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 <ul><li>A complete intraoral examination </li></ul><ul><li>Radiogra...
Clinical Examination <ul><li>Minimal obtain 1 to 2mm of attached gingiva </li></ul><ul><li>Cross section of the alveolar d...
To Determine Bone Width Harry Dym, Orrett E. Ogle : Atlas of Minor Oral Surgery.  W.B. Saunders company. 2001
Radiographic Examination <ul><li>Panoramic radiograph </li></ul><ul><li>20 to 30% distortion/magnification of the anatomic...
<ul><li>Fabricate a surgical stent </li></ul><ul><li>Guiding to the exact site of implant placement </li></ul><ul><li>Diag...
Types of Bone Grafts <ul><li>Autograft </li></ul><ul><ul><li>A graft taken from on anatomic location and placed in another...
Biology of Bone Grafts <ul><li>Phase I </li></ul><ul><ul><li>Osteogenesis: Immediate proliferation of transplanted osteocy...
Mandibular Ramus <ul><li>To create an incision starting on the lateral border of the ramus approximately 1.5cm above the m...
Mandibular Ramus 0.9% Sodium chloride solution/ Crushed into small particles or used as block
Mandibular Tori as a Donor site Harvesting Techniques II Monobevel Chisel is used, With the bevel positioned facing the li...
Grafting of the Extraction Socket <ul><li>The teeth are extracted atraumatically preserving the buccal bone. </li></ul><ul...
Extraction Socket Grafting  <ul><li>Extraction socket with particulate graft in place </li></ul><ul><li>Closure of extract...
Cortical Onlay Bone Graft <ul><li>Inadequate buccal to lingual/palatal width </li></ul><ul><li>Autogenous bone: donor site...
Bone Harvasting from the Chin <ul><li>Buccal sulcus incision: canine to caine </li></ul><ul><li>Full-thickness mucoperiost...
<ul><li>Small curve monoplane osteotome </li></ul><ul><li>Hemostasis: Avitene(MedChem Products Inc., Woburn, MA) </li></ul...
<ul><li>그림 </li></ul>
Interpositional Ridge Graft <ul><li>The approximate depth of the osteotomy should be 1cm. </li></ul><ul><li>A bibevel chis...
<ul><li>Rigde split technique 에 대한 그림 </li></ul>
Sinus-Lift Procedure Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang Univ. Kwon, Kyung-Hwan
Sinus-Lift Procedure definition <ul><li>Taum OH(1977) </li></ul><ul><ul><li>Introduced crestal approach to the sinus membr...
Evaluation of Sinus <ul><li>Fixture failure will result because of the downgrowth of antral epithelium aroud the fixture r...
Graft Material for Sinus Lift <ul><li>Autogeous Bone </li></ul><ul><ul><li>Hip/ Tibia/ Symphysis/ Ramus/ Maxillary tuberos...
Time Tables <ul><li>Waiting between 4 and 9 after grafting for implant placement and an additional 4 to 6 months before pl...
Surgical Protocol Maxillary Sinus Lifting Technique A B C D A: Sagittal view of maxillary sinus showing relationship of si...
Surgical Protocol <ul><li>Round diamond #6 burr </li></ul><ul><li>Surgical curette is place in the edges of  the inferior ...
<ul><li>Not wear a removable appliance for the first 2 postoperative weeks </li></ul><ul><li>The most common postoperative...
<ul><li>Sinus lifting 그림 </li></ul>
Principles of Implant Surgery
Essential Critical Factors -Implant placement success- <ul><li>Minimal trauma </li></ul><ul><li>Biocompatible material </l...
Relative Contraindications <ul><li>Uncontrolled diabetic patient </li></ul><ul><li>Significant smocking history </li></ul>...
Minimal Dimensional Parameters <ul><li>At least 1mm of excess bone: both the lingual and buccal  or labial side  </li></ul...
Implant Work-Up ProtocoI(1) <ul><li>Appropriate X-rays </li></ul><ul><ul><li>Panoramic film </li></ul></ul><ul><ul><li>Per...
<ul><li>Fabrication of plastic stent  </li></ul><ul><li>Peper tacing: sinus and inferior alveolar nerve </li></ul><ul><li>...
Diagnostic and Surgical Implant Placement Protocol <ul><li>Initial Dental Consultation </li></ul><ul><li>Clinical Evaluati...
Initial Dental Consultation <ul><li>Patient’s reason an motivation for dental consulatation </li></ul><ul><li>Etiology of ...
Clinical Evaluation and Dx. <ul><li>Review of indications and contraindications </li></ul><ul><li>Oral examination </li></...
Therapeutic Plan <ul><li>Implant position and sizes </li></ul><ul><li>Prosthetic restoration </li></ul><ul><li>Explanation...
Presurgical Mouth Preparation <ul><li>Extractions </li></ul><ul><li>Necessary restorative dental procedures </li></ul><ul>...
