Glycosaminoglycans in peri‐implant sulcus fluid from implants supporting fixed or removable prostheses

Previous studies have indicated that examination of glycosaminoglycans (GAG) present in peri‐implant sulcus fluid (PISF) may be a useful indicator of metabolic activity of the supporting bone. The GAG content in PISF from osseointegrated implants ad modum Bråemark in the maxilla was quantified and analysed. The study comprised 2 groups with 10 patients in each group. In one group the patients wore removable prostheses; in group 2 the patients wore fixed prostheses. The groups were matched for age, sex and function period of their prosthetic appliances. Clinical data were recorded, and the levels of the GAG hyaluronan (HA) and chondroitin‐4‐sulphate (C4S) were assessed using cellulose acetate electrophoresis and densitometric scanning of Alcian blue‐stained strips against known GAG standards. PISF volumes and levels of C4S as potential bone marker showed no significant difference both groups median 0.003 μg). There was a somewhat higher median value for HA (0.015 μg) in the group of patients with removable prostheses compared with the group with fixed prosthesis =0.008 μg)(NS). HA is known to be present in high amounts in gingival tissue. As both plaque index and gingival bleeding were more frequent in patients with removable prostheses, this may be the reason for the somewhat higher value for HA in this group of patients. The difference in biomechanical properties of fixed and removable prostheses on implants do not appear to be reflected in the bone responses as measured by GAG content in PISF.     

Endosseous implants and bone augmentation in the partially dentate maxilla: an analysis of 17 patients with a follow-up of 29 to 101 months

PURPOSE: The aim of this study was to analyze the survival rate of endosseous implants placed in the partially dentate maxilla treated with sinus inlay block bone grafts. MATERIALS AND METHODS: Seventeen patients were subjected to bone augmentation procedures prior to or in conjunction with implant placement. Bone volumes were regarded as insufficient for implant treatment unless a bone grafting procedure was performed. The patients were treated with sinus inlay block bone grafts and endosseous implants in a 1- or 2-stage procedure. A total of 69 implants were placed in the patients who were followed for 29 to 101 months (mean, 53.1 months). The retrospective patient group was also prospectively followed using a standardized clinical and radiographic study design. RESULTS: The implant survival rate was 91.3% (63/69). All implants were lost during the period from abutment connection to connection of the definitive prosthesis. All bone grafts were stable. Bone grafts supported 48 implants, of which 5 failed (10.4%). In the residual bone, 21 implants were placed, of which 1 failed (4.8%). All patients received a fixed partial prosthesis, which was stable during the follow-up period. CONCLUSION: The results of this investigation revealed a satisfactory clinical outcome of implant placement in grafted partially dentate maxillae after a mean follow-up of 53.1 months.     

Composite grafting of the maxillary sinus for placement of endosteal implants. A preliminary report of 48 patients.

The maxillary sinuses in 48 patients were grafted with dense, non-resorbable hydroxylapatite (HA) particles combined with autologous, cancellous bone. After 3 months of healing, HA-coated titanium endosteal implants were placed in the maxilla, and following an additional 3-5 month healing period, the dentitions were restored with various prostheses. Of the 267 maxillary implants placed, 18 (6.4%) failed. Thirteen (6.4%) of the 203 implants placed in the grafted floor of the sinus failed, and 5 (7.8%) of the 64 implants placed in the anterior maxilla failed. Simultaneous lateral and anterior onlay grafting of the alveolar process with the same composite graft material was required in 36 (75%) patients because the width of the alveolar process was considered insufficient for placement of endosseous implants. The mean follow-up period was 17 months (range 12-32). Results from this preliminary study indicate that composite grafting of the maxillary sinus with onlay grafting of the alveolar ridge will provide the bony structure necessary for placement of endosseous implants. Further follow-up of these patients is necessary to determine the long-term stability of this technique; however, these results are promising.     

