Bone augmentation for implants / dental training

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
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CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 CLASSIFICATION OF BONE AUGMENTATIONCLASSIFICATION OF BONE AUGMENTATION
MATERIALSMATERIALS
 SURGICAL KEYS OF BONE GRAFTINGSURGICAL KEYS OF BONE GRAFTING
 INTRAORAL AUTOGENOUS BONE GRAFTSINTRAORAL AUTOGENOUS BONE GRAFTS
 EXTRAORAL AUTOGENOUS BONE GRAFTSEXTRAORAL AUTOGENOUS BONE GRAFTS
 MAXILLARY SINUS LIFT AND SINUS GRAFTMAXILLARY SINUS LIFT AND SINUS GRAFT
SURGERYSURGERY
 PREMAXILLA IMPLNAT CONSIDERATIONSPREMAXILLA IMPLNAT CONSIDERATIONS
 CONCLUSIONCONCLUSION
 REFERENCESREFERENCES

Extra Oral Donor Bone GraftsExtra Oral Donor Bone Grafts
for Endosteal Implantsfor Endosteal Implants
The Preferred extra-oral donor sites ofThe Preferred extra-oral donor sites of
autogenous bone include:autogenous bone include:
1. The iliac crest1. The iliac crest
2. Tibia2. Tibia
3. Cranium and3. Cranium and
4. At a lesser degree rib and fibula4. At a lesser degree rib and fibulawww.indiandentalacademy.comwww.indiandentalacademy.com

Ilium:Ilium:
Autogenous bone harvested from the ilium isAutogenous bone harvested from the ilium is
the donor site of choice for large defect bonethe donor site of choice for large defect bone
grafts to the jaws.grafts to the jaws.
Rapid bone resorption of 30% to 90% of iliacRapid bone resorption of 30% to 90% of iliac
crest bone grafts is reported when conventionalcrest bone grafts is reported when conventional
dentures are placed on top of thedentures are placed on top of the
reconstruction.reconstruction.

Surgical ApproachSurgical Approach
 Different approaches such as onlay grafting orDifferent approaches such as onlay grafting or
interpositional graft with Lefort 1 osteotomiesinterpositional graft with Lefort 1 osteotomies
have been proposed.have been proposed.
 Autogenous grafts for endosteal implants haveAutogenous grafts for endosteal implants have
indications and surgical approaches related toindications and surgical approaches related to
the final prosthetic design and original bonethe final prosthetic design and original bone
anatomy.anatomy.
 The surgical approach and related treatment isThe surgical approach and related treatment is
addressed for each anatomic condition.addressed for each anatomic condition.

Division C-wDivision C-w
 Autogenous grafts in the C-w ridge have a primary intentAutogenous grafts in the C-w ridge have a primary intent
to increase the width of the atrophic bone but also oftento increase the width of the atrophic bone but also often
provide some vertical increase for ideal bone volume.provide some vertical increase for ideal bone volume.
 An incision is placed on the crest of the C-w ridge, and aAn incision is placed on the crest of the C-w ridge, and a
full thickness periosteal reflection exposes thefull thickness periosteal reflection exposes the
moderately resorbed residual ridge.moderately resorbed residual ridge.
 A block of one cortical plate and cancellous bone isA block of one cortical plate and cancellous bone is
harvested from the iliumharvested from the ilium
 The overlying cortical plate of host bone is scored toThe overlying cortical plate of host bone is scored to
establish the Regional Acceleratory Phenomenon.establish the Regional Acceleratory Phenomenon.

The block of bone graft is fixated with titaniumThe block of bone graft is fixated with titanium
screws, to he lateral aspect of the recipientscrews, to he lateral aspect of the recipient
bone to restore the final ridge form in a morebone to restore the final ridge form in a more
ideal position for the future implant placement.ideal position for the future implant placement.
PRP from 10 to 40ml of blood and additionalPRP from 10 to 40ml of blood and additional
cancellous bone harvested from ilium arecancellous bone harvested from ilium are
placed around the blocks and fill in any defects.placed around the blocks and fill in any defects.
The tissues are approximated without tensionThe tissues are approximated without tension
with horizontal mattress sutures.with horizontal mattress sutures.

