Ismael Khouly

Effect of Maxillary Sinus Membrane Perforation on Vital Bone Formation and Implant Survival: A Retrospective Study

BACKGROUND The maxillary sinus augmentation procedure (SAP) using the lateral window technique has been documented to be a highly predictable procedure. However, the most common intraoperative complication has been reported to be maxillary sinus membrane perforation (MSMP). The present study evaluates the percentage of vital bone and implant survival in sinuses that had perforations repaired during surgery versus a non-perforated sinus group. METHODS Data were obtained retrospectively from an Institutional Review Board-approved anonymous database at New York University, Kriser Dental Center, Department of Periodontology and Implant Dentistry, New York, New York, from 23 patients who had undergone SAP with a total of 40 treated sinuses. Sinuses were grafted with mineralized cancellous bone allograft, anorganic bovine bone matrix, or biphasic calcium phospate. Perforation complications occurred in 15 sinuses with 25 non-perforated sinuses. All perforations were repaired during surgery with absorbable collagen membrane barriers. Histologic cores were taken from all treated sinuses 26 to 32 weeks after surgery. The implant success rate of 79 placed implants was recorded. RESULTS The average percentage of vital bone was 26.3% ± 6.3% in the perforated (repaired) sinuses versus 19.1% ± 6.3% in the non-perforated sinuses. The differences were statistically significant (SS). The implant success rate was 100% (35 of 35) compared to 95.5% (43 of 45) in the perforated/repaired vs. non-perforated sinuses, respectively. There was no SS difference in implant failure rates. CONCLUSIONS The augmented sinuses in this study that exhibited MSMPs that occurred during the SAP (which were treated during surgery) show SS greater vital bone percentages compared with the non-perforated sinus group. There were no SS differences in implant survival in the perforated versus non-perforated groups. In this study, sinus MSMPs, when properly repaired during surgery, do not appear to be an adverse complication in terms of vital bone production or implant survival.

Interobserver agreement in dysplasia grading: toward an enhanced gold standard for clinical pathology trials.

OBJECTIVE Interobserver agreement in the context of oral epithelial dysplasia (OED) grading has been notoriously unreliable and can impose barriers for developing new molecular markers and diagnostic technologies. This paper aimed to report the details of a 3-stage histopathology review and adjudication process with the goal of achieving a consensus histopathologic diagnosis of each biopsy. STUDY DESIGN Two adjacent serial histologic sections of oral lesions from 846 patients were independently scored by 2 different pathologists from a pool of 4. In instances where the original 2 pathologists disagreed, a third, independent adjudicating pathologist conducted a review of both sections. If a majority agreement was not achieved, the third stage involved a face-to-face consensus review. RESULTS Individual pathologist pair κ values ranged from 0.251 to 0.706 (fair-good) before the 3-stage review process. During the initial review phase, the 2 pathologists agreed on a diagnosis for 69.9% of the cases. After the adjudication review by a third pathologist, an additional 22.8% of cases were given a consensus diagnosis (agreement of 2 out of 3 pathologists). After the face-to-face review, the remaining 7.3% of cases had a consensus diagnosis. CONCLUSIONS The use of the defined protocol resulted in a substantial increase (30%) in diagnostic agreement and has the potential to improve the level of agreement for establishing gold standards for studies based on histopathologic diagnosis.

Effectiveness of systemic antimicrobial therapy in combination with scaling and root planing in the treatment of periodontitis: A systematic review

