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 Bone

PIKOS
MICHAEL A. PIKOS received his DDS from The Ohio State

|
University College of Dentistry, after which he completed an
internship at Miami Valley Hospital and residency training in

BONE AUGMENTATION IN IMPLANT DENTISTRY

Oral & Maxillofacial Surgery at the University of Pittsburgh

Augmentation
Montefiore Hospital. He is a Diplomate of the American
Board of Oral and Maxillofacial Surgery, the American Board
of Oral Implantology/Implant Dentistry, and the Interna-
tional Congress of Oral Implantologists and a Fellow of the
American College of Dentists. He is also an adjunct assistant

Implant
professor in the Department of Oral & Maxillofacial Sur-
gery at The Ohio State University College of Dentistry and
Nova Southeastern University College of Dental Medicine. Graft Window IN
Dr Pikos is on the editorial boards of several journals and

Dentistry
is a well-published author who has lectured extensively on
dental implants in North and South America, Europe, Asia,
and the Middle East. He is the founder and CEO of the Pikos
Institute. Since 1990, he has been teaching advanced bone
and soft tissue grafting courses with alumni that now number
more than 3,400 from all 50 states and 43 countries. Dr Pikos

MICHAEL A. PIKOS,
maintains a private practice limited exclusively to implant
surgery in Trinity, Florida (www.pikosinstitute.com). dds
with Richard J. Miron, dds, msc, phd
Sinus Augmentation

Extraction Site

ISBN 978-0-86715-825-0
90000>

9 780867 158250 A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting

Pikos Cover-AsiaPacific.indd 1 5/31/19 12:12 PM

 Bone Augmentation in Implant Dentistry:
A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting

Pikos_FM.indd 1 5/31/19 11:33 AM

Pikos_FM.indd 2 5/31/19 11:33 AM
 Bone
Augmentation
IN Implant
Dentistry
MICHAEL A. PIKOS, dds
Founder and CEO
Pikos Institute
Private Practice
Trinity, Florida

with RICHARD J. MIRON, dds, msc, phd

Group Leader, The Miron Research Lab
Lead Educator, Advanced PRF Education
Venice, Florida

A Step-by-Step Guide to Predictable Alveolar Ridge and Sinus Grafting

Berlin, Barcelona, Chicago, Istanbul, London, Mexico City, Milan,

Moscow, Paris, Prague, São Paulo, Seoul, Tokyo, Warsaw

Pikos_FM.indd 3 5/31/19 11:33 AM

 Library of Congress Cataloging-in-Publication Data

Names: Pikos, Michael A., author. | Miron, Richard J. (Richard John),

1983-
author.
Title: Bone augmentation in implant dentistry / Michael A. Pikos and
Richard J. Miron.
Description: Batavia, IL : Quintessence Publishing Co Inc, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2019005043 | ISBN 9780867158250 (hardcover)
Subjects: | MESH: Alveolar Ridge Augmentation--methods | Bone
Regeneration | Bone Transplantation | Dental Implantation--methods
Classification: LCC RK667.I45 | NLM WU 640 | DDC 617.6/93--dc23
LC record available at https://lccn.loc.gov/2019005043

97%

©2019 Quintessence Publishing Co, Inc

Quintessence Publishing Co Inc

411 N Raddant Rd
Batavia, IL 60510
www.quintpub.com

5 4 3 2 1

All rights reserved.This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Editor: Leah Huffman

Design: Sue Zubek
Production: Angelina Schmelter

Printed in China

Pikos_FM.indd 4 5/31/19 11:33 AM

 Contents
Preface vi

INSTRUMENTATION FOR ALVEOLAR RIDGE

1 AUGMENTATION AND SINUS GRAFTING 1

MEMBRANES, GRAFTING MATERIALS,

2 AND GROWTH FACTORS 11

3 EXTRACTION SITE MANAGEMENT 41

4 ALVEOLAR RIDGE AUGMENTATION 95

5 SINUS GRAFTING 169

6 GUIDED FULL-ARCH IMMEDIATE-FUNCTION

TREATMENT MODALITY FOR THE EDENTULOUS
AND TERMINAL-DENTITION PATIENT 235

Index 258

Pikos_FM.indd 5 5/31/19 11:33 AM

 6:Guided Full-Arch Immediate-Function Treatment Modality for the Edentulous and Terminal-Dentition Patient