Division C-hDivision C-h
 The initial incision for C-h available bone is inThe initial incision for C-h available bone is in
keratinized tissue and on the lingual aspect ofkeratinized tissue and on the lingual aspect of
the crest of the maxilla and the facial aspect ofthe crest of the maxilla and the facial aspect of
the crest of the mandible, from second premolarthe crest of the mandible, from second premolar
to second premolar region.to second premolar region.
 C-h edentulous available bone is usuallyC-h edentulous available bone is usually
augmented with a block graft on the crest of theaugmented with a block graft on the crest of the
atrophic bone.atrophic bone.
 The bone harvested from the donor site is a fullThe bone harvested from the donor site is a full
thichness, bicortical blockfrom the anterior ilium.thichness, bicortical blockfrom the anterior ilium.

 Surgical templates designed before surgery are usedSurgical templates designed before surgery are used
to help contour the block of bone.to help contour the block of bone.
 Four to six titanium screws 2mm in diameter and 12 toFour to six titanium screws 2mm in diameter and 12 to
16mm long usually are used to fixate the block graft of16mm long usually are used to fixate the block graft of
autogenous bone.autogenous bone.
 Additional cortical and cancellous bone harvestedAdditional cortical and cancellous bone harvested
from the ilium and stored in sterile saline is made intofrom the ilium and stored in sterile saline is made into
particulate bone and then compressed in a 5 -10mlparticulate bone and then compressed in a 5 -10ml
syringe.syringe.
 The tissues are approximated with a non-resorbableThe tissues are approximated with a non-resorbable
suture.suture. www.indiandentalacademy.comwww.indiandentalacademy.com

Division - DDivision - D
Presents with a flat maxilla or pencil thinPresents with a flat maxilla or pencil thin
mandible with dehiscent mandibular canals,mandible with dehiscent mandibular canals,
occasionally accompanied by paresthesia ofoccasionally accompanied by paresthesia of
the lower lip.the lower lip.
Exposure of the mandible should include, crestExposure of the mandible should include, crest
of the atrophic ridge, mental foramina, externalof the atrophic ridge, mental foramina, external
oblique, lateral body, ascending ramus aboveoblique, lateral body, ascending ramus above
the retromolar pad, and superior genialthe retromolar pad, and superior genial
tubercles.tubercles.
As in C-h patient, the crest of the ilium isAs in C-h patient, the crest of the ilium is
sectioned so the crest and bicortical inner andsectioned so the crest and bicortical inner and
outer table are harvested.outer table are harvested.

 Once the block is contoured using hand rongeurs, theOnce the block is contoured using hand rongeurs, the
interior cortical bone of the block is thinned,interior cortical bone of the block is thinned,
decorticated with round drills, and compressed to fitdecorticated with round drills, and compressed to fit
the atrophic ridge.the atrophic ridge.
 Four to six fixation screws are placed through theFour to six fixation screws are placed through the
block of bone and fixated into the atrophic recipientblock of bone and fixated into the atrophic recipient
bone.bone.
 In maxillary Div D bone graft, incision is carried outIn maxillary Div D bone graft, incision is carried out
from the anterior aspect of the arch to the distal aspectfrom the anterior aspect of the arch to the distal aspect
of the canines.of the canines.
 A mucoperiosteal reflection exposes the posteriorA mucoperiosteal reflection exposes the posterior
maxilla, zygomatic process, infraorbital foramina,maxilla, zygomatic process, infraorbital foramina,
lateral and inferior pyriform rims, nasal spine, incisivelateral and inferior pyriform rims, nasal spine, incisive
foramen and anterior one third of the hard palate.foramen and anterior one third of the hard palate.www.indiandentalacademy.comwww.indiandentalacademy.com

Iliac Crest AnalgesiaIliac Crest Analgesia
 The post operative pain and gait disturbance fromThe post operative pain and gait disturbance from
harvesting bone from the iliac crest are significantharvesting bone from the iliac crest are significant
surgical considerations.surgical considerations.
 The use of an epidural catheter for infusion of localThe use of an epidural catheter for infusion of local
anesthetic into the iliac donor site has shown aanesthetic into the iliac donor site has shown a
dramatic decrease in postoperative pain and muchdramatic decrease in postoperative pain and much
earlier ambulation.earlier ambulation.
 Bupivacaine is administered through catheter every 6Bupivacaine is administered through catheter every 6
-12 hrs as needed for pain relief.-12 hrs as needed for pain relief.

