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DENTAL IMPLANTS

Oral Maxillofac Surg9:482-490, 2011

Sinus Graft With Safescraper:5-Year Results

Jorge Caubet, MD, PhD,* Christiane Petzold, MSc,†

Concepción Sáez-Torres, MD,‡ Miguel Morey, MD,§

José Ignacio Iriarte, MD, DDS,� Jacobo Sánchez, MD, DDS,¶

J. Juan Torres, MD,# Joana M. Ramis, PhD,** and

Marta Monjo, PhD††

Purpose: In the procedure of sinus floor elevation, autogenous bone, allogenic grafts, and several otherbone substitutes are used. However, autogenous bone is still considered the gold standard. Donor sitesfor autogenous bone are generally the iliac crest, oral cavity, calvarium bone, and tibia. In this work theexperience with the use of a Safescraper device for harvesting of autogenous bone is reported and adecision-making algorithm for grafting in sinus floor elevation procedures is proposed.

Materials and Methods: Forty sinus augmentation procedures were performed in 34 patients. Allsinuses were filled with a mixture of autogenous bone and bovine hydroxyapatite. A Safescraper devicewas used to harvest autologous bone from the maxillary area. Platelet-rich plasma was used to sustainbone placement. Sixty-five dental implants were placed at 4 months with a flapless procedure. A clinicaland radiological 5-year retrospective case series of a cohort is reported.

Results: In all cases new bone formation was confirmed radiologically and implant placement wasperformed successfully. Analysis of samples obtained by biopsy with histology and microcomputedtomography showed the presence of mature bone. Healing problems were observed in only 1 case.

Conclusions: Sinus augmentation with bone grafts obtained from oral cavity with a bone scraper device hasthe advantage of providing autogenous bone without the need for an extra surgical approach. This procedureyields satisfactory results in bone formation, implant survival, and patient satisfaction. When combined witha flapless approach for implant placement, a decrease in the morbidity of the entire process is achieved.© 2011 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 69:482-490, 2011

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inus floor elevation, formerly known as sinus lift pro-edure, is an internal augmentation of the maxillaryinus, which is intended to allow implant placement inhose patients with insufficient bone volume condition.

*Oral and Maxillofacial Surgeon, Bone Regeneration and Oral and

axillofacial Surgery Unit (GBCOM), Palma de Mallorca, Spain.

†PhD Student, Department of Biomaterials, Institute for Clinical

entistry, University of Oslo, Oslo, Norway.

‡Research Assistant, Bone Regeneration and Oral and Maxillofa-

ial Surgery Unit (GBCOM), Palma de Mallorca, Spain.

§Oral and Maxillofacial Surgeon, Bone Regeneration and Oral and

axillofacial Surgery Unit (GBCOM), Palma de Mallorca, Spain.

�Oral and Maxillofacial Surgeon, Bone Regeneration and Oral and

axillofacial Surgery Unit (GBCOM), Palma de Mallorca, Spain.

¶Oral and Maxillofacial Surgeon, Bone Regeneration and Oral

nd Maxillofacial Surgery Unit (GBCOM), Palma de Mallorca, Spain.

#Pathologist, Hospital Universitario Son Dureta, Palma de Mal-

orca, Spain.

482

his surgical procedure was proposed by Tatum1 andescribed by Boyne and James.2

The classic sinus lift operation consists of the prep-ration of a top hinge door in the lateral maxillary

**Researcher, Group of Cell Therapy and Tissue Engineering,

esearch Institute on Health Sciences (IUNICS), University of

alearic Islands, Palma de Mallorca, Spain.

††Researcher, Group of Cell Therapy and Tissue Engineering,

esearch Institute on Health Sciences (IUNICS), University of

alearic Islands, Palma de Mallorca, Spain.