BACKGROUND The use of systemic antibiotics in conjunction with scaling and root planing (SRP) may improve the clinical outcome and even could be essential for a successful treatment of periodontitis. However, the effectiveness and clinical safety of this combination of therapy remain unclear. The authors of this study reviewed the available literature related to this hypothesis, evaluating the effectiveness of the use of systemic antimicrobials in combination with SRP versus SRP alone in the treatment of chronic periodontitis (CP) or aggressive periodontitis (AgP). METHODS The authors used 3 electronic databases and hand searched articles published from April 2001 through October 2013 in selected journals. The authors selected clinical trials with a minimum of 6 months follow-up during which patients with either CP or AgP had been treated with systemic antibiotics plus SRP in comparison with SRP alone or with placebo. The authors analyzed the gain in clinical attachment level (CAL), reduction in probing pocket depth (PPD), reduction in bleeding on probing (BOP), and patient-related variables (that is, adverse effects). RESULTS After the selection process, the authors included 23 clinical trials in this review. Assessment of the quality of the studies revealed the risk of bias as a common finding. Overall, there was a tendency toward improvement of the measured outcomes, CAL, PPD, and BOP in studies for which systemic antibiotics were used as adjunctive therapy with SRP. CONCLUSION Owing to the high level of heterogeneity of the studies included in this review, the authors could not establish definitive conclusions and guidelines regarding the use of adjunctive systemic antibiotics. However, within the limitations of this review, the use of systemic antibiotics with SRP may be beneficial for specific populations. Standardized clinical disease diagnostic criteria and additional randomized controlled clinical trials are necessary to verify the effectiveness of the use of adjunctive systemic antimicrobials with SRP. PRACTICAL IMPLICATIONS Owing to methodological differences and biases among clinical trials evaluating systemic antibiotics adjunctive to SRP, clinicians should base their decisions to prescribe on the results of weighing both benefits and risks for each patient.

Histomorphometric comparison of different concentrations of recombinant human bone morphogenetic protein with allogeneic bone compared to the use of 100% mineralized cancellous bone allograft in maxillary sinus grafting

The purpose of this study was to histomorphometrically evaluate the percentage of vital bone after grafting of maxillary sinuses using two different concentrations of recombinant human bone morphogenetic protein/acellular collagen sponge (rhBMP-2/ACS) combined with mineralized cancellous bone allograft (MCBA) and to compare the results to a control sinus grafted with MCBA only. Thirty-six sinuses in 18 patients had two of three of the graft combinations including: (1) control, MCBA only; (2) test one, MCBA + 5.6 mL of rhBMP-2/ACS (containing 8.4 mg of rhBMP-2); or (3) test two, MCBA + 2.8 mL of rhBMP-2/ACS (containing 4.2 mg of rhBMP-2). Histologic cores were taken 6 to 9 month following sinus augmentation. The results showed no statistically significant differences in vital bone between the two test groups compared to the control sinus group treated with MCBA alone. Future studies involving more cases and evaluating survival of implants placed in these augmented sinuses are needed to verify the results of this randomized prospective study.

Maxillary Sinus Grafting With Biphasic Bone Ceramic or Autogenous Bone: Clinical, Histologic, and Histomorphometric Results From a Randomized Controlled Clinical Trial.

Purpose:The present, randomized, controlled clinical trial compared the histologic and histomorphometric results from maxillary sinus augmentation with either biphasic calcium phosphate (BCP) (60% hydroxyapatite and 40% &bgr;-tricalcium phosphate) or autogenous bone (AB) as bone-grafting materials. Material and Methods:Ten patients received bilateral sinus elevation surgery with intraoral AB chips (control group) on one side and BCP (test group) on the contralateral side. After a healing period of 6 to 8 months, implant sites were created and trephine cores were harvested for histological and histomorphometric analysis of the grafted areas. Results:The histological examination of biopsies showed BCP particles interconnected by bridges of a vital newly formed bone. Histomorphometry demonstrated that the amount of newly formed bone in the control group (36.8%) was significantly greater than that in the BCP (28.2%) group (P = 0.0032). BCP and AB cores revealed an average of residual graft particles of 32.9% and 4.8%, respectively. The average percentage of soft tissue components was 38.9% in the BCP cores and 58.4% in the AB cores. Conclusions:Based on our findings, the amount of vital bone formation was significantly higher for AB than that for BCP. However, BCP seemed to be a biocompatible and osteoconductive material that can be used with success as a bone substitute in maxillary sinus procedures.

