Bone at Implant site
Bone
quality
Bone
quantity

Bone Quality assessment
Bone density
Classification:
Misch

Radiographic assessment
BONE QUALITY
DENSITY HOUNSFIELD
UNITS
D 1 1250
D 2  850-1250
D 3 350-850
D 4 150-350
D 5 < 150

Soft tissue assessment
Thin scalloped Periodontium Thick flat periodontium

Reverse Engineering
Bone based
implant
placement Prosthesis based
implant placement

Alveolar morphology
“A normal ridge is defined as one that
retains the general shape of the alveolar
process following uneventful extraction
socket healing”.

Reasons for loss of alveolar morphology
Periodontal
disease
Peri-apical
lesions
Improper tooth
extraction
Trauma
Tumor Implant failures

Classifications of alveolar ridge defects
Seibert JS, 1983:
Seibert ClassI
• Buccolingual loss of tissue
• Normal ridge height in apico-coronal direction
Seibert Class II
• Apico-coronal loss of tissue .
• Normal ridge width in bucco lingual direction
Seibert Class III
• Bucco-lingual and apico-coronal loss of tissue
• Loss of height and width

Classifications of alveolar ridge defects
Modification by Allen et al 1983
Mild : < 3mm.
Moderate : 3-6
mm.
Severe: > 6 mm.
A: Apico-coronal
loss of bone.
B: Bucco-longual
loss of bone
C: Combination
of both

HVC Ridge deficiency classification
(Hom Lay Wang et al 2002)
• Combination of Seibert and Allen classification.
• Therapeutically oriented.
• H: corelates with Seibert I, V- co-relates with Seibert
II, C- co-relates with Seibert III.
• In addition there is a sub-classification in H, V and C
as follows:
– Small (< 3mm).
– Medium (4-6 mm).
– Large ( > 7 mm).
– H (s,m,l), V (s,m,l), C (s, m, l)

Risk assessment for edentulous sites (Martin et al )
Risk factors Low risk Medium risk High risk
Medical status Healthy patient and
intact immune system
--------------- Reduced immune system
Smoking habit Non smoker Light smoker ( < 10
cigarettes per day)
Heavy smoker (>10
cigarettes per day)
Patient’s esthetic
demands
Low Medium High
Lip line Low Medium High
Gingival biotype Low scalloped, thick Medium scalloped,
medium thick
High scalloped , thin
Shape of tooth crowns Regular ----------------- Triangular
Bone level at adjacent
teeth
< 5 mm to contact point = 5 mm to contact point > 5 mm to contact point
Periodontal health status Healthy Moderately compromised Severely compromised
Restorative status of
neighboring teeth
Untouched --------------- Restored
Width of edentulous span 1 tooth (>7 mm)
1 tooth (> 5.5 mm)
1 tooth (< 7 mm)
1 tooth (< 5.5 mm)
2 Teeth or more
Soft tissue anatomy Intact soft tissue ------------------ Soft tissue defects
Bone anatomy of alveolus No bone deficiency Horizontal bpne
deficiency
Vertical bone deficiency

Implant site development: Sequence, Timing, Selection, Duration
Treatment Period Treatment timing Procedures performed Treatment Duration
Initial Site
Development
Prior to implant
placement
Extraction site
management
Hard tissue grafting
Soft tissue grafting
Prosthetic soft
tissue management
Upto 12 months
Intermediate site
development
Implant placement
through
osseointegration
period
Extraction site
management
Hard tissue grafting
Soft tissue grafting
Prosthetic soft
tissue management
6 weeks to 9 months
Final site development Transmucosal
emergence of implant
to final restoration
Abutment
connection.
Prosthesis guided
soft tissue healing.
Esthetic soft tissue
re-surfacing
Upto 4 months
Recall phase Recall period Soft tissue grafting.
Esthetic soft tissue
re-surfacing
Variable

Hard tissue
augmentation
Soft tissue
augmentation
Implant site
Development

Hard tissue Augmentation
Guided bone regeneration concept:
• Advocates that regeneration of osseous defects is predictably
attainable via the application of occlusive membranes, which
mechanically exclude non-osteogenic cell populations from the
surrounding soft tissues, thereby allowing osteogenic cell
populations originating from the parent bone to inhabit the
osseous wound.
• Based on pioneer experiments investigating healing of periodontal
tissues following surgical therapy, a principle of tissue healing was
discovered by Nyman & Karring in the early 1980’s.

• Based on osteo promotion principle.
• Osteopromotion refers to the use of physical means to seal off an
anatomical site the site where bone is intended to be (re) formed – in
order to prevent other tissues, notably connective tissue, to interfere with
osteogenesis as well as to direct bone formation.
How do Guided Bone Regeneration
works ?

• A viable source of bone cells must be available from the surrounding bone.
• New bone formation requires an adequate blood supply.
• The wound must remain mechanically stable during healing.
• Adequate space must be created and maintained between the membrane
and bone surface.
• Soft tissue cells must be excluded from the space created by the barrier
membrane.
Principles of Guided Bone regeneration
by Dahlin et al(1994)

• Augmentation around implants placed in immediate extraction sockets.
• Augmentation around implants placed in delayed extraction sockets.
• In dehiscence defects around implants.
• Localized ridge augmentation.
• Alveolar ridge reconstruction.
• Filling of bone defects after root resection, cystectomy and removal of
retained teeth.
Indications of GBR

GUIDED BONE REGENERATION
• Wound completely covered by flap
(closed system)
• Sterile condition maintained during
healing
• Membrane stable
• Adaptation of membrane easy
• Space making easy
• High predictability
• Open wound (open system)
• Sterile condition not maintained
• Membrane stabilization difficult
• Adaptation of membrane difficult
• Space making difficult
• Low predictability

Definitions of success following guided bone regeneration
Bucco-lingual
ridge
augmentation
Implant
dehiscence
Extraction socket
reconstructions
Apico-coronal
ridge
augmentation
First generation Adequate bone
to place an
implant
Coverage of
exposed implant
surface with
regenerated hard
surface
Adequate bone
to place an
implant
Adequate bone
to place a 10 mm
long implant
Second
generation
Adequate bone
to withstand
functional forces
over time
Adequate bone
to withstand
functional forces
over time
Adequate bone
to withstand
functional forces
over time
Adequate bone
to place 10 mm
long implant &
withstand
functional forces
over time
Third generation All of the above and regeneration of pre-pathologic morphology allowing
implant placement in perfect prosthetic position with maximum aesthetics
Fourth
generation
Simplification of therapy as much as possible without compromising the
treatment outcomes

