Bone Grafting for implants

Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang Univ.

Kwon, Kyung-Hwan

Diagnosis and Treatment Planning For Bone Augmentation

A complete intraoral examination Radiographs and in select cases a CT scan

Neurovascular bundles must be avoided. Paranasal sinus must be identified.

Study models

Diagnosis and Treatment Planning For Bone Augmentation

Clinical Examination

Minimal obtain 1 to 2mm of attached gingiva Cross section of the alveolar depicting periodontal probe placement for sounding the bone. To determine bone width Cutting the study model in the exact vertical location

To Determine Bone Width

Harry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunders company. 2001

Diagnosis and Treatment Planning For Bone Augmentation

Radiographic Examination

Panoramic radiograph 20 to 30% distortion/magnification of the anatomic structures Buccal to lingual width will not be appreciated Alveolar bone height, adjacent teeth and anatomic structure

Diagnosis and Treatment Planning For Bone Augmentation

Study Models

Fabricate a surgical stent Guiding to the exact site of implant placement Diagnostic wax-ups Arch form, tooth spacing, and bony contour

Types of Bone Grafts

Autograft

A graft taken from on anatomic location and placed in another location in the same individual(e.g., iliac crest)
A graft taken from a cadever treated wit certain sterilization and antiantigenic procedures and placed into a living host A chemically derived nonanimal material A graft taken from a nonhuman host for implantation into a human host

Allograft

Alloplast

Xenograft

Biology of Bone Grafts

Phase I

Osteogenesis: Immediate proliferation of transplanted osteocytes and subsequent formation of osteoid(immature bone) Osteoinduction: inducement of mesenchymal cells to produce bone(BMP) Osteoconduction: framework or scaffold for the formation of new bone tissue

Phase II

Harvesting Techniques I

Mandibular Ramus

To create an incision starting on the lateral border of the ramus approximately 1.5cm above the mandiblular occlusal plane and ending at the mandibular second molar region #9 Molt periosteal elevator: full thickness mucoperiosteal flap

Mandibular Ramus

0.9% Sodium chloride solution/ Crushed into small particles or used as block

Harvesting Techniques II

Mandibular Tori as a Donor site

Monobevel Chisel is used, With the bevel positioned facing the lingual cortex

Grafting of the Extraction Socket

The teeth are extracted atraumatically preserving the buccal bone. All granulation tissue is excised with the use of a surgical curette or a Rongeur. DFDBA(deminerized freeze-dried bone allograft) + Gore Tex Mem.

Extraction Socket Grafting

A. Extraction socket with particulate graft in place B. Closure of extraction site with interdigitating papillae

Harvesting Techniques III

Cortical Onlay Bone Graft

Inadequate buccal to lingual/palatal width Autogenous bone: donor sitesmandibular symphysis, mandibular ramus, calvarium or iliac crest Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles

Bone Harvasting from the Chin

Buccal sulcus incision: canine to caine Full-thickness mucoperiosteal flap Avoid the mental nerve Level approximately 5mm below the apices of the mandibular anterior teeth

Bone Harvasting from the Chin

Small curve monoplane osteotome Hemostasis: Avitene(MedChem Products Inc., Woburn, MA) 3-0 Vicryle suture on a tapered needle First approximate periosteum with multiple intterupted sutures being careful to maintain the mentalis muscle

Interpositional Ridge Graft

The approximate depth of the osteotomy should be 1cm. A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant Split ridge technique

Rigde split technique

Sinus-Lift Procedure
Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang Univ.

Kwon, Kyung-Hwan

Sinus-Lift Procedure definition

Taum OH(1977)

Introduced crestal approach to the sinus membrane In 1986, modified Caldwell-Luc lateral window

The grafte material is inserted between the antral floor and the Schneiderian membrane(lining of the maxillary sinus floor)

Evaluation of Sinus

Fixture failure will result because of the downgrowth of antral epithelium aroud the fixture rather than by the superior growth of oral epithelium Protocol of Sinus Lifting Indication

4 mm below: Lateral window technique 4-6mm :Summers Osteotome technique 6mm above: Simultaneous implant with bone grafting

Graft Material for Sinus Lift

Autogeous Bone

Hip/ Tibia/ Symphysis/ Ramus/ Maxillary tuberosity

Freeze-dried bone/DFDB Bovine bone(Bio-Oss)

Allograft(obtained from human cadavers)

Xenografts(Bone from nonhuman species)

Alloplastic(Natural and synthetic bone substitute)