Address correspondence and reprint requests to Dr Jorge Cau-

et: GBCOM, Clínica Juaneda, C/ Company 20, 07014 Palma de

allorca, Spain; e-mail: jcaubet@telefonica.net

2011 American Association of Oral and Maxillofacial Surgeons

278-2391/11/6902-0024$36.00/0

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CAUBET ET AL 483

inus wall. This door is luxated inward and upwardogether with the Schneiderian membrane to a hori-ontal position forming the new sinus bottom. Thepace underneath this lifted door and sinus mucosa islled with graft material.3 Autogenous bone, boneubstitutes, or a mixture of both are used for thisurpose. The graft material ideally should be osteo-enic, osteoinductive, and osteoconductive to pro-ide the best results in new bone formation. How-ver, these properties may vary among different typesf graft. The autologous bone has been classicallyegarded as the “gold standard” for grafting becausets biological activity combines the 3 properties. Al-hough other bone substitutes containing culture-ex-anded osteogenic cells or osteoinductive growth fac-ors are available, they are expensive and not availablen most offices, so the use of autogenous grafts is stillcommon practice. Donor sites for autogenous bone

re generally the iliac crest, oral cavity, calvaria, andibia, but the risks associated with the harvestingrocedure must be taken into account by the clini-ian.4,5 Therefore, advances in implantology shoulde conducted to develop new surgical approachesnd biomaterials that yield satisfactory bone regener-tion with a decrease in morbidity rates derived fromurgery.

To overcome some complications associated withhe acquisition of a graft, this work focused on the usef a bone scraper device (Curved Safescraper; Meta,eggio Emilia, Italy) for harvesting autogenous bone

rom the maxillary area through the incision per-ormed for the sinus approach. It is the aim of thiseport to describe the results obtained by the presentnvestigators with this technique combined with aapless procedure for implant placement in a retro-pective case series of a cohort of patients who un-erwent these procedures in 2004. Based on thisxperience, a decision-making protocol for grafting ininus floor elevation is proposed.

aterials and Methods

We present a 5-year retrospective case series of aohort of 34 patients (15 male, 19 female) with inad-quate bone volume condition for implant placingho underwent 40 sinus augmentations from 2003 to

004. The mean age of the patients studied was 53ears (range, 35 to 74 years). This retrospective studyas reviewed and approved by the local institutional

eview board.All patients underwent careful detailed history tak-

ng and clinical and radiographic evaluations beforeinus augmentation. Radiologic evaluation includedrthopantomography and maxillary computed tomog-aphy. All Panorex imaging was done with the same

rthopantomograph (Siemens Orthophos; Sirona I

ental Systems, Bensheim, Germany) and correctedor a constant magnification of 25%.

Antibiotics were administered to patients 24 hoursefore surgery (amoxicillin 875 mg, clavulanate po-assium 125 mg) every 8 hours for 7 days. Smokingatients were advised to cease smoking.

FIRST SURGICAL STAGE: SINUS FLOOR ELEVATIONAND BONE GRAFT HARVESTING

A local anesthesia solution of articaine with 0.5%g epinephrine was injected into the buccal andalatal maxillary area. The incision was made on theop of the alveolar ridge, or slightly on the palatal side,hrough the keratinized, attached mucosa. In thisay, wound closure can be solid and with sufficientverlap to deal with possible dehiscence.The preparation usually started with the bone

craper. Bone from the lateral wall of the sinus wasollected as part of the antrostomy. The preparationas finished with a large round diamond bur that

annot easily damage the membrane or perforate theony wall. The Schneiderian membrane was liftedsing special sinus floor elevation instruments (de-igned by Tatum) that worked in different directionsith different angles and blades.Bone from the malar and maxillary malar buttressas harvested with the bone scraper by pushing the

nd of the device toward the bone surface and simul-aneously pulling the device backward (Fig 1). Collec-ion of 2 to 3 mL of bone was feasible with a meanurgical time of 10 minutes for harvesting (Fig 2A).he collected bone was preserved in a sterile envi-onment until grafting. The graft was mixed 1:1 withio-Oss (Geistlich Pharma AG, Wolhusen, Switzer-

and) and platelet-rich plasma was added to the com-osite graft (Fig 2B, C). The platelet concentrate wasroduced using a variation of a double centrifugeechnique described by Sonnleitner et al.6 A solutionf 10% calcium chloride was used 1:10 for plateletctivation. The platelet gel containing the graft mate-ial was then placed in the sinus cavity and coveredith a fibrin membrane derived from the fractionoor in platelets obtained during platelet-rich plasmarocurement. Platelet-poor plasma had previouslyeen activated by addition of the calcium solution.Use of dentures was not permitted until these den-

ures had been adjusted and refitted at least 2 weeksfter surgery.

