Search Results (103)

Maxillary sinus augmentation is a key procedure for rehabilitating the atrophic posterior maxilla and enabling predictable implant-supported restorations. Although autogenous bone remains the biological gold standard due to its osteogenic potential, its clinical use has declined because of donor-site morbidity, limited availability, and increased surgical burden. Deproteinized bovine bone mineral (DBBM) is currently the most widely used substitute, providing excellent biocompatibility and long-term volumetric stability. However, its inert nature, limited bioactivity, and slow resorption have driven the development of next-generation graft materials. Recent biomaterial innovations aim to enhance vascularization, accelerate osteogenesis, modulate immune responses, and achieve controlled resorption while maintaining favorable handling properties. These include ion-releasing bioactive ceramics, growth factor-enhanced allografts, polysaccharide–hydroxyapatite composites, smart hydrogels, and synthetic scaffolds with tunable degradation profiles. Given the complexity of bone regeneration, effective clinical translation requires an integrated framework combining in vitro assays, animal models, and human clinical studies. This review synthesizes evidence published since 2018 on emerging biomaterials for sinus floor elevation, critically evaluating their potential to overcome the limitations of DBBM and highlighting the importance of a coordinated preclinical-to-clinical research continuum. Full article

Objective: The purpose of this study was to assess the outcome of sinus grafting with a beta-tricalcium phosphate/hydroxyapatite (ß-TCP/HA) alloplast particulate biofunctionalized with cross-linked hyaluronic acid (xHya), comparing two surgical access techniques. Clinical, histological, histochemical, immunohistochemical and histomorphometrical parameters were used to characterize the tissue samples, which were retrieved at the second surgery for implant placement five months after sinus floor elevation (SFE). Materials and Methods: Twenty patients with a residual bone height ≤ 4 mm, estimated by a Cone Beam Computed Tomography (CBCT), were randomly allocated either to an innovative transcrestal sinus floor elevation (tSFE = tests) approach or a conventional lateral window approach (lSFE = controls) using piezoelectric preparation. The tSFE was carried out using the hydraulic Jeder^®-System. Grafting in both groups was performed using a ß-TCP–HA combination, which was biofunctionalized with a cross-linked hyaluronic acid. For both access techniques, a cross-linked collagen membrane covered either the bone window or transcrestal osteotomy. For second-stage surgery, a second CBCT was used to assess the bone volume and possible implant positioning to compare it with the baseline CBCT. Bone cores were harvested at implant placement and evaluated histomorphometrically. Patients were followed for 1-year post-op for survival rate estimation. Non-superiority was hypothesized for both surgical methods; thus, the primary outcome measure assessed different discomfort levels using patient-reported outcome measures (PROMs) for each therapeutic approach. Secondary outcomes were the volume change in subantral bone after sinus floor elevation, the chance of placing a 10 mm long implant with no need for additional augmentation, histological evaluation of the newly gained tissue, and implant integration and one-year survival. Results: Eighteen patients (n = 18/20) qualified for implant placement at five months, and ten donated tissue biopsies for microscopic analysis. Primary outcome reporting using PROMs was discarded due to truncated patient enrollment. The secondary parameter, placement of a ≥10 mm long implant without additional augmentation, was achieved for nine sites/patients from the lSFE control group. All patients from the tSFE test group received an implant that was positioned alongside additional augmentation. In both groups, all implants integrated and were functionally loaded. A total of 10 core samples (3 from the tSFE group and 7 from the lSFE group) were obtained and analyzed. Microscopically, new bone formation appeared consistent in all obtained samples. Specimens revealed advanced and ongoing osteogenesis, with most histological markers reacting positively in the immunohistochemical (IHC) staining. The histomorphometric calculation revealed that a mean of 61.17 ± 16.55% of the total area was occupied by newly formed bone, 30.43 ± 10.09% by connective tissue and 8.92 ± 15.29% by residual graft substitute. One-year follow-up of the loaded implants showed a 100% implant survival rate. Conclusions: Biofunctionalizing ß-TCP + HA particulate with cross-linked hyaluronic acid in sinus floor elevation procedures appears to be a safe and beneficial approach, resulting in satisfactory clinical, radiographic and histological parameters. In our study population, which presented with very atrophic residual subantral bone conditions, the hydrodynamic transcrestal sinus floor elevation method required a back-up treatment by the conventional lateral approach. Full article

