INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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Part I
• Introduction
• Keys to bone grafting
 Bone grafting materials
 Socket grafting
Part II
 Maxillary sinus lift &...
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 Absence of infection
 Soft tissue closure
 Space maintenance
 Graft immobilization
 Regional acceleratory phenomenon...
 Rapid solution mediated resorption in conditions of
low PH
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Causes of graft material infection
 Endogenous bacteria
 Lack of aseptic surgical technique
 Failure of primary soft ti...
Guidelines
 Primary incision should be in keratinized tissue
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 Crestal incisionis designed more lingual
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 Vertical incisions
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 Vertical incisions are made to the height of MGJ &
flap is retracted only 5 mm above the height of MGJ.
This maintains m...
 Soft tissue reflection distal to graft
Site is split thickness
 Maintains some of the periosteum around incision
line
...
 2 techniques depending on
 If less than 5 mm of advancement is necessary
 To expand tissue over larger graft sites (15...
For a small graft site
 More apical tissue reflection
 Horizontal scoring of the periosteum parallel to
primary incision...
 Developed by Misch in early 1980s
 Full thickness facial flap is elevated off the facial
bone for 5 mm above the height...
 Blunt dissection is done using soft tissue scissors
(metzenbaum ) to create a tunnel apical to the
vestibule & above the...
 Thickness of facial flap should be 3 to 5 mm
 Facial flap should be able to pass the lingual flap
margin by more than 5...
Disadvantages
 Loss of vestibular depth
 Lack of keratinized tissue on facial region of grafted
site
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Methods
Tent screws
Barrier membrane
Ti reinforced membranes
Graft material beneath the membrane
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Barrier by bulk
 Concept given by Misch
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Methods
 Bone tacks
 Tent screw
 Bone screws  work better with block bone grafts
than particulate
www.indiandentalacad...
Fixed transitional prosthesis
 Indicated with barrier by bulk tech. using particulate
material
 Prosthesis should have r...
 Local response to a noxious stimulus by which tissue
forms faster than the normal regional regeneration
rate
 Healing i...
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 Source of blood vesels
 Host cortical bone (few
arterioles
 Cancellous bone
(intensely vascular
network
 Blood vessel...
 Host site is decorticated with a rotary drill to increase
amount of host blood vessels at the graft site
 There should ...
Methods to increase tissue growth factors at graft site-

 Use of autologous bone in graft
 PRP
 Use of allografts
 R...
Gerald D , Carlson ER , Gotcher JE et al
J of Oral Maxillofacial Surg 2006 : 64 (443 – 451)
PDGF mixed with autologous bon...
Factors affecting healing time
Local
Number of remaining walls of bone
Amount of autogenous bone in the
graft
Size of the ...
 4 to 6 months -- graft volume is less than
5 mm
 6 to 10 months -- graft volume is more
than 5 mm
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Defect size effect following aspects of augmentation
 Healing time
 Vascularization
 Transitional prosthesis
 Graft ma...
Augmentation will be faster in an
extraction socket surrounded by 5
walls than for a onlay graft on div
D bone
www.indiand...
Transitional resto. effects
 Soft tissue closure
 Maintenance of space
 Immobilization of graft during healing
 Restor...
 Transitional acrylic FPD
 Metal reinforced acrylic FPD
 Resin bonded prosthesis
 Fixed temporary - eg temporaray imp...
www.indiandentalacademy.com
Bone graft materials
collagen
Osteogenic
Eg autologous
bone
Osteoinductive
Eg DFDB
osteoconductive
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 Sources
Bovine collagen from achilles tendon in the
leg
DFDB
Collagen barrier membranes used for GBR
Resorption rate...
Autogenous trabecular bone
• Contains more osteoblasts
• More osteogenic
Autogenous cortical bone
• Contains more bone gro...
 Should remain vital to be able to produce osteoid
 Recipient site is prepared first
 Should be placed immediately afte...
 Should not be mixed with other synthetic graft
materials
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 Decortication of host bone
 Directly placed on host bone
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Phase I
 Osteogenesis
 Bone regeneration by
surviving cells (osteoid)
 4 weeks
Phase II
 Osteoinduction
 BMP release
...
 The only osteogenic graft material
 Osteoinductive property
 Osteoconduction
 Space maintenance- maintains contour o...
Bone autografts
Allograftsosseous transplanted tissues
from the same species as the recepient
but of different genotype
•...
 Bone can be harvested , frozen & stored to be used
in the same patient at a later date
 Allograft frozen bone is rarely...
 Cortical & trabecular bone is harvested in a sterile
fashion from a disease free donor
 Washed in distilled water & gro...
Marx RE , Wong ME
J of Oral & maxillofacial surg 1987 : 45 ( page 988)
 Solvent prserved products have been developed
ins...
 Ground bone powder is demineralized in 0.6 N HCl
or nitric acid for 6 to 16 hrs.
 After acid bath it is washed & dehydr...
Irradiation
• Doses greater than 2.5 Mrad are
destructive to BMPs
Ethylene oxide sterilization
• 5 hr sterilization at 29 ...