SECOND SURGICAL STAGE: FLAPLESS DENTALIMPLANT PLACEMENT

After a healing period of 4 months, clinical andadiographic evaluations were performed. Panoramicadiographs were used to assess new bone formationFig 3). At this time 65 Osseotite 3i dental implants (3i

mplant Innovations, Palm Beach Gardens, FL) were

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484 SINUS FLOOR ELEVATION WITH BONE GRAFT

laced in a flapless procedure under local anesthesiaFig 4). In 10 patients, biopsies of the grafted areaere obtained through this surgical approach before

mplant insertion for histologic (Fig 5) and microcom-uted tomographic (Fig 6, Table 1) analyses. Micro-omputed tomography allows 3-dimensional imagingf calcified tissues and biomaterials and can be doneefore histologic analysis. Briefly, 1 biopsy specimen

nside a trephine bur was fixed with 10% formalin andhen dehydrated for at least 3 days in 70%, 80%, 96%,nd then 100% ethanol under constant shaking, fol-owed by embedding in Technovit 7200 (Heraeusulzer, Hanau, Germany) in 30%, 50%, 70%, and then00% ethanol in the dark. The sample was light-curedor 10 hours under ventilation. The embedded sampleas scanned with a tabletop microcomputed tomo-

raphic scanner (SkyScan 1172; SkyScan, Kontich,elgium) with a pixel size of 6.84 �m, source voltagef 75 kV, and source current of 131 �A. An Al filter of.5 mm thickness was used. The sample was rotated60° in steps of 0.4° and 3 images were averaged perrame. A control sample was scanned without beingmbedded, which required adjusting the scan voltage68 kV) and current (139 �A). The scans were recon-tructed using NRecon 1.6.1.5 (SkyScan) with amoothing of 1, beam hardening of 40, ring artifactecrease of 12, and output gray scale of 0.0 to 0.3 (0.0o 0.12 for the control sample). Post-alignment wasptimized automatically. Data analysis was done withTAn 1/10/01 (SkyScan) for 1 sample in which sinus

ift and bone grafting were performed and 1 control.he sinus lift sample was divided into native bone andrafted bone (Fig 6). The control consisted of native

IGURE 1. Anatomic image of the maxillary malar region with theonor site for autogenous bone harvesting (circled area).

aubet et al. Sinus Floor Elevation with Bone Graft. J Oralaxillofac Surg 2011.

one only. A cylindric volume of 1.577 mm3 wasCM

nalyzed for each section and the control. Thresholdso divide mineralized bone from nonmineralized tis-ue were 25 to 255 for the biopsy of the sinus aug-entation and 64 to 255 for the control. Three-dimen-

ional models were calculated with CTVol 2.1SkyScan) with the same thresholds described earlier.hree-dimensional morphometric analysis and 3-di-ensional models were performed to determine the

IGURE 2. Composite graft material. A, Autogenous bone har-ested with the Safescraper. B, Autogenous bone and Bio-Oss. C,ppearance of the graft after addition and activation of platelet-

ich plasma.

aubet et al. Sinus Floor Elevation with Bone Graft. J Oralaxillofac Surg 2011.

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rchitecture of newly formed bone in the grafted areaompared with the native bone in the same biopsy.

THIRD SURGICAL STAGE: SECOND SURGERYOF IMPLANTS

Five months after implant placement, all implantsere exposed and definitive abutments were con-ected.Data were collected at the time of bone augmenta-

ion, at 4 months after the sinus graft procedure, onhe day of delivery of the permanent prosthesis, andt yearly reviews (5-year follow-up).

RADIOGRAPHIC EXAMINATION

Radiologic evaluation included preoperative ortho-antomography and maxillary computed tomogra-hy. All Panorex images were obtained with the samerthopantomograph (Siemens Ortophos) and cor-ected for a constant magnification of 25%.