Preface
Implant dentistry has evolved tremendously over the past regeneration. Chapter 2 presents barrier membranes, bone
three decades and is rapidly progressing as new materials grafting materials, as well as growth factors utilized for bone
and protocols become available. While biomaterials and augmentation procedures and describes their biologic back-
clinical guidelines were once believed to turn over every ground and clinical use in implant dentistry.
3 to 5 years, new advancements are now being brought to Chapter 3 is the first surgical chapter and is dedicated to
our field every year. Today, implant dentistry is perhaps the extraction socket management. A brief overview of dimen-
most widely researched discipline in our field and mandates sional changes occurring postextraction is presented, and there-
that clinicians stay updated on current trends and protocols. after clinical guidelines with step-by-step protocols are covered.
With the number of advancements made in digitally based Discussion of the use of various biomaterials and their ability
media and marketing, it is imperative that the clinician be able to minimize dimensional changes postextraction in both the
to separate new trends from evidence-based protocols. It is esthetic and nonesthetic zones is provided. Furthermore, proto-
without question that the goal of every clinician is that each cols for ridge preservation in the absence of buccal/lingual
patient be treated with the best possible outcome in mind. As plates are included as well as an introduction to the concept
such, we should strive to implement rational evidence-based and clinical indication for “socket shield” therapy.
decisions grounded on available literature to allow us to make Chapter 4 covers the topic of alveolar ridge augmentation.
sound and predictable choices.The goal of this textbook is to Specific indications and a description of patient selection
share my clinical experiences, both successes and failures, with criteria, step-by-step surgical procedures, and aspects of
my colleagues to facilitate learning through documented cases postoperative treatment are presented. This chapter also
that I have performed over the past 35+ years. includes background information on guided bone regener-
To accomplish this, this textbook has been separated into six ation, intraoral bone harvesting techniques, horizontal and
core chapters. Each clinical case is supplemented with italicized vertical alveolar ridge augmentation procedures in maxil-
personal notes describing learned experiences from each case, lary/mandibular posterior and anterior regions, ridge split
clinical tips and pearls from that case, technical notes geared techniques, and vestibuloplasty. The numerous complica-
toward facilitating the reader’s clinical ability to perform simi- tions faced during any of the above-mentioned procedures
lar cases/techniques, as well as in-depth analysis and critical are also discussed with solutions to such encounters.
evaluation on how I would perform each case today (many Chapter 5 focuses on sinus grafting. First, the history of
of the cases were performed 10+ years ago).Two chapters are sinus grafting is presented with an overview of anatomical
dedicated to biomaterials and instruments utilized for bone considerations. Clinical and radiographic assessment is then
augmentation protocols and form the basis for the bioma- considered with detailed discussion of the lateral window
terials and surgical instrumentation utilized throughout the versus crestal protocol utilized for specific clinical indica-
surgical chapters. It is clear that the number of changes made tions. Emphasis in this chapter includes instrumentation for
in material design/instrumentation has facilitated (and in many sinus grafting, incision design and flap management, graft
cases improved) the ability of clinicians to perform surgical selection and placement, the use of osseodensification tech-
procedures. Parallel to this and equally as important, a great nology, as well as protocols for sinus membrane repair. Both
deal of advancement has been made in biomaterial sciences. one- and two-stage protocols are discussed with cases shown
While biomaterials were once considered to act as a passive for single-tooth, multiple-tooth, and fully edentulous arches.
structural material aimed at filling voids, today they act as bioac- The final section of this chapter covers numerous potential
tive molecules responsible for rapidly stimulating new tissue complications faced during sinus grafting and their resolution.

vi

Pikos_FM.indd 6 5/31/19 11:33 AM

 Guided Full-Arch Immediate-Function Treatment Modality For the Edentulous and Terminal-Dentition Patient 235

Lastly, chapter 6 covers full-arch reconstruction utilizing remains difficult to assess and scientifically critique many of
conventional conversion protocols and newer fully guided these newer protocols without proper long-term follow-up.
immediate-reconstruction protocols in a detailed step-by- Having practiced implant dentistry for more than 35 years,
step manner utilizing the nSequence patented technology. I consider follow-up times of 1 year, 5 years, and 10 years to
My hope is that through the numerous cases presented be immeasurably important. This book focuses exclusively
throughout this textbook, clinicians will be better able to on the protocols that have been developed over numerous
implement evidence-based clinical decisions that will lead years with established long-term follow-ups to provide the
to predictable bone augmentation results and long-term reader with a set of surgical guidelines and principles with
success.We live in an age where information can be obtained predictable long-term documented outcomes. Furthermore,
through social media at an ever-increasing speed. Clinicians an online video series available at www.pikosonline.com will
are now free to post cases directly to social media following supplement the book to further guide the clinician with
surgery and obtain nearly live feedback on their work. This surgical demonstrations provided within our online teaching
provides the clinician and reader with direct responses to library. I sincerely hope that these videos in conjunction with
their surgical work; however, with the number of new tech- the content of this book will provide an enjoyable learning
niques and protocols being utilized and promoted online, it experience, and I look forward to your future feedback.