Background/Objectives: Limited residual bone height in the atrophic posterior maxilla complicates implant placement. Transcrestal sinus elevation can be used to correct bone shrinkage after sinus pneumatization or crestal bone loss. This study evaluated a minimally invasive, one-stage transcrestal sinus lift using a double-layer crosslinked collagen scaffold (MCCS) with autogenous bone from the implant osteotomy site in patients with RBH ≤ 6 mm. Methods: In this prospective series, 11 patients (48–64 years, mean RBH 4.75 mm, SD 0.95 mm) underwent one-stage transcrestal sinus floor elevation with simultaneous implants. After osteotomy, autogenous bone chips collected during drilling were compacted into the site, and two layers of MCCS were placed under the elevated Schneiderian membrane. Buccal and palatal bone heights were measured on CBCT before and after surgery to assess vertical bone gain (ΔRBH). Results: All implants achieved stable osseointegration. Mean ΔRBH was approximately 3.1 ± 0.9 mm (combined buccal–palatal). No postoperative complications occurred. Two small Schneiderian membrane perforations were sealed intraoperatively by MCCS placement, with uneventful healing. Follow-up imaging showed maintenance of the augmented bone around the implants. Conclusions: This double-layer MCCS plus autogenous bone approach is a safe, effective, and minimally invasive transcrestal sinus lift for atrophic maxillae. It yielded crestal bone gains even with minimal initial RBH, leveraging the palatal sinus wall’s osteogenic potential and the implant’s tent-pole effect. The MCCS scaffold maintained space for bone formation and enabled immediate sealing of any membrane perforations. This one-stage protocol is viable for implant placement in low-RBH sites. Full article

Background: Maxillary sinus floor augmentation is widely used to enable implant placement in the atrophic posterior maxilla, yet comparative data for porcine-derived xenografts remain limited. Objective: To evaluate long-term bone regeneration and implant outcomes following sinus augmentation using a collagenated porcine xenograft. Methods: This paper reports a retrospective case series of three partially edentulous patients (aged 46–56 years) who underwent lateral sinus augmentation with a small-particle collagenated porcine xenograft (THE Graft™, Purgo Biologics, Gyeonggi-do, Republic of Korea) and staged implant placement. In one case, a controlled perforation of the Schneiderian membrane was performed to access and remove a sinus mucocele, followed by repair using a resorbable collagen membrane. Core biopsies were harvested at implant placement for histology (hematoxylin-eosin, Masson–Goldner) and tartrate-resistant acid phosphatase (TRAP) staining. Clinical outcomes included surgical events, vertical bone gain, marginal bone levels, and implant survival at long-term follow-up. Results: Healing was uneventful in all cases. Mean vertical bone gain was 12.0 mm (baseline 1.33 mm to 13.33 mm final). At a mean 46.8-month follow-up (range 38.3–52.2 months), 100% of implants were functional without failure; marginal bone loss remained < 1 mm during the first year and was stable thereafter. Histology at 3.7, 4.7, and 7.5 months showed vascularized new trabecular bone intimately contacting residual xenograft particles (new bone 20–30%, residual biomaterial 30–40%, connective tissue 30–50%). TRAP-positive multinucleated giant cells at 7.5 months indicated ongoing biomaterial degradation without severe inflammatory reactions. Conclusions: Within the limits of a small case series, collagenated porcine xenograft supported predictable bone regeneration and stable long-term implant function after sinus floor elevation, with favorable histologic integration and gradual resorption. Full article