Radiographic records consisted of orthopantomo-rams taken before bone graft surgery, at 4 months (athe moment of implant placement), after insertion ofhe permanent prosthesis, and then at yearly reviews

IGURE 3. A, Panoramic radiograph of a patient before maxillaonths after maxillary sinus floor elevation. A 13-mm bone height

mplants placed. D, Panoramic radiograph at 5-year follow-up.

aubet et al. Sinus Floor Elevation with Bone Graft. J Oral Maxi

5-year follow-up). w

esults

Forty sinus floor elevations performed in 34 pa-ients with posterior maxillary atrophy with less than

mm between the sinus floor and the alveolar ridgeere included in the 5-year retrospective study.wenty-eight patients (82%) underwent unilateral si-us augmentation, and 6 patients (18%) bilateral aug-entation. The surgical approach included 2 stages in

ll cases. The first surgical stage consisted of sinusoor elevation, bone graft harvesting, and sinus aug-entation. The second surgical stage was performed

fter a healing time of 4 months.Surgery was carried out without major com-

lications in all cases. The sinus membrane wasotally preserved in 31 patients (77%), slightly bro-en in 8 patients (20%), and totally torn in 1 case2.5%). When the sinus membrane was slightly bro-en, an autogenous fibrin membrane was applied assealant and bone grafting was performed as de-

cribed earlier. When the membrane perforationas total, sinus floor elevation was abandoned. In

his case, re-entry was performed successfully at 8

s augmentation. B, Panoramic radiograph of the same patient 4n in the augmented sinus. C, Panoramic radiograph with dental

Surg 2011.

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Caubet et al. Sinus Floor Elevation with Bone Graft. J OralMaxillofac Surg 2011.

486 SINUS FLOOR ELEVATION WITH BONE GRAFT

No pain or infectious complications at the donorite was observed. During the healing time 1 patienthowed dehiscence and graft loss that needed to bereated with resuture and oral antibiotic treatment.

Panoramic radiographic measurements showed aotal bone height (alveolar bone plus grafted bone) of3 to 15 mm in all augmented sinuses at 4 months.one levels were maintained during the 5-year study.Histologic analysis of 10 core biopsies taken at 4onths showed formation of mature bone with no

igns of active inflammation or resorption. Microcom-uted tomographic analysis (Table 1) indicated amaller bone volume for the newly formed bone inhe grafted area compared with the native bone ininus augmentation and control. A separation of boneraft from newly formed bone was not possible due to

IGURE 4. A, Appearance of implants placed in an augmentedinus after a flapless procedure. B, Final restoration in the sameatient.

aubet et al. Sinus Floor Elevation with Bone Graft. J Oralaxillofac Surg 2011.

IGURE 5. Histologic appearance of biopsies obtained fromrafted area 4 months after sinus augmentation (hematoxylin andosin stain). A, Image of core sample at low magnification (originalagnification, �5). The superficial area is at the left side of the

mage. B, Incompletely resorbed bone graft was well integrated inhe biopsy sample (1) and was in complete continuity with newone tissue formation (2). In the medullary area, increased densityf vascular connective tissue was observed with minimal inflamma-

ory infiltrate (3) (original magnification, �10). C, Higher magni-cation (�20) of the inset shown in B.

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CAUBET ET AL 487

heir similar densities. However, the 3-dimensionalodel (Fig 6) did show good interlocking between

ew bone and bone graft, with no visible borders.he architecture of the grafted bone was more open,s indicated by a lower closed porosity and the largereparation of the trabeculae. In addition, the trabec-lar number was larger, although the thickness wasomparable for all volumes analyzed.Survival rate for implants placed in the augmented

inus was 96.9% after the 5-year follow-up (63 im-

IGURE 6. Three-dimensional models of A, sinus lift sample and B,ontrol. The models represent a cylinder cut from the center of theamples with a diameter of 2.35 mm. The approximate division inections represents native bone (red) and newly formed bone of therafted area (blue).

aubet et al. Sinus Floor Elevation with Bone Graft. J Oralaxillofac Surg 2011.