Acknowledgments My fellow clinicians and staff whom I have had the honor
of working with during my 36 years of private practice.
Although the acknowledgments are typically found in the The thousands of clinicians whom I have had the honor
first pages of a book, they are usually the last piece to be and privilege to meet both at my Institute and from main
written. And for good reason, as they allow the author to podium lectures throughout the world.
reflect on those individuals who have contributed in one The thousands of patients for entrusting me with their
way or another to its completion. implant surgical care over all these years.
For the development and production of this book, I owe Rick Miron, an awesome, highly intelligent, yet so humble
a deep sense of gratitude to the following people: colleague and friend without whose help this book would
My incredible and selfless wife Diane, daughter Lindsey, and definitely not be possible.
son Tony for sacrificing our time together and for their uncon- The entire team at Quintessence Publishing, including
ditional love, support, and encouragement during all these years. Leah Huffman (Senior Editor), Angelina Schmelter (Digital
My beloved mother Mary, and to the joyous memory & Print Production Specialist), Bryn Grisham (Director of
of my father Anthony, both of whom provided for me a Book Publications), and especially William Hartman (Execu-
sound spiritual-based and loving environment with solid tiveVice President & Director).This book certainly has been
core values from which to grow. improved many times over, and I thank each of you for your
The many teachers and mentors who have so impacted dedication, patience, and helpfulness leading to its completion.
my life and career, with special thanks to Carl Misch, Tom And Almighty God for blessing me with a profession that
Golec, Leonard Linkow, Hilt Tatum, P.D. Miller, and Pat Allen. I have had such great passion for, and more importantly for
My Institute team—Alison Thiede, Kali Kampmann, giving me the skill sets necessary to help transform people’s
Mark Robinson, and Roger Hemond—for their uncon- lives on a daily basis.
ditional commitment to excellence.

vii

Pikos_FM.indd 7 5/31/19 11:33 AM

 chapter 1

Instrumentation
for
Alveolar Ridge
Augmentation and
Sinus Grafting

Pikos_CH01.indd 8 5/31/19 11:35 AM

 T
he use of various instruments for alveolar bone
augmentation and sinus grafting has played a pivotal
role in modern regenerative dentistry. Many tools
such as cone beam computed tomography (CBCT)
have greatly improved the clinician’s ability to diagnose and
treatment plan cases with optimal accuracy and predictability
in implant dentistry. Other devices such as Osstell’s implant
stability quotient (ISQ) tool can be utilized to accurately
monitor implant stability over time. Furthermore, radio-
frequency, Piezosurgery (Mectron), and osseodensification
(OD) burs have greatly improved surgical outcomes for the
clinician. This chapter provides an overview of the various a
instruments most frequently utilized by the author on a daily
basis within his private practice and institute. Furthermore, a Fig 1-1 (a) CBCT imaging
brief overview of their technologies and uses in alveolar ridge system (Carestream [CS]
augmentation and sinus grafting is presented. 9600). (b) Notice the capa-
bility to create 3D recon-
structions of bone and teeth
with excellent resolution.

CBCT
In the last decade, the use of 3D CBCT has dramatically
increased.1,2 When computed tomography was first intro-
duced (mainly in implantology), its use was limited to a small
number of specialists, due primarily to its limited indications,
high costs, and elevated dose of radiation. In the late 1990s,
a new technology using a “cone beam” and a reciprocat-
ing detector, which rotates around the patient 360 degrees,
entered the dental implant field, making high-definition 3D
scans easily accessible to dentists and their patients. b
By 2005, I began utilizing CBCT technology in my own
private practice and teaching institution. Because my prac- dentoalveolar structures led to its more frequent use owing
tice has been limited to implant reconstruction for the past to its higher safety standards. Today, all patients within my
25 years, I require ALL of my patients to have a CBCT scan, practice requiring implant dentistry or bone augmenta-
as this 3D technology plays an integral role in overall diag- tion procedures must have a CBCT image taken prior to
nosis and treatment planning. CBCT has seen widespread implant therapy, bone augmentation, or sinus augmentation
use in all fields of dentistry, including implantology, oral in order to fully characterize anatomical features/abnor-
surgery, endodontics, and orthodontics.1,2 malities and diagnose potential pathology. Furthermore,
One of the major breakthroughs in CBCT technology the use of CBCT for postgraft evaluation prior to implant
was the ability to use significantly smaller doses of radia- placement has become routine.
tion when compared to conventional films.1,2 The estab- Carestream Dental provides a high-quality CBCT system
lishment of sensitive radiographic techniques for assessing with state-of-the-art features3 (Fig 1-1). Advantages of the

Pikos_CH01.indd 1 5/31/19 11:35 AM

 1:Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting

Fig 1-2 CS 9600 used to image a full-

arch case. (a) Notice that a single scan
can be useful to identify pathologies
with much greater accuracy than with
a conventional 2D radiograph. (b)
Fur thermore, the beauty of the CS
9600 is its capability to combine full-
head facial features into the program for
better treatment planning.

