For my loving family: my wife, Marty, and my three children, Sverre, Trygve, and Autumn.
I wish to acknowledge my surgical assistants, Cindy Formanek and Jennifer Chatting, and my auxiliary staff including Monique Stozek, Jenny Featheringill, Kathy Stenson, and Janet Zacharias.
— Ole T. Jensen
Library of Congress Cataloging-in-Publication Data
Names: Jensen, Ole T., editor.
Title: The sinus bone graft / [edited by] Ole T. Jensen.
Description: Third edition. | Batavia, IL : Quintessence Publishing Co Inc,
[2018] | Includes bibliographical references and index.
Identifiers: LCCN 2018033872 | ISBN 9780867157918 (hardcover) | eISBN 9780867158380
Subjects: | MESH: Maxillary Sinus--surgery | Bone Transplantation--methods |
Dental Implantation--methods | Reconstructive Surgical Procedures--methods Classification: LCC RF421 | NLM WV 345 | DDC 617.5/2--dc23
LC record available at https://lccn.loc.gov/2018033872
© 2019 Quintessence Publishing Co, Inc
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Editor: Marieke Zaffron
Design: Sue Zubek
Production: Sue Robinson
Printed in China
Foreword by Tomas Albrektsson
Preface
In Memoriam: Carl Erwin Misch
Contributors
Introduction by Hilt Tatum Jr
Section I: Surgical Options for Bone Grafting
1 Bone Grafting Strategies for the Sinus Floor
Craig M. Misch
2 Diagnosis and Treatment of Sinus Infections
Ashish A. Patel | Eric J. Dierks
3 Osteoperiosteal Flaps for Sinus Grafting
Ole T. Jensen
4 The Alveolar Split Approach for Sinus Floor Intrusion
Len Tolstunov | Daniel R. Cullum | Ole T. Jensen
5 Complex Techniques for Posterior Maxillary Reconstruction
Nardy Casap | Heli Rushinek
Section II: Lateral and Transcrestal Sinus Elevation
6 Lateral Window Surgical Techniques for Sinus Elevation
Tiziano Testori | Riccardo Scaini | Matteo Deflorian | Stephen S. Wallace | Dennis P. Tarnow
7 Sinus Floor Augmentation Without Bone Grafting
Giovanni Cricchio | Lars Sennerby | Stefan Lundgren
8 Intraoperative Complications with the Lateral Window Technique
Stephen S. Wallace | Dennis P. Tarnow | Tiziano Testori
9 Transcrestal Window Surgical Technique for Sinus Elevation
Michael S. Block
10 Transcrestal Sinus Augmentation with Osseodensification
Salah Huwais | Ziv Mazor
11 Transcrestal Hydrodynamic Piezoelectric Sinus Elevation
Konstantin Gromov | Sergey B. Dolgov | Dong-Seok Sohn
Section III: Implant Placement in the Resorbed Posterior Maxilla
12 Lateral and Transcrestal Bone Grafting with Short Implants
Rolf Ewers | Mauro Marincola
13 Transsinus Implants
Tiziano Testori | Gabriele Rosano | Alessandro Lozza | Stephen S. Wallace
14 Guided Extrasinus Zygomatic and Pterygoid Implants
Nardy Casap | Michael Alterman
15 Navigation for Transsinus Placement of Zygomatic Implants
Yiqun Wu | Feng Wang | Wei Huang | Kuofeng Hung
16 Arch-Length Threshold for Using Zygomatic Implants
Nicholas J. Gregory | Ole T. Jensen
17 Pterygoid Implants
Stuart L. Graves | Lindsay L. Graves
18 The Nazalus Implant
Pietro Ferraris | Giovanni Nicoli | Ole T. Jensen
19 Ultrawide Implants in Molar Sites
Costa Nicolopoulos | Andriana Nikolopoulou
20 Restoration and Abutment Options
Alexandre Molinari | Sérgio Rocha Bernardes
Section IV: Evolution and Innovations in Maxillary Bone Regeneration
21 The Sinus Consensus Conference: Results and Innovations
Vincent J. Iacono | Howard H. Wang | Srinivas Rao Myneni Venkatasatya
22 Sharpey Fiber Biologic Model for Bone Formation
Martin Chin | Jean E. Aaron
23 Using BMP-2 to Increase Bone-to-Implant Contact
Byung-Ho Choi
24 Tissue-Engineered Bone and Cell-Conditioned Media
Hideharu Hibi | Wataru Katagiri | Shuhei Tsuchiya | Masahiro Omori | Minoru Ueda
25 Tissue Engineering of the Dental Organ for the Posterior Maxilla
Fugui Zhang | Dongzhe Song | Ping Ji | Tong-Chuan He | Ole T. Jensen
Index
About 40 years ago, I defended my PhD thesis, Healing of Bone Grafts, under the tutorship of P-I Brånemark. I placed optical implants in bone tissue prior to grafting and in this manner was able to investigate what happened to the graft microvasculature after transplantation. Even if allogeneic or heterologous bone was available at the time (eg, in the Oswestry and Kiel bone banks), it was generally agreed that only autogenous bone provided adequate repair. Bank bone was mainly used for large orthopedic defects as a last resort. Some 20 years later, I participated in the consensus conference on sinus grafts arranged in the United States. At the same time, results of sinus grafts were so successful that it seemed irrelevant whether autogenous, allogeneic, or heterologous grafts were used. Lamentably, the clinical material available at the time was data collected from clinicians rather than data printed in peer-reviewed journals, and this seldom allows for a critical scientific analysis. Nevertheless, it was the first time I had heard colleagues claim that similar good clinical results could be achieved with types of grafts other than the conventionally used autograft.