Background: Maxillary sinus floor augmentation (MSFA) is frequently required for implant placement in the atrophic posterior maxilla. However, limited bone quality and volume can compromise long-term success. Strontium ranelate (SrR), a dual-acting bone agent, stimulates osteoblasts while inhibiting osteoclasts, potentially improving bone density and osseointegration in grafted sites. Objective: This 10-year preliminary split-mouth study evaluated the long-term effects of SrR on bone density, volume, and implant success following MSFA. Methods: Six patients underwent bilateral MSFA using a lateral window approach. One side received systemic SrR (2 g/day for 6 months) after grafting, while the contralateral side served as a control. CBCT and DEXA analyses were performed to assess bone density and volume. Bone biopsies were examined histologically and by microindentation. Data were analyzed using paired t-tests or Wilcoxon signed-rank tests, depending on distribution, with significance at p < 0.05. Results: After 10 years, SrR-treated sites demonstrated a mean 22.9% increase in bone density versus 12.5% in untreated controls. Although both groups experienced minor reductions in bone volume (SrR: −13.3%; control: −12.8%), SrR samples exhibited greater mineralization, hardness, and lamellar bone maturity. Conclusions: SrR improved bone density and mechanical properties but not long-term volume preservation. Given the small sample size (n = 6) and absence of implant stability and patient-reported outcomes, these results should be interpreted with caution. Future large-scale clinical trials incorporating survival, ISQ, and quality-of-life data are warranted. Full article

Background/Objectives: Sinus elevation in the posterior maxilla carries a risk of hemorrhage due to injury of the posterior superior alveolar artery (PSAA). Accurate preoperative identification of the PSAA using cone-beam computed tomography (CBCT) can enhance surgical safety. This retrospective study evaluated the prevalence, location, diameter, and visibility of the PSAA in a Saudi population. Methods: A total of 117 CBCT scans (234 sinuses) obtained between 2022 and 2024 were analyzed. The PSAA’s visibility, diameter, and distances from the alveolar crest, sinus floor, medial wall, and sinus septa were measured. Associations with age, sex, smoking status, and the presence of sinus septa were statistically assessed. Results: The PSAA was identified in 98.3% of sinuses. Intraosseous and submucosal locations predominated in premolar and molar regions, respectively. Class A arteries (≤1 mm) were most frequent. Significant differences were found between premolar and molar regions in arterial location and distances from the alveolar crest and sinus walls (p < 0.001). Older individuals exhibited medial displacement of the artery in the molar region, and smokers showed significantly smaller diameters (p < 0.05). Sinus septa were associated with increased PSAA distances from the sinus floor and medial wall. Conclusions: The PSAA demonstrates high detectability and marked variability in position and caliber within this Saudi cohort. Recognition of these anatomical variations is essential for reducing complications during sinus-augmentation procedures. Full article

Background and Clinical Significance: Maxillary sinus augmentation is a well-established surgical procedure for dental implant placement in the posterior maxilla when the residual alveolar bone height is insufficient. Traditionally, the lateral approach has been preferred in cases with less than 4 mm of bone; however, the crestal approach has emerged as a less invasive alternative, particularly with the advent of advanced techniques and tools such as hydraulic pressure systems and dedicated osteotomy kits. Case Presentation: This case report presents the clinical management of a 68-year-old female patient requiring rehabilitation of the right maxillary molars, where the residual bone height measured only 3.6 mm (in position 1.6) and 2.5 mm (in position 1.7). Using the CAS kit system with rounded drills and hydraulic pressure, a controlled crestal sinus elevation was performed, followed by simultaneous implant placement. Despite the extremely limited bone height, a final insertion torque of 30 Ncm was achieved for both implants, likely due to favorable sinus floor anatomy, under-preparation of the implant sites, and the use of tapered, macro-textured implants. Postoperative follow-up over three years showed stable bone levels and successful prosthetic rehabilitation with single crowns. Conclusions: This case report highlights the potential of the crestal approach in anatomically challenging scenarios. Proper planning, technique, and implant selection are mandatory to achieve predictable and long-lasting outcomes, even in cases previously considered contraindicated for this method. Further randomized controlled trials are needed to confirm this preliminary result. Full article

