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    As dental implant reconstruc-tion has evolved into a main-stream alternative to replace miss-ing teeth, bone grafting techniqueshave also evolved as an ancillaryprocedure for site development,sinus augmentation, and guided bone regeneration. Concurrently,imaging technologies have beendeveloped which allow unsur-passed inspection of the dental-alveolar complex, providing clini-cians with innovative tools to planfor dental implant reconstruction.The ability to diagnose and treatdental implants have been foreverchanged by the ability to assesspatient anatomy using ComputedTomography (CT), Cone Beam(CBCT), and interactive treatmentplanning software within the uni-versal standard language of data

    called DICOM (Digital Imagingand Communications inMedicine). This increased abilityhas been expanded to includeappraisal of bone grafting receptorand donor sites through innova-tions in the interpretation of threedimensional data.

    In the completely edentulousmandible or maxilla, the use of CBCT technology is an essentialtool for assessing anatomy inpreparation for implants or graft-ing. The ability to visualize theextent of a defect from variousangles, views, and 3-D reconstruc-tions has helped to define a newset of diagnostic paradigms. Atwo-dimensional panoramic recon-struction of the maxilla can pro-vide a good scout film of theanatomy; however, as a two-dimensional modality, it has inher-ent limitations and distortion. Theright and left maxillary alveolar bone height can be approximated,and the relative size of the bilater-al maxillary sinuses or extent of pnuematization can be assessed inrelation to the underlying bone

    and nasal cavity. However, it isnot until all possible two-dimen-sional and 3-D views have beenexamined that the actual boneanatomy can be appreciated andassessed in relation to the plannedreconstruction.

    Using CBCT, several different

    Volume 20, Number 6 June 2009

    Bone Grafting Assessment: Focus on the Anterior and Posterior Maxilla Utilizing Advanced 3-D Imaging Technologies

    By Scott D. Ganz, DMD

    EDITOR

    Arun K. Garg, DMDEditor in Chief

    EDITORIAL ADVISORS

    Editor Emeritus: Morton L. Perel, DDS, MScD

    Renzo Casselini, MDTProfessor of Restorative DentistryLoma Linda UniversityLoma Linda, CA

    Leon Chen, DMD, MSPrivate PracticeLas Vegas, NV

    Scott D. Ganz, DMDPrivate Practice of Prosthodontics, MaxillofacialProsthetics and Implant DentistryFort Lee, NJ

    Jim Kim, DDS, MPH, MSPrivate Practice of PeriodonticsDiamond Bar, CA

    Sachin Mamidwar, MD, MSCo-Founder and General Manager, Orthogen, LLCSpringfield, NJ

    Carl E. Misch, DDS, MDSCo-Director, Oral ImplantologyUniversity of Pittsburgh School of Dental Medicine

    Peter Moy, DMDPrivate Practice,West Coast Oral and Maxillofacial Surgery Centerand Center for OsseointegrationLos Angeles, CA

    Myron Nevins, DDSAssociate Professor of PeriodontologySchool of Dental MedicineHarvard UniversityBoston, MA

    Paul Petrungaro, DDS, MSPrivate Practice of PeriodonticsChicago, IL

    Andre Saadoun, DDS, MSPrivate Practice of PeriodonticsParis, France

    All images contained within this issue are fromDr. Ganzs practice.

    NOW AVAILABLE ON-LINE!Go to www.ahcmedia.com/online.html for access.

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    views can provide invaluable infor-mation as to the patients anatomicalpresentation. They include the axial,cross-sectional, panoramic, and 3-Dviews. The axial view helps to revealthe true magnitude of atrophy exhibit-ed in the anterior maxilla of a patientwearing a complete denture ( seeFigure 1). Scrolling through the cross-sectional images, allows for an exami-nation of the extremely thin strip of cortical bone representing the residualalveolar ridge supporting a completedenture ( see Figure 2). Moving posteri-orly, the lack of remaining vertical bone height beneath the maxillarysinus is evident ( see Figure 3a). Thesinus can be examined for pathology,thickening of the membrane, widthand, in some instances, theosteomeatal complex can be clearlyvisualized. Additionally, the extent of sinus pneumatization can be visual-ized and substantiated through undis-torted measurements available withinthe diagnostic tools of the software.Sometimes overlooked, but certainlyimportant, are the significant arteriesthat supply vascularization to themaxillary sinus. These include theposterior/superior alveolar artery, the

    anterior superior alveolar artery, andthe infraorbital artery. In a significantpercentage of CT/CBCT scans, thesevessels can be detected and differenti-ated in terms of vertical position on

    the external wall of the sinus, as wellas a superficial, intraosseous, or intra-sinus location ( see Figure 3b). The loca-tion and diameter of these vesselsshould be an important considerationwhen performing a sinus augmenta-tion because of the potential risk of bleeding during the procedure. Whenpossible, depending upon the soft-ware utilized, a 3-D reconstruction of the maxilla is the final step to confirmthe actual maxillary anatomy ( seeFigure 4a). Looking down upon themaxillary arch, the volume and asym-metry of the right and left maxillarysinus can be fully appreciated, as theyare delineated from the nasal cavity(see Figure 4b). The treatment alterna-tives for this type of clinical presenta-tion are narrowed considerably oncethese images are assimilated, yet theseoptions will be based upon accurateknowledge of the anatomy, and can be decided well in advance of the sur-gical intervention.