Hydrozyapatite/ Tricalcium phosphate(TCP)/ Bioactive glass ceramics

Time Tables

Waiting between 4 and 9 after grafting for implant placement and an additional 4 to 6 months before placing final restoration In my clinics, Simultaneous implantation study show result of 95% success rate. but, case by case

Maxillary Sinus Lifting Technique

Surgical Protocol
A B C D

A: Sagittal view of maxillary sinus showing relationship of sinus membrane B: Showing outline of bony cuts for creation of lateral window C: Mucosal flap elevated and slow round bur being used to create bony window D: Antral membrane shown tented upwards with implant place and bone filling

Maxillary Sinus Lifting Technique

Surgical Protocol

Round diamond #6 burr Surgical curette is place in the edges of the inferior osteotomy between the bone and the antrum and gently used to peel away the membrane from the inside wall of the sinus Perforation of membrane: CollaTape used Leave sutures in place fo 7 to 10 days Antibiotics, analgesics and decongestant coverage

Maxillary Sinus Lifting Technique

Not wear a removable appliance for the first 2 postoperative weeks The most common postoperative complication: Infection- irrigated daily until resolution

Sinus lifting

Principles of Implant Surgery

Essential Critical Factors

-Implant placement success

Minimal trauma Biocompatible material Buried and untouched for 3 to 4 months before prosthetic loading Copious internal or external irrigation to minimize thermal bone demage Precious attachment of implant and prosthesis

Implant Placement

Relative Contraindications

Uncontrolled diabetic patient Significant smocking history Jawbone irradiation less than 1 year before implant placement Acute psychotic disorders Severe bone resorption in patient who refuses bone grafting

Minimal Dimensional Parameters

At least 1mm of excess bone: both the lingual and buccal or labial side At least 2 mm of bone: implant and any adjacent tooth or implant Vertical ridge height must ideally provide a 1- or 2 mm margin of safety from the inferior alveolar mandibular canal, maxillary sinus, and other adjacent vital structures Adequate vertical space: minimum of 8mm

Implant Work-Up ProtocoI(1)

Appropriate X-rays

Panoramic film Periapical X-rays CAT scan(if deemed necessary) Lateral cephalogram(when indicated in edentulous lower arch)

Models of upper/lower arches Mock wax-up of missing teeth on mounted upper/lower casts

Implant Work-Up Protocol(2)

Fabrication of plastic stent Peper tacing: sinus and inferior alveolar nerve Detect thickness and concavities Evaluation of existing periodontal condition Patient education: Risks and complication

Diagnostic and Surgical Implant Placement Protocol

Initial Dental Consultation Clinical Evaluation and Diagnosis Therapeutic Plan Presurgical Mouth Preparation Surgical Implantation Prosthetic Management Follow-Up Care and Maintenance

Diagnostic and Surgical Implant Placement Protocol (1)

Initial Dental Consultation

Patients reason an motivation for dental consulatation Etiology of edentulous or patially edentulous state General medical history Indications and contraindications Specific dental/oral complaints Oral Examination Psychosocial evaluation Preliminary diagnosis

Diagnostic and Surgical Implant Placement Protocol(2)

Clinical Evaluation and Dx.

Review of indications and contraindications Oral examination Evaluation of existing dentition Periodontal evaluation: prophyaxis Occlusal analysis Analysis of models in a semiadjastabl articulator Radiographic findings Full mount Panorex radiogaph Specific periapical and/or lateral jaw radiographs Photographic documentation

Diagnostic and Surgical Implant Placement Protocol(3)

Therapeutic Plan

Implant position and sizes Prosthetic restoration Explanation of treatment plan Establishment of treatment sequence and schedule Establishment of financial arrangements

Diagnostic and Surgical Implant Placement Protocol(4)

Presurgical Mouth Preparation

Extractions Necessary restorative dental procedures Periodontal therapy Endodontal therapy Orthodontal therapy Prophylatic splinting Presurgical measurement radiograph with surgical template in place

Diagnostic and Surgical Implant Placement Protocol(5)

Surgical Implantation

Confirm measurement of potential implant sites on radiograph Positioning of the surgical template Surgical insertion of implant(Stage 1) Reopening of the implant sites(Stage 2) Removal of first phase healing screw

Diagnostic and Surgical Implant Placement Protocol(6)

Prosthetic Management

Preparation of adjacent natural teeth Removal of second phase healing screw Making impression Fabrication of master model Try-un and adjustment of prosthesis Delivery of prosthesis

Diagnostic and Surgical Implant Placement Protocol(7)

Follow-Up Care and Maintenance

Oral prophylaxis Periodotnal evaluation Oral hygiene reeducation and remotivation Implant recommandation
Partial Denture ? Or Implant?