Today, of course, we have a large bulk of evidence that many types of bone grafts function very well when placed in sinuses. Admittedly, as evidenced in one chapter of the present volume, in some cases we do not necessarily see improved clinical results of implants after grafting compared to nongrafting—the preparation of bone tissue may provide a satisfactory supply of autogenous bone particles for clinical success. However, this type of very simple autografting may not work in severely resorbed clinical cases, and clinicians trying it in cases with 2 to 4 mm of bone thickness are advised to carefully check implant stability after placement.
One commonly used source of sinus graft material today can be heterologous bone such as Bio-Oss (Geistlich). We investigated the long-term fate of sinus-grafted Bio-Oss particles 11 years after grafting and found them largely unchanged in size and morphology.1 These particles, like the implant, may represent a foreign body with osteoconductivity (ie, new bone growth that explains the good clinical results achieved). In fact, the clinical fate of autografts may be quite similar in behavior. We analyzed the histologic outcome of small autogenous bone columellas used to replace the ossicular bones in hearing impairment in humans. The actual grafts had died, but they continued to function clinically with clear evidence that new live bone grew on the surfaces of the old grafts.2
The main reason why a volume such as the third edition of The Sinus Bone Graft is so important depends on the clinical reports made available. Sinus grafts are indeed most positive for patient treatment and have since long proven their clinical efficacy. Dr Jensen, the editor of this book, is one of very few in the world who has experience from more than 30 years working with sinus grafts, and I can think of no one more suited to be editor of this volume. He has put together a great number of excellent contributors to write about their experiences with sinus grafts under different conditions. This book is highly recommended to anyone using oral implants, and since major innovations have been presented in this third edition, I would even recommend it to those who already own the previous editions.
Tomas Albrektsson, md, phd
Professor Emeritus
Department of Biomaterials
Institute of Clinical Sciences
Gothenburg University
Gothenburg, Sweden
Visiting Professor
Faculty of Odontology
Malmö University
Malmö, Sweden
1. Mordenfeld A, Hallman M, Johansson CB, Albrektsson T. Histological and histomorphometrical analyses of biopsies harvested 11 years after maxillary sinus floor augmentation with deproteinized bovine and autogenous bone. Clin Oral Implants Res 2010;21:961–970.
2. Kylén P, Albrektsson T, Ekvall L, Hellkvist H, Tjellström A. Survival of the cortical bone columella in ear surgery. Acta Otolaryngol 1987;104:158–165.
With each passing year, I continue to be amazed at how far we have come and how we continue to advance in the highly specialized procedure of sinus elevation and grafting. Only a few decades ago, the sinus elevation was performed in just one general dental office in Opelika, Alabama; it is now an international cross-specialty collaboration. As the techniques have evolved, so has this book. The third edition of The Sinus Bone Graft updates current scientific rationale and clinical practice for what continues to be a necessary procedure for posterior maxillary dental implant reconstruction. In this volume, attention is given to historical recognition of pioneers in this field, including Hilt Tatum, Philip Boyne, and Carl Misch. But there are countless contributors to sinus elevation, from the members of the 1996 Sinus Consensus Conference sponsored by the Academy of Osseointegration to the authors of the now over 2,000 publications concerning modifications related to sinus floor treatment.
In 1986, I made the pilgrimage taken by many general dentist implantologists before me to visit Dr Hilt Tatum’s office and learn firsthand from the master clinician. After observing him over a few days, I remember leaving in a kind of daze wondering if a “sinus lift,” as he called it, could be real. It wasn’t until 10 years later that a group of 38 clinicians met in Boston to present their early sinus elevation results. After everyone had presented their data, including disparate methods and modifications to the original procedure, we came to understand quite remarkably that we all had success! We were stunned, almost to silence, that Dr Tatum’s work had so summarily been replicated. From that point forward, the world of implant dentistry changed as the sinus elevation was confidently recommended to patients.
A few years later, after having collaborated in Sweden, I had a discussion with P-I Brånemark and Ulf Lekholm, who still viewed the sinus procedure with skepticism. At the time, Dr Brånemark was hatching the idea of the zygomatic implant and told me that the sinus graft might not be necessary after all. I did not understand his meaning then, but I do now. In addition to an overview of the types of graft material and techniques, this book is filled with alternatives to the sinus graft. Among them are the use of the zygomatic implant and the idea that the sinus membrane should be reflected but not necessarily grafted, as Stefan Lundgren has shown.
In 2011, I met separately with Tatum and Boyne, the two great innovators of the sinus floor bone graft, and recorded their independent creative thought processes firsthand. Interestingly, they both described inspiration being triggered by a problem of deficient interocclusal space. Though surgeons, they were thinking as restorative dentists, struggling with how to obtain room for crowns or a prosthesis, when the sudden thought occurred of developing bone “on the other side” (ie, on the sinus floor). Bone grafting had never solved a problem in this way before. Similarly, many of the innovators in this book—the best and the brightest minds throughout the world—continue to creatively solve a portion of the riddle that is regenerative medicine.