 Age of cadaver
 Type of bone
 Cortical bone contains higher conc. Of BMPs than trabecular
bone
 Membranous cortical b...
 Putty consistency products
 Fillers do not participate in bone formation
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Allografts
• Freeze
dried bone
Alloplasts
• Ceramics
• Polymers
• composites
Xenografts
• Fabricated
from
inorganic
portio...
• Aluminium oxide
• Ti oxideBioinert
• Ca Phosphate
• Synthetic HA
• Bovine derived bone matrix
• Tricalcium phosphates
• ...
• Non resorbable
• resorbable
• Dense
• porous
• Crysstalline
• amorphous
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Atraumatic tooth extraction
Socket grafting
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 Periosteum should not be reflected if bone volume is
ideal as it helps bone remodellimg or repair
 Soft tissue drape ar...
An incision within the sulcus is made preferrably with
a thin scalpel blade , 360 degree around the tooth
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Tooth to be extracted should be reduced mesio
distally if the path of removal is obstructed by
adjacent teeth
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Time period for socket regeneration is usually 3 to 6
months depending on
 Tooth size
 Root no.
 No. of bony walls arou...
In 1993 Miesch & Dietsh suggested different graft
materials & techniques based on the no. of bony
walls remaining after to...
 Any resorbable graft material such as alloplast ,
allograft or autograft
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 Socket grafting is indicated if
 Labial plate of bone is missing
 One of the lateral plates is thinner than 1.5 mm
 H...
 A periotome or thin periosteal elevator is used to
tunnel under the bone periosteum
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 barrier membrane is then slid into the pocket created
under the tissue & it extends apical , mesial & distal
beyond the ...
 Bone graft material is placed & BM covers the top of
the socket & is tucked in below the palatal tissue
www.indiandental...
 Developed by Misch et al
 It’s a composite graft consisting of connective tissue
, periosteum & trabecular bone used to...
Advantages
 CT graft blends into the surrounding attached
gingiva , offering similar colour & texture of the
epitheliumco...
• Treated similar to 4 wall defect
 Defect size is larger so more bone is
reqd.
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 Block graft or cortical autogenous
bone
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Misch in 1990, Implant Dent 1993 ;2 (pages 158- 167)
Layers in GBR include the following
 host bone -: decorticated to en...
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Sinus grafting was introduced by Tatum in 1970s
 In early 1970s Tatum began to augment post. Maxilla
with autogenous rib ...
 Initial publication on sinus grafting was by Boyne &
James in 1980s
 In 1983 Misch observed that the most predictable
i...
 Root tips in the antrum
 Pseudocysts
 Oral antral opening
 Extraction of hopeless teeth
 Unerupted teeth
www.indiand...
 Narrowing of osteomeatal complex
 Enlargement of an air cell in the roof of sinus ( haller
cell )
Smoking
 Smokers hav...
 Active sinus infection on the day of surgery
 Significant recurrent history of chronic
sinusitis
 Significant recurren...
 Antimicrobial medication
Administered at least 1 full day before surgery &
extended for 5 days after surgery
 Local ant...
 Oral antimicrobial rinse
Gentle oral rinses of chlorhexidine gluconate 0.12 %
should be used twice daily for 2 weeks aft...
 Analgesics
Codeine containing drugs such as tylenol 3 are the
drug of choice as they have a potent antitussive
effect
 ...
 In 1984 Misch organised a treatment approach for
posterior maxilla based upon the amount of bone
below the antrum
www.in...
 in 1995 , Misch modified his classificationto include
the lateral dimension of sinus cavity to modify the
healing period...
 SA1 conventional implant placement
 SA2 sinus lift & simultaneous implant placement
 SA3 sinus graft with immediate or...
 Indicated when sufficient bone height is present
for the placement of endosteal implants
 Evaluation of sinus is less c...
 Root form implants are used
 At least a 12 mm in height implant for a 4
mm threaded implant
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 Osteoplasty or augmentation is suggested to
increase width of bone
 Augmentation may be done by
 Bone spreading
 Auto...
Onlay autogenous bone grafts are
indicated
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 indicated when10-12 mm of vertical bone is present
 Tatum originally developed the technique in 1970 &
Misch published ...
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 Indicated when at least 5 mm of vertical bone &
sufficient width are present between the anral floor &
crest of residual...
 Anesthesia
 Maxillary branch of trigeminal nerve is blocked
 Long acting anesthetic such as bupivacaine(0.5%) or
etido...
Access window
 Tatum access window is 2-5 mm above the antral
floor , 2-5 mm from the anterior wall 15 mm long &
10 mm in...
Carbide bur in paint brush stroke is used to outline the
access window
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 Flat ended metal punch & mallet is used to lightly
tap & green stick fracture the access window from
the lateral wall of...
 Sharp blade of the curette is placed against the inner
wall of bone & is used to scrape off the sinus
membrane from the ...
 Layered approach to grafting
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 Implant placement
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 Soft tissue closure
Soft tissues & periosteum must be approximated for
closure without tension
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 Indicated when less than 5 mm bone exists between
sinus floor & crest of residual ridge
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 Lateral wall approach is performed for sinus graft as
in SA 3 procedure
 Medial wall of sinus membrane is elevated at l...