Surgical Implantation <ul><li>Confirm measurement of potential implant sites on radiograph </li></ul><ul><li>Positioning o...
Prosthetic Management <ul><li>Preparation of adjacent natural teeth </li></ul><ul><li>Removal of second phase healing scre...
Follow-Up Care and Maintenance <ul><li>Oral prophylaxis </li></ul><ul><li>Periodotnal evaluation </li></ul><ul><li>Oral hy...
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Bone Grafting for implants.ppt

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Bone Grafting for implants.ppt

  1. 1. Bone Grafting for implants Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang Univ. Kwon, Kyung-Hwan
  2. 2. Diagnosis and Treatment Planning For Bone Augmentation <ul><li>A complete intraoral examination </li></ul><ul><li>Radiographs and in select cases a CT scan </li></ul><ul><ul><li>Neurovascular bundles must be avoided. </li></ul></ul><ul><ul><li>Paranasal sinus must be identified. </li></ul></ul><ul><li>Study models </li></ul>
  3. 3. Clinical Examination <ul><li>Minimal obtain 1 to 2mm of attached gingiva </li></ul><ul><li>Cross section of the alveolar depicting periodontal probe placement for “sounding the bone”. </li></ul><ul><li>To determine bone width </li></ul><ul><li>Cutting the study model in the exact vertical location </li></ul>Diagnosis and Treatment Planning For Bone Augmentation
  4. 4. To Determine Bone Width Harry Dym, Orrett E. Ogle : Atlas of Minor Oral Surgery. W.B. Saunders company. 2001
  5. 5. Radiographic Examination <ul><li>Panoramic radiograph </li></ul><ul><li>20 to 30% distortion/magnification of the anatomic structures </li></ul><ul><li>Buccal to lingual width will not be appreciated </li></ul><ul><li>Alveolar bone height, adjacent teeth and anatomic structure </li></ul>Diagnosis and Treatment Planning For Bone Augmentation
  6. 6. <ul><li>Fabricate a surgical stent </li></ul><ul><li>Guiding to the exact site of implant placement </li></ul><ul><li>Diagnostic wax-ups </li></ul><ul><li>Arch form, tooth spacing, and bony contour </li></ul>Study Models Diagnosis and Treatment Planning For Bone Augmentation
  7. 7. Types of Bone Grafts <ul><li>Autograft </li></ul><ul><ul><li>A graft taken from on anatomic location and placed in another location in the same individual(e.g., iliac crest) </li></ul></ul><ul><li>Allograft </li></ul><ul><ul><li>A graft taken from a cadever treated wit certain sterilization and antiantigenic procedures and placed into a living host </li></ul></ul><ul><li>Alloplast </li></ul><ul><ul><li>A chemically derived nonanimal material </li></ul></ul><ul><li>Xenograft </li></ul><ul><ul><li>A graft taken from a nonhuman host for implantation into a human host </li></ul></ul>
  8. 8. Biology of Bone Grafts <ul><li>Phase I </li></ul><ul><ul><li>Osteogenesis: Immediate proliferation of transplanted osteocytes and subsequent formation of osteoid(immature bone) </li></ul></ul><ul><li>Phase II </li></ul><ul><ul><li>Osteoinduction: inducement of mesenchymal cells to produce bone(BMP) </li></ul></ul><ul><ul><li>Osteoconduction: framework or scaffold for the formation of new bone tissue </li></ul></ul>
  9. 9. Mandibular Ramus <ul><li>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 </li></ul><ul><li>#9 Molt periosteal elevator: full thickness mucoperiosteal flap </li></ul>Harvesting Techniques I
  10. 10. Mandibular Ramus 0.9% Sodium chloride solution/ Crushed into small particles or used as block
  11. 11. Mandibular Tori as a Donor site Harvesting Techniques II Monobevel Chisel is used, With the bevel positioned facing the lingual cortex
  12. 12. Grafting of the Extraction Socket <ul><li>The teeth are extracted atraumatically preserving the buccal bone. </li></ul><ul><li>All granulation tissue is excised with the use of a surgical curette or a Rongeur. </li></ul><ul><li>DFDBA(deminerized freeze-dried bone allograft) + Gore Tex Mem. </li></ul>
  13. 13. Extraction Socket Grafting <ul><li>Extraction socket with particulate graft in place </li></ul><ul><li>Closure of extraction site with interdigitating papillae </li></ul>
  14. 14. Cortical Onlay Bone Graft <ul><li>Inadequate buccal to lingual/palatal width </li></ul><ul><li>Autogenous bone: donor sites-mandibular symphysis, mandibular ramus, calvarium or iliac crest </li></ul><ul><li>Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles </li></ul>Harvesting Techniques III