system include the ability to perform all necessary exam- the leaders in the field, and together we have codeveloped
inations with one system (CS 9600 family). Image reso- many specific trays for implant surgery (Fig 1-3), soft tissue
lution can reach up to 75 μm (sizes up to 16 × 17 cm), grafting (Fig 1-4), block grafting (Fig 1-5), and sinus grafting
ideal for a wide range of applications from implantology to (Fig 1-6). Each kit contains various useful instruments that
oral surgery, orthodontics, and endodontics (Fig 1-2).These have assisted our team in surgery.
features will only further improve over time. Low-dose Nevertheless, each instrument must be chosen according
imaging modes are also possible with 3D image quality, to the treating surgeon’s preference. For example, one instru-
utilizing lower doses of radiation when compared to tradi- ment used specifically when dealing with full-arch cases is
tional panoramic radiographs. Box 1-1 provides a list of the right-angle torque wrench (Salvin AccessTorq Right
relevant features of the system. AngleVariable Torque Driver), with adjustable Ncm features
from 10 to 35 Ncm (Fig 1-7). This instrument is valuable
for hard-to-reach areas. Another tool frequently utilized in
large bone augmentation procedures is the Pro-fix Preci-
Hand Instruments sion Fixation System (Osteogenics).4,5 This system includes
self-drilling membrane fixation screws, self-drilling tent-
Hand instruments are widely utilized within any dental office, ing screws, and self-tapping bone fixation screws (Fig 1-8),
with various companies now promoting sales of their indi- shown in a number of bone augmentation procedures in
vidual items. Salvin Dental has been recognized as one of chapter 4.

Pikos_CH01.indd 2 5/31/19 11:35 AM

 Hand Instruments

Box 1-1 Features of the CS 9600 system

3D modality Cephalometric modality

Technology: Dental volumetric reconstruction Sensor technology: CCD
Sensor technology: CMOS Exposure time: 0.1–3.2 seconds
Volume field of view (cm): 4×4, 5×5, 5×8, 6×6, 8×5, 8×8, 10×5, Radiologic examination options: Lateral, frontal
10×10, 12×5, 12×10, 16×6, 16×10, 16×12, 16×17 AP or PA, oblique, submentovertex, carpus
Gray scale: 16,384; 14 bits Acquisition format size (cm): 18×18, 18×24, 24×24,
Magnification: 1.4 24×30, 30×30
Voxel size: 75 μm minimum
X-ray generator and other specifications
Exposure time: 5.5–40 seconds (2 × 20 s)
Tube voltage: 60–90 kV
Scan mode: Continuous
Tube current: 2–15 mA
Panoramic modality Frequency: 140 kHz
Sensor technology: CMOS Tube focal spot: 0.3 or 0.7 mm
Image field (mm): 6.4×140 (for adult patient), 6.4×120 (for
child patient), 120×140 (for sinus one-shot examination)
Magnification: 1.28
CMOS, complementary metal oxide semiconductor;
Exposure time: 0.5–13 seconds CCD, charge-coupled device; AP, anteroposterior; PA, posteroanterior.

Fig 1-3 The Pikos implant surgical kit: Quinn Type Periosteal Elevator, 2 Fig 1-4 The Pikos soft tissue grafting instrumentation kit: UNC Perio Probe,
Minnesota Retractors, Jacobson Long Castroviejo Needle Holder, Seldin Frazier 3mm Surgical Aspirator, Siegel Round Scalpel Handle, Handle For
Retractor, Dean Scissor, Siegel Round Scalpel Handle, Adson 1×2 Tissue Bendable Micro Blades, Bendable Micro Blades–Nordland #69 (Box of 6),
Forceps, Adson Serrated Tissue Forceps, Gerald Micro Surgical Tissue Quinn Type Periosteal Elevator, Adson 1×2 Tissue Forceps, Adson Serrated
Forceps–Serrated, Gerald Micro Surgical Tissue Forceps–1×2, Kelly Curved Tissue Forceps, Gerald Micro Surgical Tissue Forceps–Serrated, Gerald
Hemostat, Crile-Wood Needle Holder, Castroviejo Micro Scissors–Curved, Micro Surgical Tissue Forceps–1×2, Rhodes Chisel, Gracey 11/12 Curette,
Periotome Straight, Molt Mouth Gag, Weider Tongue Retractor, Castroviejo Kelly Curved Hemostat, Corn Plier, Crile-Wood Needle Holder, Dean
Caliper, Friedman Rongeur, 10×6 Instrument Cassette, 10×6 Instrument Scissor, Micro Needle Holder, Castroviejo Micro Scissors, 10×6 Instrument
Deep Cassette. (Courtesy of Salvin Dental.) Cassette, 10×6 Instrument Deep Cassette. (Courtesy of Salvin Dental.)