 Intra operative
 Membrane perforation
 Antral septa
 Bleeding
 Short term
 Incision line opening
 Paresthesia
 Ac...
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 Mandible
 Symphysis
 Body
 Ramus
 Maxillary tuberosity
 Extraosseous tori
 Ridge osteoplasty
 Extraction sites
 ...
 Convenient surgical access
 No cutaneous scar
 Patients report minimal donor site discomfort
 Inherent biological ben...
 Early revascularization of membranous bone grafts
helps in improved maintenance of graft volume
 Bone from the maxillof...
 In 1992 Misch et al used mandibular symphysis &
ramus bone grafts for endosteal dental implants
J of oral maxillofacial ...
Symphysis
Ramus
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 Easier graft harvest
 Less post – op discomfort
 Less neurosensory complications
 Less incision line opening
 Less a...
Less width & length of bone
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 Slight curved triangular shape in the midlineis often
well suited for re-establishing the arch form in
maxillary anterio...
 Width & height requirements for augmentation
 Mandibular symphysis : when more than 4 cm of
bone is desired ( C-w bone ...
 Location of the host or recepient site
Recepient site
• Anterior mandible
• Posterior mandible
• maxilla
Donor site
• Sy...
 host site prepration
 Bone harvest
 Graft fixation
 Post operative instructions
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 Presence or absence of molars
 Width & height of external oblique ridge in the body
of the mandible
 Distance from the...
 As a result of these
variables a rectangular
piece of cortical bone
about 3 – 6 mm in
thickness may be
harvested from th...
 After harvesting graft may be stored in sterile saline
or immediately fixed to the recepient site
 Trabecular surface o...
 Holes in the donor
block should be
slightly larger than the
outer diameter of
fixation screws but
smaller in diameter
th...
 A high speed lindemann bur or carbides are then
used to recontour the block bone & smmothen any
sharp edges or corner af...
 Flap should be approximated &
sutures placed such that there is no
incision line tension or tissue ischemia
www.indiande...
 Stop smoking at least 3 days before surgery &
until incision line has healed
 Removeble soft tissue prosthesis should n...
 Intraoral block grafts
 4 months for maxillary recepient
 5 – 6 months for mandibular recepient sites
 Particulate on...
 Iliac crest
 Tibia
 Cranium
 Rib
 fibula
www.indiandentalacademy.com
Advantages
 Large volumeouter portion of the graft may be
primarily cortical with major portion of trabecular
bone undern...
Disadvantages
 Rapid bone resorption of 30 – 90 % has been
reported when conventional dentures are placed on
top of the r...
Complications
 Pain
 Herniation of the abdominal contents
 Fracture neuralgia
 Hematoma seroma
 Infection cosmetic de...
 Proximal tibial metaphysis provides an excellent
source of trabecular bone
 Primarily used with with BM & GBR procedure...
Disadvantages
 Contraindicated in adolescents & children coz
disruption of epiphyseal growth centre my occur
 Fat conten...
Complications
 Hematoma
 Post operative pain
 Infection
 Dhiscence ( incidence ranging from 1-4% )
www.indiandentalaca...
Sites
 Iliac crest
 Scapula
indications
 Blood supplybto the graft site is severely
compromised
 Recipient bed is scar...
Advantages
 Maintains normal physiologic function
 Simultaneous placement of implants with
microvascular bone flap recon...
 Disadvantages
 Attaing primary graft stability is often
difficult coz graft is often very
spongeous with a thin cortica...
 Refers to the formation of new bone between
vascular bone surfaces created by an osteotomy &
separated by gradual distra...
www.indiandentalacademy.com
 Contemporary implant dentistry by Carl E Misch ; 3
ed
 Dental update 1997 ; 24 (332-337)
www.indiandentalacademy.com
www.indiandentalacademy.com
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Ridge preservation & augmentation /cosmetic dentistry course

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Ridge preservation & augmentation /cosmetic dentistry course

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Part I • Introduction • Keys to bone grafting  Bone grafting materials  Socket grafting Part II  Maxillary sinus lift & sinus graft surgery  Intraoral autogenous donor bone grafts  Extraoral autogenous donor bone grafts www.indiandentalacademy.com
  3. 3. www.indiandentalacademy.com
  4. 4. www.indiandentalacademy.com
  5. 5.  Absence of infection  Soft tissue closure  Space maintenance  Graft immobilization  Regional acceleratory phenomenon (RAP)  Host bone vascularization  Growth factors  BMPs  Healing time  Defect size & topography  Transitional prosthesis www.indiandentalacademy.com
  6. 6.  Rapid solution mediated resorption in conditions of low PH www.indiandentalacademy.com
  7. 7. Causes of graft material infection  Endogenous bacteria  Lack of aseptic surgical technique  Failure of primary soft tissue closure  Lack of blood supply in early stages of grafting www.indiandentalacademy.com
  8. 8. Guidelines  Primary incision should be in keratinized tissue www.indiandentalacademy.com