Biomaterials for hard tissue augmentation
Guided bone regeneration
Grafts
Barrier
membranes

Bone Grafts
Bone graft : Bone or bone like synthetic
substance used to fill a defect in a bone or to
augment new bone formation

Grafts
Bone
Derived
Autogenous Allografts Xenografts
Non Bone
Derived
Alloplast
Classification of Bone Grafts

• AUTOGRAFT
OSTEOGENIC
• AUTOGRAFT
• ALLOGRAFT
OSTEOINDUCTIVE
• AUTOGRAFT
• ALLOGRAFT
• XENOGRAFT
• ALLOPLASTS
OSTEOCONDUCTIVE
Principles of Bone Grafts

Autogenous Bone Grafts, and
Donor Sites

Graft form and maximum volume available from autogenous bone donor sites
Donor Site Forms available Maximum volume (ml)
Extraoral
Posterior iliac crest Block and or particulate 140
Anterior iliac crest Block and or particulate 70
Tibia Particulate 20 to 40
Cranium Dense cortical block 40
Intra oral
Ascending ramus Block 5 to 10
Anterior mandible Block and or particulate 5
Tuberosity Particulate 2
Miscellaneous ( one
shavings)
Particulate Varies

Cortical grafts vs
• Thich dense lamellar bone.
• Resorption is slower.
• Volume of bone fill
achieved is higher.
• Stabilization is not a
problem.
• Graft re-vascularization is
slower
Cancellous grafts
• Trabecular bone- less dense.
• Resorption is faster.
• Volume of bone fill achieved
is lower.
• Need GBR membranes for
stabilization.
• Graft re-vascularization is
faster.

Mandibular symphisis
Rule of FIVE: 5 mm anterior to mental foramen, 5 mm above the ridge crest, 5 mm
apical to anterior root tips. (Hunt and Jovanovic, 1999)

BLOCK GRAFTS
TREPHINE CORES
Olympic design: Sascha
Jovanovic

Key factors for success: Mandibular symphisis
grafts
• Contra-indicated in
1. Patients with long anterior teeth.
2. Inadequate mandibular height or width.
3. If defect width is more than four teeth.

Incision Techniques: Symphisis access
• Indicated in patients with low vestibular sulcus,
tense mentalis posture and a donor site without
periodontal disease.
• Disadv: recession of gingiva
Sulcular incision
and mucoperiosteal
flap
• Indicated when there is marginal inflammation or
bone loss around incisors
• Disadv: scarring can occur.
Vestibular incision
• Indicated when there is 3 mm of keratinized gingiva
and thin scalloped periodontium.
• Disadv: fine suturing required.
Attached gingival
incision

AUDI
DESIGN
REVERSE
OLYMPIC RING
DESIGN
DENNIS HUNT AND SASCHA JOVANOVIC , 1999

Harvesting technique:
• Rule of five has to be followed.
Trephine cores:
• Different diameters, 4.1, 6.0 mm commonly used.
• Position drill 4 to 5 mm below apex of tooth.
• 50,000 rpm with irrigation.
• Insert into cortex.
• Avoid lingual perforation: can compromise airway.
• Drill to depth planned and cant drill to break core of bone and remove with
trephine.
Block grafts:
1. Prepare template with bone wax.
2. 3 mm from inferior border, 5 mm from anterior to mental foramen, 5 mm below
teeth apex.
3. Graft size – 2 to 3mm larger than defect size.
4. Outline graft with bur/ micro saw.
5. Depth of cut : cortex upto cancellous bone.
6. Use chisels to remove block graft.
7. Harvest cancellous marrow with rongeur/ bone curettes.

Potential complications of harvesting bone from symphisis
Complications Causes
Damage to submental/ sub-lingual
arteries
Lingual perforation
Damage to roots Long anterior root
Mental nerve paresthesia Over-extension of incisions
Incision dehiscence Post-op edema, hematoma, tense
mentalis
Chin ptosis Improper suturing, damage to mentalis
muscle.

Key factors to success:
• Access to ramus.
• Avoid neurovascular bundle.
Surgical Technique:
• Incision: start on ascending ramus at the level of occlusal plane. Move down
towards ridge and continue in buccal sulcus if molar teeth are present or mid
crestal if edentulous.
• Muco-periosteal flap reflection.
• Ramus osteotomy:
1. Start at level of occlusal plane along anterior border of ramus, maintain 3 to 4
mm medial to external oblique ridge.
2. Anterior Vertical cut in ramus body extending inferiorly from the anterior aspect
of the cut.
3. Posterior vertical cut at the upper end along lateral body of ramus
perpendicular to horizontal cut.
4. Inferior cut joins anterior and posterior vertical cuts.
5. Cuts should be made only in cortex of bone.
6. Wedge with chisel to harvest graft.

Potential complications of harvesting bone from the ramus
Complication Cause
Damage to inferior alveolar nerve Coronal portion of alveolar nerve
Limitation of graft size and shape Harvesting thin graft to avoid nerve
damage.
Incision dehiscence in donor area Hematoma, post –op edema
Post-op trismus Excessive trauma to muscle fibers during
harvesting
Damage to lingual nerve Lingually placed incision

Decision making for graft material usage in bone defect

DECISION MAKING FOR GRAFT
SELECTION
AUTOGENOUS
CORE OR BLOCKS
NON AUTOGENOUS GRAFTS
PARTICULATE OR
BONE GRAFT
PASTE PARTICULATE
OR BONE
PUTTY GRAFT
BONE PUTTY
GRAFT
Autogenous
graft available at
primary site
Autogenous graft
not available at
primary site
Intact extraction
socket
Moderately
compromised
extraction
socket
Onlsy /
severely
compromised
extraction
socket
THUMB RULE:
MAXIMIZE
AUTOGENOUS
GRAFTS

Graft materials and their indications and contraindications in alveolar grafting
Graft material Approx resorption
time
Volume available Indication/
contraindication
AUTOGENOUS BONE
Iliac crest 3- 6 months 70-140 ml Full arch
reconstruction.
Severe atrophy areas.
Higher morbidity risk
Tibial plateau 3-6 months 20-40 ml Moderate to large
reconstructions.
Used along with
titanium meshes
Mandibular symphisis 4-8 months 5 ml Small to moderate
defects with low to
moderate osteogenic
potential. Sinuses and
moderate ridge defects.
Maxillary tuberosity
Bone shavings
3- 6 months
3- 6 months
2-4 ml
0.5 – 2.5 ml
Small defects such as
unilateral sinus lift. Use
along with allografts.
Exposed implant
threads.