    Sinus Grafting Assessment Advanced imaging technologies

    greatly enhance planning and execu-tion of sinus augmentation proce-dures. In the cross-sectional view, the

    amount of bone volume necessary can be accurately determined by measur-ing from the lateral to the medial wall,and the height necessary to supportan implant ( see Figure 5a).

    Additionally, the surgical access win-dow can be planned in advance of the procedure. Using the sinus graftsoftware tool, a simulated implant can be placed within the sinus and a sim-ulated graft can be software-generatedto fill the cavity ( see Figure 5b)(SimPlant; Materialise Dental, GlenBurnie, Md). Using advanced clip-ping features, the 3-D reconstructedmaxilla can be sliced to view the sin-gle realistic simulated implant sittingin the sinus (green) with a yellowabutment projection aiding the posi-tion to emerge through the plannedrestoration ( see Figure 6a). Informationon graft volume can then be calculat-ed by filling the sinus cavity with sim-ulated bone to help predict the typeand quantity of bone required forproper augmentation ( see Figure 6b).

    Using low-dose CBCT, post aug-mentation scans can be taken to veri-fy the quality of the bone augmenta-tion, to determine medial fill, densi-ty, height and width of the graft, andif perforations or graft leakageoccurred. These unparalleled viewscan be of great value for all clinicianswho are interested in achieving ahigher degree of accuracy with sur-

    gical augmentation procedures and,when post-operative CBCT scans aremade available, understanding actu-al treatment outcomes in threedimensions. The post-augmentation

    Dental Implantology Update June 2009

    42

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    scan can be utilized to properlyassess the newly created graft vol-ume and surrounding structures forsubsequent implant placement ( seeFigure 7a). Undistorted measure-ments help provide valuable infor-mation which could not be deter-mined without these advanced inter-active tools. Once verified, the pre-cise length and diameter of the mostappropriate implant can be simulat-ed to take advantage of the most

    available bone ( see Figure 7b). Theability to slice through the 3-D recon-struction provides yet another valu-able interactive view verifyingimplant placement within the zoneof the Triangle of Bone (TOB)described in various articles since1995 (see Figure 7c).

    Block Bone Graft Assessment: Receptor and Donor Sites

    The use of CT and CBCT has beendemonstrated to be invaluable insmall bone defects, and also large bone defects, when planning for eitherparticulate or block grafting proce-dures. Proper assessment of large bony defects can be essential to long-term restorative success. It is not onlyimportant to visualize the defect itself

    but it is critical to understand therestorative requirements of the regionso that the graft can be properly con-figured. A 3-D reconstructed viewreveals loss of four maxillary incisorswith concurrent loss of substantialalveolar ridge volume ( see Figure 8).Depending upon philosophy andtraining, three or four implants wouldideally be required to support the

    missing four anterior teeth. However,without a diagnostic wax-up, it could be difficult to place the implants with-in the desired restorative envelopewhile avoiding embrasures and, withresultant, proper emergence profilesfor soft tissue maintenance and esthet-ic appearance. This would be especial-ly significant if the patient has a highlip and smile line. To achieve truerestoratively driven implant dentistry,the position of the teeth must be

    appreciated prior to placing a graft oran implant.Through the use of diagnostic

    wax-ups and barium sulfate scan-ning appliances, the tooth positioncan be visualized on the scan. Often,patients are scanned without a tem-plate, which does not relate thedesired tooth position to the under-lying residual defect. The evolution

    June 2009 Dental Implantology Update

    43

    Figure 1: Axial view of severely atrophic anterior maxilla. Figure 2: Cross-sectional view of thin alveolar crestal bone.

    Figure 3b: Location of intraosseous vessel on wall of sinus.Figure 3a: Maxillary sinus volume as seen in cross-section.

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    of the virtual tooth, or virtual occlu-sion, has added a new and impor-tant tool set for interactive treatmentplanning. When several teeth aremissing, more control of the processis required and, thus, these virtualtools must continue to evolve intostrategic diagnostic modalities. Dueto the volumetric loss of buccal boneand to support the ideal, occlusion

    implants need to be placed facial tothe residual bone, necessitating asubstantial amount of graft thick-ness. The position of the four miss-ing virtual incisor teeth should becreated in the ideal position, so thatthe simulated implants can be posi-tioned to best support the anticipat-ed restoration ( see Figure 9).However, there is insufficient bone

    to cover the exposure of threads onthe facial aspect of the implants or toallow the implants to be fixated. Thenext step would, therefore, be to sim-ulate the bone graft volume neces-sary to surround and fixate theimplants after graft maturation.Using a simulated j-graft blockgraft shape, measurements can bemade from the ideal implant posi-

    tion to determine the thickness of graft required to support the implantand the surrounding soft tissue.Once a virtual implant, virtual abut-ment, and virtual tooth have beenplaced, additional measurements can be made from the outer aspect of theimplant to the outer aspect of thegraft ( see Figure 10a). With such alarge volumetric defect crossing the

    midline of the anterior maxilla, itmight be desirable to place morethan one block bone graft, or use areinforced membrane, to containparticulate grafting material. For thisexample, bilateral simulated bonegrafts placed to support fourimplants, abutments, and the desiredposition of the restorations can beseen in Figure 10b. Of note, are the

    fixation screws that have also beenstrategically placed to help stabilizethe grafts. The precision of this plan-ning can not be underestimated.