A Histomorphometric Comparison of Bio-Oss Alone Versus Bio-Oss and Platelet-Derived Growth Factor for Sinus Augmentation: A Postsurgical Assessment

The purpose of this study was to assess vital bone formation at 4 to 5 months and 7 to 9 months following sinus augmentation with anorganic bovine bone matrix (ABBM) with and without recombinant human platelet-derived growth factor (rhPDGF). Twenty-four subjects received bilateral sinus elevation surgery with ABBM on one side and ABBM and rhPDGF on the contralateral side. Twelve patients had core sampling at 4 to 5 months and 12 patients at 7 to 9 months postoperatively. In subjects with cores taken at 4 to 5 months, mean vital bone, connective tissue, and residual graft were 11.8%, 54.1%, and 33.6%, respectively, with ABBM alone. Cores of sinuses filled with ABBM and rhPDGF showed mean 21.1% vital bone, 51.4% connective tissue, and 24.8% residual graft. Paired t test showed a statistically significant difference in vital bone. In cores taken at 7 to 9 months, the values for ABBM alone and ABBM + rhPDGF were 21.4% vs 19.5% vital bone, 28.4% vs 44.2% connective tissue, and 40.3% residual graft vs 35.5%. There was no statistically significant difference in vital bone at 7 to 9 months after surgery. Test and control groups showed clinically acceptable levels of vital bone both at 4 to 5 months and 7 to 9 months postsurgery. However, vital bone formation was significantly greater in the 4- to 5-month sections of ABBM + rhPDGF vs the Bio-Oss alone. In the 7- to 9-month specimens, this difference disappeared. More rapid formation of vital bone with the addition of rhPDGF may allow for earlier implant placement.

The use of a xenogeneic collagen matrix at the time of implant placement to increase the volume of buccal soft tissue.

The purpose of this study was to evaluate the efficacy of Mucograft (MG; a porcine-derived purified collagen membrane) to increase the thickness and height of the buccal soft tissue when placed at the time of implant placement in patients with thin or deficient keratinized tissue (KT). The primary endpoint of the study was the change in thickness and height of the buccal KT. Secondary endpoints included stability of the midbuccal soft tissue level; clinician rating of color, texture, and contour of treatment site; probing pocket depths (PPDs); assessment of satisfaction outcome; and patient assessment of pain/discomfort. Thirty-two patients were enrolled and 31 patients completed the study. There were no statistically significant (SS) differences between the MG and control groups for height measures. There was no SS difference for KT thickness (P = .117) between the groups at the final measurement (3 months postsurgery). However, there was an SS difference (P = .009) in favor of the MG group when comparing the difference in presurgical KT thickness to that 3 months postsurgery. Thus, MG was successful (compared to the control) in increasing the buccal KT. There were no SS differences between the groups for any of the other endpoints, including color, texture, contour, and pain assessment at any visit or successful outcome between the treatment group and the control. More cases and longer follow-up of implants placed with MG are needed to verify the results of this randomized prospective study.

Insufficient evidence for sinus lifts over short implants for dental implant rehabilitation

Data sourcesThe Cochrane Oral Health Groups Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase databases were searched with no language or date restrictions.Study selectionTwo reviewers independently selected studies. Randomised controlled trials (RCTs) of different techniques and materials for augmenting the maxillary sinus for rehabilitation with dental implants that reported the outcome of implant success or failure at least four months after initial loading were considered.Data extraction and synthesisData were extracted independently by two reviewers and study risk of bias assessed. Results were expressed using fixed-effect models as there were either fewer than four studies or we used Peto odds ratios (ORs) for dichotomous data when there were zero cells in either the treatment or control or both arms and the number of trials was small.ResultsEighteen trials involving 650 patients were included. Five studies were considered to be at low risk of bias, 11 at high risk and two of unclear risk. Four trials (102 patients) evaluated short implants (5 to 8.5 mm long) as an alternative to sinus lift in bone with residual height between 4 and 9 mm. One year after loading there was insufficient evidence to claim differences between the two procedures for prosthesis failure (OR (Peto) 0.37, 95% confidence interval (CI) 0.05 to 2.68; three trials) or implant failure (OR (Peto) 0.44, 95% CI 0.10 to 1.99; four trials). There was however an increase in complications at treated sites when undertaking the sinus lift (OR (Peto) 4.77, 95% CI 1.79 to 12.71, P value = 0.002; four trials).Fourteen trials (548 patients) compared different sinus lift techniques. Only three comparisons included more than one trial. These were bone graft versus no bone graft, autogenous bone versus bone substitute, bone graft with or without platelet-rich plasma (PRP). There was insufficient evidence to claim a benefit for any of these techniques for the primary outcomes of prosthesis and implant failure.The other comparisons with single studies were rotary versus piezosurgery to open a lateral sinus window, two different bone substitutes, use or not of a membrane to seal the lateral window, one- versus two-stage lateral sinus lift, two-stage granular bone versus one-stage autogenous bone blocks and crestal versus lateral sinus lift; two trials compared three different crestal sinus lifting techniques: rotatory versus hand malleting (patients preferred rotatory instruments over hand malleting) and hand versus electric malleting. There was no evidence of a benefit for any sinus lift procedure compared to any other for the primary outcomes prosthesis or implant failure.ConclusionsThere is moderate quality evidence which is insufficient to determine whether sinus lift procedures in bone with residual height between 4 and 9 mm are more or less successful than placing short implants (5 to 8.5 mm) in reducing prosthesis or implant failure up to one year after loading. However, there are more complications at sites treated with sinus lift procedures. Many trials compared different sinus lift procedures and none of these indicated that one procedure reduced prosthetic or implant failures when compared to the other. Based on low quality evidence, patients may prefer rotary instruments over hand malleting for crestal sinus lift.