  15. 15. Bone Harvasting from the Chin <ul><li>Buccal sulcus incision: canine to caine </li></ul><ul><li>Full-thickness mucoperiosteal flap </li></ul><ul><li>Avoid the mental nerve </li></ul><ul><li>Level approximately 5mm below the apices of the mandibular anterior teeth </li></ul>
  16. 16. <ul><li>Small curve monoplane osteotome </li></ul><ul><li>Hemostasis: Avitene(MedChem Products Inc., Woburn, MA) </li></ul><ul><li>3-0 Vicryle suture on a tapered needle </li></ul><ul><li>First approximate periosteum with multiple intterupted sutures being careful to maintain the mentalis muscle </li></ul>Bone Harvasting from the Chin
  17. 17. <ul><li>그림 </li></ul>
  18. 18. Interpositional Ridge Graft <ul><li>The approximate depth of the osteotomy should be 1cm. </li></ul><ul><li>A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant </li></ul><ul><li>Split ridge technique </li></ul>
  19. 19. <ul><li>Rigde split technique 에 대한 그림 </li></ul>
  20. 20. Sinus-Lift Procedure Dept. of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang Univ. Kwon, Kyung-Hwan
  21. 21. Sinus-Lift Procedure definition <ul><li>Taum OH(1977) </li></ul><ul><ul><li>Introduced crestal approach to the sinus membrane </li></ul></ul><ul><ul><li>In 1986, modified Caldwell-Luc lateral window </li></ul></ul><ul><li>The grafte material is inserted between the antral floor and the Schneiderian membrane(lining of the maxillary sinus floor) </li></ul>
  22. 22. Evaluation of Sinus <ul><li>Fixture failure will result because of the downgrowth of antral epithelium aroud the fixture rather than by the superior growth of oral epithelium </li></ul><ul><li>Protocol of Sinus Lifting Indication </li></ul><ul><ul><li>4 mm below: Lateral window technique </li></ul></ul><ul><ul><li>4-6mm :Summer’s Osteotome technique </li></ul></ul><ul><ul><li>6mm above: Simultaneous implant with bone grafting </li></ul></ul>
  23. 23. Graft Material for Sinus Lift <ul><li>Autogeous Bone </li></ul><ul><ul><li>Hip/ Tibia/ Symphysis/ Ramus/ Maxillary tuberosity </li></ul></ul><ul><li>Allograft(obtained from human cadavers) </li></ul><ul><ul><li>Freeze-dried bone/DFDB </li></ul></ul><ul><li>Xenografts(Bone from nonhuman species) </li></ul><ul><ul><li>Bovine bone(Bio-Oss) </li></ul></ul><ul><li>Alloplastic(Natural and synthetic bone substitute) </li></ul><ul><ul><li>Hydrozyapatite/ Tricalcium phosphate(TCP)/ Bioactive glass ceramics </li></ul></ul>
  24. 24. Time Tables <ul><li>Waiting between 4 and 9 after grafting for implant placement and an additional 4 to 6 months before placing final restoration </li></ul><ul><li>In my clinics, Simultaneous implantation study show result of 95% success rate. but, case by case </li></ul>
  25. 25. Surgical Protocol Maxillary Sinus Lifting Technique 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
  26. 26. Surgical Protocol <ul><li>Round diamond #6 burr </li></ul><ul><li>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 </li></ul><ul><li>Perforation of membrane: CollaTape used </li></ul><ul><li>Leave sutures in place fo 7 to 10 days </li></ul><ul><li>Antibiotics, analgesics and decongestant coverage </li></ul>Maxillary Sinus Lifting Technique
  27. 27. <ul><li>Not wear a removable appliance for the first 2 postoperative weeks </li></ul><ul><li>The most common postoperative complication: Infection- irrigated daily until resolution </li></ul>Maxillary Sinus Lifting Technique
  28. 28. <ul><li>Sinus lifting 그림 </li></ul>
  29. 29. Principles of Implant Surgery
  30. 30. Essential Critical Factors -Implant placement success- <ul><li>Minimal trauma </li></ul><ul><li>Biocompatible material </li></ul><ul><li>Buried and untouched for 3 to 4 months before prosthetic loading </li></ul><ul><li>Copious internal or external irrigation to minimize thermal bone demage </li></ul><ul><li>Precious attachment of implant and prosthesis </li></ul>
  31. 31. Relative Contraindications <ul><li>Uncontrolled diabetic patient </li></ul><ul><li>Significant smocking history </li></ul><ul><li>Jawbone irradiation less than 1 year before implant placement </li></ul><ul><li>Acute psychotic disorders </li></ul><ul><li>Severe bone resorption in patient who refuses bone grafting </li></ul>Implant Placement