This collection of prescient advancements in sinus graft technology would clearly not be possible without these innovators and scientists, the doctors of medicine and dentistry. However, we must also recognize all those who participate in the art of healing a human being: the surgical and research assistants, auxiliary staff, supportive families, and of course the patients themselves. Thank you for your devotion to this worthy cause.
Ole T. Jensen
Dr Carl Misch (left) and Dr Craig Misch (right) at the Academy of Osseointegration Annual Meeting, 2016.
“Being his brother I could feel I live in his shadow, but I never have and do not now. I live in his glow.”—Michael Morpurgo
In 2017, the dental profession and implant field lost a true icon: my brother, Dr Carl E. Misch. Carl often stated that his professional goal was to elevate the standard of care in implant dentistry, and he worked tirelessly in pursuit of that achievement. He had a gift for organizing and simplifying information and used that gift to develop numerous principles and classifications that became integral concepts in the origins of modern implant dentistry. Carl had the good fortune to meet Dr Hilt Tatum in the late 1970s and to be taught sinus bone grafting techniques from one of the originators of the procedure. He had exceptional clinical skills and was one of the first prosthodontists in the United States to perform complex implant surgeries. In 1987, Carl published the first classification for managing the posterior maxilla based on the amount of bone below the sinus. These practical guidelines are still relevant today and were included in the second edition of The Sinus Bone Graft. He was also an early proponent of using bone substitutes for sinus grafting and presented his data alongside me at the first Sinus Consensus Conference at Babson College in 1996.
Carl had a passion for learning and sharing information. He founded the Misch Implant Institute, a continuing education program with an organized curriculum on implant dentistry. He was also on the faculty at several dental schools and served as director of one of the first university-based implant programs at the University of Pittsburgh from 1986 to 1993. His lectures—enthusiastic, authoritative, charismatic, and personal—always captured the audience’s attention. This text, Contemporary Implant Dentistry (Mosby/Elsevier, 1993), was one of the first books detailing sinus anatomy, physiology, and surgical approaches to manage the atrophic posterior maxilla. This text is now in its third edition and is considered by many as the most complete reference on surgical and prosthetic implant topics. Carl was a prolific author and published over 100 peer-reviewed articles on various implant-related topics. His commitment to the profession truly changed the lives of his students, colleagues, and patients. Dr Carl Misch was a true pioneer, leader, professor, and master clinician of implantology. He had a remarkable career, and we will all miss his influence and passion for implant dentistry.
Craig M. Misch
Jean E. Aaron, PhD
Bone Structural Biologist and Visiting Lecturer
School of Biomedical Sciences
University of Leeds
Leeds, United Kingdom
Michael Alterman, DMD
Director of Outpatient Clinic
Hadassah and Hebrew University Medical Center
Jerusalem, Israel
Sérgio Rocha Bernardes, BDS, MSc, PhD
Head of New Product Development and Clinical Practice
Neodent Global
Professor
Latin American Institute of Dental Research and Education
Curitiba, Brazil
Michael S. Block, DMD
Private Practice Limited to Oral and Maxillofacial Surgery
Metairie, Louisiana
Nardy Casap, DMD, MD
Professor and Chairman
Department of Oral and Maxillofacial Surgery
Hadassah and Hebrew University Medical Center
Jerusalem, Israel
Martin Chin, DDS
Private Practice Limited to Oral and Maxillofacial Surgery
San Francisco, California
Byung-Ho Choi, DDS, PhD
Professor
Department of Oral and Maxillofacial Surgery
Wonju College of Medicine
Yonsei University
Wonju, South Korea
Giovanni Cricchio, DDS, PhD
Research Fellow
Department of Oral and Maxillofacial Surgery
Umeå University
Umeå, Sweden
Daniel R. Cullum, DDS
Private Practice Limited to Oral and Maxillofacial Surgery
Coeur d’Alene, Idaho
Guest Lecturer
Department of Oral and Maxillofacial Surgery
Loma Linda University
Loma Linda, California
Guest Lecturer
Department of Oral and Maxillofacial Surgery
University of California, Los Angeles
Los Angeles, California
Matteo Deflorian, DDS
Tutor at the Section of Implant Dentistry and Oral Rehabilitation
Department of Biomedical, Surgical, and Dental Sciences
School of Medicine
University of Milan
Milan, Italy
Eric J. Dierks, DMD, MD
Private Practice Limited to Head and Neck Surgery
Portland, Oregon
Sergey B. Dolgov, DDS, MSD
Private Practice Limited to Periodontics and Implant Dentistry
Mankato, Minnesota
Rolf Ewers, MD, DMD, PhD
Chairman Emeritus
Department of Cranio-Maxillofacial and Oral Surgery
Medical University of Vienna
Vienna, Austria
Pietro Ferraris, MD, DDS
Private Practice Limited to Oral and Maxillofacial Surgery and Prosthodontics
Alessandria, Italy
Lindsay L. Graves, DMD
Resident
Division of Oral and Maxillofacial Surgery
UT Southwestern/Parkland Memorial Hospital
Dallas, Texas
Stuart L. Graves, DDS, MS