  9. 9.  Crestal incisionis designed more lingual www.indiandentalacademy.com
  10. 10.  Vertical incisions www.indiandentalacademy.com
  11. 11.  Vertical incisions are made to the height of MGJ & flap is retracted only 5 mm above the height of MGJ. This maintains more blood supply to the facial flap  Incision is not extended to mobile mucosa www.indiandentalacademy.com
  12. 12.  Soft tissue reflection distal to graft Site is split thickness  Maintains some of the periosteum around incision line  Early vascularization of incision line  Adhesion of the margins to reduce retraction during initial healing www.indiandentalacademy.com
  13. 13.  2 techniques depending on  If less than 5 mm of advancement is necessary  To expand tissue over larger graft sites (15 x 10 mm) -- submucosal space technique www.indiandentalacademy.com
  14. 14. For a small graft site  More apical tissue reflection  Horizontal scoring of the periosteum parallel to primary incision www.indiandentalacademy.com
  15. 15.  Developed by Misch in early 1980s  Full thickness facial flap is elevated off the facial bone for 5 mm above the height of vestibule  One incision 1 to 2 mm deep is made through the periosteum parallel to the crestal incision and 3 to 5 mm above the vestibular height of periosteum www.indiandentalacademy.com
  16. 16.  Blunt dissection is done using soft tissue scissors (metzenbaum ) to create a tunnel apical to the vestibule & above the unreflected periosteum www.indiandentalacademy.com
  17. 17.  Thickness of facial flap should be 3 to 5 mm  Facial flap should be able to pass the lingual flap margin by more than 5 mm www.indiandentalacademy.com
  18. 18. Disadvantages  Loss of vestibular depth  Lack of keratinized tissue on facial region of grafted site www.indiandentalacademy.com
  19. 19. Methods Tent screws Barrier membrane Ti reinforced membranes Graft material beneath the membrane www.indiandentalacademy.com
  20. 20. Barrier by bulk  Concept given by Misch www.indiandentalacademy.com
  21. 21. Methods  Bone tacks  Tent screw  Bone screws  work better with block bone grafts than particulate www.indiandentalacademy.com
  22. 22. Fixed transitional prosthesis  Indicated with barrier by bulk tech. using particulate material  Prosthesis should have rest seats & clasps to prevent loading soft tissues www.indiandentalacademy.com
  23. 23.  Local response to a noxious stimulus by which tissue forms faster than the normal regional regeneration rate  Healing is 2 to 10 times faster than normal physiologic healing  Begins within a few days after injury , peaks at 1 to 2 months usually lasts 4 months in bone & may take upto 6 to 24 months to subside www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25.  Source of blood vesels  Host cortical bone (few arterioles  Cancellous bone (intensely vascular network  Blood vessels are needed to  Help the autograft maintain vitality  To repopulate the area with osteoblasts www.indiandentalacademy.com
  26. 26.  Host site is decorticated with a rotary drill to increase amount of host blood vessels at the graft site  There should be spaces available between graft particles for blood vessels to enter www.indiandentalacademy.com
  27. 27. Methods to increase tissue growth factors at graft site-   Use of autologous bone in graft  PRP  Use of allografts  RAP www.indiandentalacademy.com
  28. 28. Gerald D , Carlson ER , Gotcher JE et al J of Oral Maxillofacial Surg 2006 : 64 (443 – 451) PDGF mixed with autologous bone can accelerate mineralization by as much as 40 % during the first year www.indiandentalacademy.com
  29. 29. Factors affecting healing time Local Number of remaining walls of bone Amount of autogenous bone in the graft Size of the defect Systemic Diabetes Hyperparathyroidism Thyrotoxicosis Osteomalacia Osteoporosis Paget’s disease www.indiandentalacademy.com
  30. 30.  4 to 6 months -- graft volume is less than 5 mm  6 to 10 months -- graft volume is more than 5 mm www.indiandentalacademy.com
  31. 31. Defect size effect following aspects of augmentation  Healing time  Vascularization  Transitional prosthesis  Graft material selection www.indiandentalacademy.com
  32. 32. Augmentation will be faster in an extraction socket surrounded by 5 walls than for a onlay graft on div D bone www.indiandentalacademy.com
  33. 33. Transitional resto. effects  Soft tissue closure  Maintenance of space  Immobilization of graft during healing  Restores esthetics & function  Contours the soft tissue www.indiandentalacademy.com
  34. 34.  Transitional acrylic FPD  Metal reinforced acrylic FPD  Resin bonded prosthesis  Fixed temporary - eg temporaray implants  Removable restoration www.indiandentalacademy.com
  35. 35. www.indiandentalacademy.com
  36. 36. Bone graft materials collagen Osteogenic Eg autologous bone Osteoinductive Eg DFDB osteoconductive www.indiandentalacademy.com
  37. 37.  Sources Bovine collagen from achilles tendon in the leg DFDB Collagen barrier membranes used for GBR Resorption rates vary from a few months to 1 year www.indiandentalacademy.com
  38. 38. Autogenous trabecular bone • Contains more osteoblasts • More osteogenic Autogenous cortical bone • Contains more bone growth factors • More osteoinductive www.indiandentalacademy.com