Maxillary sinus floor augmentation is frequently performed to increase bone height for dental implants, with stem cells suggested to boost bone regeneration. Consequently, this study aimed to assess the effects of incorporating stem cells in maxillary sinus floor augmentation. Two reviewers conducted an extensive search using a mix of controlled vocabulary (MeSH) and free-text terms to locate published systematic reviews. Searches were conducted in three major electronic databases (Medline via PubMed, Embase, and Cochrane database) up to July 2025. Initially, 250 articles were found, but only five studies met inclusion criteria for meta-analysis. The meta-analysis revealed a pooled standardized mean difference in new bone formation of 1.06 (95% confidence interval of −0.31 to 2.44). In a subgroup analysis comparing mesenchymal stem cells with autogenous bone, the pooled standardized mean difference was 0.88 (95% confidence interval of 0.34 to 1.42). The study’s results indicated a positive trend towards better outcomes with the use of mesenchymal stem cells, although the effect was not statistically significant at the pooled level. Additionally, combining stem cells with xenograft may yield more favorable results compared to using autogenous bone with xenograft. These findings suggest potential clinical advantages, highlighting the need for further standardized research to verify long-term outcomes. Full article

Background: During maxillary sinus floor augmentation, the elevated sinus mucosa may come into close contact with the pristine mucosa. The presence of xenograft granules can lead to unintended mechanical and biological interactions between the two layers, and the resulting tissue damage remains poorly understood. The aim of this study was to perform a focused histological evaluation of graft-mediated interactions between the elevated and pristine sinus mucosae. Methods: Histological slides from five previously published rabbit sinus augmentation studies using grafts with different resorption rates were retrospectively analyzed. The following main patterns of tissue alteration were identified: (1) Proximity stage, characterized by epithelial thickening, goblet cell hyperactivity, and ciliary shortening; (2) Fusion stage, with epithelial interpenetration and loss of distinct mucosal boundaries; (3) Synechiae stage, featuring connective tissue bridges linking the two mucosae; and (4) Pristine mucosa lesions, caused by direct contact between residual graft particles and the pristine sinus mucosa. Results: A total of 192 sinuses were evaluated. Sinuses augmented with slowly resorbable grafts showed proximity stage in 22.3% of cases, fusion in 7.7%, direct lesions in 9.6%, and only one instance of synechia. In contrast, the faster resorbable xenograft presented only 11.1% of proximity stage, without further alterations. Conclusions: In this rabbit model, xenografts were associated with histological alterations of the sinus mucosa, while synechiae formation was rare. These preclinical findings should not be directly extrapolated to humans but may provide a basis for future investigations. Full article

Background: In atrophic posterior maxillary regions, sub-antral surgery is often used for rehabilitation with implants. In order to stimulate bone regeneration, autogenous, xenogenic, alloplastic and platelet-rich fibrin (PRF) grafts are commonly used. Aim: To assess the effectiveness of PRF alone or combination with synthetic bone substitutes on bone formation, implant stability, and survival in sub-antral surgery. Materials and Methods: A literature review was carried out from September 2024 to April 2025, according to PRISMA guidelines using the PubMed, Cochrane Library, Wiley, ScienceDirect, and Web of Science databases. From a total of 601 articles identified, 11 met the inclusion criteria and were selected for analysis. Results: PRF in combination with synthetic materials has shown potential benefits, especially in increasing biomechanical stability and bone formation. Although, most studies have not reported statistically significant differences when comparing the use of synthetic material alone against its combination with PRF. Discussion: The use of synthetic grafts in combination with PRF has become increasingly common in sub-antral implant procedures. PRF promotes angiogenesis, osteoprogenitor cell differentiation and bone regeneration, favouring the healing and remodelling process of the tissues, as well as greater stability and longevity of the implant. Conclusions: The combination of PRF with synthetic bone grafting shows promising results; however, further studies are needed to confirm the efficacy of PRF in maxillary sinus grafts in conjunction with the use of biomaterials. Full article