Autogenous mandibular bone grafts and osseointegrated implants for reconstruction of the severely atrophied maxilla: a preliminary report

The purpose of this study is to present results obtained with a new procedure for reconstruction of the severely atrophied maxillary alveolar ridge that involves the use of intramembranous corticocancellous bone grafts obtained from the mandibular symphysis fixed to the residual bone by endosseous implants. A total of 107 implants were installed in grafted regions in 26 patients. The follow-up period ranged from 6 to 32 months, with a mean of 16 months. In partially edentulous patients the bone grafts were fixed with implants to the residual bone as 1) onlay graft to the alveolar ridge (8 implants in 4 patients); 2) grafts to the nasal and/or sinus floor after a transoral exposure and elevation of the mucosa of the maxillary sinus and/or the nasal mucosa (33 implants in 11 patients); or 3) a combination of these two (5 implants in 2 patients). In totally edentulous patients, implants and grafts were used as a combination of grafting to both the alveolar ridge and nasal and/or sinus floor sites (61 implants in 9 patients). One hundred of 107 implants showed normal clinical and radiologic healing, whereas 7 implants in 4 patients (6.5%) were lost prior to loading. Seventeen patients have had the implants and bone grafts loaded by a prosthodontic reconstruction from 6 to 26 months (mean, 14 months) without loss of any implants. Postoperative marginal resorption of the onlay bone graft of less than 15% was observed. These findings suggest, that the previously observed rapid resorption of endochondral iliac crest onlay bone grafts and the number of lost implants can be significantly reduced if bone from the mandibular symphysis firmly anchored with titanium implants is used.     

Stability Evaluation of Implants Integrated in Grafted and Nongrafted Maxillary Bone: A Clinical Study from Implant Placement to Abutment Connection

Background: Clinical studies have shown a higher degree of implant failures in grafted bone compared with normal nongrafted maxillary bone. Additionally, a prolonged time for integration of titanium implants in grafted block bone has been shown by means of resonance frequency analysis (RFA). Purpose: The aim of this prospective study was to compare the stability of implants placed in particulate bone, onlay block bone, interpositional bone, and nongrafted maxillary bone during the early phase of osseointegration using RFA and implant failure. Material and Methods: Thirty‐five patients with edentulism in the maxilla were included in the study. In all, 260 Astra Tech TiOblast? implants (Astra Tech AB, Mölndal, Sweden) were installed. Twenty‐five of these patients had severe maxillary atrophy and were treated with iliac bone grafts 5 to 6 months prior to implant placement, 19 with lateral onlay block grafts on one side (group A, 38 implants) and particulate bone for lateral augmentation on the other (group B, 38 implants). These 19 patients also got bilateral sinus floor augmentation with particulate bone (group C, 76 implants). Six patients had an unfavorable sagittal relation between the jaws and underwent a LeFort I operation with interpositional bone blocks grafted to the nasal and sinus floors (group D, 48 implants). The remaining 10 patients could be treated with implants without bone augmentation and served as control (group E, 60 implants). RFA was performed at implant placement and abutment connection 6 months later and an implant stability quotient (ISQ) value was given for each implant. Results: Four implants (1.5%) were found mobile at abutment connection and removed (two in group A and two in group D). RFA showed a slight increase in stability from installation to abutment connection but the differences were not statistically significant in any of the groups (Wilcoxon signed rank test for comparison of paired data). Implants installed in group D had a significantly lower ISQ value at both measurements compared with the other groups (Wilcoxon Rank Sum test for comparisons of independent samples, p = .05). Conclusion: It is concluded that TiO₂‐blasted implants placed in nongrafted and grafted maxillary bone using a two‐staged protocol show similar stability during the early phase of osseointegration. Patients reconstructed with interpositional bone graft after a LeFort I osteotomy showed lower implant stability values than nongrafted patients and other grafting techniques.     

A new porous hydroxyapatite for promotion of bone regeneration in maxillary sinus augmentation: clinical and histologic study in humans

PURPOSE: This study was undertaken to evaluate clinically, histologically, and immunohistochemically the use of a new porous hydroxyapatite (HA) (B. Agra, Cabon, Milan, Italy) as a grafting material for maxillary sinus augmentation with simultaneous implant placement. MATERIALS AND METHODS: A total of 28 titanium implants were placed in 12 patients with an average of 4.5 mm of bone on the sinus floor. HA granules were packed around the implants in the sinus cavity. After a healing period of 5 to 6 months, second-stage surgery was carried out. In 5 patients, bone cores were harvested from grafted areas and processed for histology and immunocytochemistry. RESULTS: All implants were clinically stable at second-stage surgery and were followed for an average of 3 years. The histology showed newly formed bone in direct contact with the HA granules. Immunohistochemistry showed the presence of large quantities of bone sialoprotein and osteopontin in and around the granules of HA. DISCUSSION AND CONCLUSION: This study suggests that a new porous HA accommodated sinus floor augmentation in patients with 3 to 5 mm of bone height preoperatively. By possibly attracting circulating biocomponents at sites of tissue repair, it may promote bone regeneration.     