  39. 39.  Should remain vital to be able to produce osteoid  Recipient site is prepared first  Should be placed immediately after harvesting or stored in  Sterile saline  lactated ringers solution www.indiandentalacademy.com
  40. 40.  Should not be mixed with other synthetic graft materials www.indiandentalacademy.com
  41. 41.  Decortication of host bone  Directly placed on host bone www.indiandentalacademy.com
  42. 42. Phase I  Osteogenesis  Bone regeneration by surviving cells (osteoid)  4 weeks Phase II  Osteoinduction  BMP release  2 wks to 6 months , peak at 6 wks Phase III  Osteoconduction  Inorganic matrix replaced by creeping substitution Phase IV  Cortical plate acts as a barrier membrane www.indiandentalacademy.com
  43. 43.  The only osteogenic graft material  Osteoinductive property  Osteoconduction  Space maintenance- maintains contour of desired augmentation www.indiandentalacademy.com
  44. 44. Bone autografts Allograftsosseous transplanted tissues from the same species as the recepient but of different genotype • Frozen bone • Freeze dried bone • Demineralized freeze dried bonewww.indiandentalacademy.com
  45. 45.  Bone can be harvested , frozen & stored to be used in the same patient at a later date  Allograft frozen bone is rarely used because of risk of rejection & disease transmission www.indiandentalacademy.com
  46. 46.  Cortical & trabecular bone is harvested in a sterile fashion from a disease free donor  Washed in distilled water & ground to a particle size of 500 micron to 5 mm  Immersed in 100 % ethanol to remove fat  Frozen in nitrogen  Freeze dried & ground to smaller particle size of 250 to 1500 micron www.indiandentalacademy.com
  47. 47. Marx RE , Wong ME J of Oral & maxillofacial surg 1987 : 45 ( page 988)  Solvent prserved products have been developed instead of freeze drying to reduce antigenicity & assure a minimal risk of contamination www.indiandentalacademy.com
  48. 48.  Ground bone powder is demineralized in 0.6 N HCl or nitric acid for 6 to 16 hrs.  After acid bath it is washed & dehydrated www.indiandentalacademy.com
  49. 49. Irradiation • Doses greater than 2.5 Mrad are destructive to BMPs Ethylene oxide sterilization • 5 hr sterilization at 29 degree celsius to maintain osteoinductive properties www.indiandentalacademy.com
  50. 50.  Age of cadaver  Type of bone  Cortical bone contains higher conc. Of BMPs than trabecular bone  Membranous cortical bone exhibits greater conc. Of BMPs than endochondral cortical bone  Particle size Particles smaller than 150 micron are less effective than 250 micron or larger  Fibres of cortical bone (eg grafton ) are more effective than particles. www.indiandentalacademy.com
  51. 51.  Putty consistency products  Fillers do not participate in bone formation www.indiandentalacademy.com
  52. 52. Allografts • Freeze dried bone Alloplasts • Ceramics • Polymers • composites Xenografts • Fabricated from inorganic portion of bone from animals other than humans www.indiandentalacademy.com
  53. 53. • Aluminium oxide • Ti oxideBioinert • Ca Phosphate • Synthetic HA • Bovine derived bone matrix • Tricalcium phosphates • Calcium carbonates Bioactive www.indiandentalacademy.com
  54. 54. • Non resorbable • resorbable • Dense • porous • Crysstalline • amorphous www.indiandentalacademy.com
  55. 55. www.indiandentalacademy.com
  56. 56. Atraumatic tooth extraction Socket grafting www.indiandentalacademy.com
  57. 57.  Periosteum should not be reflected if bone volume is ideal as it helps bone remodellimg or repair  Soft tissue drape around the tooth is also affected by reflection of periosteum www.indiandentalacademy.com
  58. 58. An incision within the sulcus is made preferrably with a thin scalpel blade , 360 degree around the tooth www.indiandentalacademy.com
  59. 59. Tooth to be extracted should be reduced mesio distally if the path of removal is obstructed by adjacent teeth www.indiandentalacademy.com
  60. 60. Time period for socket regeneration is usually 3 to 6 months depending on  Tooth size  Root no.  No. of bony walls around the socket  Size of alveolus  Trauma of extraction www.indiandentalacademy.com
  61. 61. In 1993 Miesch & Dietsh suggested different graft materials & techniques based on the no. of bony walls remaining after tooth is removed-  5 bony wall defect  4-5 wall defect  2-3 wall defect  1 wall defect www.indiandentalacademy.com
  62. 62.  Any resorbable graft material such as alloplast , allograft or autograft www.indiandentalacademy.com
  63. 63.  Socket grafting is indicated if  Labial plate of bone is missing  One of the lateral plates is thinner than 1.5 mm  Height is desired  2 techniques  BM with a mineralized alloplast or freeze dried bone  Modified socket seal surgery www.indiandentalacademy.com
  64. 64.  A periotome or thin periosteal elevator is used to tunnel under the bone periosteum www.indiandentalacademy.com
  65. 65.  barrier membrane is then slid into the pocket created under the tissue & it extends apical , mesial & distal beyond the extraction site  Approx 6-8 mm of BM should extend above the marginal tissue www.indiandentalacademy.com
  66. 66.  Bone graft material is placed & BM covers the top of the socket & is tucked in below the palatal tissue www.indiandentalacademy.com