Pikos_CH01.indd 3 5/31/19 11:35 AM

 1:Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting

Fig 1-5 The Pikos bone block grafting instrumentation kit: Tatum “D” Fig 1-6 The Pikos sinus elevation kit: Set of 5 Sinus Curettes (#1, #5, Freer,
Shaped Spreader #3,Tatum “D” Shaped Spreader #4, 6mm Cottle Curved Pikos #7, Pikos #8), Graft Material Packer–Double Ended, Bone Spoon /
Chisel, 6mm Sheehan Straight Chisel, Pikos Ramus Retractor, Quinn Type 4mm Graft Packer Combination, Stainless Steel Organizing Cassette. (Cour-
Periosteal Elevator, Siegel Round Scalpel Handle, Castroviejo Caliper–Short, tesy of Salvin Dental.)
Pikos Block Grafting Bur Kit, 1.5mm Wire Passing Bur, Stainless Steel Orga-
nizing Cassette. (Courtesy of Salvin Dental.)

Fig 1-8 The Pro-fix Precision

Fixation System is manufac-
tured to precise tolerances to
ensure easy pickup of screws,
stable transfer to the surgical
site, and quick engagement in
cor tical bone. (Cour tesy of
Osteogenics.)

Fig 1-9 The Osstell IDx is a

fast, noninvasive, and easy-to-
use system to determine
implant stability and assess
osseointegration. It provides
accurate, consistent, and objec-
tive information needed to
Fig 1-7 Right-angle torque
assess when implants may be
wrench with adjustable Ncm
loaded. (Courtesy of BioHori-
features from 10 to 35 Ncm.
zons.) Note: I utilize Osstell
(Courtesy of Salvin Dental.)
te chnology primarily in
delayed loading implant
cases. This gives me a frame of
reference at the time of
implant placement compared
to the time of loading. My goal
is for an ISQ value of 65 or
higher after an appropriate
healing time.
4

Pikos_CH01.indd 4 5/31/19 11:35 AM

 Radiosurgery Device

Fig 1-10 The Surgitron Dual 120

surgical device (Ellman Interna-
tional), utilized to cauterize blood
vessels during surgery.

Osstell IDx
The value of the Osstell system is that it helps clinicians
objectively determine implant stability and assess the
progress of osseointegration6–12 (Fig 1-9), with many peer-
reviewed research articles supporting its use. It is a fast, easy,
and reliable way to provide accurate and objective informa-
tion needed to proceed with implant loading. My cases are
routinely tested for ISQ values to assess implant stability. ISQ
values may potentially reduce treatment time, better manage
risk, and offer an ability to better communicate findings
with patients. The Osstell system allows for the quick and
easy identification of which implants are ready for loading
and which need additional healing time in an objective way,
with hundreds of publications now supporting its use.6–14 Fig 1-11 Use of the Ellman Surgitron device to cauterize a blood vessel
following flap elevation.

Fully rectified waveform

Radiosurgery Device
• Produces an incision with concurrent coagulation
A radiosurgical energy source (Fig 1-10) delivers advanced • Allows increased visibility due to enhanced coagulation
radiowave technology and provides outstanding surgical
control, precision, and versatility.15,16 Unlike lasers, the high
Partially rectified waveform
frequency of the 4-MHz Surgitron Dual 120 surgical device
minimizes heat dissipation, and thus cellular alteration, while • Strictly a coagulating waveform
cutting and coagulating soft tissues.Approximately 50 watts of • Used in areas of bleeding or oozing
power is utilized with the ability to micro-coagulate pinpoint
locations.This favors minimal charring or tissue necrosis and
Bipolar radiosurgery
is ideal for the oral maxillofacial region with critical anatomy.
Advantages include reduced postoperative discomfort and • Bipolar electrodes coupled with a radiosurgical wave form.
minimal scar formation. Typical radiosurgery systems come • Higher radiofrequency of 4 MHz versus bipolar electro-
with the following four waveforms. surgical signal of 1.8 MHz.
• Research has shown that high-frequency radiosurgery
produces less tissue alteration and lateral heat to the
Fully rectified filtered waveform
surrounding tissue than does the low-frequency elec-
• Used for performing deep surgical incisions. trosurgical signal (Fig 1-11).
• Waveform mimics the cut of a scalpel blade with only • The bipolar componentry of radiosurgery is a must for
minimal coagulation. clinicians involved with implant surgery. This is true
• When used with a varied-tip straight-wire electrode, because it allows for cauterization in the presence of
produces the most delicate of incisions. body fluids (blood and saliva).

Pikos_CH01.indd 5 5/31/19 11:36 AM

 1:Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting

Fig 1-12 Mectron’s Piezosurgery

device. Its patented technology
allows for the precise cutting of
alveolar bone while minimizing
the risk of soft tissue injury.