Bone reformation and implant integration following maxillary sinus membrane elevation: an experimental study in primates

Background: Recent clinical studies have described maxillary sinus floor augmentation by simply elevating the maxillary sinus membrane without the use of adjunctive grafting materials. Purpose: This experimental study aimed at comparing the histologic outcomes of sinus membrane elevation and simultaneous placement of implants with and without adjunctive autogenous bone grafts. The purpose was also to investigate the role played by the implant surface in osseointegration under such circumstances. Materials and Methods: Four tufted capuchin primates had all upper premolars and the first molar extracted bilaterally. Four months later, the animals underwent maxillary sinus membrane elevation surgery using a replaceable bone window technique. The schneiderian membrane was kept elevated by insertion of two implants (turned and oxidized, Brånemark System®, Nobel Biocare AB, Göteborg, Sweden) in both sinuses. The right sinus was left with no additional treatment, whereas the left sinus was filled with autogenous bone graft. Implant stability was assessed through resonance frequency analysis (Osstell^TM, Integration Diagnostics AB, Göteborg, Sweden) at installation and at sacrifice. The pattern of bone formation in the experimental sites and related to the different implant surfaces was investigated using fluorochromes. The animals were sacrificed 6 months after the maxillary sinus floor augmentation procedure for histology and histomorphometry (bone‐implant contact, bone area in threads, and bone area in rectangle). Results: The results showed no differences between membrane‐elevated and grafted sites regarding implant stability, bone‐implant contacts, and bone area within and outside implant threads. The oxidized implants exhibited improved integration compared with turned ones as higher values of bone‐implant contact and bone area within threads were observed. Conclusions: The amount of augmented bone tissue in the maxillary sinus after sinus membrane elevation with or without adjunctive autogenous bone grafts does not differ after 6 months of healing. New bone is frequently deposited in contact with the schneiderian membrane in coagulum‐alone sites, indicating the osteoinductive potential of the membrane. Oxidized implants show a stronger bone tissue response than turned implants in sinus floor augmentation procedures.     

Brånemark and ITI dental implants in the human bone-grafted maxilla: a comparative evaluation

Abstract: The development of new characteristics concerning implant surface makes it interesting to clinically compare different implant systems in the bone‐grafted maxilla. The aim of this evaluation was to compare clinical data of a two‐staged procedure on the augmented extremely atrophic maxilla using either Brånemark‐ or ITI‐fixures. In 25 patients (18 females, seven males) the severely atrophied maxilla was reconstructed with autogenous iliac or mandibular bone and either Brånemark or ITI implants. Seventy‐eight Brånemark implants and 80 SLA‐ITI implants were inserted in the augmented bone and the patients were followed between 20 and 67 months post implantation. The bone graft was transplanted to add bony volume in the maxillary sinus, the anterior floor of the nose and/or the alveolar ridge. After a healing period of 4½ months, dental implants were inserted and left for healing for 8 months. Twelve consecutive patients received machine‐surfaced Brånemark fixtures and 13 consecutive patients received SLA‐ITI fixtures. Gradual loading was applied after healing abutment application. After 6 months the permanent prosthetic reconstruction was provided to the patient, either as a fixed or removable bridge. Comparison in survival rate was performed: 15 machined Brånemark fixtures were lost, resulting in an overall survival rate of 81%. Two ITI fixtures were lost, resulting in an overall survival rate of 98%. The results of this evaluation show that sandblasted large grit acid etched surface‐treated ITI implants has a significant higher survival rate than machine‐surfaced Brånemark implants in autogenous grafted maxillary bone.     

自体胫骨骨松质移植提升上颌窦与骨内牙种植

本文通过8例自体胫骨骨松质移植提升上颌窦的成功．认为上颌窦底自体胫骨骨松质移植对于解决上颌后区牙槽嵴萎缩、上颌窭与牙槽嵴接近而又需要进行骨内种植牙的病人提供了一种良好的方法。胫骨近中外上髁作为供骨区有明显的优点，可以获得质量高、数量较多的骨质．骨面与皮肤接近．创口小，并发症少。     

Bone grafting to the maxillary sinuses, nasal floor and anterior maxilla in the atrophic edentulous maxilla: A two-stage technique

This study presents the results from 20 consecutive patients treated with an autogenous bone graft from the iliac crest. In ten patients the graft was placed in the maxillary sinuses and the floor of the nose (inlay group). Ten patients, in addition to the inlay graft, had a corticocancellous bone block secured with mini-screws to the anterior maxillary ridge (inlay/onlay group). Endosteal implants (Brånemark^®) were placed six months after surgery. A total of 136 implants were placed, of which eight failed to integrate during the six-month healing period. A further 15 implants were lost during the follow-up period. For the inlay group the average follow-up period was 22 months and for the inlay/onlay group 19 months. Donor site morbidity was significantly less when iliac bone was harvested with a trephine (inlay group) than in patients treated with our routine procedure for bone harvesting (inlay/onlay group). Surgical technique, donor site morbidity, implant survival and patient acceptance are presented.     

