Bone augmentation for implants / orthodontics training courses

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implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic

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Bone augmentation for implants / orthodontics training courses

  1. 1. BONE AUGMENTATION FORBONE AUGMENTATION FOR IMPLANTSIMPLANTS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. CONTENTSCONTENTS  INTRODUCTIONINTRODUCTION  CLASSIFICATION OF AUGMENTATION MATERIALSCLASSIFICATION OF AUGMENTATION MATERIALS  SURGICAL KEYS OF BONE GRAFTINGSURGICAL KEYS OF BONE GRAFTING  INRAORAL AUTOGENOUS DONOR BONE GRAFTSINRAORAL AUTOGENOUS DONOR BONE GRAFTS - General considerations- General considerations - Donor sites- Donor sites EXTRAORAL AUTOGENOUS DONOR GRAFTSEXTRAORAL AUTOGENOUS DONOR GRAFTS MAXILLARY SINUS LIFT AND SINUS GRAFT SURGERYMAXILLARY SINUS LIFT AND SINUS GRAFT SURGERY - Pathologic assessment- Pathologic assessment - Premedications- Premedications - Surgical techniques- Surgical techniques - Complications- Complications PREMAXILLA IMPLANT CONSIDERATIONSPREMAXILLA IMPLANT CONSIDERATIONS - Premaxilla surgery- Premaxilla surgery - Subnasal Elevation and Augmentation- Subnasal Elevation and Augmentation BONE GRAFTING AND MAINTENANCE OF ALVEOLAR BONE FORBONE GRAFTING AND MAINTENANCE OF ALVEOLAR BONE FOR CONVENTIONAL PROSTHESISCONVENTIONAL PROSTHESIS www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. INTRODUCTIONINTRODUCTION To satisfy the ideal goals of implant dentistry, the hardTo satisfy the ideal goals of implant dentistry, the hard and soft tissues need to present ideal volumes andand soft tissues need to present ideal volumes and quality.quality. The alveolar process is affected so often after toothThe alveolar process is affected so often after tooth loss, augmentation is usually indicated to achieveloss, augmentation is usually indicated to achieve optimum results.optimum results. Because of an improved understanding ofBecause of an improved understanding of biomechanics requirements for long term prosthesisbiomechanics requirements for long term prosthesis survival and the increasing use of implants in estheticsurvival and the increasing use of implants in esthetic restorations, ridge reconstruction before implantrestorations, ridge reconstruction before implant placement has become a necessary procedure for aplacement has become a necessary procedure for a number of edentulous patients.number of edentulous patients.www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. Bone Augmentation MaterialsBone Augmentation Materials ClassificationClassification Based on Mode of action they areBased on Mode of action they are classified into:classified into: 1. Osteoconductive1. Osteoconductive 2. Osteoinductive and2. Osteoinductive and 3. Osteogenic Graft materials.3. Osteogenic Graft materials. www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5. Current Osteocunductive Grafting Materials Include:Current Osteocunductive Grafting Materials Include: 1. Calcium Phosphates1. Calcium Phosphates a. HA synthetic - Calcitea. HA synthetic - Calcite - orthomatrix HA- orthomatrix HA - osteogen- osteogen - osteograf D, LD- osteograf D, LD b. HA Natural - Bioossb. HA Natural - Biooss - Osteograf N- Osteograf N - Osteomin- Osteomin c. TCP - Augmenc. TCP - Augmen - CalciResorb- CalciResorb - SynthoGraf- SynthoGraf 2. Calcium Carbonate2. Calcium Carbonate - Interpore 200- Interpore 200 - Biocoral- Biocoral 3. Bioactive Glass Ceramics3. Bioactive Glass Ceramics - Bioglass- Bioglass - Biogran- Biogran - Perioglass- Perioglass 4. Biocompatible Composite Polymer4. Biocompatible Composite Polymer - Bioplant HTR- Bioplant HTR www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. OSTEOCONDUCTIONOSTEOCONDUCTION  Osteoconduction characterizes bone growth byOsteoconduction characterizes bone growth by apposition from the surrounding bone. Thereforeapposition from the surrounding bone. Therefore this process must occur in the presence of bonethis process must occur in the presence of bone or differentiated mesenchymal cells.or differentiated mesenchymal cells. The most common osteoconductive bone graftingThe most common osteoconductive bone grafting materials used in implant dentistry arematerials used in implant dentistry are alloplastsalloplasts andand xenograftsxenografts.. Alloplasts are further classified into:Alloplasts are further classified into: Ceramics - BioinertCeramics - Bioinert - Bioactive- Bioactive polymers andpolymers and composites.composites.www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. XenograftsXenografts Are fabricated from the inorganic portionAre fabricated