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Ridge augmentation - Dr. Kinjal ghelani
- 1. Ridge Augmentation BY: DR. KINJAL GABANI PART III
- 2. Contents SOFT TISSUE AUGMENTATION Definition – Classification – Indications – Contraindications – Materials used – Soft tissue and esthetic considerations before ridge augmentation procedure – Techniques – Techniques used during 1st and 2nd stage implant therapy
- 3. HARD TISSUE AUGMENTATION Classification • Materials used • Techniques • Complications • Conclusion
- 4. Definition Ridge augmentation is a periodontal procedure used to repair the deficient edentulous ridge It can be corrected by – Hard tissue only – Soft tissue only – Soft and hard tissues
- 5. Classification Sieberts classification (1983) – Class 1 – buccolingual loss of tissue with normal ridge height in the apicocoronal direction – Class 2 - apicocoronal loss of tissue with normal width in the buccolingual direction – Class 3 – combination buccolingual and apicocoronal loss of tissue, resulting in loss of normal height and width Allens classification – Mild - less than 3 mm reduction – Morderate - between 3 to 6 mm reduction – Severe - more than 6 mm reduction
- 8. Rationale Transmucosal seal – Esthetic appearance – Good emergence profile – Convexity to simulate root prominence – To withstand prosthetic mechanical challenge – Good contour – Self cleansing – Withstand recession
- 9. Materials used Autogenous graft • Free gingival graft • Connective tissue graft – Allograft – Xenografts
- 10. Free gingival graft First used graft – Reliable and efficacious – High and predictable success rate – Used to increase amount of keratinized tissue (rocuzzo M et al., 2007) – Gold standard procedure when keratinisation is needed – Mostly taken from palatal area – Used as rescue procedures, in place of high smile line, when there is a need for extensive soft tissue augmentation and where there is no esthetic concern Disadvantages – “Patch like appearance” – colour doesn’t blend with the adjacent tissues. Kills the purpose of esthetics. – Less amount of tissue available
- 11. Connective tissue graft Overcomes the esthetic drawback of FGG. Good colour match – Gold standard when it comes to recession coverage procedures in esthetic areas (Imberman M et al., 2007) – Good vascularity – Controversy over attachment with implant surface Drawbacks – Technique sensitiv – Lack of adequate tissue in the case of a large defect
- 12. Allografts Xenografts Soft tissue expanders: 2 types • Silicon balloons • Osmotic tissue expanders
- 13. Techniques Full thickness soft tissue onlay graft (Meitzer 1979) Pouch procedure (Garber and Rosenberg 1981) Improved technique ( allens modification 1985) Subepithelial connective tissue graft (Langers method 1980) Interpositional graft (Siebert 1990) Interpositional onlay graft (Siebert 1992) Azzi modification 1991 Pediculated connective tissue graft (Sclar 2003) Roll technique Modified papilla preserving roll procedure
- 14. Full thickness soft tissue onlay graft Meltzer 1979 published first clinical report – To correct esthetic anterior vertical ridge defect Siebert 1983 published a series of classic articles that detail the technique and applications
- 15. Pouch procedure Garber and Roenberg 1981 developed this technique – For treating ridges that had a horizontal loss o dimension.
- 16. Improved technique In 1985, allen and colleagues improved a surgical technique for localised ridge augmentation that was similar to the technique by kahldahl and colleagues 1982 except that the graft material was HA graft
- 17. Subepithelial connective tissue graft Langer and calagna 1980 1982 designed a procedure that combined partial thickness flap anda connective tissue graft. Advantages Disadvantages Indication – For correction of all types of ridge deformitues
- 19. Interpositional graft Its is given by siebert 1992 – Almost identical to the pouch procedure Used for treatment of class 1 ridge defects
- 20. Interpositional onlay graft Siebert and Louis 1995 96 developed this procedure – For large class 3 ridge defects Meant to combine the best procedures of the interpositional graft and the onlay graft into one procedure
- 21. Pediculated connective tissue graft It si a vascularised subepithelial connective tissue graft designed for esthetic reidge augmentation befire, during and after implant placement Will help prevent premature membrane exposure Provide sufficient additional vascularized tissue For vertical and buccal ridge augmentation Involves passive rotation of an interpositional periosteal retained connective tissue flap over the edentulous area into the buccal surface
- 23. Roll technique
- 24. Hard tissue augmentation Classification • Materials used • Techniques • Complications • Conclusion
- 25. The alveolar ridge undergoes accelerated bone loss within the first 6 months of tooth extraction,1 resulting in an eventual estimated 40% loss of ridge height and 60% loss of ridge width. Resorption of the buccal plate occurs at a faster and greater extent compared to the palatal or lingual plates because of the loss of bundle bone.