  32. 32. Minimal Dimensional Parameters <ul><li>At least 1mm of excess bone: both the lingual and buccal or labial side </li></ul><ul><li>At least 2 mm of bone: implant and any adjacent tooth or implant </li></ul><ul><li>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 </li></ul><ul><li>Adequate vertical space: minimum of 8mm </li></ul>
  33. 33. Implant Work-Up ProtocoI(1) <ul><li>Appropriate X-rays </li></ul><ul><ul><li>Panoramic film </li></ul></ul><ul><ul><li>Periapical X-rays </li></ul></ul><ul><ul><li>CAT scan(if deemed necessary) </li></ul></ul><ul><ul><li>Lateral cephalogram(when indicated in edentulous lower arch) </li></ul></ul><ul><li>Models of upper/lower arches </li></ul><ul><li>Mock wax-up of missing teeth on mounted upper/lower casts </li></ul>
  34. 34. <ul><li>Fabrication of plastic stent </li></ul><ul><li>Peper tacing: sinus and inferior alveolar nerve </li></ul><ul><li>Detect thickness and concavities </li></ul><ul><li>Evaluation of existing periodontal condition </li></ul><ul><li>Patient education: Risks and complication </li></ul>Implant Work-Up Protocol(2)
  35. 35. Diagnostic and Surgical Implant Placement Protocol <ul><li>Initial Dental Consultation </li></ul><ul><li>Clinical Evaluation and Diagnosis </li></ul><ul><li>Therapeutic Plan </li></ul><ul><li>Presurgical Mouth Preparation </li></ul><ul><li>Surgical Implantation </li></ul><ul><li>Prosthetic Management </li></ul><ul><li>Follow-Up Care and Maintenance </li></ul>
  36. 36. Initial Dental Consultation <ul><li>Patient’s reason an motivation for dental consulatation </li></ul><ul><li>Etiology of edentulous or patially edentulous state </li></ul><ul><li>General medical history </li></ul><ul><li>Indications and contraindications </li></ul><ul><li>Specific dental/oral complaints </li></ul><ul><li>Oral Examination </li></ul><ul><li>Psychosocial evaluation </li></ul><ul><li>Preliminary diagnosis </li></ul>Diagnostic and Surgical Implant Placement Protocol (1)
  37. 37. Clinical Evaluation and Dx. <ul><li>Review of indications and contraindications </li></ul><ul><li>Oral examination </li></ul><ul><li>Evaluation of existing dentition </li></ul><ul><li>Periodontal evaluation: prophyaxis </li></ul><ul><li>Occlusal analysis </li></ul><ul><li>Analysis of models in a semiadjastabl articulator </li></ul><ul><li>Radiographic findings </li></ul><ul><li>Full mount Panorex radiogaph </li></ul><ul><li>Specific periapical and/or lateral jaw radiographs </li></ul><ul><li>Photographic documentation </li></ul>Diagnostic and Surgical Implant Placement Protocol(2)
  38. 38. Therapeutic Plan <ul><li>Implant position and sizes </li></ul><ul><li>Prosthetic restoration </li></ul><ul><li>Explanation of treatment plan </li></ul><ul><li>Establishment of treatment sequence and schedule </li></ul><ul><li>Establishment of financial arrangements </li></ul>Diagnostic and Surgical Implant Placement Protocol(3)
  39. 39. Presurgical Mouth Preparation <ul><li>Extractions </li></ul><ul><li>Necessary restorative dental procedures </li></ul><ul><li>Periodontal therapy </li></ul><ul><li>Endodontal therapy </li></ul><ul><li>Orthodontal therapy </li></ul><ul><li>Prophylatic splinting </li></ul><ul><li>Presurgical measurement radiograph with surgical template in place </li></ul>Diagnostic and Surgical Implant Placement Protocol(4)
  40. 40. Surgical Implantation <ul><li>Confirm measurement of potential implant sites on radiograph </li></ul><ul><li>Positioning of the surgical template </li></ul><ul><li>Surgical insertion of implant(Stage 1) </li></ul><ul><li>Reopening of the implant sites(Stage 2) </li></ul><ul><li>Removal of first phase healing screw </li></ul>Diagnostic and Surgical Implant Placement Protocol(5)
  41. 41. Prosthetic Management <ul><li>Preparation of adjacent natural teeth </li></ul><ul><li>Removal of second phase healing screw </li></ul><ul><li>Making impression </li></ul><ul><li>Fabrication of master model </li></ul><ul><li>Try-un and adjustment of prosthesis </li></ul><ul><li>Delivery of prosthesis </li></ul>Diagnostic and Surgical Implant Placement Protocol(6)
  42. 42. Follow-Up Care and Maintenance <ul><li>Oral prophylaxis </li></ul><ul><li>Periodotnal evaluation </li></ul><ul><li>Oral hygiene reeducation and remotivation </li></ul><ul><li>Implant recommandation </li></ul>Diagnostic and Surgical Implant Placement Protocol(7) Partial Denture ? Or Implant?

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