Sinus lift grafts and endosseous implants. Treatment of the atrophic posterior maxilla.

Patients from multicenters were treated with sinus lift graft operations and placement of implants. Surgical procedures healed uneventfully with minimum pain, swelling, or morbidity. Grafts healed with few complications or failures. Implants placed into the grafts support prosthetic reconstruction and are predictable over time. The question of what graft material to use is discussed. Grafts of non-resorbable HA (Interpore 200), bovine cortical HA (Bio-Oss), resorbable HA (OsteoGen), and freeze-dried demineralized bone powder and granules are presented. Results of biopsy, histometry, backscattered electron microscopy, cell labeling, and special stain suggest consistent bone growth into a variety of graft materials. In the authors' opinion investigation must continue to 1. Determine the healing time for different graft materials. At present, anecdotal evidence suggests that sinus grafts of autogenous bone heal for 4 to 6 months; freeze-dried demineralized bone heals for 12 to 16 months; and alloplastic materials with freeze-dried demineralized bone heal for 9 to 11 months. 2. Evaluate histologic evidence of bone growth into different bone replacement graft materials. 3. Evaluate the long-term follow-up and success of implants placed within sinus grafts. 4. Determine the remodeling potential of different hard tissue graft materials under implant functional loads.     

自体植骨上颌窦底提升同期种植体植入术近期疗效观察

目的:评价自体骨开窗式上颌窦提升术对上颌后牙区牙槽骨高度严重不足(高度4～6mm)的患者种植治疗的近期疗效。方法:对4例上颌后牙骨量不足(高度4～6mm)而需种植修复的病例,实施自体植骨的开窗式上颌窦提升术,并同期植入种植体共9枚。自体移植骨来自种植窝制备时中空钻取骨,在需做牙槽嵴修整处的牙槽骨棘取骨,如不够再用刮骨器取骨或从颏部手术取骨,将所取之骨碾碎备用。结果:术后7个月拍片,均显示骨性愈合;冠修复后行使功能18～24个月效果理想。结论:自体取骨植骨用于上颌窦提升,可扩大种植手术适应证,降低种植成本。     

Dental implants placed in grafted maxillary sinuses: a retrospective analysis of clinical outcome according to the initial clinical situation and a proposal of defect classification

Objective of the study: To present a classification of maxillary defects necessitating sinus floor elevation procedures (SFEPs) with two objectives: (a) to propose a standardization of surgical procedures according to initial type of atrophy and (b) to allow the evaluation of the success/survival rates of implants placed in the grafted areas according to the initial situation. Materials and methods: Nine‐hundred and fifty‐two consecutive SFEP were performed on 692 patients. Initial defects were classified according to a new classification, which considered not only residual bone height below the sinus but also the width of the alveolar crest and horizontal/vertical intermaxillary relationship. Results were evaluated according to the different classes. The sinuses were grafted with autogenous bone taken from intra‐oral or extra‐oral sites: 579 SFEP were associated with vertical and/or horizontal onlay grafts to correct concomitant alveolar ridge deficits. A total of 2037 implants were inserted into the grafted sinuses either immediately or 4–6 months later. Three to 6 months afterwards, implants were loaded. The mean follow‐up was 59 months (range: 12–144 months). Results: The success rate of the reconstructive procedures varied between 93.2% and 100%, according to class of atrophy; the overall survival and success rates of implants were 95.8% and 92.5%, respectively, whereas the survival and success rates according to class of atrophy varied between 90% and 97.6%, and between 85.4% and 95.5%, respectively. Lower success rates were found in classes presenting with more severe atrophy. Conclusion: The results obtained demonstrated that sinus floor elevation, alone or in association with reconstructive procedures with autogenous bone grafts, is a reliable procedure to allow implant placement in atrophic edentulous maxillae, irrespective of the initial clinical situation. However, it must be underlined that the success rates of reconstructive procedures and implants differ according to class of atrophy, showing lower success rates in classes presenting with more severe atrophy.     