time
contraindication
ALLOGRAFTS
Puros 6-15 months Unlimited Small reconstructions
in defects with low to
moderate osteogenic
potential- sinus lifts,
moderate ridge defects
with other grafts
FDBA 6-15 months Unlimited Small reconstructions
in defects with low to
moderate osteogenic
with other grafts
DFDBA 2-4 months Unlimited For periodontal defects
only.

time
contraindication
ALLOPLASTS/ XENOGRAFTS
PepGen P-15
(Bovine derived
hydroxyapatite with
synthetic peptide)
18-36 months Unlimited Small reconstructions
in defects with
moderate osteogenic
with other grafts.
Very expensive
C- Graft ( Calcified algae) 6-18 months Unlimited Small reconstructions
in defects with high
osteogenic potential-
minimalridge defects,
exposed implant threads,
extraction sockets.
Bio-Oss ( anorganic
bovine bone)
extraction sockets

time
contraindication
Osteograf (microporous
hydroxyapatite )
in defects with
moderate osteogenic
with other grafts.
Osteogen (Porous
anorganic crystal)
extraction sockets.
Cerasorb (beta-TCP) 4-12 months Unlimited Resorbs too quickly to
recommend use alone
for bone grafting.
Interpore 200 (porous
coral)
5-7 years Unlimited Resorbs too slowly to
recommend use alone
for bone grafting

time
contraindication
Cap Set (medical grade
calcium sulphate)
1-2 months Unlimited Requires some time to
mix.
Used for small defects
along with allografts.
Bioplant HTR polymer
(microporous composite
with calcium hydroxide
surface)
10-15 months Unlimited Resorbs too slowly to
recommend use alone
for bone grafting
Can be used in
extraction sockets below
pontic of bridges.
Perioglass (synthetic
particulate glass ceramic)
18-24 months Unlimited Recommended for
periodontal defects only.
Biogran (synthetic
particulate glass ceramic)
20-22 months Unlimited Recommended for
periodontal defects only

Membranes in brief
• More predictable restoration of architecture of
newly formed bone.
• Creates a suitable environment in which the
natural biologic potential can be maximized.
Rationale:
• Stabilize blood clot.
• Isolate space from undesirable tissues.
• Prevent soft tissue collapse.

Physical barrier membrane which are used for GBR should
satisfy the following five basic criteria (Hardwick et al 1994)
• Biocompatibility
• Cell occulisivity
• Tissue integration
• Space making
• Clinical manageability
Requirements of barrier membrane

Barrier membrane -
Classification
Barrier
membranes
Non
resorbable
membranes
Resorbable
membranes

• e-PTFE
• Ti reinforced ePTFE
• High-density PTFE (Bartee BK.1995)
• Titanium mesh (Mellonig et al 1995, Jovanovic et al 1995)
Ti mesh as a barrier maximizes graft containment and eliminates the space
maintenance collapse problems associated with conventional membranes
(Von Arx et al 1996, Boyne PJ 1996)
Non Resorbable Membrane

The membranes at present available are either made from:
• Synthetic polymers (lactide-glycolide copolymers or polylactic acid
blended with citric acid ester) e.g. Guidor, resolut.
• Natural biomaterials (collagen) e.g. Biogide
Additional requirements
• Bioresorbability
• No foreign body reaction
• No interaction with bone regeneration.
Resorbable Membrane

Membranes and their indications and contraindications in guided bone
regeneration
Membrane Composition Approximate
resorption time
Indication/
contraindication
Non- Resorbable Membranes
Gore-tex E-PTFE NA Original barrier
material.
Effective around small
to moderate defects
GTAM E-PTFE with titanium
reinforcement
NA Small to large defects.
Pin fixation for vertical
height augmentation.
Titanium Titanium NA Vertical and horizontal
ridge defcts with
particulate grafts.
High risk of soft tissue
dehiscence.
Regentex GBR 200 PTFE NA Not recommended.
Limited documented
success.

regeneration
resorption time
Indication/
contraindication
Resorbable Membranes
Biomend extend Bovine tendon collagen 4 months Lateral sinus window.
Small to moderate
defects with pin fixation.
Around Implant
dehiscence
Alloderm Acellular freeze dried
cadaver skin
4 months Best for cases where
primary closure cannot
be achieved.
Also for large
schneiderian membrane
tears.
Atrisorb Liquid PLA 4 months Suitable for
periodontal defects.
Biomend Bovine tendon collagen 2 months Large schneiderian
membrane tears.
Alveolar socket
defects.
Around implants.

regeneration
resorption time
Indication/
contraindication
Resolut Adapt PLA/PGA 3 months For lateral window
closure.
Not suitable for ridge
augmentation
Resolut Adapt LT PLA/ PGA 4 months For lateral window
closure.
augmentation
Biogide Porcine dermal collagen 3-4 months For lateral window
closure.
augmentation
Epigide PLA/PGA 4 months Small ridge defect with
or without implants
Ossix Bovine tendon collagen 6 months For lateral window
closure.
augmentation

regeneration
resorption time
Indication/
contraindication
Reguarde Bovine tendon collagen 4 months Large schneiderian
membrane tears.
Alveolar socket
defects.
Around implants.
Resolut PLA/ PGA 3 months Small ridge defects
with or without
implants.
Resolut XT PLA/PGA 4 months Small ridge defects
with or without implants
Cap set Medical grade calcium
sulphate
2 months Cover grafted
extraction sockets.
Lambone Thin sheet of DFDBA 5 months Ridge width and ridge
height in conjunction
with particulate grafts
Lyodura Freeze dried human dura
mater
2-3 months Not recommended for
clinical use.

regeneration
resorption time
Indication/
contraindication
OsseoQuest PLA/ PGA 6 months Not recommended for
clinical use.
Too stiff, too costly.
Vicryl periodontal mesh Woven vicryl 1 month Not recommended due
to fast resorption and
wicking effect.
Colla tape Bovine tendon collagen 2 weeks Not a true barrier
membrane.
Schneiderian tears and
small defects.