Private Practice Limited to Oral, Maxillofacial, and Implant Surgery
Burke, Virginia
Nicholas J. Gregory, DDS
Private Practice Limited to Oral and Maxillofacial Surgery
Monroe, Louisiana
Konstantin Gromov, DDS
Private Practice Limited to Periodontics and Implant Dentistry
Glenview, Illinois
Private Practice Limited to Perioprosthodontics and Implant Dentistry
Moscow, Russia
Tong-Chuan He, MD, PhD
Associate Professor
Department of Surgery
Biological Sciences Division
University of Chicago
Associate Professor and Director
Molecular Oncology Laboratory
Department of Orthopaedic Surgery and Rehabilitation Medicine
University of Chicago Medical Center
Chicago, Illinois
Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences
The Affiliated Hospital of Stomatology
Chongqing Medical University
Chongqing, China
Hideharu Hibi, DDS, PhD
Professor and Chair
Department of Oral and Maxillofacial Surgery
Nagoya University Graduate School of Medicine
Nagoya, Japan
Wei Huang, DDS, MS
Professor
Department of Oral Maxillofacial Implantology
Ninth People’s Hospital
School of Medicine
Shanghai Jiao Tong University
Shanghai, China
Kuofeng Hung, DDS, MS
Department of Oral Maxillofacial Implantology
Second Dental Clinic
Ninth People’s Hospital
School of Medicine
Shanghai Jiao Tong University
Shanghai, China
Salah Huwais, DDS
Adjunct Assistant Clinical Professor
Department of Restorative Sciences
School of Dentistry
University of Minnesota
Minneapolis, Minnesota
Private Practice Limited to Periodontics and Implantology
Jackson, Michigan
Vincent J. Iacono, DMD
SUNY Distinguished Service Professor, Tarrson Family Professor of Periodontology and Chair
Department of Periodontology
Director of Postdoctoral Education
Stony Brook School of Dental Medicine
Stony Brook, New York
Ole T. Jensen, DDS, MS
Adjunct Professor
Department of Oral and Maxillofacial Surgery
School of Dentistry
University of Utah
Salt Lake City, Utah
Ping Ji, DDS, PhD
Professor and President
Chongqing Key Laboratory of Oral Diseases
National Clinical Research Center for Oral Diseases
The Affiliated Hospital of Stomatology
Chongqing Medical University
Chongqing, China
Wataru Katagiri, DDS, PhD
Associate Professor
Division of Reconstructive Surgery and Oral and Maxillofacial Region
Niigata University Graduate School of Medical and Dental Sciences
Niigata, Japan
Alessandro Lozza, MD
Chief Assistant and Senior Consultant
Neurophysiopathy Service, IRCCS Mondino Foundation
Pavia, Italy
Stefan Lundgren, DDS, PhD
Professor and Chairman
Department of Oral and Maxillofacial Surgery
Umeå University
Umeå, Sweden
Mauro Marincola, DDS, MS
Professor and Clinical Director
International Implantology Center
Department of Implant Dentistry
University of Cartagena
Cartagena, Colombia
Ziv Mazor, DMD
Associate Professor
Department of Implantology
Titu Maiorescu University
Bucharest, Romania
Private Practice
Tel Aviv, Israel
Craig M. Misch, DDS, MDS
Clinical Associate Professor
Department of Periodontics/Prosthodontics
School of Dental Medicine
University of Florida
Gainesville, Florida
Private Practice Limited to Oral and Maxillofacial Surgery and Prosthodontics
Sarasota, Florida
Alexandre Molinari, DDS, MSc, PhD
Director
Clinical Professional Relations and Education
Neodent USA
Andover, Massachusetts
Visiting Professor
Latin American Institute of Dental Research and Education
Curitiba, Brazil
Srinivas Rao Myneni Venkatasatya, DDS, MS, PhD
Assistant Professor
Department of Periodontics
Stony Brook School of Dental Medicine
Stony Brook, New York
Giovanni Nicoli, MD
Maxillofacial Surgery Specialist
ASST Vallecamonica Hospital
Brescia, Italy
Costa Nicolopoulos, BDS, FFD
Private Practice Limited to Oral and Maxillofacial Surgery
Dubai, United Arab Emirates
Andriana Nikolopoulou, MD
Private Practice
Glyfada, Greece
Masahiro Omori, DDS, PhD
Postdoctoral Researcher
Department of Oral and Maxillofacial Surgery
Nagoya University Graduate School of Medicine
Nagoya, Japan
Ashish A. Patel, DDS, MD
Consultant at a Private Practice Limited to Head and Neck Surgery
Associate Professor
Department of Oral and Maxillofacial Surgery
School of Dentistry
Oregon Health and Science University
Portland, Oregon
Gabriele Rosano, DDS, PhD
Oral Surgeon
Lake Como Institute
Como, Italy
Heli Rushinek, DMD
Oral and Maxillofacial Surgeon
Department of Dentistry
Hadassah and Hebrew University Medical Center
Jerusalem, Israel
Riccardo Scaini, DDS
Tutor at the Section of Implant Dentistry and Oral Rehabilitation
Department of Biomedical, Surgical, and Dental Sciences
IRCCS Istituto Ortopedico Galeazzi
University of Milan
Milan, Italy
Lars Sennerby, DDS, PhD
Professor
Institute of Odontology
Sahlgrenska Academy
University of Gothenburg
Gothenburg, Sweden
Dong-Seok Sohn, DDS, PhD
Professor and Chair
Department of Oral and Maxillofacial Surgery
Catholic University Medical Center of Daegu
Daegu, South Korea
Dongzhe Song, DDS, PhD
Molecular Oncology Laboratory
Department of Orthopaedic Surgery and Rehabilitation Medicine
University of Chicago Medical Center
Chicago, Illinois
State Key Laboratory of Oral Diseases
National Clinical Research Center for Oral Diseases
West China Hospital of Stomatology
Sichuan University
Chengdu, China
Dennis P. Tarnow, DDS
Clinical Professor and Director of Implant Education
College of Dental Medicine