from the inorganic portion of bone from animals other than manof bone from animals other than man and are also osteoconductive.and are also osteoconductive. Ostoconductive matrials for hard tissueOstoconductive matrials for hard tissue maintenance and augmentation may bemaintenance and augmentation may be charactrized as:charactrized as: Nonresorbable – resorbableNonresorbable – resorbable Dense – porousDense – porous crystalline - amorphouscrystalline - amorphous www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. The resorbable osteoconductive materialsThe resorbable osteoconductive materials are made up of HA, Beta- tricalciumare made up of HA, Beta- tricalcium phosphate or various combinations ofphosphate or various combinations of both.both. ““Solution Mediated Resorption”Solution Mediated Resorption” is ais a consequence of the pH of the surroundingconsequence of the pH of the surrounding media.media. ““Cell Mediated Resorption”Cell Mediated Resorption” cells surrounding the grafted material act by phagocytosis and then intracellular degradation. www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. OSTEOINDUCTIONOSTEOINDUCTION  Osteoinduction involves new boneOsteoinduction involves new bone formation from osteoprogenitor cellsformation from osteoprogenitor cells derived from primitivemesenchymal cellsderived from primitivemesenchymal cells under the influence of one or moreunder the influence of one or more inducing agents that emnate from theinducing agents that emnate from the bone matrix.bone matrix.  The most commonly used osteoinductiveThe most commonly used osteoinductive materials in implant dentistry arematerials in implant dentistry are bonebone allografts and autografts.allografts and autografts.www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. There are primarily three types ofThere are primarily three types of bone allograftsbone allografts  Frozen boneFrozen bone  Freeze – Dried (FDBAs) andFreeze – Dried (FDBAs) and  Demineralized freeze – DriedDemineralized freeze – Dried (DFDBAs)(DFDBAs) www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. OSTEOGENESISOSTEOGENESIS  Osteogenesis refers to the growth of boneOsteogenesis refers to the growth of bone from viable cells transferred within thefrom viable cells transferred within the graftgraft  New bone is regenerated from endostealNew bone is regenerated from endosteal osteoblasts and marrow stem cellsosteoblasts and marrow stem cells transferred with the graft.transferred with the graft.  The storage medias includeThe storage medias include - Sterile saline- Sterile saline - Lactated ringer’s solution- Lactated ringer’s solution - D5W- D5Wwww.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. Surgical Keys of Bone GraftingSurgical Keys of Bone Grafting The keys of bone grafting are local factors that affect theThe keys of bone grafting are local factors that affect the prognosis of the procedure and include:prognosis of the procedure and include: Absence of infectionAbsence of infection Soft tissue closureSoft tissue closure Defect morphologyDefect morphology Autologous boneAutologous bone Space maintenanceSpace maintenance Healing timeHealing time Graft immobilizationGraft immobilization Nutrient blood vesselsNutrient blood vessels Growth factorsGrowth factors Regional acceleratory phenomenonRegional acceleratory phenomenon Collagen and calcium phosphateCollagen and calcium phosphatewww.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. Soft Tissue CoverageSoft Tissue Coverage Primary soft tissue closure and absense of infection are mandatoryPrimary soft tissue closure and absense of infection are mandatory conditions for the success of grafting procedures.conditions for the success of grafting procedures. The guidelines to reduce the incidence of postoperativeThe guidelines to reduce the incidence of postoperative complications include:complications include: 1. The primary incision should be in1. The primary incision should be in keratinized tissue.keratinized tissue. 2. The crestal incision is designed more palatal in2. The crestal incision is designed more palatal in maxilla and more facial in the mandiblemaxilla and more facial in the mandible 3. Vertical relief incisions are designed away from the3. Vertical relief incisions are designed away from the graft sitegraft site 4. Tension free wound closure.4. Tension free wound closure. 5. Should use nonresorbable sutures.5. Should use nonresorbable sutures. 6. Patients are instructed not to smoke until incision line has healed.6. Patients are instructed not to smoke until incision line has healed. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. Surgical AsepsisSurgical Asepsis  Contamination of the graft can occur fromContamination of the graft can occur from endogenous bacteria, lack of asepticendogenous bacteria, lack of aseptic surgical technique, or failure of primary softsurgical technique, or failure of primary soft tissue closure.tissue closure.  Barrier membranes or fixation screws thatBarrier membranes or fixation screws that become exposed often becomebecome exposed often become contaminated by bacteria.contaminated by bacteria.  The bacteria invade the graft site and causeThe bacteria invade the graft site and cause local inflammation with resultant decrease inlocal inflammation with resultant decrease in bone formation.bone formation. www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. Defect Size and TopographyDefect Size and Topography  The graft material selected for maintenance orThe graft material selected for maintenance or augmentation of ridge form after tooth extraction isaugmentation of ridge form after tooth extraction is related to the number of walls of bone remaining afterrelated to the number of walls of bone remaining after tooth loss.tooth loss.  A five wall bony defect will grow bone with noA five wall bony defect will grow bone with no augmentation and almost no alloplast, allograft, oraugmentation and almost no alloplast, allograft, or autograft.autograft.  One missing labial plate requires some autologous boneOne missing labial plate requires some autologous bone or guided bone regeneration.or guided bone regeneration.  As the number of bony walls decreases, moreAs the number of bony walls decreases, more autogenous bone is required, and autologous blockautogenous bone is required, and autologous block onlay grafts are used for defects with only one bony wallonlay grafts are used for defects with only one bony wall left.left. www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. Autologous BoneAutologous Bone  Autologous bone is the only graftAutologous bone is the only graft material that directly forms bone frommaterial that directly forms bone from the transplanted cancellous bonethe transplanted cancellous bone cells.cells.  It is kept in sterile, normal saline ratherIt is kept in sterile, normal saline rather than patients blood.than patients blood. www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. Space MaintenanceSpace Maintenance Tent screws , Titanium reinforcedTent screws , Titanium reinforced membranes, and/or graft materialmembranes, and/or graft material beneath the membrane have beenbeneath the membrane have been advocated to maintain the desiredadvocated to maintain the desired space during the augmentationspace during the augmentation process.process. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. Healing TimeHealing Time Graft volume less than 5mm - four toGraft volume less than 5mm - four to six months healing timesix months healing time Graft volume more than 5mm – six toGraft volume more than 5mm – six to ten monthsten months www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. Graft ImmobilizationGraft Immobilization Graft mobility leads to poor bloodGraft mobility leads to poor blood supply and sequestration of the graftsupply and sequestration of the graft material.material. There should not be any load over theThere should not be any load over the graft.graft. www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. Blood VesselsBlood Vessels  The primary source are cortical boneThe primary source are cortical bone and cancellous bone.and cancellous bone.  The secondary source for transplantedThe secondary source for transplanted bone cells is introduced into the graftbone cells is introduced into the graft site from soft tissues (andsite from soft tissues (and periosteum).periosteum). www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. Host Bone Blood VesselsHost Bone Blood Vessels  The host bone blood vessels are ofThe host bone blood vessels are of primary importance for predictableprimary importance for predictable bone augmentation.bone augmentation.  Blood vessels from bone that enter theBlood vessels from bone that enter the graft site provide pleuripotentialgraft site provide pleuripotential perivascular cells that have theperivascular cells that have the capability to become osteoblasts.capability to become osteoblasts. www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. Regional AcceleratoryRegional Acceleratory PhenomenonPhenomenon  The regional acceleratory phenomenonThe regional acceleratory phenomenon which is the local response to a noxiouswhich is the local response to a noxious stimulus, describes a process by whichstimulus, describes a process by which tissue forms faster than the normal regionaltissue forms faster than the normal regional regioneration process.regioneration process.  