- 26. Classification Cologne Classification of Alveolar Ridge Defects
- 27. Three part codes to describe the effect of the alveolar ridge as comprehensively as possible with a view to existing therapeutic options: Part 1: Orientation of the defect h: horizontal V: vertical c: combined S (or +S): sinus area Part 2: Reconstruction needs associated with the defect 1. low: <4mm 2. medium: 4-8mm 3. high: >8mm Part 3: Relation of augmentation and defect region i: internal, inside the contour e: external, outside the ridge contour
- 28. MATERIALS Autogenous Allograft Xenograft Alloplast Biological agents Membranes
- 29. TECHNIQUES Conventional techniques (3 main groups) • Onlay bone block grafting • Guided bone regeneration • Distraction osteogenesis Other techniques • Khoury's protocol • Tenting screws • Orthodontic bone regeneration • Fence technique • I Gen • 3D printed bone • Box technique • Interpositional grafting Complex surgical procedures • Le Fort 1 osteotomy • Nerve transposition (technically not an augmentation)
- 30. Autogenous bone block Site Tibia - 5 – 40 mL uncompressed cancellous marrow Anterior ilium - 30 – 50 mL of corticocancellous marrow 1- 5 cm corticocancellous bone block Posterior ilium - 40 – 120 mL uncompressed cancellous marrow 4 – 12 cm corticocancellous bone block Cranial bone corticocancellous bone block (onlay graft) for midface, orbital, zygomatic and nasal reconstructions Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub
- 31. Guided bone regeneration PASS principal for regeneration Primary wound closure Angiogenesis Space Stability Wang and Boyapati 2006. “PASS” principles for predictable bone regeneration. Implant Dent
- 32. Distraction osteogenesis The basic principles include: Latency period of 7 days for initial post-surgical soft tissue wound healing A distraction phase during which the two pieces of bone undergo gradual incremental separation at a rate of 0.5–1 mm/day A consolidation phase that allows bone regeneration in the created space Maron 2012. Dental Implant Prosthetic Rehabilitation: Vertical Distraction Osteogenesis. Chapter 20.
- 33. Maron 2012. Dental Implant Prosthetic Rehabilitation: Vertical Distraction Osteogenesis. Chapter 20.
- 35. Horizontal Bone Augmentation Features of ridge resorption: Most bone remodeling occurs within the first 6 months after extraction An estimated 40% loss of ridge height and 60% loss of ridge width Inevitable loss of bundle bone Buccal plates resorb more than palatal or lingual plates Center of the ridge is shifted to the palatal or lingual side Rate of reduction of the residual ridge is 0.1 mm/year for the maxilla and 0.4 mm/year for the mandible
- 36. Common techniques introduced for horizontal bone augmentation are GBR, ridge splitting and expansion, and block grafts of either autogenic or allogenic origin. In horizontal bone augmentation, GBR can be applied simultaneously with implant placement (eg, the ”sandwich” bon augmentation technique18) or in a staged approach.
- 37. Ridge splitting and ridge expansion osteotomies use the ability to compress trabecular bone to create space for the implant. Monocortical or corticocancellous autogenous or allogenic block grafts can be secured to the ridge to increase its width for implant placement.
- 39. With the proposed guideline, which follows basic surgical principles, predictable bone augmentation can be achieved. In implant therapy and ridge augmentation, stability of the implant or graft material is essential in obtaining a successful treatment outcome. This guideline takes into account the benefits of different techniques and graft materials and uses them in various clinical situations to achieve the most favorable bone augmentation.