• To guarantee stabilization of the barrier membranes during suturing of the
mucoperisteal flaps and during the healing phase, use of minipins or
miniscrews are recommended which serve as “tentpole” for the barrier
membrane.
• These minipins and miniscrews are also available in non-bioresorbable and
bioresorbable materials. For non bioresorbable membrane such as ePTFE,
stainless steel miniscrew are successfully used which are removed along
with the membrane after the entire healing period of 6 to 9 months.
Membrane Fixation

FIXATION SYSTEMS ADVANTAGES DISADVANTAGES
Titanium screws Ease of use in dense bone Need to pre-drill the site
Length of time
Need to remove
Titanium tacks Predictability in dense
bone
No need to pre-drill
Ease and speed of use
Need to remove
Resorbable screws Do not have to be removed Need to pre-drill the site
Prone to fracture in dense
bone
Resorbable screws with air
gun insertion
Do not have to be removed
Ease and speed of use
Problematic in delicate
bone
Potentially disconcerting to
the patient
Membrane Fixation Options

Membrane selection for
GBR Procedure
Autogenous
block graft
placed
Paticulate or
“putty” graft
placed
Resorbable
membrane
Resorbable
membrane
Titanium
reinforced
membrane
Space
maintaining defect
Non Space
maintaining
defect
Non Space
maintaining
defect
Space
maintaining
defect

Basics for surgical technique for augmentation
Flap design Technique
Incisions Beveled incision.
Preserve papilla by leaving 2mm of tissue in mesial and distal
aspects of edentulous sites: anterior esthetic areas.
Vertical incisions at least one tooth away from the edentulous
site to enable complete coverage of GBR membranes.
If sufficient width of keratinized tissue is present: Mid crestal.
If insufficient width of keratinized tissue:
1. Palatal incision – 4 to 5 mm from the crest in palatal
direction: Maxilla.
2. Buccal muco-gingival junction of mandible.
Flap reflection Initial partial thickness followed by full thickness once bone is
reached by beveled incision.
Reflect beyond the muco-gingival junction: allows
advancement.

FLAP DESIGN FOR EDENTULOUS RIDGE AUGMENTATION

Techniques for hard tissue augmentation
• Onlay.
• Particulate grafting with titanium mesh.
• Ridge split.
• Interpositional.
• Particulate grafting with membrane.
• Distraction osteogenesis.
• Tissue engineering constructs.

Onlay Blocks
• Onlay: “Placed over”
• Useful for augmentation of moderate and severe horizontal and vertical ridge
defects
• Source of blocks : mandibular symphisis, ramus, iliac crest, rib grafts.
• Basic technique:
1. Full thickness flap is elevated at the surgical site.
2. Cortical plate of bone at the recipient site is drilled with round bur: to improve
vascularity.
3. Block is scored on inner aspect to obtain as close a adaptation as possible with
the recipient site.
4. Fixation screws used to stabilize graft in place and to minimize micromotion to
allow bone regeneration.
5. Small gaps can be filled with allogratfs, cancellous grafts.
6. No membrane is required. Membrane is used only if primary closure cannot be
achieved.

Particulate Grafts with Titanium mesh
• Developed by Boyne PJ 1997 and further refined by Maiorana
C et al 2001.
• Main indication: Severe vertical ridge deficiencies involving
full arch. Mostly used for atrophic maxilla.
• Involves use of a custom made titanium mesh with 1:1
mixture of cancellous bone and anorganic bovine bone.
• Adv: mesh creates an appropriate contour of the edentulous
area and allows good blood supply to the underlying
cancellous bone during 5 month healing period.

Particulate Grafts with Titanium mesh
Technique:
• Pre- surgical phase: mesh preparation
1. Polyether impression of maxilla.
2. Wax is placed over the cast to simulate the desired augmentation of the atrophic area.
3. Cast is then duplicated in acrylic.
4. Titanium mesh is adapted to the shape of the ridge as in the duplicated cast.
Surgical Phase:
1. Crestal incision with relieving incision in midline and tuberosity areas.
2. Full thickness flap reflection.
3. Titanium mesh with mixture of autogenous bone and allograft particles placed over the
maxillary bone and fixed with transcortical screws.
4. Periosteal incisions are made at the base of the flaps and flap is advanced to obtain
complete closure.
Limitation: vestibular sulcus is eliminated.
After 5 months the mesh is removed and vestibuloplasty can be performed to
establish keratinized gingiva in the maxillary area.

Particulate Graft with Titanium mesh

Particulate graft with Titanium mesh

Interpositional grafts (inlay technique)
• Indication: extreme atrophy of the edentulous maxilla in which the
relationship between the upper and lower jaw can be restored on a
vertical and sagittal plane.
• Pre-surgical technique:
1. Lateral and frontal cephalometric tracings are taken.
2. Surgical stent is prepared pre-operatively to plan for re-positioning of
the maxilla after osteotomy.
Surgical technique:
1. Full thickness incision from molar to molar in the unattached portion of
the vestibule.
2. Le- fort I osteotomy is performed and cortico-cancellous graft is placed
in the inner part of the maxilla after removing the mucosa of the sinus
floor.
3. Layer of anorganic bone is placed over the iliac graft to reduce the
resorption.
Limitation : post-operative morbidity is high, technique sensitive.

Atrophic maxilla: Downfracture of maxilla with onlay and
interpositional grafts

Particulate grafts with Membranes
• First reported in 2000, Kirkland G et al.
• Uses autogenous bone/ particulate graft with
resorbable or non resorbable membranes.
• PASS principle: Hom Lay Wang to ensure success.
• Indicated for localized ridge augmentation and
implant dehiscence management.

Particulate grafts with Membranes
• Technique:
1. Lateral incision and vertical releasing incisions.
2. Muco-periosteal flap reflection.
3. Soft tissue debridement if any.
4. De-cortication of bone defect.
5. Membrane preparation.
6. Graft placement into defect.
7. Followed by membrane stabilization over graft.
8. Flap advancement and closure.

Seibert Class I defect
Flap Reflection

Graft placement Membrane placement

PRE-OP POST-OP: 3 MONTHS
SURGICAL RE-ENTRY IMPLANT PLACEMENT

Regional acceleratory Phenomenon (RAP)
• It is the local response of bone to a noxious stimulus .
• A process by which tissue form faster than normal
regeneration time. ( 2 to 10 times faster)
• RAP begins within a few days and peaks at 1 to 2
months and lasts till 4 months.
• Noxious stimuli can be injury, fracture, intentional
drilling of bone.
• RAP mediated by growth factors at site (PDGF and TGF
beta) and cells of bone.
• It can be accomplished by systemic response (systemic
acceleratory phenomenon)

Caging effect
• Exclusion of the periosteum and fibrous tissue
elements have repeatedly demonstrated graft
preservation,which is described by Murray et al as
“caging effect.”
Guided bone regeneration in Implant Dentistry, Quintessence books, Buser,
Dahlin, Schenk)

Ridge split
• Pioneered by Nentwig and Kniha, 1986.
• Called the “ bone splitting/ spreading technique”
• Allows expansion of the alveolar bone with simultaneous implant
placement.
• Surgical technique:
1. Preparation of buccal partial thickness flap.
2. Osteotomy in the middle of the crest with chisels and knifes.
3. Luxation of periosteum pedicled buccal bone in the vestibular direction.
4. Enlargement of crest from 2.5 mm to 5 mm.
5. Implant bed preparation with bone expanders.
6. Implant placement and submergence.
Scipioni et al 1994, 5 year success rate of 88% - 93% with this mehod.