Noxious stimuli of sufficient magnitude, suchNoxious stimuli of sufficient magnitude, such as fractures, mechanical abuses, andas fractures, mechanical abuses, and noninfectious inflammatory injuriesnoninfectious inflammatory injuries (including dental implant procedures) can(including dental implant procedures) can evoke RAP.evoke RAP. www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. Bone and Tissue Growth FactorsBone and Tissue Growth Factors There are mainly five groups:There are mainly five groups: 1. PDGF – Platelet Derived Growth1. PDGF – Platelet Derived Growth FactorFactor 2. FGF - Fibroblast Growth Factor2. FGF - Fibroblast Growth Factor 3. TGF - Transforming Growth3. TGF - Transforming Growth FactorFactor 4. IGF - Insulin like Growth Factor4. IGF - Insulin like Growth Factor 5. BMP - Bone Morphogenic Protiens5. BMP - Bone Morphogenic Protiens www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24. Collagen and Calcium PhosphateCollagen and Calcium Phosphate  One of the source of type 1 collagen isOne of the source of type 1 collagen is DFDBA.DFDBA.  The source of calcium phospahte isThe source of calcium phospahte is from the surrounding bone and alsofrom the surrounding bone and also through blood supply.through blood supply. www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25. Intraoral Autogenous Donor Bone Grafts forIntraoral Autogenous Donor Bone Grafts for Implant DentistryImplant Dentistry • The advantage of local grafts is their convenientThe advantage of local grafts is their convenient surgical access. The proximity of donor and recipientsurgical access. The proximity of donor and recipient sites can reduce operative and anesthsia time.sites can reduce operative and anesthsia time. • Bone harvested from the maxillofacial region appearsBone harvested from the maxillofacial region appears to have inherent biologic benefits for augmentation andto have inherent biologic benefits for augmentation and is attributed to the embryonic origin of the donor boneis attributed to the embryonic origin of the donor bone as well as biochemical similarity in the protocollagen ofas well as biochemical similarity in the protocollagen of the donor and recipient bone.the donor and recipient bone. www.indiandentalacademy.com
  26. 26. Preoperative EvaluationPreoperative Evaluation • Includes esthetic concerns, soft tissueIncludes esthetic concerns, soft tissue topography, periodontal and endodontic healthtopography, periodontal and endodontic health of the adjacent teeth.of the adjacent teeth. • A diagnostic waxing of the reconstructed ridgeA diagnostic waxing of the reconstructed ridge and restored dentistionand restored dentistion • Removal of foreign bodies, soft tissue surgery,Removal of foreign bodies, soft tissue surgery, and tooth extractions.and tooth extractions. www.indiandentalacademy.com
  27. 27. Intra Oral Donor SitesIntra Oral Donor Sites TheThe mainmain donor sites are:donor sites are: 1. Mandibular Symphysis1. Mandibular Symphysis 2. Mandibular Ramus and2. Mandibular Ramus and 3. Maxillary Tuberosity.3. Maxillary Tuberosity. TheThe miscellaneousmiscellaneous sites are:sites are: 1. Residual ridge crest area1. Residual ridge crest area 2. Canine eminence areas2. Canine eminence areas 3. Lateral to the nasal spine3. Lateral to the nasal spine 4. Maxillary and mandiblar tori and exostosis4. Maxillary and mandiblar tori and exostosis 5. Particulate bone from implant drills and screw5. Particulate bone from implant drills and screw taps.taps. www.indiandentalacademy.com
  28. 28. Mandibular Symphysis Donor SiteMandibular Symphysis Donor Site • Surgical incision through vestibular incision.Surgical incision through vestibular incision. • Mucoperiosteal flap reflected to the level of pogonion.Mucoperiosteal flap reflected to the level of pogonion. • The most inferior bone cut is made first and theThe most inferior bone cut is made first and the superior osteotomy is ideally made at least 5mm belowsuperior osteotomy is ideally made at least 5mm below the tooth apices.the tooth apices. • A bone chisel is tapped along the osteotomy with theA bone chisel is tapped along the osteotomy with the exception of the inferior border to fracture the graftexception of the inferior border to fracture the graft free.free. www.indiandentalacademy.com