Columbia University Irving Medical Center
New York, New York
Tiziano Testori, MD, DDS
Head of the Section of Implant Dentistry and Oral Rehabilitation
Department of Biomedical, Surgical, and Dental Sciences
University of Milan
Milan, Italy
Private Practice Limited to Implantology
Como, Italy
Adjunct Clinical Associate Professor
Department of Periodontics and Oral Medicine
School of Dentistry
University of Michigan
Ann Arbor, Michigan
Len Tolstunov, DDS, DMD
Associate Clinical Professor
School of Dentistry
University of the Pacific
Assistant Clinical Professor
School of Dentistry
University of California, San Francisco
Private Practice Limited to Oral and Maxillofacial Surgery
San Francisco, California
Shuhei Tsuchiya, DDS, PhD
Assistant Professor
Department of Oral and Maxillofacial Surgery
Nagoya University Graduate School of Medicine
Nagoya, Japan
Minoru Ueda, DDS, PhD
Professor Emeritus
Department of Oral and Maxillofacial Surgery
Nagoya University Graduate School of Medicine
Nagoya, Japan
Stephen S. Wallace, DDS
Clinical Associate Professor
Department of Periodontics
College of Dental Medicine
Columbia University
New York, New York
Private Practice Limited to Periodontics
Waterbury, Connecticut
Feng Wang, DDS, MD
Assistant Professor
Department of Oral Maxillofacial Implantology
Ninth People’s Hospital
School of Medicine
Shanghai Jiao Tong University
Shanghai, China
Howard H. Wang, DDS, MS, MPH, MBA
Private Practice Limited to Endodontics, Periodontics, and Implant Dentistry
New York, New York
Yiqun Wu, DDS, MD
Professor
Department of Oral Implantology
Ninth People’s Hospital
Second Dental Clinic
School of Medicine
Shanghai Jiao Tong University
Shanghai, China
Fugui Zhang, DDS, PhD
Molecular Oncology Laboratory
Department of Orthopaedic Surgery and Rehabilitation Medicine
University of Chicago Medical Center
Chicago, Illinois
Chongqing Key Laboratory of Oral Diseases and Biomedical Sciences
The Affiliated Hospital of Stomatology
Chongqing Medical University
Chongqing, China
Hilt Tatum Jr, DDS
When Dr Jensen contacted me about contributing to this third edition, I was uncertain. It had not been possible for me to participate in the Sinus Consensus Conference, and at the time I had not read his book. After reading the second edition, I realized it would be an honor to participate in this one.
My journey leading to the sinus augmentation procedure started in 1956, when I attended the first course on oral implants given in an American dental school, the Emory University School of Dentistry. The course was presented by Col Roy Bodine. My clinical experience began with 2 years of service in the Marine Hospital located in Savannah, Georgia. The next 2 years were spent doing full-mouth restorative dentistry in Savannah before I joined my father, Hilt Tatum Sr, and brother, Crawford Tatum, DDS, in Opelika, Alabama. There, our practice quickly became oriented to extensive restorative dentistry.
We recognized patients’ and our own dissatisfaction with free-end partial dentures and felt that this need could be met with the use of endosteal implants and fixed restorations. In an attempt to fix the problem, we acquired two sheets of commercially pure titanium, 0.25 inch thick and 0.75 inch thick. Using these sheets, we began to make and successfully use endosteal implants with different shapes that were designed to fit into the available bone found in different patients. After the implants were placed, we waited to load them until after a healing period similar to that used for mandibular fractures. However, because most of these patients had worn partial dentures for extended periods of time, we recognized the severe vertical bone loss and the need to restore the missing bone before the patients could receive implants.
The obvious answer to this need was to restore the missing bone volume with autogenous bone augmentation. However, as we began our preparation period before performing these surgeries, a startling event occurred. I had the chance to meet with Dr Frank Morgan, who had extensive experience doing bone grafting to treat battlefield wounds during the Vietnam War. When I discussed our plans with Frank, he shocked me with the following words: “Hilt, if you do this elective surgery on your private restorative patients, it will bury you with the complications you will encounter.” This completely stopped our efforts toward bone construction for some time.
Don Tillery, an oral surgeon and close friend, was aware of the preparation we had done and the effect that Dr Morgan’s advice had on our plans. In early 1969, Don called and said that he had seen a technique that he thought would safely meet our goal. He told me about an oral surgeon, Dr James Alley, who had successfully done a series of preprosthetic bone augmentations on edentulous mandibles before denture construction. We contacted Dr Alley, and he invited us to visit his office. We spent a week with him, observed two surgeries, and were able to see several patients who were at different periods of time postsurgically. The technique consisted of placing an autogenous rib (with no screws) on an edentulous mandible. This was followed by a 6-month unloaded healing period and then the construction of a new mandibular denture. He reported no postoperative healing complications.