Split thickness flap
Buccal pedicled bone, Ridge split and
expansion

Implant placement in
expanded bone

Distraction Osteogenesis
• Biologic rationale:
 New bone apposition occurs in a surgically created bone
fracture.
 New bone formation is due to tension induced between
two pieces of slowly separated bone.
Originally used in long bone growth, Ilizarov G, 1989.
 Introduced for oral surgical procedures by Mc Carthy JG,
1992.
Primary Indication is vertical bone augmentation prior to
implant placement.

Surgical technique:
• Buccal full thickness flap elevation beyond the mucogingival
junction.
• Lingual flap is left in place for blood supply to distracted segment of
bone.
• A horizontal osetotomy is made with oscillating saw and burs and
the distractor is secured.
• Vertical cuts are made to mobilize the bone segment to be
distracted
• The flap is sutured and a provisional prosthesis is given.
• After 1 to 2 weeks of latency the distractor is activated to achieve
progressive bone separation until required height of bone is
achieved.
• Moderate over correction is recommended
• After a period of bone consolidation, the distractor is removed.

Buccal Full
thickness flap
Horizontal Osteotomy

• Potential Risks:
Distractor instability ( poor bone quality).
Flap dehiscence.
Premature consolidation of bone.
Transport bone segment fracture

Decision making for management of Ridge defects
Ridge Thickness Procedure
7-8 mm Particulate graft with barrier membrane with pin fixation.
6-7 mm Osteotomes for ridge expansion
5-6 mm Allogenic block of bone.
4-5 mm Autogenous block of bone
1-4 mm Down fracture of maxilla, titanium mesh ( both with
autogenous bone graft), distraction osteogenesis.
Adapted from: Guided bone regeneration: Textbook
by Buser.

Tissue engineering constructs
• Based on concept of tissue engineering.
• A combination of scaffolds, cells, growth
factors are used to obtain regeneration of
target tissue.
• Important addition is : Blood supply

Literature Review: in vitro studies: alveolar bone
Author Scaffold Cells Findings
Xiao yin et al, 2003 Three dimensional
collagen matrix
Osteoblast like cells New bone formation
at all sites treated
with osteoblast matrix
at 28 days.
Turhani D et al 2005 Hydroxyapatite from
red algae
Cambial layer of cells
cultured in vitro
Osteoblast cell
phenotype.
Good viability of
cultured cells.
Young CS et al 2005 PLGA Rat osteoblasts in
bioreactor
Histological
demonstration of
bone like issue
(BSP and osteocalcin
positive)
Turhani D et al 2005 PLGA vs
Hydroxyapatite
Mesenchymal cambial
precursor cells
Substrate influenced
the parameters of
differentiation.
HA was better.

Literature Review: in vitro studies: alveolar bone
Author Scaffold Cells Findings
Weng Y et al 2006 Calcium alginate gel Bone marrow
stromal cells in
dogs
Bone formation
demonstrated
histologically
Yefang Z et al 2007 Polycaprolactone-
tricalcium
phosphate
Human osteoblasts
culture
Mineral nodule
formation
demonstrated.
Abukawa H et al
2009
Mini pig model,
autologous bone
Osteoblasts of mini
pig
Bone formation
demonstrated

Tissue engineered constructs with PRP
• Platelet rich plasma: autologous concentrate
of platelets.
• Rich source of growth factors.
• Proven soft tissue healing.
• Bone healing is not proven: on stand alone
basis.
• Used with other bone substitutes for
improving healing.

Literature Review: PRP with bone substitutes: bone augmentation
Author STUDY design Findings
Kassolis JD et al 2000 Case series on ridge
augmentation and sinus
augmentation along with
allograft
Histologic demonstration of
bone formation in
augmented areas.
Rosenberg ES, Torosian J
2000
Case report- sinus
augmentation
Technique demonstration
Shanaman R et al 2001 Case reports: ridge
augmentation by autogenous
grafts and PRP
PRP did not enhance bone
quantity or quality when
used with autogenous bone.
Robiony M et al 2008 Distraction osteogenesis for
ertical augmentation of
mandible.
Autgenous bone and PRP
filler
Effective method for bone
gain.
Total bone volume loss was
only 2.3 %

Literature Review: PRP with bone substitutes: bone augmentation
Author STUDY design Findings
Mooren RE et al 2010 Retrospective study.
Mandible re-construction
with titanium plates,
block and particulate
grafts, PRP gel
Healing was uneventful.
Continuity was attained in
all cases.
High PRP concentration:
more granulation tissue
formation.
Schuckert KH et al 2010 Case report.
Tri calcium phosphate
blocks soaked in rh BMP 2
and PRP
Vital lamellar bone
formation
Torres J et al 2010 PRP effect on preventing
titanium mesh exposure
PRP completely
eliminated the titanium
mesh exposure.
Improved soft tissue
healing.

Soft tissue augmentation techniques
Soft tissue
augmentation
Free grafts
1. Onlay
2. Pouch
1. Interpositional
2. Onlay-
Interpositional
Pedicle grafts
Roll

Roll method
• Indication: Small to moderate class I defects.
• Developed by Abrams in 1980 and modified by Scharf and Tarnow
in 1992.
1. Preparation of de-epithelialized connective tissue pedicle from
palatal surface of edentulous area.
2. Pouch preparation with partial thickness dissection in the supra
periosteal connective tissue of the buccal surface of the ridge.
3. Vertical releasing incisions may be used to augment flap mobility.
4. The connective tissue flap is inserted into the pouch and secured
by sutures.
Modified Roll method: “Trap Door” Approach

Roll Flap method (Abrams 1980)

MODIFIED ROLL FLAP METHOD: FOR IMPLANTS

MODIFIED ROLL FLAP
METHOD FOR IMPLANTS

Pouch procedure with connective tissue grafts
• Indication: Class I Seibert defects.
• Developed by Graber and Rosenberg, 1981, modified by
Bahat et al 1987.
• Surgical Technique:
1. A horizontal incision is made at the crest of the ridge in the edentulous area.
Three different approaches for pouch preparation
Corono-apical, apico-coronally, lateral approach.
2. A partial thickness incision is made with a no 15 scalpel blade and extended
apically and laterally over the deformity.
3. Blunt dissection may be used to extend the pouch.
4. Connective tissue graft is harvested from palate.
5. Placed in pouch and first suture is passed through base of pouch for stabilization
of graft.
6. Second incision is in middle of pouch and final incision is used for closure of
horizontal incision.