Cranial Bone GraftsCranial Bone Grafts
 Cranial bone grafts are useful for theCranial bone grafts are useful for the
reconstruction of craniofacial anomalies,reconstruction of craniofacial anomalies,
posttraumatic defects, tumor resection, alveolarposttraumatic defects, tumor resection, alveolar
clefts and jaw augmentation.clefts and jaw augmentation.
 A hemicoronal incision is made over the parietalA hemicoronal incision is made over the parietal
bone. A subgaleal scalp flap is elevated, andbone. A subgaleal scalp flap is elevated, and
Raney clips are placed to control hemorrhage.Raney clips are placed to control hemorrhage.

 An area of parietal bone awayAn area of parietal bone away
from suture lines and thefrom suture lines and the
midline of the skull is selected.midline of the skull is selected.
 The bone graft is outlined onThe bone graft is outlined on
the outer cortex down to diploethe outer cortex down to diploe
with a fissure bur to createwith a fissure bur to create
rectangles of 1 to 2cm wide.rectangles of 1 to 2cm wide.
 The osteotome is gently tappedThe osteotome is gently tapped
along the cancellous layer, andalong the cancellous layer, and
the strips of outer cortex arethe strips of outer cortex are
elevated.elevated.

 The bony edges of theThe bony edges of the
donor site should bedonor site should be
smoothened and asmoothened and a
layered closure of thelayered closure of the
scalp is performed.scalp is performed.
 The disadvantage ofThe disadvantage of
cranial graft is that thecranial graft is that the
donor and recipient sitesdonor and recipient sites
are in the same operatingare in the same operating
field.field.

Tibial Bone GraftsTibial Bone Grafts
 Access to the tibialAccess to the tibial
plateau is obtained byplateau is obtained by
a 2 to 3cm obliquea 2 to 3cm oblique
incision through theincision through the
skin on theskin on the
anterolateral aspectanterolateral aspect
of the leg directly overof the leg directly over
Gerdy’s tubercle,Gerdy’s tubercle,
which is lateral to thewhich is lateral to the
tuberosity.tuberosity.

 The outer corticalThe outer cortical
bone and core ofbone and core of
cancellous bone maycancellous bone may
be removed with abe removed with a
large 8 -10mmlarge 8 -10mm
trephine bur undertrephine bur under
copious sterile salinecopious sterile saline

Fixation at the recipient site followsFixation at the recipient site follows
general grafting principles.general grafting principles.
The tibial wound is approximated in layersThe tibial wound is approximated in layers
with a resorbable suture and closed usingwith a resorbable suture and closed using
a continuous subcuticular suture ora continuous subcuticular suture or
staples.staples.

The Maxillary Sinus Lift and SinusThe Maxillary Sinus Lift and Sinus
Graft SurgeryGraft Surgery
Patient Evaluation:Patient Evaluation:
Acute, allergic or chronic maxillary sinusitis may be diagnosedAcute, allergic or chronic maxillary sinusitis may be diagnosed
by patient history and clinical examination.by patient history and clinical examination.
A physical examination evaluates the middle one third of theA physical examination evaluates the middle one third of the
face for the presence of asymmetry, deformity etc.face for the presence of asymmetry, deformity etc.
A clinical examination for maxillary sinusitis concerns theA clinical examination for maxillary sinusitis concerns the
regions surrounding the maxillary antrum.regions surrounding the maxillary antrum.
The intra oral examination assesses alveolar ulceration,The intra oral examination assesses alveolar ulceration,
expansion, tenderness, paresthesia and oro-antral fistulae.expansion, tenderness, paresthesia and oro-antral fistulae.www.indiandentalacademy.comwww.indiandentalacademy.com

Pathologic AssessmentPathologic Assessment
 The pathologic conditions that involve theThe pathologic conditions that involve the
mucosa of the maxillary sinus includemucosa of the maxillary sinus include
inflammatory conditions, neoplasms, and cysts.inflammatory conditions, neoplasms, and cysts.
 A radiographic thickening of the membrane oftenA radiographic thickening of the membrane often
indicates chronic sinusitis.indicates chronic sinusitis.
 CT is currently the modality of choice, in theCT is currently the modality of choice, in the
evaluation if diseases of the nose and Paranasalevaluation if diseases of the nose and Paranasal
sinuses.sinuses.
 Any sign of acute sinusitis, root tips, cysts, orAny sign of acute sinusitis, root tips, cysts, or
tumors complicate the procedure and mandatetumors complicate the procedure and mandate
further evaluation.further evaluation.www.indiandentalacademy.comwww.indiandentalacademy.com