  29. 29. • Hemostatic materials (collagen, gelatin, sponge,Hemostatic materials (collagen, gelatin, sponge, oxidized regenerated cellulose) can be placedoxidized regenerated cellulose) can be placed into the area after bone harvest.into the area after bone harvest. • The soft tissue superior to the initial vestibularThe soft tissue superior to the initial vestibular incision is elevated to reduce tension on the flapincision is elevated to reduce tension on the flap from edema and lip movement.from edema and lip movement. • The two layered suturing is recommended forThe two layered suturing is recommended for suturing.suturing. www.indiandentalacademy.com
  30. 30. Mandibular Ramus Donor SiteMandibular Ramus Donor Site • A rectangular piece of cortical bone upto 4mmA rectangular piece of cortical bone upto 4mm in thickness may be harvested from the ramus.in thickness may be harvested from the ramus. • This bone may also be particulated and used inThis bone may also be particulated and used in sinus grafting.sinus grafting. • Smaller bone blocks /trphine cores may beSmaller bone blocks /trphine cores may be procured from the retromolar regionprocured from the retromolar region www.indiandentalacademy.com
  31. 31. • An incision begins in the buccal vestibule medialAn incision begins in the buccal vestibule medial to the external oblique ridge and extendsto the external oblique ridge and extends anteriorly and laterally to the retromolar pad.anteriorly and laterally to the retromolar pad. • The mucoperiosteal flap is reflected from theThe mucoperiosteal flap is reflected from the mandibular body exposing the lateral aspect ofmandibular body exposing the lateral aspect of the ramus.the ramus. • The flap is elevated with the notched ramusThe flap is elevated with the notched ramus retractor.retractor. www.indiandentalacademy.com
  32. 32. • The osteotomy is started anterior to theThe osteotomy is started anterior to the coronoid process at a point where adequatecoronoid process at a point where adequate thickness develops.thickness develops. • The osteotomy is extended anteriorly to theThe osteotomy is extended anteriorly to the distal aspect of the first molar area.distal aspect of the first molar area. • The posterior superior cut is made on the lateralThe posterior superior cut is made on the lateral aspect of the ramus.aspect of the ramus. • The inferior osteotomy is extended into theThe inferior osteotomy is extended into the cortex only.cortex only. www.indiandentalacademy.com
  33. 33. • Wedge chisel/Potts elevator is levered to pry theWedge chisel/Potts elevator is levered to pry the buccal segment free.buccal segment free. • A hemostatic dressing is placed into the donorA hemostatic dressing is placed into the donor area and closure of the site may be completedarea and closure of the site may be completed following fixation of the graft.following fixation of the graft. www.indiandentalacademy.com
  34. 34. Maxillary Tuberosity Donor SiteMaxillary Tuberosity Donor Site • Convenient for use in maxillary sinus grafting.Convenient for use in maxillary sinus grafting. • A vertical incision is made posteriorly at theA vertical incision is made posteriorly at the lateral aspect of the maxilla.lateral aspect of the maxilla. • Following reflection of a mucoperiosteal flap,Following reflection of a mucoperiosteal flap, bone may be harvested from the tuberositybone may be harvested from the tuberosity with a rongeur or chisel.with a rongeur or chisel. www.indiandentalacademy.com
  35. 35. Comparison of Donor SitesComparison of Donor Sites Syphysis Ramus TuberositySyphysis Ramus Tuberosity Surgical access good fair to good good to fairSurgical access good fair to good good to fair Patient cosmetic high low lowPatient cosmetic high low low ConcernsConcerns Graft Shape Thicker block Thinner veneer Porous blockGraft Shape Thicker block Thinner veneer Porous block Graft Morphology Coticocancellous cortical cancellousGraft Morphology Coticocancellous cortical cancellous Graft Size >1cm3 <1cm3 <1cm3Graft Size >1cm3 <1cm3 <1cm3 Graft resorption minimal minimal minimalGraft resorption minimal minimal minimal Healed Bone D1,D2 D1,D2 D3Healed Bone D1,D2 D1,D2 D3 QualityQuality Donor site Complications:Donor site Complications: Postop pain/edema moderate minimal to moderate minimalPostop pain/edema moderate minimal to moderate minimal Neurosensory –teeth common(temp) uncommon noneNeurosensory –teeth common(temp) uncommon none Neurosensory tissue common(temp) uncommon uncommonNeurosensory tissue common(temp) uncommon uncommon Icision Dehiscence Occasional(vestibular) uncommon uncommonIcision Dehiscence Occasional(vestibular) uncommon uncommon Sinus Perforation None None occasionalSinus Perforation None None occasional www.indiandentalacademy.com
  36. 36. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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