Pouch Technique (Graber and Rosenberg, 1981)

Onlay soft tissue grafts
• Indication: Correction of Class I,II,III defects.
• Melcher (1979): developed technique. Technique
detailed by Seibert et al 1983.
1. Recipient bed preparation: removal of epithelium
from edentulous area by means of multiple parallel
incisions entering into connective tissue and scarping
of epithelium.
2. Free Autogenous soft tissue graft is harvested from
the palate and secured to the recipient bed.
3. Used as a part of two step augmentation procedure
along with provisional prosthesis.

Onlay grafts
around implant
sites
Increase width of
keratinized tissue

ONLAY GRAFTS: EDENTULOUS
MANDIBLE WITH IMPLANTS

Inter-positional (inlay) grafts
• Indications: Correction of class I ridge and small Class
II,Class III defects.
• Seibert (1992) developed this technique.
1. The surgical procedure requires the use of a thick wedge
shaped connective tissue graft harvested from the palate.
2. The graft is then inserted into recipient bed created
similar to pouch procedure by means of partial thickness
dissection.
3. The graft is sutured leaving the epithelial surface at the
level of surrounding tissues.
4. If vertical augmentation is desired, the epithelial portion
of the graft is positioned above the adjacent tissue.

Inter-positional graft ( Seibert, 1992)

Recipient pouch
Wedge shaped
Graft from palate
Seibert Class III
defect

Graft placed in
pouch and sutured
Post- op and Provisional
prosthesis

Vascularized Interpositional -CT GRAFT : FOR IMPLANTS
Anthony G Sclar . Soft tissue and esthetic considerations in Implant therapy

Vascularized Inter- positional graft
Surgical technique:
Recipient site: Curvilinear with vertical incisions.
• Allows full exposure of ridge crest.
Donor site: Exaggerated curvilinear incisions with horizontal incision
extending to distal of second premolar 2 mm apical to free gingival
margin.
• Graft dissection done sub-epithelially and vertical releasing incision
through periosteum at distal end of sub-epithelial dissection.
• Mobilize periosteal-CT graft anteriorly with horizontal incision at
inferior aspect of dissection.
• Rotate graft and mobilize to buccal aspect.
• Suture graft and close flaps on buccal and palatal aspects.

VIP-CT GRAFT : FOR
IMPLANTS
RECIPIENT SITE
DONOR SITE

VIP-CT GRAFT : FOR
IMPLANTS
ROTATED
PEDICLE

Combination of onlay and inter-positional grafts
Indication: Primary indication is for Class III ridge defects.
• Developed by Seibert and Louis (1995,1996).
• Combines inter-positional graft and the onlay graft.
Advantages:
• Increased re-vascularization of the onlay graft.
• Smaller palatal wound.
• Less morbidity.
• Increased ability to control direction of augmentation.
• No alteration in vestibular depth.

Surgical procedure:
Recipient site preparation:
1. De-epithelialization: Epithelium over the coronal aspect of ridge is
removed by a bevelled inision upto mesial and distal aspect of
adjacent papilla. Vertical grooves are placed to improve
vascularity.
2. Pouch preparation: partial thickness pouch is prepared towards
buccal aspect. Two vertical releasing incisions given at terminal
ends of de-epithelialized ridge.
3. Graft: harvesting the graft requires a full thickness dissection in
the coronal portion of the graft (epithelialized section) and a more
apical partial thickness dissection (non epithelialized connective
tissue).
4. The harvested graft is composed of two parts: a completely de-
epithelialized connective tissue segment and an epithelialized
onlay section.
5. The harvested graft ( connective tissue section) is then placed into
the pouch and onlay section is placed on the depithelialized
portion and stabilized with sutures.

Combination of onlay and interpositional graft

Seibert Class III
defect
De-epithelialization and
Pouch preparation

Graft Insertion and Stabilization
Post –op and Provisional prosthesis

Decision making for management of ridge defects with
soft tissue grafts
Indications for ridge augmentation procedures with soft tissue grafts
Indicated procedure Ridge defect
Connective tissue pedicle grafts (Roll procedure,
Abrams)
Class I Ridge defect
Connective tissue grafts ( Pouch method, Garber
and Rosenberg)
Class I defect
Sub- epithelial connective tissue graft ( Lagner and
Calagna)
Class I defect, mild to moderate
Class II and Class III defect.
Full thickness grafts ( Onlay Grafts) Class II and Class III ridge defects
Combination of onlay and interpositional grafts
(Seibert and Louis)
Severe Class III ridge defects
Anthony G Sclar . Soft tissue and esthetic considerations in Implant therapy

Treatment option based on HVC classification
(Hom Lay Wang et al , 2002)
Defect For FPD For Implants
H-s Roll method
Pouch method
Inlay soft tissue graft
Onlay grafts,
GBR,
Ridge expansion
H-m Pouch, inlay soft tissue graft Onlay cortical grafts, GBR
H-l Inlay/ inter-positional soft tissue grafts Onlay cortical grafts, GBR
V-s Inter-positional soft tissue graft Orthodontic extrusion, GBR
V-m Inter-positional/ onlay soft tissue graft Orthodontic extrusion, GBR,
Onlay osseous graft,
distraction osteogenesis.
V-l Inter-positional/ onlay soft tissue graft Onlay osseous graft,
distraction osteogenesis.
C-s Combination of soft tissue grafting Inlay/ onlay/ GBR
C-m Combination of soft tissue grafting Combination of ilay/ onlay,
Distraction osteogenesis
C-l Difficult to correct: combination of procedures Difficult to correct:
combination of procedures

Role of provisional prosthesis in achieving aesthetics
• Helps establish and mimic final soft tissue
contour.
• Ovate pontic is preferred.
• Fit of pontic into extraction site helps mold
soft tissue contour.