Surgical TechniqueSurgical Technique
There are four surgical options for Maxillary sinus lift :There are four surgical options for Maxillary sinus lift :
Subantral option 1 – Conventional implantSubantral option 1 – Conventional implant
placementplacement
Subantral option 2 – Sinus lift andSubantral option 2 – Sinus lift and
simultaneous implantsimultaneous implant
placementplacement
Subantral option 3 – Sinus graft with DelayedSubantral option 3 – Sinus graft with Delayed
endosteal implant placementendosteal implant placement
Subantral option 4 - Sinus graft and Extended Delay ofSubantral option 4 - Sinus graft and Extended Delay of
Endosteal Implant PlacementEndosteal Implant Placement

Antisepsis:Antisepsis:
 Intra oral – chlorhexidine scrub and rinse are advisedIntra oral – chlorhexidine scrub and rinse are advised
 Extra oral – Either iodophor or chlorhexidineExtra oral – Either iodophor or chlorhexidine
antiseptics.antiseptics.
Anesthesia:Anesthesia:
 Infiltration anesthesia or more profound anesthesia byInfiltration anesthesia or more profound anesthesia by
blocking secondary division of maxillary nerve.blocking secondary division of maxillary nerve.
 Bupivacaine 0.5% or etidocaine 1.5% with epinephrineBupivacaine 0.5% or etidocaine 1.5% with epinephrine
1:200000.1:200000.

Subantral Option 1: ConventionalSubantral Option 1: Conventional
Implant PlacementImplant Placement
 The first treatment option in the posterior maxilla, SA -1,The first treatment option in the posterior maxilla, SA -1,
Corresponds to 12mm or more of bone height available.Corresponds to 12mm or more of bone height available.
 Augmentation includes bone spreading, which is veryAugmentation includes bone spreading, which is very
effective in the softer bone of the posterior maxilla.effective in the softer bone of the posterior maxilla.
 In C-w, ridges osteoplasty rarely is sufficient to increase theIn C-w, ridges osteoplasty rarely is sufficient to increase the
width to greater than 5mm, without significant increase inwidth to greater than 5mm, without significant increase in
ridge height.ridge height.
 Implant are left to heal for 4 -8 months.Implant are left to heal for 4 -8 months.

Subantral Option 2: Sinus Lift andSubantral Option 2: Sinus Lift and
Simultaneous Implant PlacementSimultaneous Implant Placement
 It is selected when the available bone is 0 toIt is selected when the available bone is 0 to
2mm insufficient in length for ideal implant2mm insufficient in length for ideal implant
length.length.
 The goal of the sinus lift surgery is to increaseThe goal of the sinus lift surgery is to increase
the vertical bone height up to 2mm. The implantthe vertical bone height up to 2mm. The implant
is inserted simultaneously with the sinus liftis inserted simultaneously with the sinus lift
procedure.procedure.

 A full thickness incision is made on the crest of theA full thickness incision is made on the crest of the
ridge from the tuberosity to the distal of the canineridge from the tuberosity to the distal of the canine
region.region.
 A vertical, lateral relief incision is made at its distal andA vertical, lateral relief incision is made at its distal and
anterior extension for approximately 5mm.anterior extension for approximately 5mm.
 The full thickness palatal tissue is reflected.The full thickness palatal tissue is reflected.
 The crest is not used to leverage the tissue, as theThe crest is not used to leverage the tissue, as the
ridge may not have any cortical bone, and this mightridge may not have any cortical bone, and this might
result in gouging of the underlying residual ridge.result in gouging of the underlying residual ridge.

 The depth of the osteotomy is approximately 1 to 2mmThe depth of the osteotomy is approximately 1 to 2mm
short of the floor of the antrum.short of the floor of the antrum.
 The implant osteotomy is prepared to the appropriateThe implant osteotomy is prepared to the appropriate
final diameter following the established protocol.final diameter following the established protocol.
 The osteotome is inserted and tapped firmly into theThe osteotome is inserted and tapped firmly into the
final position upto 2mm beyond the prepared implantfinal position upto 2mm beyond the prepared implant
osteotomy.osteotomy.
 A greenstick fracture is created in the antral floor andA greenstick fracture is created in the antral floor and
elevates the bone and sinus membrane over theelevates the bone and sinus membrane over the
broad based osteotome.broad based osteotome.www.indiandentalacademy.comwww.indiandentalacademy.com