Background: Maxillary sinus floor augmentation (MSFA) is commonly used to increase posterior maxillary bone volume prior to implant placement. Although generally successful, late complications can impact long-term outcomes. The purpose of the study was to estimate the incidence and timing of atypical late complications following (MSFA) using bovine xenohybrid bone grafts. The study also aimed to evaluate whether preoperative bone volume is associated with the risk of complications. Methods: This retrospective cohort study was conducted at the Center of Oral and Maxillofacial Surgery, Danube Private University, Krems-Stein, Austria, and included patients who underwent MSFA with bovine xenohybrid bone grafts and either simultaneous or staged implant placement between January 2020 and December 2023. Preoperative bone volume of the posterior maxilla measured via cone beam computed tomography (CBCT) in the planned implant insertion position. The primary endpoint was the time (days) from MSFA to the occurrence of a graft-related complication (defined as atypical if occurring more than 6 months after MSFA and not related to peri-implantitis) The covariates included subjects’ age, sex, the quantity of graft used for MSFA, timing of dental implant insertion (simultaneous vs. staged) and implant dimensions. Kaplan–Meier analysis and Cox proportional hazards regression were used to evaluate time-to-event data. Only one graft site per patient was analyzed. Results: Atypical complications occurred in 9 out of 47 patients (19.1%), with an average time to onset of 645 days. In a multivariable analysis, a lower preoperative bone volume was found to be an independent predictor of an increased risk of complications (hazard ratio [HR]: 0.972; 95% confidence interval [CI]: 0.925–1.021; p = 0.252). However, the quantity of graft used for MSFA was not found to be a predictor (p = 0.46). Conclusions: Within the limitations of a retrospective study, reduced native bone volume appears to increase the risk of atypical late complications following MSFA with bovine xenohybrid grafts. This makes closer clinical and radiologic follow-up of patients over a longer period very necessary. Full article

Background: Dynamic computer-aided navigation systems are a real-time motion tracking technology widely applied in oral implantology and endodontics to enhance precision and reduce complications. However, their reliability, accuracy, and usability in dentoalveolar surgery and maxillary bone augmentation remain underinvestigated. Methods: A systematic review following PRISMA guidelines was conducted and registered on PROSPERO (CRD42024610153). PubMed, Scopus, Web of Science, and Cochrane Library databases were searched until October 2024 to retrieve English eligible studies, without restrictions on the publication year, on dynamic computer-assisted navigation systems in dentoalveolar and bone augmentation surgeries. Exclusion criteria were surgery performed without dynamic computer-assisted navigation systems; dental implant placement; endodontic surgery; and maxillo-facial surgery. The outcomes were reliability, accuracy, post-operative course, surgical duration, complications, patient- and clinician-reported usability, acceptability, and satisfaction. Included studies were qualitatively synthetized and judged using dedicated tools for the different study designs. Results: Twenty-nine studies with 214 patients were included, showing high reliability in dentoalveolar and bone augmentation surgeries comparable to or superior to freehand surgeries, higher accuracy in dentoalveolar surgery compared to maxillary bone augmentation, and reduced complication rates across all surgeries. While overall surgical duration slightly increased due to technology installation, operative time was reduced in third molar extractions. Patient-reported outcomes were poorly investigated. Clinician-reported outcomes were mixed, but difficulties in the differentiation of soft tissue from hard tissue were recorded, especially in sinus floor elevation. Conclusions: Dynamic computer-assisted navigation systems enhance accuracy and safety in dentoalveolar and bone augmentation surgery. Further studies are needed to assess the underinvestigated patient-reported outcomes and standardize protocols. Full article

