VERTICAL RIDGE AUGMENTATION

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Edentulism 
Once the teeth are lost, a continuous

resorptive process  Results
Diminished volume and strength of residual bone Loss of facial vertical dimension Impaired masticatory function Difficulty choosing a balanced diet Speech difficulty Facial soft tissue changes Pathologic fracture possibility
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SITE DEVELOPMENT 
Reconstruction of deficient alveolar ridges

that lacks sufficient volume, contour, or height 
Ultimate surgical goal
Restore function, form, and long-term stability 

Surgical approach selection
Type, size, and shape of the defect Surgical expertise or experience level of surgeon Intended direction of the augmentation
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SITE DEVELOPMENT 
Hard tissue management
Ridge(socket) preservation Ridge augmentation
‚ Vertical ridge augmentation ‚ Horizontal ridge augmentation 

Soft tissue management

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SITE DEVELOPMENT 
Hard tissue management
Ridge(socket) preservation Ridge augmentation
‚ Vertical ridge augmentation ‚ Horizontal ridge augmentation 

Soft tissue management

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Defect size 
Small edentulous segments (such as single tooth)
Particulate autogenous bone with membrane (Fugazzotto 1997) 

Large ridge reconstructions
Controversial (Lang et al 1994, Chiapasco et al 1999) Autogenous block bone
‚ Extra-oral ‚ Intra-oral

Distraction (>5mm vertical deficiency)
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TMI 
Bosker Transmandibular Implant (TMI)
In the late 1970s Without the need for autologous bone graft Technique sensitive both surgeon & prosthodontist Significant reversible complication rate
‚ 22.2% (Keller et al, Int JOMI 1986;1:101) ‚ Infection, superstructure fx, mandible fx, fail to osseointegrate

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Ridge augmentation methods 
Bone grafting  Biomaterials  GBR  Alveolar distraction osteogenesis

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Distraction Osteogenesis
for vertical ridge augmentation 

History
1992, McCarthy and coworker 1996, Block & colleager ; dog 1996, Chin & Toth ; DO & Implant 

Advantage
No additional surgery involving a harvesting procedure No limit to lengthening Simultaneous lengthening of surround soft tissue 

Dis-advantage
Long treatment period Need for suitable distractor Danger of infection 

Ilizarov (1989)
Preservation of blood supply at the corticotomy site 

Kojimoto & coworkers (1988)
Preservation of periosteum : distraction Vestibular incision rather than crestal incision
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Ridge augmentation methods 
Bone grafting  Biomaterials  GBR (Guided Bone Regeneration)  Alveolar distraction osteogenesis

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Titanium membrane only 
Cornelini (2000)
Ti-memb only, 3mm vertical ridge augmentation

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Simultaneous implant placement and vertical ridge augmentation with a titanium-reinforced membrane: A case report
Cornelini R, Cangini F, Covani U, Andreana S (Int JOMI, 2000;15:883-888) 

  

Vertical ridge augmentation with titanium reinforced memb. 2nd surgery : 12 months later 3mm hard tissue augmentation 2mm dense connective tissue covered the newly formed bone

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Ridge augmentation methods 
Bone grafting  Biomaterials  GBR  Alveolar distraction osteogenesis

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Autogenous bone graft
Gold standard for bone augmentation procedures Block bone or particulate forms
‚ Block bone - reduced osteogenic activity & slow revascularization than particulate bone marrow

Extra-oral or Intra-oral donor-site
‚ Intraoral harvested intramembraneous bone graft may have minimal resorption, enhanced revascularization, and better incorporation at the donor site

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Autogenous bone graft 
Advantage
Osteogenic potential Block grafts that maintain form and shape Ability to correct any size or shape deformity Elimination of the possibility for an immunogenic reaction 

Disadvantage
2nd surgical intervention Morbidity associated with the donor site Unpredictable bone resorption Longer recovery period Difficulty in managing soft tissue coverage Increased treatment time Increased risks

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Autogenous block bone grafts 
Width deficiency
Veneer or saddle graft Most predictable and resistant to resorption 

Vertical deficiency
Onlay or saddle graft Difficult to gain and maintain, high resorption rate 