Table 1. THREE-DIMENSIONAL MORPHOMETRIC PARAMNATIVE BONE

Parameter UnitNew Bone (GraftedSinus-Augmented

one volume % 13.24one-specific surface mm�1 41.3losed porosity % 0.013rabecular thickness mm 0.114rabecular separation mm 0.168rabecular number mm�1 0.9

aubet et al. Sinus Floor Elevation with Bone Graft. J Oral Maxillofac

lants integrated and 2 implants failed). One non-sseointegrated implant failed at the moment ofxposition in the course of the second surgical pro-edure and the other failed after 9 months of func-ional loading.

iscussion

The oral cavity is an excellent source of autogenousone for several bone regeneration techniques. These of a bone scraper has proved to be of special

nterest to obtain amounts of bone that are required inost sinus augmentation procedures. The literature

escribes the use of scrapers for harvesting autoge-ous bone from the oral cavity and several otherxtraoral sources.7-11 Zaffe and D’Avenia10 publishedata regarding bone quality of cortical bone chipsarvested with a Safescraper. They described chips of.9 to 1.7 mm in length (roughly 100 mm thick).hips had an oblong or quadrangular shape and con-

ained live osteocytes (mean viability, 45% to 72%).one chip grafting produced newly formed bone tis-ue suitable for implant insertion. Trabecular boneolume measured on biopsies decreased with timefrom 45% to 55% to 23%). Grafted chips made up0% or less of the calcified tissue in biopsies. Biopsiesresented remodeling activities, new bone formationy apposition, and live osteocytes (�35%).10,11

In this work, the harvesting procedure is of specialnterest because autogenous bone is obtained fromhe maxillary malar area through the same incisionerformed for the sinus approach. This procedure

ntroduces some advantages by decreasing surgicalime and morbidity caused to the patient. Accordingo the results reported by Peleg et al12 using thisechnique, the present patients showed satisfactoryone regeneration rates with minimum discomfort inhe donor site area.

Considering that the average dimensions of thedult maxillary sinus are 25 to 35 mm (width), 36 to5 mm (height), and 38 to 45 mm (length),3 it may beoncluded that most sinus augmentations can be suc-essfully performed with 2 to 3 mL of autogenous

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488 SINUS FLOOR ELEVATION WITH BONE GRAFT

one in a composite graft. This amount of bone cane easily harvested from each side with the Safe-craper device.

Careful evaluation of a patient before performinginus augmentation, including clinical and radiologicxaminations, is of great importance to prevent fur-her complications.13,14 Moreover, the previous statef pneumatization of the sinus is of great importanceo predict the amount of bone that may be requestednd to decide which type of graft is to be used. At thisoint, we propose a decision-making algorithm thatay help the clinician to select those cases where the

se of the bone scraper would be specially indicated.s seen in Figure 7, the state of pneumatization of theinus is a key consideration in the selection of aarvesting procedure. Those sinuses presenting nor-al pneumatization in radiologic examination can be

ugmented with a mixture of bovine hydroxyapatitend autogenous bone obtained from the oral cavitysing a bone scraper. If pneumatization of the sinus isigh, the requirements of bone graft volume increasend other donor sites for autogenous bone such as theliac crest, tibia, or calvaria might be considered.15-17

Some minimally invasive techniques to harvest ex-raoral sources of autogenous bone grafts have beeneported. Sándor et al18 reported satisfactory resultssing a trephine to procure bone from the anterior

liac crest. The amount of bone obtained was relatedo the number of cores taken. Using the cores alone,he mean volume obtained per site ranged from 3 to1 mL of compacted bone. In this study, the trephineechnique of bone harvesting was associated withinimal morbidity. The postoperative complication

ate was 3.6% and did not involve any long-term

IGURE 7. Decision-making guidelines for sinus augmentationrocedures and selection of a donor site for autologous bone. PRP,latelet-rich plasma.

aubet et al. Sinus Floor Elevation with Bone Graft. J Oralaxillofac Surg 2011.

omplications. t

Some investigators have reported satisfactory re-ults in the sinus augmented with different bone sub-titutes when used alone or in combination with au-ogenous bone.19-22 A mixture of autogenous bonend other materials increase bone regeneration byombining the advantages derived from each mate-ial. Autogenous bone may accelerate the healing pro-ess because it is a source of osteogenic cells andther growth factors.23 Bovine hydroxyapatite consti-utes an excellent osteoconductive material and,ecause of nonresorptive properties, it behaves asn excellent scaffold for new bone formation overime.15,24