Survival Rates and Bone and Soft Tissue Level Changes Around One-Piece Dental Implants Placed with a Flapless or Flap Protocol: 8.5-Year Results.

The purpose of the current study was to determine the survival rates and to measure marginal bone changes and peri-implant conditions 8.5 years after placement of one-piece implants with an anodically oxidized surface (AOS). A total of 52 subjects who received a one-piece implant with an AOS using a flapless or flap protocol and completed a previous randomized clinical trial were contacted for a recall visit 8.5 years after implant placement (T8.5). Implant success and survival rates, probing pocket depth (PPD), presence of bleeding on probing (BoP), papilla level, and incidence of complications and peri-implant disease were assessed by a single, blinded examiner. A second blinded examiner evaluated marginal bone level changes. Results for 8.5 years were compared to those at the time of implant placement, implant loading (0.5 year), and 1 and 1.5 years follow-up. The results based on 28 patients who attended the follow-up visit (half had flapless and half a flap protocol) showed a 100% implant survival rate and a 96.4% implant success rate 8.5 years after implant placement using one-piece implants, with no difference in survival and success rates between the flapless and the flap protocol. During the same follow-up period, a significant increase in crestal bone height from 1.5 to 8.5 years was observed. Analysis suggested decreasing mean levels of bone loss with time (P < .001). Moreover, there was 0.8 to 1.0 mm of bone loss through year 1.5, which decreased to 0.3 mm at 8.5 years (P < .05). There was no statistically significant difference in PPD or BoP over time. Similar mean levels of PPD were found in flap and flapless groups (mean [SD] = 2.4 [0.3] and 2.2 [0.4] mm, respectively [P = .18]), as well as similar rates of BoP (22.8% vs 17.9%, respectively). Papilla levels increased during the first year after implant loading. However, there was little additional change between 1.5 and 8.5 years. A total of eight fractured porcelain crowns and three crown loosenings were reported. One-piece implants with an AOS showed high survival rates and stable marginal bone and periimplant soft tissue levels regardless of whether a flapless or flap protocol was used.

Human Histologic and Radiographic Evidence of Bone Formation in a Previously Infected Maxillary Sinus Graft Following Debridement Without Regrafting: A Case Report.

The aim of this case report was to evaluate the histologic and radiographic new bone formation following maxillary sinus reentry surgery without a bone graft. A 61-year-old woman was referred with a failure of a sinus augmentation procedure. A reentry procedure was performed to retreat the sinus complication. The procedure involved removal of the bone graft plus debridement of the sinus. No additional bone graft material was used. A cone beam computed tomography scan was taken 6 months following the reentry procedure. During implant placement surgery, a core biopsy specimen was retrieved, stored, and prepared to obtain thin ground undecalcified sections. The histologic and radiographic analysis showed formation of new bone at the time of implant placement. At 18 months following implant placement, successful evidence of integration was determined by implant stability and radiographs. Space maintained by the previously elevated sinus membrane at the time of sinus reentry was sufficient to induce formation of bone without regrafting. However, more cases involving survival of implants placed in augmented sinuses without the use of bone grafts at the time of reentry are needed to confirm the results of this case report study.