vestibular flap and to seal the wound with horizontal mattress and single sutures. Due to the histologic structure made of dense connective tissue, the palatal flap eversion is impossible, negatively impacting the wound seal and primary healing. This case report describes the effectiveness and efficacy of an incision design to improve palatal flap management during bone augmentation procedures in the maxilla. Indeed, palatal flap verticalization is achieved. The incision line is proportionally shifted on the vestibular side, based on the defect anatomy, to obtain a palatal flap length extending at least 4 mm coronal to the bone graft level prior to wound closure. The described approach simplifies the optimal adaptation of the inner faces of the palatal and vestibular flaps, reducing the risk of nonprimary wound healing.

The aim of this study is to evaluate the anatomical characteristics of the posterior region of the mandible and their surgical relevance related to bone harvesting procedures. Fifty retromolar cone beam computed tomography scans were analyzed considering the donor site anatomies. For each site, linear measurements were taken of cross-sectional scans to record perpendicular distances between the mandibular canal (MC) and the vestibular and crestal bone walls. Data showed that the distance from the MC to the vestibular bone wall is lower in the ramus area than in the external oblique ridge area (< 2.00 mm in 26% of cases). However, the distance between the MC and the crestal bone wall is higher in the ramus area than in the external oblique ridge area. There is less bone thickness in the ramus area, and this could expose the inferior alveolar nerve to damage if osteotomies are performed with fewer depth limitations, as reported in the literature.

Tooth loss generally leads to a corresponding loss of supporting bone structures, jeopardizing correct implant placement. Bone augmentation procedures facilitate reconstruction of the alveolar contours but lengthen treatment time by about 4 to 9 months. The aim of this case series report is to describe the short-term results of the combination of three-dimensional bone augmentation using the shell technique in conjunction with simultaneous implantation. A total of 10 patients who underwent autologous bone augmentation using the shell technique with simultaneous implantation were retrospectively examined. The shell technique is an augmentation procedure using thin cortical bone plates adapted to the buccal and oral walls of the defect to rebuild the contours of the alveolar ridge. The remaining spaces are filled with bone chips. Healing time before second stage surgery was 4 months. The vertical bone defect at the beginning (VD), the height of the vertical bone graft, resorption at the time of second-stage surgery (BR1) and 1 year after prosthetic rehabilitation (BR2), the total resorption between augmentation and 1 year (BRtot), and the vertical bone loss of the implant (VBL) were measured. VD was 3.1 mm. Values for BR1 and BR2 were 0.4 and 0.45 mm, respectively, resulting in a total bone loss of 0.85 mm of bone loss (BRtot). VBL was 0.45 mm 1 year after prosthetic rehabilitation. The simultaneous approach of vertical bone augmentation in the shell technique and implantation shows excellent results in bone reconstruction and stability up to 1 year after prosthetic reconstruction and can shorten treatment time by 4 to 9 months.

Autogenous bone harvesting is a well-documented surgical procedure. Autogenous mandibular bone harvesting carries a risk of anatomical structural damage because the surgeon has no three-dimensional (3D) control of the osteotomy planes. The aim of this case series was to describe the results of mandibular bone block harvesting applying computer-guided surgery. A sample of 13 partially dentate patients presenting bone deficiencies in the horizontal and/ or vertical plane were selected for autogenous mandibular bone block graft. The bone block dimension was planned through a computer-aided design (CAD) process, defining ideal bone osteotomy planes to avoid damage to anatomical structures (nerves, teeth roots, etc) and to generate a surgical guide that imposed the 3D working direction to the bone-cutting instrument. The bone block dimension was always related to the defect dimension to be compensated. A total of 13 mandibular bone blocks were harvested to treat 16 alveolar defects (9 vertical and 7 horizontal). The mean planned mesiodistal dimension of the bone block was 24.8 ± 7.3 mm, the mean height was 8 ± 1 mm, and the mean thickness was 4 ± 2 mm. None of the treated patients experienced neurologic alteration of their alveolar nerve function. The preliminary data from this case series suggested that computer-guided bone harvesting could be a concrete opportunity for clinicians to obtain an appropriate volume of autogenous bone in a safe manner.