The implant may be inserted into the osteotomyThe implant may be inserted into the osteotomy
up to 4mm beyond the initial osteotomyup to 4mm beyond the initial osteotomy
preparation or 2mm above the floor of thepreparation or 2mm above the floor of the
sinus.sinus.
The apical portion of the implant engages theThe apical portion of the implant engages the
cortical floor, with bone over the apex, and ancortical floor, with bone over the apex, and an
intact sinus membrane.intact sinus membrane.
Six months after surgical procedure in D2 andSix months after surgical procedure in D2 and
D3 bone, or 8 months in D4 bone, a radiographD3 bone, or 8 months in D4 bone, a radiograph
indicates the success of the 0 -2 mm increasedindicates the success of the 0 -2 mm increased
vertical height.vertical height. www.indiandentalacademy.comwww.indiandentalacademy.com

Subantral Option 3: Sinus Graft withSubantral Option 3: Sinus Graft with
Delayed Endosteal Implant PlacementDelayed Endosteal Implant Placement
Indicated when at least 5mm of vertical boneIndicated when at least 5mm of vertical bone
height is present between the crest of the ridgeheight is present between the crest of the ridge
and the antral floor, and the width of theand the antral floor, and the width of the
available bone is greater than 5mm.available bone is greater than 5mm.
A crestal incision on the palatal aspect of theA crestal incision on the palatal aspect of the
edentulous ridge. A relief incision is madeedentulous ridge. A relief incision is made
through the maxillary tuberosity.through the maxillary tuberosity.

 The reflection of a fullThe reflection of a full
thicknessthickness
mucoperiosteal flap ismucoperiosteal flap is
performed.performed.

 The outline of the lateralThe outline of the lateral
access window is scoredaccess window is scored
on the bone with a rotaryon the bone with a rotary
instrument under copiousinstrument under copious
sterile saline.sterile saline.
 The most superior aspectThe most superior aspect
of the lateral accessof the lateral access
window should bewindow should be
approximately 5mmapproximately 5mm
below the superior aspectbelow the superior aspect
of the soft tissueof the soft tissue
reflectionreflection

The anterior vertical line is scored 5mm distalThe anterior vertical line is scored 5mm distal
to the anterior vertical wall of the antrum.to the anterior vertical wall of the antrum.
The distal vertical line on the lateral maxilla isThe distal vertical line on the lateral maxilla is
15mm from the anterior limit of the window in15mm from the anterior limit of the window in
the region of the first molarthe region of the first molar
The vertical score lines on the lateral maxillaThe vertical score lines on the lateral maxilla
should be at least 8mm in height.should be at least 8mm in height.

The inferior score line of the access opening isThe inferior score line of the access opening is
placed approximately 2 -5mm above the levelplaced approximately 2 -5mm above the level
of the antral floor.of the antral floor.
A flat ended metal punch or mirror handle andA flat ended metal punch or mirror handle and
mallet are used to gently separate the lateralmallet are used to gently separate the lateral
window from the surrounding bone, while stillwindow from the surrounding bone, while still
attached to the thin sinus membrane.attached to the thin sinus membrane.
A firm tap with the mallet will cause greenstickA firm tap with the mallet will cause greenstick
fracture of the bone along the score line.fracture of the bone along the score line.www.indiandentalacademy.comwww.indiandentalacademy.com

 A soft tissue curette is introduced along the margin ofA soft tissue curette is introduced along the margin of
the window.the window.
 The curette is slid along the bone, completely 360The curette is slid along the bone, completely 360
degrees around the access window margin.degrees around the access window margin.
 This ensures the release of the membrane withoutThis ensures the release of the membrane without
tearing from the sharp bony access margins.tearing from the sharp bony access margins.
 A nonresorbable HA mixed with antibiotic and fewA nonresorbable HA mixed with antibiotic and few
drops of saline is placed into the elevated antral floordrops of saline is placed into the elevated antral floor
region.region. www.indiandentalacademy.comwww.indiandentalacademy.com

A layered type of graft is placed into the antrumA layered type of graft is placed into the antrum
which includes three layers namely;which includes three layers namely;
1. Dense HA1. Dense HA
2. Microporous HA + DFDBAs2. Microporous HA + DFDBAs
3. Autogenous bone3. Autogenous bone
The antral floor and anterior wall areThe antral floor and anterior wall are
decorticated to setup adecorticated to setup a Regional acceleratoryRegional acceleratory
phenomenon.phenomenon.

The healing time varies from 4 to 10 monthsThe healing time varies from 4 to 10 months
depending on the medial lateral dimension.depending on the medial lateral dimension.
The soft tissues and periosteum areThe soft tissues and periosteum are
reapproximated with care to eliminate graftreapproximated with care to eliminate graft
particles in the incision line and tension.particles in the incision line and tension.
Interrupted horizontal mattress or a continuousInterrupted horizontal mattress or a continuous
suture is placed.suture is placed.