Fig 1-13 The Piezosurgery handpiece is a

Piezo-ceramic
Insert tip Concentrator rings Resonator Generator high-frequency electrical impulse from the
console to the ceramic disks. The electricity
induces mechanical deformations of the
ceramic disks, which are transferred to the
insert to generate a micrometric cutting action.
The micrometric movement is approximately
80 µm in the horizontal amplitude and 5 µm
in the vertical direction.
5 µm 80 µm
Mechanical dipole

Piezosurgery Device direction (Fig 1-13).The device comes with more than 100
different tips characterized by their ability to seamlessly and
One of the most widely utilized new tools in implant efficiently cut bone all while being capable of differentiat-
dentistry over the past decade has been the Piezosurgery ing between hard and soft tissues.These features have been
device (Fig 1-12). More specifically, Mectron’s dual-wave demonstrated to decrease the risk of damage to important
technology has been frequently cited owing to its patented anatomical structures such as nerves and membranes. Piezo-
technology overcoming the limitations of single wave.17 surgery has been shown to clinically lower the rate of sinus
Work pioneered by Professor Tomaso Vercellotti in Italy membrane perforations and has also been frequently utilized
demonstrated that a primary wave between 24 and 36 kHz during ridge split procedures and harvesting of bone blocks
modulated by a secondary low-frequency wave from 30 to (Fig 1-14). The author utilizes piezosurgical technology on
60 Hz could be utilized to efficiently maximize bone cutting a daily basis for a variety of bone-based surgical procedures
while preventing overheating and necrosis.18–21 The Piezo- that include but are not limited to the following: sinus graft-
surgery handpiece is therefore a high-frequency electrical ing, ridge splitting, harvesting autogenous bone blocks, and
impulse unit with micrometric movement of approximately recipient site preparation for bone grafts.
80 µm in the horizontal amplitude and 5 µm in the vertical

Pikos_CH01.indd 6 5/31/19 11:36 AM

 Versah Burs

a b
Fig 1-14 (a and b) Use of a Piezosurgery device to harvest a symphysis bone block.

Fig 1-15 Group of 12 OD burs (Versah) utilized during crestal sinus augmentation procedures to compact bone.

Versah Burs Bone has long been considered an ideal tissue in the
body because it is flexible, changing shape via deformation
The use of OD burs has also substantially improved our (without necessarily breaking/cracking), can withstand and
ability to obtain primary stability in low-density bone (Fig widen during compression, and is able to lengthen during
1-15).The biomechanical stability of implants has typically tension.23
been dependent on several factors, including implant macro Bone is typically prepared prior to implant placement
and micro design as well as the quality and quantity of utilizing standard drill burs. Because fresh, hydrated trabecu-
surrounding bone.22 Several protocols have been identified lar bone is a ductile material, it has a good capacity for plastic
to increase implant primary stability over the years: deformation. Osseodensification is essentially a burnishing
process that redistributes bone material on the bony surface
• Drilling protocol: underpreparation of osteotomy through plastic deformation.The counterclockwise rotation
• Implant type: macrotexture and microtexture of OD burs causes the lands of the bur to slide across the
• Longer implants providing greater bone-to-implant surface of the bone via low plastic deformation; these burs
contact (BIC) are purposefully designed with a compressive force less than
• Techniques for osseocondensation of bone the ultimate strength of bone. As a result, OD burs have

Pikos_CH01.indd 7 5/31/19 11:36 AM

 1:Instrumentation for Alveolar Ridge Augmentation and Sinus Grafting

SD ED OD

Fig 1-17 Clinical use of OD burs during a sinus augmentation proce-

dure with minimal residual bone height.

Fig 1-16 Results from a preclinical study demonstrating the

capability of OD to densify bone when utilized correctly. (a)
Surface view of 5.8-mm standard drilling (SD), extraction drill-
ing (ED), and OD osteotomies. (b and c) Microcomputed
tomography midsection and cross section. Notice the layer of
dense bone produced on the outer surface of the OD group.
(Reprinted with permission from Huwais and Meyer.24)

several reported advantages. First, they create live, real-time laterally compresses bone during the continuously rotating
haptic feedback that informs the surgeon if more or less and concurrently advancing bur. This facilitates “compaction
force is needed, allowing the surgeon to make instanta- autografting” or “osseodensification.” During this process,
neous adjustments to the advancing force depending on the bone debris is redistributed up the flutes and is pressed into
given bone density.These burs rotate in a counterclockwise the trabecular walls of the osteotomy24 (Fig 1-16).The auto-
direction and do not “cut” as expected with conventional grafting supplements the basic bone compression, and the
burs. They therefore densify bone (D3, D4) by rotating in condensation effect acts to further densify the inner walls
the noncutting direction (counterclockwise at 800–1,200 of the osteotomy.25 Trisi et al were one of the first to study
rotations per minute). It has been recommended by the the OD technique in an animal model.25 It was found that
manufacturer that copious amounts of irrigation fluid be OD burs increased the percentage of bone density/BIC
used during this procedure to provide lubrication between values around dental implants inserted in low-density bone
the bur and bone surfaces and to eliminate overheating. compared with conventional implant drilling techniques25
OD burs have been shown to produce compression waves, (Fig 1-17).These burs are highlighted primarily in chapter
where a large negative rake applies outward pressure that 5 under sinus augmentation procedures.