  67. 67.  Developed by Misch et al  It’s a composite graft consisting of connective tissue , periosteum & trabecular bone used to seal a fresh extraction socket J of Oral Implantology 1999 ; 25 (pages 244 – 250 ) www.indiandentalacademy.com
  68. 68. Advantages  CT graft blends into the surrounding attached gingiva , offering similar colour & texture of the epitheliumcontains autogenous bone  Blood supply is established from the surrounding soft tissue  Rapid healing (4 – 5 months ) www.indiandentalacademy.com
  69. 69. • Treated similar to 4 wall defect  Defect size is larger so more bone is reqd. www.indiandentalacademy.com
  70. 70.  Block graft or cortical autogenous bone www.indiandentalacademy.com
  71. 71. Misch in 1990, Implant Dent 1993 ;2 (pages 158- 167) Layers in GBR include the following  host bone -: decorticated to enhance blood supply , growth factors & RAP  An autograft-: results in more predictable & rapid bone growth by osteogenesis & osteoinduction  Mixture of DFDB (30%) , FDB (70%) , & PRP --: Provides growth factors & space maintenance  BM & Tent screw -:  BM prevents fibroblasts from invading the graft site for at least 6 wks.  Tent screw decreases mobility  Primary closure without tension -: prevents contamination & loss of graft materialwww.indiandentalacademy.com
  72. 72. www.indiandentalacademy.com
  73. 73. www.indiandentalacademy.com
  74. 74. Sinus grafting was introduced by Tatum in 1970s  In early 1970s Tatum began to augment post. Maxilla with autogenous rib bone to produce adequate vertical bone for implant support  In 1974 he developed modified caldwell luc procedure  In 1975 he developed a lateral approach surgical technique toelevate sinus membrane & place implant simultaneously  From 1974 to 1979 primary material for sinus grafting was autologous bone. In 1980 , Tatum introduced the use of synthetic bone www.indiandentalacademy.com
  75. 75.  Initial publication on sinus grafting was by Boyne & James in 1980s  In 1983 Misch observed that the most predictable intraoral region to grow boneis the max. sinus floor once the mucosa has been elevated www.indiandentalacademy.com
  76. 76.  Root tips in the antrum  Pseudocysts  Oral antral opening  Extraction of hopeless teeth  Unerupted teeth www.indiandentalacademy.com
  77. 77.  Narrowing of osteomeatal complex  Enlargement of an air cell in the roof of sinus ( haller cell ) Smoking  Smokers have a 7 % greater failure rate than non smokers  Pt. should refrain from smoking at least 15 days before surgery & 4-6 weeks after surgery  Chronic maxillary rhinosinusitiswww.indiandentalacademy.com
  78. 78.  Active sinus infection on the day of surgery  Significant recurrent history of chronic sinusitis  Significant recurrent history of fungal sinusitis  Uncontrolled late stage diabetes  Cystic fibrosis  maxillary sinus hypoplasia  Neoplasms www.indiandentalacademy.com
  79. 79.  Antimicrobial medication Administered at least 1 full day before surgery & extended for 5 days after surgery  Local antibiotic medications To ensure adequate antibiotic levels in a sinus graft , it is recommended to add antibiotic to the graft mixture Mabry TW , Yukna RA J Periodontology 1985 ; 56 (74 – 81) www.indiandentalacademy.com
  80. 80.  Oral antimicrobial rinse Gentle oral rinses of chlorhexidine gluconate 0.12 % should be used twice daily for 2 weeks after surgery  Glucocorticoids Initiated 1 day before surgery & continued foe 2 days after surgery to control oedeme  Decongestant medications  Oxymetazoline (0.05%)  Phenylephrine (1% ) www.indiandentalacademy.com
  81. 81.  Analgesics Codeine containing drugs such as tylenol 3 are the drug of choice as they have a potent antitussive effect  Cryotherapy  Cold dressings for the first 24 – 48 hrs ,elevation of head & limited activity for 2-3 days helps reduce swelling  After 2-3 days heat may be applied to increase blood flow & lymph flow www.indiandentalacademy.com
  82. 82.  In 1984 Misch organised a treatment approach for posterior maxilla based upon the amount of bone below the antrum www.indiandentalacademy.com
  83. 83.  in 1995 , Misch modified his classificationto include the lateral dimension of sinus cavity to modify the healing period protocol  Smaller width sinnus (0-10 mm) -: less healing time  Larger width(> 15 mm) -: more time www.indiandentalacademy.com
  84. 84.  SA1 conventional implant placement  SA2 sinus lift & simultaneous implant placement  SA3 sinus graft with immediate or delayed endosteal implant placement  SA4 sinus graft healing & extended delay of implant insertion www.indiandentalacademy.com
  85. 85.  Indicated when sufficient bone height is present for the placement of endosteal implants  Evaluation of sinus is less critical  Implants left to heal for 4-8 months  Progressive loading suggested in d3 & d4 bone www.indiandentalacademy.com
  86. 86.  Root form implants are used  At least a 12 mm in height implant for a 4 mm threaded implant www.indiandentalacademy.com
  87. 87.  Osteoplasty or augmentation is suggested to increase width of bone  Augmentation may be done by  Bone spreading  Autogenous onlay  Appositional grafts www.indiandentalacademy.com