    Utilization of 3-D scans can alsohelp locate graft donor sites in theposterior ramus or the symphysis.The thickness of the facial corticalplate and the location of the inferioralveolar nerve help to identify a safe

    Dental Implantology Update June 2009

    44

    Figure 4a: Three dimensional reconstruction of maxilla. Figure 4b: Bi-lateral sinus volume, and nasal cavity in3-D view.

    Figure 5b: A simulated bone graft can be generated tosurround an implant placed within the sinus.

    Figure 5a: The width and height of the sinus can be mea-sured in the cross-sectional view.

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    and adequate donor site in theramus ( see Figure 11a). The proximityto the path of the nerve, the thick-ness of the cortical plate, and thedensity of the medullary bone can befully appreciated. The shape and sizeof the graft can then be pre-deter-mined and assessed for fit in thereceptor site ( see Figure 11b). Usingthe same process, donor sites can beevaluated in the anterior symphysisof the mandible. Once the graft has been harvested from either theramus, the symphysis, or a bone bank, the receptor site is prepared toreceive the graft. To continue theplanning process, virtual positioningof the fixations screws helps toensure intimate fit and stability of the graft. The cross-sectional clip-

    ping of the 3-D reconstructionshows how two fixation screws have been planned, the relationship between the simulated implant to beplaced (after the graft has matured),and the underlying pre-existing alve-olus ( see Figure 12a). The 3-D recon-structions further emphasize theplanning capabilities inherent instate-of-the-art treatment planningsoftware by revealing the entiretooth-abutment-implant complexwithin the simulated grafted recep-tor site ( see Figure 12b). To ensureaccuracy of placement and to deter-mine proper embrasures, the enve-lope of the teeth should be complete-ly visualized in the occlusal view of the 3-D reconstruction with the fourvirtual maxillary incisors ( see Figure

    13). An actual bilateral graft proce-dure demonstrates the planning con-cepts presented in this paper ( seeFigure 14).

    ConclusionImaging technology has

    advanced significantly in the pasttwo decades. Both CT and ConeBeam CT scanning have gained

    acceptance as necessary pre-surgicalplanning tools for placement of den-tal implants and for an understand-ing of the patients three dimension-al bony anatomy for grafting proce-dures. When using software associ-ated with the CBCT scan machine,details of the patients anatomy canallow for inspection of the area of interest by utilizing several different

    June 2009 Dental Implantology Update

    45

    Figure 6a: A realistic implant (green) and abutment pro- jection (yellow) positioned within the sinus.

    Figure 6b: To determine the volume of bone necessarythe software generated bone graft fills the sinus.

    Figure 7b: Undistorted measurements help provide valu-able information regarding the placement of an implantwithin the new graft.

    Figure 7a: Post augmentation scan allows for assessmentof the graft placement.

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    June 2009 Dental Implantology Update

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    Figure 10b: Bilateral simulated bone grafts placed toreconstruct the anterior maxilla in anticipation of sup-

    porting four teeth.

    Figure 11a: Donor sites can be identified in the posteriorramus through cross-sectional assessment of the path of the nerve and the cortical bone thickness.

    Figure 12a: Cross-sectional "clipping" shows how two fixa-tion screws are planned to secure the simulated bone graft.

    Figure 11b: The shape and size of the donor graft can be pre-determined.

    Figure 12b: The implant-abutment-crown complex andthe fixated bone graft in a slice of the 3-D reconstruction.

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    6. Mandelaris GA, Rosenfeld A. The

    expanding influence of computed

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    7. Ganz SD. Using interactive tech-

    nology: in the zone with the

    Triangle of Bone. Dent Implantol

    Update . 2008;19:33-38.

    8. Sharan A, Madjar D. Maxillarysinus pneumatization following

    extractions: a radiographic study.

    Int J Oral Maxillofac Implants .

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    9. Wallace SS. Maxillary sinus aug-

    mentation: evidence-based decision

    making with a biological surgical

    approach. Compend Contin Educ

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    10. Sharan A, Madjar D. Correlation

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    11. Ganz SD. Presurgical planning

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    12. Pikos MA. Mandibular block auto-

    grafts for alveolar ridge augmenta-

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    13. Pikos MA. Atrophic posterior maxilla

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    Figure 13: The envelope of the virtual occlusion aids indetermining embrasures, and insures implant positioningwithin the body of each tooth.

    Figure 14: An actual bilateral bone graft in the anteriormaxilla demonstrates the outcome of proper planning.