The secret to Dr Alley’s success was in making two vertical incisions in the vestibule of each canine area, tunneling and mobilizing the soft tissue over the entire mandible, decorticating the crest of the mandible, shaping and placing the rib, and closing the remote incisions. The secret therefore was good asepsis, no incisions over the graft material, decortication, and an unloaded healing period. One patient who had worn the postoperative denture for 2 years appeared to have very little of the augmentation left.
Fig 1 Autogenous rib with one thickness (a) and two thicknesses (b) from 1970.
Fig 2 (a and b) By 1980, we were using autogenous iliac bone for the maxilla and bilateral sinuses done with two vertical vestibular incisions.
These were our takeaways from this visit:
• Surgical asepsis would be critical.
• Decortication aided the augmentation union with the mandible.
• Remote incisions had prevented postoperative infections.
• Loading of the denture had largely destroyed the newly formed crestal bone.
• Placement of endosteal implants should not destroy the new crestal bone.
• Placement of endosteal implants should internally load and stimulate new crestal bone.
• Most importantly, we could safely begin to restore alveolar bone.
In January of 1970, we performed the first of four successful autogenous rib augmentations on posterior edentulous mandibles (Fig 1) harvested by Dr William Lazenby. Following his suggestion, we later began using the ilium as a bone source. Over a period of 9 years, Dr Lazenby and Dr Doyle Hanes routinely harvested bone for our augmentation patients (Fig 2) until I relocated my practice to St Petersburg, Florida, in 1979. Because all of these patients were treated in a hospital environment with remote incisions and Millipore filters (MilliporeSigma) over the augmented bone, we experienced a very limited number of postoperative surgical complications.
I have had the opportunity to give more than 2,000 podium presentations demonstrating these principles of creative remote incisions for all augmentation locations. These have been presented to a wide range of dental meetings, practitioners, and specialists. It surprised me that a large majority of alveolar augmentations have continued to be completed with crestal incisions over the augmentation material, sometimes resulting in complications. With good asepsis, remote incisions, adequate tissue mobilization, effective augmentation material, and precise tissue closures, complication rates will be significantly reduced.
We also found that augmented bone remained stable after implant placement, healing, and restoration. We did observe that when large augmentations were done within the esthetic zone, it was wise to maintain patients with provisional restorations in function for a period of 2 years before the definitive restorations were placed. This resulted in the most desirable esthetic results.
As our augmentation experience progressed, we recognized that it was impossible to do a vertical onlay augmentation in a posterior maxilla with no vertical loss and a severely pneumatized sinus without infringing on the vertical space required for the dental restorations. For the longest time, this seemed an insurmountable challenge. Then, in 1974, the thought occurred to me that we were looking at the problem backward and should be putting the bone inside of the sinus rather than on the crest. Immediately after this epiphany, I had parallel feelings of both exhilaration and fear. I was exhilarated by the thought that it might be possible, but the fear was that which any dentist might have on considering contact with a maxillary sinus.
During the remainder of 1974, we placed a number of posterior maxillary implants in the following way. We would either machine a titanium implant or cast a Vitallium implant that would fit into the medullary space between the sinus floor and the crest of the ridge (Fig 3). We also cast a try-in that had the same side dimensions but was longer than the implant. A remote palatal flap was lifted to expose the ridge crest, and curettes were used to prepare the implant site by removing bone to the floor of the sinus to match the dimension of the implant. The try-in was then fitted into this socket and lightly tapped to release the sinus floor. The floor and mucosal lining were vertically elevated a few millimeters, and some of the curetted bone was placed into the space around the elevated floor. The implant was then placed into the deepened socket and additional bone was placed over the implant to the crest of the ridge, with only the implant neck exposed. The flap was rotated and sutured on the palatal wall. The healing around each of these implants was uneventful, and they were restored.
Fig 3 Custom-made implants elevating the sinus floor and custom-made root form from 1974.
Fig 4 Sinus floor elevated by compressing bone and without entering the sinus.
Fig 5 Inflated Fogarty catheter elevating the sinus membrane.
We have always referred to this procedure as a sinus lift. By 1980, we had modified the technique into compressing the cancellous bone threads into an intertwined mat that could elevate the floor as it deepened the socket without entering the sinus (Fig 4). We now use these bone manipulation osteotomes to form the sockets, compress the cancellous bone, and elevate the sinus floor.
Our first sinus augmentation with autogenous, particulate, iliac bone was done in February of 1975. This, along with our next four augmentations, was done from the crest of the ridge and opened with a palatal flap. We then began to primarily use a crestal incision and prepare a sinus window anterior to the zygomatic buttress on the lateral wall of the maxilla. However, our fear of the word sinus was so strong that in the hospital operative notes, we would describe the operation as an inverted maxillary bone graft.
At the 1976 Alabama Implant Congress meeting in Birmingham, Alabama, we reported on the sinus augmentation procedure and the results we had observed during the previous 15 months. I was invited to make a presentation in the fall of 1977 on sinus augmentation at the American Academy of Implant Dentistry annual meeting and asked Dr Philip Boyne to join me. In a 1994 meeting of the Alabama Implant Congress (at the same podium from which I first presented in 1976), he confirmed our success with this procedure before an audience of more than 300 attendees.