Stability of bone grafting and placement of implants in the severely atrophic maxilla

A severely atrophic maxilla can be restored by bone grafts to allow the insertion of implants. We present 30 consecutive patients treated with autogenous inlay and onlay bone grafts from the iliac crest to the floor of the maxillary sinus and the alveolar crest. A total of 200 implants were inserted 4-6 months after bone grafting. A mean vertical increase in bone thickness of 14mm was achieved. After a mean bone loss of 1.3mm during the first year after bone grafting only minimal resorption was observed during the second and third year. Seven implants failed to integrate and a further four implants were lost during follow-up.     

A prospective 1-year clinical and radiographic study of implants placed after maxillary sinus floor augmentation with bovine hydroxyapatite and autogenous bone.

PURPOSE: The purposes of this study were 1) to evaluate the survival rate of implants placed in maxillary sinuses augmented with bovine hydroxyapatite and autogenous bone 6 months before implant surgery and 2) to estimate dimensional changes of the bone graft with time using a new radiographic method. PATIENTS AND METHODS: Thirty maxillary sinuses in 20 consecutive patients with severe resorption (mean, 3.8 mm of remaining alveolar bone) were augmented with a mixture of 80% bovine hydroxyapatite and 20% autogenous bone mixed with fibrin glue to enable the placement of screw-shaped dental implants. After 6 months of primary healing, 108 implants were placed and followed with clinical and radiographic examinations during the first year of loading. Measurements of changes in height, width, and length of the grafted material were made on tomographic Scanora (Soredex Orion Corporation Ltd, Helsinki, Finland) and panoramic radiographs taken 3 and 12 months after grafting and after 1 year of bridge loading. RESULTS: Ten implants in 6 patients were lost during the study (9 before loading and 1 after 1 year of functional loading), for a survival rate of 90.7%. All patients received fixed restorations, and the bridge survival rate was 100% after 1 year of loading. Small (<10%) but statistically significant dimensional changes in the grafted material were seen during the study period. CONCLUSIONS: Acceptable short-term results can be obtained with implants placed after the use of bovine hydroxyapatite and autogenous bone for maxillary sinus floor augmentation. These grafts show good resistance to resorption.     

Particulate inlay nasal graft with immediate dental implant placement in a patient with repaired alveolar cleft: case report

Primary bone grafts in congenital cleft alveolus do not always provide sufficient bulk or height of bone for ideal placement of endosseous implants. Thus, maxillary sinus or nasal floor elevation and inlay bone grafts in previously grafted areas are not exceptions in the daily routine. This case report stresses the need of a detailed treatment plan and careful surgical management of nasal floor elevation with particulate autogenous bone graft to successfully provide the patient with osseointegrated prostheses.     

Clinical and histologic comparison of two different composite grafts for sinus augmentation: a pilot clinical trial

Background and objectives: Sinus augmentation is a procedure used for augmenting insufficient bone height that is often observed in the maxillary posterior areas. Many different techniques as well as bone graft regimens have been suggested for performing this procedure. It was the goal of this study to compare, clinically and histologically, two different composite grafting regimens used for sinus augmentation.
Material and methods: Five patients, needing a bilateral sinus augmentation to allow implant placement, were recruited for this study. Right sinuses were grafted with cortical bone (collected from overlying the sinus membrane) and bovine hydroxyapatite (HA), while the left side sinuses were grafted with overlying autologous bone plus a bioglass (BG) material. Bone core biopsies were taken at 6 months after sinus graft or at the time of implant insertion. A waiting period of 6 additional months was granted to allow healing, before prosthetic restoration and functional loading. The level of peri-implant bone was evaluated 12 months after loading. A comparative histomorphometric analysis was conducted and a statistical analysis was performed.
Results: All implants in both groups were functional after a 12-month loading period. No bone loss was observed radiographically or clinically in both groups. Histologic analysis revealed that both composite grafts had a high biocompatibility. In the bovine HA-containing group, minimal xenogenic graft absorption was noted. In contrast, BG group samples presented a high absorption rate with some remaining particles imbedded in new normal bone.
Conclusions: Sinus augmentation using a combination of autogenous bone plus either bovine HA or BG is a predictable technique.     