Background: Radiographic evaluation of bone regeneration following maxillary sinus floor elevation commonly emphasizes volumetric gains. However, the qualitative microarchitecture of the regenerated bone, particularly when assessed via two-dimensional imaging modalities, such as panoramic radiographs, remains insufficiently explored. This study aimed to evaluate early trabecular changes in grafted maxillary sinus regions using fractal dimension, first-order statistics, and gray-level co-occurrence matrix analysis. Methods: This retrospective study included 150 patients who underwent maxillary sinus floor augmentation with bovine-derived xenohybrid grafts. Postoperative panoramic radiographs were analyzed at 6 months to assess early healing. Four standardized regions of interest representing grafted sinus floors and adjacent tuberosity regions were analyzed. Image processing and quantitative analyses were performed to extract fractal dimension (FD), first-order statistics (FOS), and gray-level co-occurrence matrix (GLCM) features (contrast, homogeneity, energy, correlation). Results: A total of 150 grafted sites and 150 control tuberosity sites were analyzed. Fractal dimension (FD) and contrast values were significantly lower in grafted areas than in native tuberosity bone (p < 0.001 for both), suggesting reduced trabecular complexity and less distinct transitions. In contrast, higher homogeneity (p < 0.001) and mean gray-level intensity values (p < 0.001) were observed in the grafted regions, reflecting a more uniform but immature trabecular pattern during the early healing phase. Energy and correlation values also differed significantly between groups (p < 0.001). No postoperative complications were reported, and resorbable collagen membranes appeared to support graft stability. Conclusions: Although the grafted sites demonstrated radiographic volume stability, their trabecular architecture remained immature at 6 months, implying that volumetric measurements alone may be insufficient to assess biological bone maturation. These results support the utility of advanced textural and fractal analysis in routine imaging to optimize clinical decision-making regarding implant placement timing in grafted sinuses. Full article

Background: The combination of polynucleotides and hyaluronic acid with bovine bone grafts in maxillary sinus lift procedures appears to be a promising strategy to enhance bone regeneration. This study aimed to analyze implant osseointegration, bone repair and sinus mucosa integrity using Bio-Oss^® and Hyaluronic Acid-Polynucleotide Gel (Regenfast^®) in maxillary sinus augmentation in rabbits. Methods: Sinus floor elevation was performed in 12 rabbits, with one implant placed per sinus simultaneously. In the control group, sinuses were grafted with deproteinized bovine bone mineral (Bio-Oss^®) alone; in the test group, Bio-Oss^® was combined with Regenfast^®. Two histological slides were obtained per sinus after 2 weeks (six animals) and 10 weeks (six animals): one from the grafted area alone (non-implant sites), and one from the implant site. Primary outcome variables included the percentage of newly formed bone, the extent of implant osseointegration, and the number of sinus mucosa perforations caused by contact with graft granules. Results: After 10 weeks of healing, the test group showed a significantly higher percentage of new bone formation (37.2 ± 6.7%) compared to the control group (26.8 ± 10.0%; p = 0.031); osseointegration extended to the implant apex in both groups; fewer sinus mucosa perforations were observed in the test group (n = 5) than in the control group (n = 14). Conclusions: The addition of Regenfast^® to Bio-Oss^® granules promoted enhanced bone regeneration within the elevated sinus area and was associated with a lower incidence of sinus membrane perforations compared to the use of Bio-Oss^® alone. Full article

Implant–prosthetic rehabilitation of the posterior edentulous maxilla is challenging due to inadequate bone volume resulting from alveolar ridge resorption and maxillary sinus pneumatization. This study explores the use of hyaluronic acid (HA) as a biomaterial in maxillary sinus elevation, particularly in combination with a fluid dynamic approach, as an alternative to traditional lateral approaches and granular biomaterials. Methods: A prospective study was conducted on 58 patients with posterior maxillary edentulism. Preoperative CBCT scans assessed residual bone height and sinus width. A minimally invasive surgical protocol utilizing a device for fluid-dynamic membrane elevation and injection of 2% cross-linked hyaluronic acid was employed, followed by simultaneous implant placement. Postoperative follow-up included a CBCT scan at 12 months to evaluate new bone height, measured mesially and distally. Implant stability was assessed using resonance frequency analysis at second-stage surgery. Results: A significant increase in bone height was observed at 12 months post-surgery, with an average bone gain of 7.5 mm. All 58 implants achieved primary stability, and no implant failures or signs of peri-implantitis were noted during the follow-up period. Higher bone gain was observed in wider sinuses. Conclusions: The fluid-dynamic transcrestal sinus floor elevation technique combined with hyaluronic acid appears to be a minimally invasive and effective method for achieving significant bone regeneration in the posterior maxilla, facilitating implant–prosthetic rehabilitation with potentially low risks and morbidity. Further large-scale studies are warranted to validate these findings across diverse clinical scenarios. Full article