Pikos_CH01.indd 8 5/31/19 11:36 AM

 References

Conclusion 7. Shin SY, Shin SI, Kye SB, et al.The effects of defect type and depth, and
measurement direction on the implant stability quotient (ISQ) value. J
Oral Implantol 2015;41:652–656.
The use of novel instruments has facilitated the ability of 8. Yoon HG, Heo SJ, Koak JY, Kim SK, Lee SY. Effect of bone quality and
the clinician to perform more predictable and accurate bone implant surgical technique on implant stability quotient (ISQ) value. J
augmentation and sinus grafting.Today, the use of CBCT has Adv Prosthodont 2011;3:10–15.
9. Baldi D, Lombardi T, Colombo J, et al. Correlation between insertion
been shown to markedly improve diagnostics and treatment torque and implant stability quotient in tapered implants with knife-
planning in implant dentistry, and it is something I consider edge thread design. Biomed Res Int 2018;2018:7201093.
a necessity and standard for the field. In addition to hand 10. Bruno V, Berti C, Barausse C, et al. Clinical relevance of bone density
instruments that have been utilized and further refined over values from CT related to dental implant stability:A retrospective study.
Biomed Res Int 2018;2018:6758245.
the years, new instrumentation has become available. This 11. Buyukguclu G, Ozkurt-Kayahan Z, Kazazoglu E. Reliability of the
includes but is not limited to radiosurgery, Piezosurgery, Osstell implant stability quotient and Penguin resonance frequency
Osstell ISQ implant stability devices, and OD burs, all of analysis to evaluate implant stability. Implant Dent 2018;27:429–433.
which can be utilized on a routine basis for alveolar ridge 12. Nakashima D, Ishii K, Matsumoto M, Nakamura M, Nagura T. A study
on the use of the Osstell apparatus to evaluate pedicle screw stability:An
augmentation and sinus grafting in implant dentistry.While in-vitro study using micro-CT. PLoS One 2018;13:e0199362.
their introduction was brief in this chapter, their use is 13. Balleri P, Cozzolino A, Ghelli L, Momicchioli G, Varriale A. Stability
further highlighted in the clinical chapters of this textbook. measurements of osseointegrated implants using Osstell in partially
edentulous jaws after 1 year of loading:A pilot study. Clin Implant Dent
Furthermore, as the field continues to advance rapidly,
Relat Res 2002;4:128–132.
new devices will certainly be brought to market in the 14. Sim CP, Lang NP. Factors influencing resonance frequency analysis
coming years. For a current list of the tools and instruments assessed by Osstell™ mentor during implant tissue integration: I. In-
utilized for alveolar ridge augmentation in my practice and strument positioning, bone structure, implant length. Clin Oral Implants
Res 2010;21:598–604.
guidelines for their use, a detailed and up-to-date description 15. Sherman JA. Oral Radiosurgery: An Illustrated Clinical Guide, ed 2.
is provided at www.pikosonline.com. London: Martin Dunitz, 1997.
16. Sharma S, Gambhir R, Singh S, Singh G, Sharma V. Radiosurgery in
dentistry: A brief review. Ann Dent Res 2014;2:8–21.
17. Vercellotti T, Nevins ML, Kim DM, et al. Osseous response following

References
resective therapy with Piezosurgery. Int J Periodontics Restorative Dent
2005;25:543–549.
18. Vercellotti T, De Paoli S, Nevins M.The piezoelectric bony window
1. Scarfe WC,Angelopoulos C (eds). Maxillofacial Cone Beam Computed osteotomy and sinus membrane elevation: Introduction of a new tech-
Tomography: Principles, Techniques and Clinical Applications. New nique for simplification of the sinus augmentation procedure. Int J
York: Springer, 2018. Periodontics Restorative Dent 2001;21:561–567.
2. Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed 19. Vercellotti T. Piezoelectric surgery in implantology: A case report—A
tomography in implant dentistry: The International Congress of Oral new piezoelectric ridge expansion technique. Int J Periodontics Re-
Implantologists consensus report. Implant Dent 2012;21:78–86. storative Dent 2000;20:358–365.
3. Ludlow J,Timothy R,Walker C, et al. Effective dose of dental CBCT—A 20. Vercellotti T, Nevins ML, Kim DM, et al. Osseous response following
meta analysis of published data and additional data for nine CBCT units. resective therapy with piezosurgery. Int J Periodontics Restorative Dent
Dentomaxillofac Radiol 2014;44:20140197. 2005;25:543–549.
4. Urban I, Jovanovic SA, Buser D, Bornstein MM. Partial lateralization of 21. Vercellotti T, Pollack AS. A new bone surgery device: Sinus grafting and
the nasopalatine nerve at the incisive foramen for ridge augmentation in periodontal surgery. Compend Contin Educ Dent 2006;27:319–325.
the anterior maxilla prior to placement of dental implants: A retrospec- 22. Meyer U,Vollmer D, Runte C, Bourauel C, Joos U. Bone loading pat-
tive case series evaluating self-reported data and neurosensory testing. tern around implants in average and atrophic edentulous maxillae: A
Int J Periodontics Restorative Dent 2015;35:169–177. finite-element analysis. J Craniomaxillofac Surg 2001;29:100–105.
5. Chan HL, Benavides E,Tsai CY,Wang HL.A titanium mesh and partic- 23. Seeman E. Bone quality: The material and structural basis of bone
ulate allograft for vertical ridge augmentation in the posterior mandible: strength. J Bone Miner Metab 2008;26:1–8.
A pilot study. Int J Periodontics Restorative Dent 2015;35:515–522. 24. Huwais S, Meyer EG.A novel osseous densification approach in implant
6. Herrero-Climent M, Santos-García R, Jaramillo-Santos R, et al. osteotomy preparation to increase biomechanical primary stability, bone
Assessment of Osstell ISQ’s reliability for implant stability measure- mineral density, and bone-to-implant contact. Int J Oral Maxillofac
ment: A cross-sectional clinical study. Med Oral Patol Oral Cir Bucal Implants 2017;32:27–36.
2013;18:e877–e882. 25. Trisi P, Berardini M, Falco A, PodaliriVulpiani M. New osseodensification
implant site preparation method to increase bone density in low-density
bone: In vivo evaluation in sheep. Implant Dent 2016;25:24–31.