Journal of California Dental Association, July 2003, Winston L Chee

“PREVENTION IS BETTER THAN
CURE”

Ridge preservation/ Socket preservation
Biologic Rationale:
• Studies have shown significant alteration in ridge dimensions post-
extraction (Atwood 1963, Carlson 1967, Abrams 1987, Lekovic et al 1997).
• Schropp et al 2003 reported changes ranging from 1.5 to 2mm in vertical
dimension and 40 % to 60 % loss of bone width in the alveolus within 6 to
12 months post extraction, with most of the loss occurring during the first
three months.
 Prevention of alveolar bone loss following post- extraction was first
described by Greenstein (1985) and Ashman and Bruins (1985).
 Term socket preservation – first coined by Cohen (1988).

Alveolar Socket Defects
• Defects are categorized based on number of
walls remaining in the socket after extraction.
Five walls Four walls
Three
walls
Two wall One wall

Management of alveolar socket wall defects
Five wall defect
•Extraction site with all five bony walls intact may not require any grafting if there is a
large amount of interseptal bone
•If grafting is desired, use any graft material in putty or gel consistency for wall
support.
Four wall defect
•Extraction site is missing any one wall.
•Autogenous bone is preferred choice.
•Combination of allograft with autogenous graft acceptable.
•Use GBR membranes if allografts/ alloplasts are used.
Three wall defect
•Extraction site has lost two walls
•Autogenous bone is graft of choice.
•Allogenic blocks combine with putty and GBR membrane is acceptable

Management of alveolar socket wall defects
Two wall defect
• Extraction site has only two walls present (ie) three walls
missing
• Particulate autogenous graft with GBR membrane (non
resorbable) with pin fixation.
One wall defect
• Also referred to as knife edge defects.
• Requires cortial block graft obtained from ramus or symphisis
stabilized with fixation screws.

Two wall defect
Two wall
defect
Autogenous
graft with
membrane
Membrane
fixed with
pins

ADVANCED PROCEDURES
SINUS LIFT.
LATERAL NERVE RE-POSITIONING
.

Maxillary sinus- Applied anatomy
• Two maxillary sinuses form the upper limits for
implant placement in posterior maxilla.
• When less than 10 mm bone in posterior maxilla:
sinus lift is indicated.
• Implies lifting of the Schneiderian membrane and
placement of autogenous bone or bone substitutes
to increase vertical bone height.
• First pioneered by Tatum in 1970

Sinus Augmentation Methods
• Augmentation of maxillary sinus can be accomplished by
any one of the following methods
1. Lateral window sinus augmentation.
2. Crestal window sinus augmentation.
3. Lateral window sinus augmentation with implant placement.
4. Summer’s bone added osteotome technique.
5. Summer’s bone added osteotome technique with implant
placement.
6. Trephine and osteotome technique.
7. Trephine and osteotome technique with implant placement.
8. Balloon technique for sinus lift.

Maxillary sinus: Classifications
• Patients have been classified according to width and
height of the residual alveolar ridge and according to
inter-arch distance as follows
(Matteo Chiapasco and Paolo Casentini).

Sinus classification Features
Class A Ridge height between 4-8 mm.
Ridge width >5 mm.
Maintenance of acceptable vertical inter- maxillary inter-relationship.
Class B Ridge height 4-8 mm
Ridge width < 5mm.
Maintenance of acceptable vertical inter-arch distance.
Class C Ridge height < 4 mm.
Ridge width > 5mm
Maintenance of acceptable vertical inter-arch distance
Class D Ridge height < 4mm.
Ridge Width < 5 mm.
Maintenance of acceptable vertical inter-arch distance
Class E Same characteristics as Class A but with increased crown height
space.
Class F Same characteristics as class B but increased vertical crown height
space.
Class G Same characteristics as Class C but with increased vertical crown
height space.
Class H Same characteristics as Class D but with increased crown height
space.
Class I Severe tri-dimensional atrophy of edentulous maxilla , with increased
vertical crown implant space, horizontal resorption and maxillary
retrusion

Sinus classification Management options
Class A Sinus floor elevation via lateral approach/ trans- alveolar approach.
Simultaneous implants if good primary stability is present.
Short implants are another option.
Class B Sinus floor elevation with crest expansion, GBR/ grafting with
autogenous bone grafts on the buccal side of maxilla
Class C Sinus floor elevation with lateral approach
Class D Sinus grafting and horizontal GBR
Class E Maxillary sinus pneumatization: Sinus elevation along with vertical
GBR.
Vertical ridge resorption: vertical GBR, onlay grafts, distraction
osteogenesis.
Class F Vertical and buccal onlay grafts. Sinus grafting required only if
pneumatization of sinus has happened.
Class G Maxillary sinus grafting with vertical onlay grafts.
Class H Maxillary sinus grafting with vertical and horizontal GBR.
Class I Le fort I osteotomy with placement of inter-positional bone grafts in
maxillary sinuses and floor of the nose.
Sinus Defect Management Options

Sinus Classification ( Jensen, Chapter 8, Guided bone regeneration in Implant
Dentistry, Quintessence books, Buser, Dahlin, Schenk)

ABC Classification of Sinus
( Hom Lay Wang, Amar Katranji, 2008)
• Combination of Misch ( based on divisions of
bone) and Simon classification ( bone crest in
relation to CEJ of adjacent tooth).
• Based on the assumption that minimum
implant specification is 4 mm in diameter and
10 mm in length.

Sinus Class A: Abundant bone
• Sinus floor is 10 mm
from the crest.
• Width is 5 mm or
greater.
• CEJ to bone crest is 3
mm or less,

Sinus Class B : Barely sufficient bone
• Sinus floor to crest is 6
to 9 mm
• Width ≥ 5mm.
• CEJ to bone crest: 3
mm

Sinus Class B
Class B Div h ( Horizontal defect)
• Sinus floor : 6 to 9 mm.
• Width < 5 mm.
• CEJ to bone crest: 3 mm
Class B Div ‘v ‘ ( vertical defect)
• Sinus floor : 6 to 9 mm.
• Width > 5 mm.
• CEJ to bone crest > 3 mm.
• Crown to implant ratio
altered.

Sinus Class B
Sinus Class B Div c (Combined defect)
• Sinus floor to bone crest: 6
to 9 mm.
• Bone width < 5 mm.
• CEJ to bone crest > 3 mm

Sinus Class C : Compromised bone
Sinus Class C: Compromised bone
• Sinus to bone crest : < 5 mm
• Bone width : ≥ 5mm.
• CEJ to bone crest: < 3mm.