Sinus floor augmentation with bovine hydroxyapatite mixed with fibrin glue and later placement of nonsubmerged implants: a retrospective study in 50 patients

PURPOSE: The aim of the present study was to evaluate retrospectively both the results of using a mixture of bovine hydroxyapatite (BHA) and fibrin glue as the only grafting material in the floor of the maxillary sinus and the outcome of nonsubmerged implants placed later. MATERIALS AND METHODS: A total of 50 consecutive patients (71 maxillary sinuses) were augmented with a mixture of BHA and fibrin glue. The grafts were allowed to heal for a mean of 8 months prior to implant placement. A total of 218 solid titanium screw-type implants were placed in a nonsubmerged fashion and allowed to heal for a mean of 10 weeks before loading (range, 10 days to 10 months). The outcome of the placed dental implants was evaluated retrospectively. RESULTS: Twelve implants were lost, giving a cumulative survival rate of 94.5% after a mean loading time of 20 months (range, 6 to 42 months). DISCUSSION: This study shows that augmentation of the maxillary sinus with a BHA/fibrin glue mixture and later placement of nonsubmerged implants with short healing times preceding functional loading can be a predictable concept. However, the use of autogenous bone and placement of submerged implants in the grafts with long healing times is routine in many clinics. This article discusses the evidence on which this protocol is based. CONCLUSION: The short-term results from this retrospective clinical study indicated that BHA/fibrin glue can be used as a grafting material without autogenous bone in the maxillary sinus to produce a high survival rate for later placement of nonsubmerged implants.     

Sinus bone formation and implant survival after sinus membrane elevation and implant placement: a 1- to 6-year follow-up study

Objectives: To investigate the long‐term clinical and radiographic results of the maxillary sinus membrane elevation technique where implants were inserted in a void space created by the elevation of the sinus membrane without adding any graft material. Materials and methods: A total of 84 patients were subjected to 96 membrane elevation procedures and simultaneous placement of 239 implants. Changes of intra‐sinus and marginal bone height in relation to the implants were measured in intraoral radiographs taken at insertion, after 6 months of healing, after 6 months of loading and then annually. Computerized tomography was performed pre‐surgically and 6 months post‐surgically. Resonance Frequency Analyses measurements were performed at the time of implants placement, at abutment connection and after 6 months of loading. The implant follow‐up period ranged from a minimum of one to a maximum of 6 years after implants loading. Results: All implants were stable after 6 months of healing. A total of three implants were lost during the follow‐up period giving a survival rate of 98.7%. Radiography demonstrated on average 5.3±2.1 mm of intra‐sinus new bone formation after 6 months of healing. RFA measurements showed adequate primary stability (implant stability quotient 67.4±6.1) and small changes over time. Conclusion: Maxillary sinus membrane elevation and simultaneous placement of implants without the use of bone grafts or bone substitutes result in predictable bone formation with a high implant survival rate of 98.7% during a follow‐up period of up to 6 years. The intra‐sinus bone formation remained stable in the long‐term follow‐up. It is suggested that the secluded compartment allowed for bone formation according to the principle of guided tissue regeneration. The high implant survival rate of 98.7% indicated that the implants sufficiently supported the fixed bridges throughout the study period. This technique reduces the risks for morbidity related to harvesting of bone grafts and eliminates the costs of grafting materials. To cite this article:
Cricchio G, Sennerby L, Lundgren S. Sinus bone formation and implant survival after sinus membrane elevation and implant placement: a 1‐ to 6‐year follow‐up study.
Clin. Oral Impl. Res. 22 , 2011; 1200–1212.
doi: 10.1111/j.1600‐0501.2010.02096.x     

Demineralized perforated bone implants in craniofacial surgery.

Between July 1990 and September 1991, demineralized perforated allogeneic bone implants (Pacific Coast Tissue Bank, Los Angeles, CA) were placed in 72 patients. Because many patients received more than one implant, a total of 248 implants were used in 80 procedures. The technology of processing demineralized bone implants is described in detail. All patients were operated on by one surgeon (K.E.S.) at the Humana Craniofacial Institute in Dallas, Texas. Forty-one patients had craniofacial deformities, 16 had secondary deformities following cleft lip and palate repair, 8 had bony defects following removal of tumors, and 10 had various skeletal deformities following trauma. Of the 72 patients, 6 had two surgical procedures during which additional implants were inserted. Implants placed in the cranial vault and the maxillary complex, including alveolar grafts, were inlay grafts, whereas implants placed in the orbital, nasal, paranasal, temporal, and malar areas were onlay grafts used for contouring, augmentation, or both. Complications were limited to delayed wound healing in 6 patients. According to our observations, demineralized perforated bone implants represent an encouraging alternative to autogenous bone grafting. Further clinical and experimental studies are necessary to obtain more information about this material.