Combined deficiency

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Donor Sites of Autogenous Bone 
Cortical Bone
Mandible, Cranium 

Cancellous Bone
Mx. Tuberosity Inner Cancellous part 

Cortico-Cancellous Bone
Iliac bone

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Intra-oral vs Extra-oral 
Kusiak et al (1985)
Intramembranous bone grafts accelerate revascularization and healing as compared to endochondral bone grafts Cortical membranous grafts revascularize more rapidly than endochondral bone graft with a thicker cancellous part 

Zins & Whittacker (1983), Philips & Rhan (1990)
Membranous bone (such as mandible) undergoes less resorption than endochondral bone (such as iliac crest) 

Intraoral harvested intramembraneous bone grafts
Minimal resorption Enhanced revascularization Better incorporation at the donor site

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Iliac bone

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Chin bone

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Ramus bone

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Ramus bone

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Chin vs Ramus 
Complication (chin vs ramus)
Less cosmetic concern Less wound dehiscence No gingival recession Less sensory disturbance Less discomfort complain Trismus & edema (medication)

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Chin vs Ramus
Parameter Surgical access Cosmetic concern Graft shape Graft Size Graft Morphology Graft Resorption Healed Bone Quality Post-OP pain/edema Teeth Nerve damage Incision dehiscence Symphysis Good High Thick rectangular >1cm3 Corticocancellous Minimal Type 2>type 1 Moderate Common(temporary) Common(temporary) Occasional(Vestibular) Ramus Fair to good Low Thinner rectangular veneer <1cm3 Cortical Minimal Type1>Type2 Minimal to moderate Uncommon Uncommon Uncommon

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Maxilla vs Mandible 
Maxilla
More vascularity 

Mandible
Less vascularity
‚ Cortical bone perforation with bur

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Critical Success Factors 
Stability of grafting materials  Condition of recipient sites  No infections  Resistance to resorptions  Soft tissue coverage

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Stability of grafting materials 
Bony irregularity contouring  Graft fixation
Block bone : at least 2 fixation screws for immobilization

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Condition of recipient sites 
Inlay graft (3~4 wall defect)
More favorable 

Onlay graft (1~2 wall defect)
More prone to resorption

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Infection 
Disrupt the process and halts the growth of new

bone 

Rupture of the soft tissue closure  Block graft exposure
Exposure time (2002, proussaefs)
‚ Late exposure : no clinical & histologic sign of pathosis or necrosis ‚ Early exposure : partial or total necrosis 

Fixation screw infection  Adjacent teeth(structure) pathologic conditions
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Resistance to resorption 
Immobilization  Satisfactory to restore mandibular volume
In function the grafted bone underwent rapid resorption 

Onlay graft
Use membranous bone & graft stability (Philips & Rhan 1990) 

Cortical bone  Use of membrane  Adequate implant placement timing
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Soft tissue coverage 
Crestal incision with releasing incisions  Lingual flap
Mesially at least 3 teeth include Raise extending beyond mylohyoid muscle 

Tension-free suture  Mattress suture : contact over 3mm  Soft tissue graft
Free graft : FGG, CT Pedicle graft : palatal or labial
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Controversy 
1 stage surgery (bone graft & implant

placement)
Single surgical intervention Potentially reduced healing time 

2 stage surgery
Prosthetically better implant placement Superior esthetics

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1 stage surgery 
1 stage surgery (bone graft & implantation)
Long-term implant survival rates : 25~100% Implant position & angulation are critical factors Implant survival alone does not predict successful restoration of occlusion Verhoeven et al 1997 Carr & Laney 1987 Marx & Morales 1988

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Advantage of delayed implantation 
Reducing the infection rate & graft failure rate  Proper angulation & more precise positioning  After 5 years of masticatory functional loading  Onlay grafting & simultaneous implantation in

maxilla
Success rate : 51~83% 

Secondary implantation
Schliephake et al (1997, JOMS) 20% higher success rate
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Resorption rate 
Proussaefs, Lozada et al (2002)
Block graft with Bio-oss : 16.34 %, 17.58 % 