  88. 88. Onlay autogenous bone grafts are indicated www.indiandentalacademy.com
  89. 89.  indicated when10-12 mm of vertical bone is present  Tatum originally developed the technique in 1970 & Misch published it in 1987  Antral floor is elevated through implant osteotomy by 0-2mm  Compresses the bone below the antrum , causes a greenstick fracture in the antral floor & slowly elevates the unprepared bone & sinus membrane over the broad based osteotome  Prosthetic treatment similar to SA1 after 4-6 months www.indiandentalacademy.com
  90. 90. www.indiandentalacademy.com
  91. 91. www.indiandentalacademy.com
  92. 92.  Indicated when at least 5 mm of vertical bone & sufficient width are present between the anral floor & crest of residual ridge www.indiandentalacademy.com
  93. 93.  Anesthesia  Maxillary branch of trigeminal nerve is blocked  Long acting anesthetic such as bupivacaine(0.5%) or etidocaine(1.5%) is preferred  Incision line & reflection  Crest incision is made on the palatal aspect of maxilla from tuberosity to one tooth anterior to the anterior wall of sinus  Vertical relief incision is made on the distal to enhance access to max. tuberosity  Anterior incision is made at least 10 mm ant to the ant wall of sinus www.indiandentalacademy.com
  94. 94. Access window  Tatum access window is 2-5 mm above the antral floor , 2-5 mm from the anterior wall 15 mm long & 10 mm in height www.indiandentalacademy.com
  95. 95. Carbide bur in paint brush stroke is used to outline the access window www.indiandentalacademy.com
  96. 96.  Flat ended metal punch & mallet is used to lightly tap & green stick fracture the access window from the lateral wall of maxilla www.indiandentalacademy.com
  97. 97.  Sharp blade of the curette is placed against the inner wall of bone & is used to scrape off the sinus membrane from the bone www.indiandentalacademy.com
  98. 98.  Layered approach to grafting www.indiandentalacademy.com
  99. 99.  Implant placement www.indiandentalacademy.com
  100. 100.  Soft tissue closure Soft tissues & periosteum must be approximated for closure without tension www.indiandentalacademy.com
  101. 101.  Indicated when less than 5 mm bone exists between sinus floor & crest of residual ridge www.indiandentalacademy.com
  102. 102.  Lateral wall approach is performed for sinus graft as in SA 3 procedure  Medial wall of sinus membrane is elevated at least 16 mm fron the crest so that adequate height is available for implant placement  If bone from max tuberosity is not enough , additional bone may be harvested from above the roots of maxillary premolars or mandibular ascending ramus www.indiandentalacademy.com
  103. 103.  Intra operative  Membrane perforation  Antral septa  Bleeding  Short term  Incision line opening  Paresthesia  Acute maxillary rhinosinusitis  Long term  Oroantral fistula  Maxillary surgical cysts www.indiandentalacademy.com
  104. 104. www.indiandentalacademy.com
  105. 105.  Mandible  Symphysis  Body  Ramus  Maxillary tuberosity  Extraosseous tori  Ridge osteoplasty  Extraction sites  Implant osteotomy www.indiandentalacademy.com
  106. 106.  Convenient surgical access  No cutaneous scar  Patients report minimal donor site discomfort  Inherent biological benefits attributable to the embryologic origin of donor bone  Experimental evidence shows that grafts from membranous bone show less resorption than endochondral bone. Maxilla & body of mandible are membranous bones J Oral Maxillofacial surgery 1996 : 54 (15- 20) www.indiandentalacademy.com
  107. 107.  Early revascularization of membranous bone grafts helps in improved maintenance of graft volume  Bone from the maxillofacial skeleton contains increased concentration of growth factors & BMPs Plastic reconstructive surgery 1994 : 93 ( 732 – 738) Improved survival of craniofacial bone grafts is caused by their 3-D structure J oral maxillofacial surg 1996 :54 (15 – 20 ) Mand. Cortical bone grafts show little volume loss & show good incorporation at short healing times www.indiandentalacademy.com
  108. 108.  In 1992 Misch et al used mandibular symphysis & ramus bone grafts for endosteal dental implants J of oral maxillofacial implants 1992 : 7 ( 360 – 366 ) www.indiandentalacademy.com
  109. 109. Symphysis Ramus www.indiandentalacademy.com
  110. 110.  Easier graft harvest  Less post – op discomfort  Less neurosensory complications  Less incision line opening  Less anesthesia reqd.  More profound LA with fewer drugs  Less concern of changes in facial morphology www.indiandentalacademy.com
  111. 111. Less width & length of bone www.indiandentalacademy.com
  112. 112.  Slight curved triangular shape in the midlineis often well suited for re-establishing the arch form in maxillary anterior ridges  Average interforaminal distance is greater than 4 cm , so more bone volume is available www.indiandentalacademy.com
  113. 113.  Width & height requirements for augmentation  Mandibular symphysis : when more than 4 cm of bone is desired ( C-w bone volume )  Mandibular ramus :when graft width is less than 4 mm ( div. B to B-w bone volume )  Mandibular symphysis along with its cortical inferior border : when an augmentation for height is required www.indiandentalacademy.com