During the first several years of sinus augmentations, we had limited instruments and relied heavily on modified Fogarty catheters to aid in the elevation of the sinus membrane. These were shortened to a few inches long and attached to a syringe. When slid under the sinus lining and gently inflated, they could safely lift the membrane (Fig 5). By 1978, we had created suitable instruments and no longer needed the Fogarty catheters.
Until 1984, autogenous iliac bone was our primary augmentation material. However, from 1972 until 1982, we were furnished some frozen human allograft by Dr Bill Hiatt from the VA-funded study, 1962–1982, for which he was a codirector. We established and maintained the same cryogenic banking capability as was used in the study and would always have a suitable human lymphocyte antigen match between the donor and recipient for anyone treated with this bone. Results comparable with autogenous bone were observed on the sinus augmentation patients treated with this allograft.
From 1978 forward, we began to utilize a titanium root form system I had developed, which became the first titanium root form system with FDA marketing approval (Fig 6). This system also included a selection of designs that were used to elevate the sinus floor and used the curetted bone that was harvested during the socket preparation (Fig 7).
From 1979 until 1983, we did the surgical cases for the US Food and Drug Administration (FDA) preclinical study on tricalcium phosphate ceramic (TCP) as a bone augmentation material. We evaluated and found this product to be successful for sinus augmentations, though slower in its replacement than human bone.
In the summer of 1982, Martin Lebowitz, DDS, MS, left the chairmanship of the OMS Department at the University of Florida School of Dentistry to join me. Following this, many of the Le Fort I surgical cases also had simultaneous sinus augmentations. Martin was left-handed and I was right-handed, which allowed us to both operate at the same time with the following steps:
• Careful attention was given to achieve optimum asepsis within each nasal passageway during preparation and intubation.
• After maxillary downfracture, a careful, meticulous freeing of the nasal mucosa from bone to prevent tears in this tissue was done. This was important to protect the augmentation material from risk of contamination from bacterial flora occurring in the nose.
• We also provided a hyperbaric oxygen chamber within our office to aid in the management of potential anaerobic infections.
In 1984, my son, Hilt Tatum III, DMD, joined our practice. During that same year, multiple augmentation products became available with the freeze-dried demineralized bone products reported as the most favorable. We used multiple products for sinus augmentations during this period, but by 1986, our clinical results were varied and confusing. We decided to evaluate each class of products by comparing results with histomorphometric evaluations taken from bilateral sinuses in the 4th postoperative month. We obtained three to five results from each type of the tested materials and were surprised by what we found. The best results (37% new bone) were obtained from irradiated cancellous human bone (ICB, Rocky Mountain Tissue Bank), and the second best was from 1- to 2-mm demineralized freeze-dried cortical bone chips (12% new bone).
Fig 6 (a and b) Transmucosal implants and soft tissue reconstruction in augmented maxilla and bilateral sinuses.
Fig 7 Sinus implant selection and try-ins. This photograph shows 4 of the 16 sizes made.
Since 1988, the ICB from Rocky Mountain Tissue Bank has been our product of choice for sinus augmentations. This recognition that ICB provided a sinus augmentation product comparable with autogenous bone permitted a readily available and reliable material for in-office surgical procedures. Also, this product allowed us to perform lateral wall augmentations and place root-form implants rather than the special sinus implants. The average amount that we have used for each sinus has been 7 g.
In the mid-1990s, I designed and made a number of instruments to improve our ability to perform sinus procedures. These included flap retractors to fit over different shapes found on zygomatic buttresses and curettes made to fit the different anatomical areas found within sinuses. These instruments have significantly simplified and improved the precision of the surgeries.
Even when following a strict protocol under exact specified patient conditions, complications may occur. When a tear is present in the mobilized mucosal lining, excess tissue is folded over the tear and stabilized with a shaped collagen tape just prior to placing the bone. The tape will momentarily adhere to the lining, and by placing the bone immediately against the tape, it will stabilize the tape and hold the torn tissue in position. When postoperative infections occur, they will typically become symptomatic within a few days after the surgical procedure. Immediate attention, including culture and sensitivity testing, modification or expansion of antibiotic coverage with therapeutic doses, and further modification as directed following sensitivity testing, has proven to be effective in the majority of patients. If this does not completely eliminate the symptoms within a period of 7 to 14 days, removal of all augmentation material is usually indicated. If implants were placed during the augmentation procedure, this regimen would not be expected to be successful as a result of the biofilm-shielded bacterial colonies growing and shielded on the implants. In our 43 years of sinus augmentations, we have lost the grafts in less than 1% of the sinuses treated.
By 1980, we recognized that sinus and interpositional bone augmentations as well as free-flap procedures were safer and more precise than onlay procedures. Hoping to demonstrate this, I took a training course in microvascular surgery. We then attempted to replace onlay autogenous procedures with free-flap microvascular procedures using autogenous iliac sources. Though we could make the microvascular connections, we found that developing the correct bone shapes in the precise locations needed on the alveolar ridges was like fitting a square peg in a round hole. Still, the idea fascinated me, and in early 1982, we did a maxillary vascularized osteotomy procedure attempting to achieve a free-flap result by using the natural alveolus with its blood supply and without the need for microvascular surgery.