Cordaro et al (2002)
Block bone : Mn 41.5%, Mx 43.5% (mean 42%) 

Wang and colleagues (1976) : onlay bone graft
During the first 3 years : 14%~100% 

Bell et al (2002)
Iliac crest block bone : 33%
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The use of ramus autogenous block grafts for vertical alveolar ridge augmentation and implant placement: A pilot study Lozada J, Kleinman A, Rohrer M (Int JOMI 2002;17:238-248) Proussaefs P, 

Ramus block autograft for vertical alveolar ridge augmentation
Ramus block bone, Fixation screws, Periphery : Bio-Oss 4~8 months later : HA implant (Steri-Oss) 

Results
Radiographic
‚ 6.12 mm (1 month) p 5.12 mm (4~6 months) : 16.34 %

Laboratory volumetric
‚ 0.91 mL (1 month) p 0.75 mL (6 months) : 17.58 %

Peripheral pariculate bone (Bio-Oss)
‚ Bone (34.33%), fibrous tissue (42.17%), residual Bio-Oss particle (23.50%) 

Discussion
Early exposure appeared to compromised the results, while late exposure did not affect the vitality of the block autografts

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Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially edentulous patients prior to implant placement

Cordaro L, Amade DS, Cordaro M (Clin oral impl res, 2002;13:103-111) 

15 partially edentuous patients
Ramus & symphysis block bone Fixed with titanium screw After 6 months screw remove, implant placed 12 months later implant supported fixed bridges 

Mean reduction rate
Lateral : 23.5% Vertical : 42 % Mandibular site more resorption rate than maxillary sites
% reduction of lateral aug. 23.5% 20% 27.5% Vertical aug. at bone grafting 3.4+0.66 4.75+1.5 2.4+0.2 Vertical aug. at implant placement 2.2+0.66 2.75+1.5 1.4+0.2 % reduction of vertical aug. 42% 41.5% 43.5%

Groups

No. of aug. sites 18 10 8

Lateral aug. at bone grafting 6.5+0.33 6.5+0.6 6.5+0.37

Lateral aug. at implant placement 5.0+0.23 5.2+0.4 4.75+0.12

Group 1 & 2 Group 1 : Mx Group 2 : Mn

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Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (JOMS, 2002;60:1135-1141) 

Materials and Methods
Vertical mandibular height <7mm (atrophic mandible) Iliac crest bone graft to the mandible via an extraoral approach After 4~6 months, implantation 

Results
Mean pre-op bone height : 9mm (midline), 5mm (body) Before implantation (4~6months) vertical bone loss : 33% After implantation (24 months)
‚ Non-implant supported region bone loss 11% per year ‚ Implant-supported region bone loss negligible 

Conclusions (improve success rates)
Prosthetically sound implant positioning Provide an affordable reconstructive option Staged reconstruction

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Complications of grafting in the atrophic edentulous or Bahat O, Int JPRD 21:487-495 2001 partially edentulousFontanesi RV jaw 

Intraoperative complications
Bone
‚ Insufficent donor material ‚ Over-reduction ‚ Inadequate fixation 

Postoperative complications
Gerneral
‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚ ‚
Infection Excessive resorption (early exposure, loss of graft) Inadequate bone for implant Hematoma Flap retraction Flap necrosis Color or tissue-type mismatch Loss of papilla Shallowing of vestibule External root resorption Sinusities Nasal bleeding Oroantral fistula

Bone

Soft tissue
‚ Perforation ‚ Inability to mobile

Soft tissue

Teeth
‚ Root damage

Other anatomy
‚ Sinus : membrane tear ‚ Nerve injury

Teeth Other anatomy

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CASE REPORT

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Conclusions 
Autogenous block bone graft (chin or ramus)
5~7mm gaining About 30% resorption rate 

Staging the grafting and implant procedure

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Primary stability (+)
Exposed threads can be covered with autogenous bone associated with a membrane Jovanovic et al (1992), Jovanovic & Buser (1994), Giovannolli & Renouard (1995), Antoun et al (1996) 

Primary stability (-)
Ridge augmentation should be performed before implantation

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