During autogenous mandibular bone harvesting, there is a risk of damage to anatomical structures, as the surgeon has no three-dimensional control of the osteotomy planes. The aim of this proof-of-principle case report is to describe a procedure for harvesting a mandibular bone block that applies a computer-guided surgery concept. A partially dentate patient who presented with two vertical defects (one in the maxilla and one in the mandible) was selected for an autogenous mandibular bone block graft. The bone block was planned using a computer-aided design process, with ideal bone osteotomy planes defined beforehand to prevent damage to anatomical structures (nerves, dental roots, etc) and to generate a surgical guide, which defined the working directions in three dimensions for the bone-cutting instrument. Bone block dimensions were planned so that both defects could be repaired. The projected bone block was 37.5 mm in length, 10 mm in height, and 5.7 mm in thickness, and it was grafted in two vertical bone augmentations: an 8 × 21-mm mandibular defect and a 6.5 × 18-mm defect in the maxilla. Supraimposition of the preoperative and postoperative computed tomographic images revealed a procedure accuracy of 0.25 mm. This computerguided bone harvesting technique enables clinicians to obtain sufficient autogenous bone to manage multiple defects safely. Schlagwörter: bone block, computer-guided surgery, mandibular bone harvesting

Purpose: To define the role played by a suspended external-internal (SEI) suture in reducing marginal flap tension after bone augmentation in the maxilla and in enhancing primary wound healing. Materials and Methods: Twenty partially edentulous patients requiring bone augmentation (either guided bone regeneration or autogenous bone block placement) before or simultaneous with implant insertion in the maxilla were enrolled in this clinical prospective cohort study. Flap tension was measured by a dynamometer, which was accurate to within 1 g. The force recorded was that needed to enable the vestibular extensible flap to reach the edge of the palatal nonextensible flap. Flap tension was recorded after the periosteum-releasing incision was made (before application of any suture; T1), and after the SEI suture was applied (T2). Final marginal flap adaptation was accomplished via horizontal mattress sutures and simple stitches. Wound healing was monitored at 1, 2, 4, and 16 weeks and classified as "obtained primary closure" or "compromised" as a result of dehiscence or marginal flap necrosis. Results: The mean flap tension measured at T1 was 32.9 ± 7.7 g. After the SEI suture was applied, the mean marginal flap tension decreased to 4.1 ± 1.5 g. The marginal flap tension was reduced by 87.6% compared to the initial strain. All patients healed uneventfully, and no complications such as dehiscences or marginal flap necrosis were recorded. Conclusion: The application of the SEI suture reduced the tension on the margins of the flaps and played a decisive role in obtaining primary wound healing. In case of passive wound closure (strain < 5 g), the type of augmentation procedure (guided bone regeneration or autogenous block) was revealed to have no impact on the quality of wound healing. Schlagwörter: bone augmentation, internal suture, primary wound closure, wound dehiscence

The aim of this study was to report the outcome of the management of alveolar crest vertical defects using the tunnel technique approach associated with autogenous bone blocks prior to implant placement in 10 partially dentate consecutively treated patients. Four clinical linear measurements were taken: maximal extension of the vertical defect (VD) at the time of the augmentation procedure (time 0), vertical bone graft (VBG) recorded at time 0, bone resorption at implant placement (time 1), and bone resorption during implant healing at the time of abutment connection (time 2). All patients healed uneventfully, and no complications were recorded. Both mean VD and VBG at time 0 were 6.50 ± 1.43 mm. Mean bone resorption at time 1 was 0.30 ± 0.48 mm and mean bone resorption at time 2 was 0.25 ± 0.26 mm, yielding an overall vertical bone remodeling of 0.55 ± 0.49 mm (8.4%) after 8 months. This study supports the capability of a minimally invasive approach to regenerate bone in vertical defects prior to implant placement.

Purpose: The aim of this case series is to propose an approach to help maintain autogenous bone grafts. This is done by applying a collagen membrane (CM) and anorganic bovine bone (ABBM) at the time of implant surgery, rather than at the time of ridge augmentation, to avoid volume loss after implants are inserted. Materials and Methods: Ten patients with severe horizontal bone atrophy were consecutively enrolled in this study. A staged approach was chosen for implant placement following horizontal ridge augmentation. A block graft was harvested from the retromolar area and secured to the recipient site with fixation screws; contour overbuilding was avoided. The width of the ridge was measured before and after horizontal augmentation. After 4 months of healing, implants were inserted, the augmented site was relined with ABBM, and CM was applied to prevent bone volume loss. Another 4 months later, at the time of abutment placement, cone beam computed tomography was performed to quantify the end result. Results: The mean horizontal ridge width prior to treatment was 2.1 ± 0.5 mm. Mean postsurgical crest width was 6.9 ± 0.5 mm. After the 4-month healing period, the mean alveolar crest width was 6.6 ± 0.6 mm. At the time of abutment connection, the mean width of the regenerated ridge, as measured on three-dimensional cone beam images, was 7.7 ± 0.8 mm. Conclusions: Minimal bone loss occurred in unprotected autogenous bone grafts with respect to alveolar bone contour (0.25 ± 0.29 mm). After the implants were inserted, no further remodeling/resorption occurred with sites treated by ABBM and CM relining; moreover, an additional increase in alveolar crest width was evident. The nonresorbable ABBM osseointegrated clinically and radiologically, preventing bone loss prior to implant loading. This layer appeared to maintain the regenerated crest volume. Schlagwörter: autogenous bone graft, bone augmentation, bone resorption, volume maintenance