When sinuses are augmented with biomateriallone, a period of 9 to 12 months before implantlacement is recommended.25 The addition of autog-nous bone to hydroxyapatite, as described in thiseport, seems to account for a decrease in healingime to 4 to 6 months, with satisfactory long-termesults in implants placed beyond this period.26-28 Inhis work all implants were successfully placed 4onths after the sinus augmentation with a flapless

pproach and bone levels were maintained during the-year follow-up as assessed by radiographic examina-ion. With this flapless approach, surgical trauma isinimal, accounting for a decrease of morbidity in the

ntire implant placement procedure.29 According to aeview by Brodala,30 there are statistically significantecreases in immediate postoperative discomfort, du-ation of discomfort, facial edema, and use of analge-ics using flapless surgery. Flapless surgery may haveenefits in decreasing patient discomfort in the im-ediate postoperative period. Information based onrospective cohort studies has shown high survivalsurvival rate, 98.6%; 95% confidence interval, 97.6 to9.6) for implants placed using a flapless technique.etrospective studies and case series have demon-trated a 95.9% survival rate (95% confidence interval,4.8 to 97.0).30-32

Complications with flapless surgery may be intra-perative or delayed. The most frequent complication

s perforation of the buccal or lingual bone plate. Itccurs in 3.8% of surgical procedures. Owing to theaxillary resorption pattern, perforation of the bonelate is more common in the anterior maxilla than inhe region of premolars and molars. This may explainhe absence of bone plate perforations in the presentatients.In all patients bone formation was achieved suc-

essfully after 4 months and enabled implant place-ent. Histologic analysis of 10 core samples obtained

t this time showed the presence of mature bone andhese findings were consistent with images observedn radiologic examinations of the regenerated areand the findings from histologic and microcomputed

omographic analyses. Furthermore, survival rates for

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CAUBET ET AL 489

he implants placed in the augmented sinuses wereimilar to those reported in the literature using otherrafting techniques.21,33,34

Platelet-rich plasma was mixed with the graft ma-erial in all patients in this study. Although a directffect of the platelet-rich plasma in promoting sub-tantial enhancement of bone regeneration has noteen proved,35-37 there are some advantages derivedrom its use that may be taken into account. Thelatelet gel improves the handling properties of theraft material by facilitating graft placement and sta-ility and delivers a highly concentrated dose ofrowth factors that increase and accelerate soft tissueealing.38,39 In contrast, platelet-rich plasma plays an

mportant role in those cases where the sinus mem-rane is damaged during the sinus elevation proce-ure. This complication occurred in 8 patients andas successfully treated by covering the defect with

he platelet gel, thus further permitting normal place-ent of the graft material with the same surgical

pproach.Final restoration was completed successfully in all

atients, achieving good esthetics and clinical func-ioning. After a 5-year follow-up, no complicationsave occurred and bone levels have been maintained,s can be seen in the radiologic examinations at thisime.

The results of this work indicate that this graftingrocedure appears to be a clinically reliable proce-ure with rare complications. Furthermore, the surgi-al morbidity when using a bone scraper device forone harvesting and a flapless approach for implantlacement is very low, so the entire process can beonsidered a minimally invasive technique. Avoidinghe need for extra surgical approaches seems to be ofreat importance in overcoming the risk of infectionnd discomfort for patients.

eferences1. Tatum OH: Maxillary and sinus implant reconstruction. Dent

Clin North Am 30:207, 19862. Boyne P, James RA: Grafting of the maxillary sinus floor with

autogenous marrow and bone. J Oral Maxillofac Surg 17:113,1980

3. van den Bergh JPA, ten Bruggenkate CM, Disco FJM, TuinzingDB: Anatomical aspects of sinus floor elevations. Clin OralImplants Res 11:256, 2000

4. Clavero J, Lundgren S: Ramus or chin grafts for maxillary sinusinlay and local onlay augmentation: Comparison of donor sitemorbidity and complications. Clin Implant Dent Relat Res5:154, 2003

5. Criccio G, Lundgren S: Donor site morbidity in two differentapproaches to anterior iliac crest bone harvesting. Clin ImplantDent Relat Res 5:161, 2003

6. Sonnleitner D, Huemer P, Sullivan D: A simplified technique forproducing platelet JOMS rich plasma and platelet concentratefor intraoral bone grafting techniques: A technical note. IntJ Oral Maxillofac Implants 15:879, 2000