This was successful, so we published a paper on maxillary augmentations with the technique and have developed and expanded its utilization through the years.1 It instantly produces the results sought with a distraction osteogenesis procedure with minimal or no hardware. Typically, a long titanium screw (ie, 18 to 24 mm) is used to stabilize the vertically moved bone. ICB and irradiated corticocancellous (ICC) blocks are used for the interpositional material (Fig 8). Alterative vertical stabilization can be achieved with miniplates or ICC blocks. It is true that the shape of a healed alveolar ridge is not the shape of an alveolus surrounding teeth. However, the plasticity of vascularized alveolar bone, combined with the correct instruments, knowledge, and skill of bone manipulation, makes it possible to transform the vertically corrected but misshaped bone into a perfect socket. An implant can then be crestally positioned within the same location previously occupied by the root it is replacing (Figs 9 and 10). The correct use of this concept will produce the safest, simplest, and most precise correction of a vertical deficiency.
Fig 8 (a to d) Tatum vascularized osteotomy (TVO). The goal is to regain bone attachment in the mandible by using a vertical fixation screw and implants.
Fig 9 (a to d) Bone expansion, implant, and restorative treatment by Dr Jose Pedroza.
Fig 10 (a to d) Bone expansion, implants, and restorative central crown restorations by Dr Ana Ayala.
We have used this to perform office procedures with intravenous sedation and local anesthesia, including the following:
• Move healed implants (Fig 11)
• Move segments of teeth and bone (Fig 12)
• Correct single implant sites (Fig 13)
• Move multiple edentulous segments (Fig 14)
• Correct vertical defects simultaneously with sinus augmentations (Fig 15)
• Move full maxillary arches (Fig 16)
The safety lies in the maintained vascularity and vitality of the bone, surgical asepsis, the interpositional location of the augmentation material, and the remoteness of the incisions. We have described this procedure as a Tatum vascularized osteotomy (TVO).
Fig 11 (a to d) TVO used to move an implant.
Fig 12 (a) Preoperative maxillary extrusion and an extreme buccal relationship. (b) TVO to correct abnormality and with implants placed. (c) Completed case with restorations by Dr Jose Pedroza.
Fig 13 (a and b) Preoperative. (c to e) Using TVO. (f and g) Implant and restoration by Dr Jose Pedroza.
Fig 14 (a and b) TVO correction before implant placement.
Fig 15 Simultaneous sinus augmentation and TVO, implants with bone expansion and manipulation of gingiva. (a) Preoperative. (b) Postoperative.
Fig 16 (a to d) Full maxillary alveolus moved 8 mm down and 4 mm forward and crossbite correction all as in-office procedures.
It is our opinion that the future of the sinus augmentation procedure will include the simultaneous correction of vertical deficiencies. For a number of years, over half of the sinuses we have augmented have had simultaneous vertical corrections. These have been accomplished with either a TVO or an onlay block, and we will describe both. When a block is to be placed, an incision is made one tooth and one papilla anterior to the edentulous area and the same palatally to the midline or beyond, and a full-thickness flap is rotated over this tooth to prevent any incision from being present over the block. This flap must be completely elevated from the maxilla, including a buccal cut through the periosteum.
When the TVO is indicated, it can be correctly done and the implants later placed with bone manipulation. The TVO is safer than an onlay and produces the most precise results. The greater challenge here is that this requires the implant placements to be done with bone manipulation; this is a skill and an art that requires patience and training. The further complication is that we have a limited number of instructors with these special skills.
Bone cuts are made with a set of microtomes that are designed for this procedure. The greater palatine vascularity to the soft tissue and bone should be preserved. The sinus elevation is completed as described previously and must be above the level of the hard palate. All bone cuts are made from the buccal without penetrating the palatal soft tissue and with progressive microtomes (5 mm, 7.5 mm, 10 mm, 12.5 mm, and 15 mm) to produce a straight cut.
Fig 17 (a) After the elevation, collagen is placed against the lining. (b) ICB is placed, and a stent is added to allow placement of bone blocks with a screw for stabilization. (c) Palatal view of completed surgery and area to granulate.
Fig 18 Onlay block and sinus augmentation showing (a) incision, (b) remote vascularized flap elevation, and (c) occlusal view of block in place, palatal tissue, and area to granulate.
The anterior vertical cut is anterior to the vertical deficiency and is made through the alveolus to the level of the hard palate. Note that roots are never stripped of bone. A horizontal cut is made through the sinus and palatal slope just below the hard palate and anterior to the greater palatine foramen. The distal vertical cut is made through the tuberosity to the level of the hard palate or as a separation between the pterygoid plates and the maxilla to that level.
A superficial horizontal bone cut to protect the greater palatine bundle is made with a wide microtome to the distal vertical cut in the area of the greater palatine foramen. The microtome is then rotated downward to complete the horizontal fracture.
A periosteal elevator is slid through this horizontal cut (anterior to the greater palatine) to elevate and mobilize the soft tissue from the hard palate over to or across the midline (artery is safely within this tissue).
A semicircular incision is made (facing the surgical site) in the tissue over the hard palate. This permits the segment to be moved downward as this flap slides laterally—the greater palatine artery is avoided and always protected. The exposed bone will granulate over in 2 weeks.
Fig 17