Sinus Class C
Class C Div h ( horizontal defect)
• Bone width : < 5mm.
• CEJ to bone crest: < 3mm.
Class C Div v ( vertical defect)
• Bone width : ≥ 5mm.
• CEJ to bone crest: > 3mm.
• Altered crown to implant
ratio

Sinus Class C
Class C Div c ( Combined defect)
• Bone width : < 5mm.
• CEJ to bone crest: > 3mm

ABC classification for sinus lift and recommended trmt options (Hom Lay Wang,
Amar Katranji 2008)
Class Recommended procedure Implant placement
A Implant Placement Immediate
B Osteotome Immediate
B-h Osteotome and risge expansion
GBR/ onlay graft
Immediate
Delayed
B-v GBR followed by osteotome Delayed
B-c GBR and /or onlay graft followed
by osteotome
Delayed
C Lateral wall sinus elevation Immediate with implant stability.
Delayed without implant stability
C-h Lateral wall sinus elevation and
GBR / onlay graft
Delayed
C-v Lateral wall sinus elevation and
GBR followed by onlay graft if
indicated
Delayed
C-c Lateral wall sinus elevation and
GBR followed by onlay graft if
indicated
Delayed

Lateral nerve re-positioning
• Effective bone height over mandibular canal is less
than 10 mm, implant insertion has high risk of
damaging inferior alveolar nerve.
• Indication:
1. When the clearance between the opposing
maxillary teeth and ridge crest of the mandible is in
excess.
2. If prosthetic space is reduced in vertical
dimension.

Lateral nerve re-positioning
• Surgical procedure:
1. Two techniques: Lateralization and Posterization.
2. Lateralization: nerve is pushed out from its canal
laterally after preparation and luxation of a bony lid
using micro saw.
3. Lateralization requires wide exposure of nerve and
tension of nerve can result in altered sensation.
4. Posterization: done to reduce tension. Involves cut
of the nerve mesial to mental foramina to relieve
tension.

Bony lid preparation
Nerve exposure
Nerve lateralization

Implant placement
Crestal
augmentation

New techniques
Piezosurgery. Zygomatic Implants

Systematic reviews and Meta- analysis
AUTHOR SYSTEMATIC
REVIEW
PARAMETERS EVAULATED CONCLUSION
Fiorelli JP, Nevins
ML 2003
Localized ridge
augmentation/
preservation
Implant survival rate in ridge
augmentation/ preservation
sites
18 studies included : 13 GBR, 5
distraction osteogenesis
High level of
predictable implant
survival in sites
treated by GBR or
distraction
osteogenesis sites and
these are similar to
those of implants in
native bone.
Rocchietta I,
Fontana F, Simion
M, 2008
Vertical bone
augmentation
4 techniques: GBR, DO, Onlay
grafting, others.
Outcomes: success/ failure rate
of procedure, complication rate,
implant success, failure, survival
rates. Out of 189 studies only 7
studies of GBR, 13 Do, 5 onlay
graft, three other techniques
Clinical and
histological data exist
for its use.
Limited studies:
difficult to conclude.

AUTHOR SYSTEMATIC
REVIEW
Esposito M et al
2009
Efficacy of
horizontal and
vertical bone
augmentation
for dental
implants
RCT of various horizontal and
vertical augmentation
techniques.
Of 18 , 13 RCT were included. 3
RCT- horizontal augmentation
and 10 RCT : vertical
augmentation.
Compare with short implants
Short implants are
better alternative to
vertical grafting of
resorbed mandibles.
Complications are
more common for
vertical augmentation.
DO- reliable technique
for vertical
augmentation.
No significant
differences between
different techniques
for horizontal
augmentation

AUTHOR SYSTEMATIC
REVIEW
Waasdorp J,
Reynolds MA,
2010
Clinical
effectiveness of
Allogenic bone
grafts for ridge
augmentation
1950-2008.
Vertical and horizontal gain/
loss.
Graft failure rate and
complications.
Implant survival rate.
Out of 35, nine studies met
inclusion criteria.
Clinical evidence: case
reports and case
series.
Variations in ridge
defect selection,
treatment, end points.
Insufficient evidence
on long term dental
implant survival.
Klijn RJ et al 2010 Sinus floor
augmentation-
autogenous
bone: Meta
Analysis
1995-2009.
Of 147 studies, 25 included for
analysis.
Intra- oral and extra oral source
of autogenous bone graft
Total bone volume gain analyzed
Iliac crest: lower TBV
as compared to intra
oral bone .
But iliac crest is gold
standard for atrophic
maxilla mgmt.

AUTHOR SYSTEMATIC
REVIEW/
META
ANALYSIS
Plachokova AS et
al 2008
Clinical
effectiveness of
PRP on bone
regeneration
Upto 2006.
Out of 108, 17 included.
Heterogenous data
Effective for
periodontal defects.
Not conclusive in sinus
augmentation
Arora NS et al
2010
PRP in sinus
augmentation
Clinical, radiographic,
histological evidence of bone
formation.
PRP and bone substitutes
Paucity of controlled
trials .
Significant improved
soft tissue healing.
Graft handling
improved.
Bae JH et al 2011 Meta analysis.
PRP in sinus
augmentation
Out of 61 articles, 8 controlled
trials.
Implant survival,
Bone-implant contact
PRP improved both
bone survival rates
and bone-implant
contact rates.

Take home message
• Prosthesis derived implant placement: bone augmentation is
important.
• Various techniques with specific indications.
• Autogenous bone is Gold Standard.
• Soft tissue augmentation in pre-prosthetic surgery.
• Prognosis improved if ridge preservation is done.
• Sinus augmentation has become more predictable.
• Zygomatic implants in severe atrophic cases: acceptable
alternative.
• Further controlled trials required as current systematic reviews
inconclusive

References
• Bone: Biology, Harvesting, Grafting for Dental
Implants. Arun . K. Garg. Quintessence books.
• Soft tissue and Esthetic considerations in Implant
Therapy: Anthony G Sclar. Quintessence Books.
• Guided Bone regeneration in Implant Dentistry.
Buser D, Dhalin C, Schenk RK. Quintessence books.
• Contemporary Implant Dentistry. Carl E Misch.
Mosby Publications.
• Bone augmentation in Oral Implantology. Khoury F,
Antoun H, Missika P. Quintessence books.

 Prof. R. Suresh, Dean , Prof and Head, Dept of
Periodontology and Implantology.FDS, SRU
 Staff and Post graduate students , Department of
Periodontology and Implantology, FDS, SRU

IMPLANT SITE PREPARATION.pptx

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to IMPLANT SITE PREPARATION.pptx

Similar to IMPLANT SITE PREPARATION.pptx (20)

More from PrasanthThalur

More from PrasanthThalur (20)

Recently uploaded

Recently uploaded (20)

IMPLANT SITE PREPARATION.pptx