7. Artzi Z, Kozlovsky A, Nemcovsky CE, Weinreb M: The amountof newly formed bone in sinus grafting procedures depends on

tissue depth as well as the type and residual amount of thegrafted material. J Clin Periodontol 32:193, 2005

8. Klainulainen VT, Sándor GK, Carmichael RP, Oikarinen KS:Safety of zygomatic bone harvesting: A prospective study of 32consecutive patients with simultaneous zygomatic bone graft-ing and 1-stage implant placement. Int J Oral Maxillofac Im-plants 20:245, 2005

9. Al-Sebaei MO, Papageorge MB, Woo T: Technique for in-officecranial bone harvesting. J Oral Maxillofac Surg 62(suppl 2):120,2004

0. Zaffe D, D’Avenia F: A novel bone scraper for intraoral harvest-ing: A device for filling small bone defects. Clin Oral ImplantsRes 18:525, 2007

1. Johansson LA, Isaksson S, Lindh C, et al: Maxillary sinus flooraugmentation and simultaneous implant placement using lo-cally harvested autogenous bone chips and bone debris: Aprospective clinical study. J Oral Maxillofac Surg 68:837, 2010

2. Peleg M, Garg AK, Misch CM, Mazor Z: Maxillary sinus andridge augmentations using a surface-derived autogenous bonegraft. J Oral Maxillofac Surg 62:1535, 2004

3. Beaumont C, Zafiropoulos GG, Rohmann K, Tatakis DN: Prev-alence of maxillary sinus disease and abnormalities in patientsscheduled for sinus lift procedures. J Periodontol 76:461, 2005

4. Timmenga NM, Raghoebar GM, van Weissenbruch R, Vissink A:Maxillary sinus floor elevation surgery. A clinical, radiographicand endoscopic evaluation. Clin Oral Implants Res 14:322, 2003

5. Simion M, Fontana F: Autogenous and xenogeneic bone graftsfor the bone regeneration. A literature review. Minerva Stoma-tol 53:191, 2004

6. Iturriaga MT, Ruiz CC: Maxillary sinus reconstruction withcalvarium bone grafts and endosseous implants. J Oral Maxil-lofac Surg 62:344, 2004

7. Hernandez-Alfaro F, Marti C, Biosca MJ, Gimeno J: Minimallyinvasive tibial bone harvesting under intravenous sedation.J Oral Maxillofac Surg 63:464, 2005

8. Sándor G, Rittenberg B, Clokie C, Caminiti M: Clinical successin harvesting autogenous bone using a minimally invasive tre-phine. J Oral Maxillofac Surg 61:164, 2003

9. Tong DC, Rioux K, Drangsholt M, Beirne OR: A review ofsurvival rates for implants placed in grafted maxillary sinusesusing meta-analysis. Int J Oral Maxillofac Implants 13:175, 1998

0. Merkx MA, Maltha JC, Stoelinga PJ: Assessment of the value ofanorganic bone additives in sinus floor augmentation: A reviewof clinical reports. Int J Oral Maxillofac Surg 32:1, 2003

1. Hurzeler MB, Kirsch A, Ackermann KL, Quinones CR: Recon-struction of the severely resorbed maxilla with dental implantsin the augmented maxillary sinus: A 5-year clinical investiga-tion. Int J Oral Maxillofac Implants 11:466, 1996

2. Raghoebar GM, Schortinghuis J, Liem RS, et al: Does platelet-rich plasma promote remodelling of autologous bone graftsused for augmentation of the maxillary sinus floor? Clin OralImplants Res 16:349, 2005

3. Hallman M, Sennerby L, Lundgren S: A clinical and histologicevaluation of implant integration in the posterior maxilla aftersinus floor augmentation with autogenous bone, bovine hy-droxyapatite, or a 20:80 mixture. Int J Oral Maxillofac Implants17:635, 2002

4. Schlegel KA, Fichtner G, Schultze-Mosgau S, Wiltfang J: Histo-logic findings in sinus augmentation with autogenous bonechips versus a bovine bone substitute. Int J Oral MaxillofacImplants 18:53, 2003

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