Pikos_CH01.indd 9 5/31/19 11:36 AM

 chapter 2

Membranes,
Grafting Materials,
and
Growth
Factors

Pikos_CH02.indd 10 5/31/19 1:41 PM

 T
he use of biomaterials has played a pivotal role in
modern regenerative dentistry. While they were
once thought to act as passive structural materi-
als capable of filling bone voids, more recently,
a number of regenerative agents with bioactive properties
have been brought to market. These materials act to facil-
itate bone regeneration and have vastly improved the ease
and predictability of bone augmentation procedures. This a b
chapter provides an overview of the various biomaterials Fig 2-1 The first barrier membranes utilized in dentistry for GTR were cellu-
used for bone regeneration and discusses the regenerative lose acetate laboratory filter or ePTFE membranes dating back to the 1980s.
properties of commercially available barrier membranes, Demonstrated here are more modern smooth (a) and textured (b) Cytoflex
Tefguard (Unicare) ePTFE membranes.
bone grafting materials, and growth factors. Each bioma-
terial is discussed in the context of its biologic properties,
and clinical indications are provided with respect to their
application in alveolar bone augmentation procedures.

selectively guiding tissue regeneration around tissues in the

periodontium. The first barrier membranes utilized were
Barrier Membranes cellulose acetate laboratory filter or expanded polytetraflu-
oroethylene [ePTFE]) membranes6 (Fig 2-1). Following 3
Guided tissue and bone regeneration were first introduced months of healing, it was concluded by histologic evaluation
to the dental field over 20 years ago. Interestingly, in the that the test root surfaces protected from epithelial down-
early 1970s, it was not common knowledge that periodontal growth by membranes exhibited considerably more new
ligament cells were responsible for the healing capabilities attachment and bone regrowth.6 The results from this study
of bone found in the periodontium.1 From the 1970s until confirmed the hypothesis that by selectively controlling the
the mid-1980s, it was widely accepted and believed that proliferation of cells in the periodontium, and by prevent-
progenitor cells for all tissues found in the periodontium ing contact with the epithelial and connective tissues, the
were located within alveolar bone.2 It was not until the space-maintaining capability of the membrane would allow
late 1980s, and convincingly at the beginning of the 1990s for increased regeneration of underlying tissues.
following a series of experiments in monkeys, that conclu- Subsequently, the basic principles of guided bone regen-
sive evidence supported the notion that progenitor cells eration (GBR) were introduced by providing the cells from
in the periodontium were derived from the periodontal bone tissues with the necessary space intended for bone
ligament tissue.3–5 regeneration away from the surrounding connective tissue
Based on these results, it was hypothesized that a higher using a barrier membrane.7 A number of preclinical and
regenerative potential might be obtained if cells derived clinical studies have since demonstrated that by applying the
from the periodontal ligament and alveolar bone were concepts of GBR, an increase in bone regeneration may be
exclusively allowed to repopulate the root surface away obtained.8–11 While various approaches for increasing new
from the faster-growing epithelium and gingival connec- tissue regeneration have been developed, GBR has remained
tive tissues.6 Thus, the development of a “membrane-like” one of the most predictable solutions to bone defect healing.
mechanical barrier was introduced.6 This technique was first This section presents the advantages and disadvantages of
attempted in the field of periodontology under the work- various membranes for GBR procedures, discussing their
ing name guided tissue regeneration (GTR) and was aimed at mechanical properties and degradation rates.

11

Pikos_CH02.indd 11 5/31/19 1:41 PM

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Crown 8vo, cloth, 3s. 6d. each.

This Little World.
Tales in Prose and Verse. With Frontispiece by Arthur Hopkins.