  114. 114.  Location of the host or recepient site Recepient site • Anterior mandible • Posterior mandible • maxilla Donor site • Symphysis • Ramus • ramus www.indiandentalacademy.com
  115. 115.  host site prepration  Bone harvest  Graft fixation  Post operative instructions www.indiandentalacademy.com
  116. 116. www.indiandentalacademy.com
  117. 117. www.indiandentalacademy.com
  118. 118. www.indiandentalacademy.com
  119. 119. www.indiandentalacademy.com
  120. 120. www.indiandentalacademy.com
  121. 121. www.indiandentalacademy.com
  122. 122.  Presence or absence of molars  Width & height of external oblique ridge in the body of the mandible  Distance from the external oblique ridge & ramus to the inferior alveolar nerve  Width of posterior ramus is evaluated using reformatted CT image www.indiandentalacademy.com
  123. 123.  As a result of these variables a rectangular piece of cortical bone about 3 – 6 mm in thickness may be harvested from the ramus. Length may range from 1 – 3.5 cm & height usually is not greater than 1 cm www.indiandentalacademy.com
  124. 124.  After harvesting graft may be stored in sterile saline or immediately fixed to the recepient site  Trabecular surface of the graft should be in contact with decorticated surface of the host bone  Donor block & recepient site contouring  2 or more fixation screw sites should be prepared for each bone block www.indiandentalacademy.com
  125. 125.  Holes in the donor block should be slightly larger than the outer diameter of fixation screws but smaller in diameter than the head of the screw www.indiandentalacademy.com
  126. 126.  A high speed lindemann bur or carbides are then used to recontour the block bone & smmothen any sharp edges or corner after it is fixed  Barrier membrane  Not routinely used with cortical block bone grafts  Indicated if more particulate or trabecular bone is used  Indicated if block graft is inadequate to fill the entire space www.indiandentalacademy.com
  127. 127.  Flap should be approximated & sutures placed such that there is no incision line tension or tissue ischemia www.indiandentalacademy.com
  128. 128.  Stop smoking at least 3 days before surgery & until incision line has healed  Removeble soft tissue prosthesis should not be worn  Confirm to regular post operative follow up www.indiandentalacademy.com
  129. 129.  Intraoral block grafts  4 months for maxillary recepient  5 – 6 months for mandibular recepient sites  Particulate onlay grafts 6 -9 months www.indiandentalacademy.com
  130. 130.  Iliac crest  Tibia  Cranium  Rib  fibula www.indiandentalacademy.com
  131. 131. Advantages  Large volumeouter portion of the graft may be primarily cortical with major portion of trabecular bone underneath  Volume of the bone harvested permits contouring of 2/3 of the mandible or maxilla or filling a large bony defect  Relative ease of access & harvesting www.indiandentalacademy.com
  132. 132. Disadvantages  Rapid bone resorption of 30 – 90 % has been reported when conventional dentures are placed on top of the reconstruction Curtis et al JPD 1987 ; 57 (73- 78) • post operative pain & gait disturbances www.indiandentalacademy.com
  133. 133. Complications  Pain  Herniation of the abdominal contents  Fracture neuralgia  Hematoma seroma  Infection cosmetic deformity www.indiandentalacademy.com
  134. 134.  Proximal tibial metaphysis provides an excellent source of trabecular bone  Primarily used with with BM & GBR procedure because major part of the harvest is trabecular in nature www.indiandentalacademy.com
  135. 135. Disadvantages  Contraindicated in adolescents & children coz disruption of epiphyseal growth centre my occur  Fat content of the marrow is sometimes greater than that found in the ilium www.indiandentalacademy.com
  136. 136. Complications  Hematoma  Post operative pain  Infection  Dhiscence ( incidence ranging from 1-4% ) www.indiandentalacademy.com
  137. 137. Sites  Iliac crest  Scapula indications  Blood supplybto the graft site is severely compromised  Recipient bed is scarred  Carcinoma patients who have undergone radiation therapy  Div. E bone anatomy : discontinuity defects of thewww.indiandentalacademy.com
  138. 138. Advantages  Maintains normal physiologic function  Simultaneous placement of implants with microvascular bone flap reconstruction has shown an approximately 80% success rateusing Ti implants with a short follow up www.indiandentalacademy.com
  139. 139.  Disadvantages  Attaing primary graft stability is often difficult coz graft is often very spongeous with a thin cortical layer www.indiandentalacademy.com
  140. 140.  Refers to the formation of new bone between vascular bone surfaces created by an osteotomy & separated by gradual distraction Indications  Mucoskeletal conditions such as post traumatic defects  Repair of continuity defects  Mandibular lengthening  Maxillary advancement www.indiandentalacademy.com
  141. 141. www.indiandentalacademy.com
  142. 142.  Contemporary implant dentistry by Carl E Misch ; 3 ed  Dental update 1997 ; 24 (332-337) www.indiandentalacademy.com
  143. 143. www.indiandentalacademy.com
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