Subantral Option 4: Sinus Graft andSubantral Option 4: Sinus Graft and
Extended Delay of Endosteal ImplantExtended Delay of Endosteal Implant
PlacementPlacement
This option is indicated when less than 5mmThis option is indicated when less than 5mm
remains between the residual crest of bone andremains between the residual crest of bone and
the floor of the maxillary sinus.the floor of the maxillary sinus.
The fewer bony walls, less favorable vascularThe fewer bony walls, less favorable vascular
bed, minimal local autogenous bone, and largerbed, minimal local autogenous bone, and larger
graft volume all mandate a longer healinggraft volume all mandate a longer healing
period and altered surgical approach.period and altered surgical approach.www.indiandentalacademy.comwww.indiandentalacademy.com

The medial wall of the sinus membrane isThe medial wall of the sinus membrane is
elevated at least 16mm so that adequate heightelevated at least 16mm so that adequate height
is available for future endosteal implantis available for future endosteal implant
placement.placement.
In SA -4, insufficient autologous bone isIn SA -4, insufficient autologous bone is
harvested from the tuberosity, an additionalharvested from the tuberosity, an additional
harvest site is usually required, typically fromharvest site is usually required, typically from
ramus.ramus.
The augmented region matures for 6 -10The augmented region matures for 6 -10
months before reentry for placement ofmonths before reentry for placement of
endosteal implants.endosteal implants.www.indiandentalacademy.comwww.indiandentalacademy.com

ComplicationsComplications
1. During Surgery:1. During Surgery:
a. Membrane perforationa. Membrane perforation
b. Septab. Septa
2. Short Term Complications:2. Short Term Complications:
a. Incision Line Openinga. Incision Line Opening
b. Infectionb. Infection
3. Long Term Complications:3. Long Term Complications:
a. Oroantral fistulaa. Oroantral fistula
b. Cyst formationb. Cyst formationwww.indiandentalacademy.comwww.indiandentalacademy.com

Premaxilla Implant ConsiderationsPremaxilla Implant Considerations
In the premaxilla, esthetics and phoneticsIn the premaxilla, esthetics and phonetics
dictate that the replacement teeth be placed atdictate that the replacement teeth be placed at
or near their original position which is oftenor near their original position which is often
cantilevered off the residual ridge which is morecantilevered off the residual ridge which is more
palatal and superior.palatal and superior.
The premaxilla requires the most variedThe premaxilla requires the most varied
surgical approaches to improve success and issurgical approaches to improve success and is
the most critical region for esthetics andthe most critical region for esthetics and
phoneticsphonetics

Pre maxilla SurgeryPre maxilla Surgery
Division A Premaxilla:Division A Premaxilla:
Stage 1 Surgery -Stage 1 Surgery -
The incision is made on the lingual aspect of the ridge.The incision is made on the lingual aspect of the ridge.
The anterior implant osteotomy is evaluated with aThe anterior implant osteotomy is evaluated with a
probe.probe.
If fenestrations occur on the apical one – half of theIf fenestrations occur on the apical one – half of the
implant, an autogenous bone graft mixed with plateletimplant, an autogenous bone graft mixed with platelet
rich plasma may prevent further bone loss.rich plasma may prevent further bone loss.
A dense HA may be placed on the facial aspect of theA dense HA may be placed on the facial aspect of the
bone to increase the tissue thickness, ridge contour.bone to increase the tissue thickness, ridge contour.www.indiandentalacademy.comwww.indiandentalacademy.com

Stage 2 surgery:Stage 2 surgery:
If the bone loss is suspected, the soft tissuesIf the bone loss is suspected, the soft tissues
should be reflected for direct observation.should be reflected for direct observation.
Correction of cervical horizontal defect includesCorrection of cervical horizontal defect includes
local autogenous grafts mixed with dense HAlocal autogenous grafts mixed with dense HA
because bone growth is less predictable.because bone growth is less predictable.
A barrier membrane may be used to improveA barrier membrane may be used to improve
the prognosis of the bone augmentation.the prognosis of the bone augmentation.

Division B PremaxillaDivision B Premaxilla
The Div B maxillary bone is 4 -5mm in width.The Div B maxillary bone is 4 -5mm in width.
Bone expansion and simultaneous implantBone expansion and simultaneous implant
placement may be performed in D3 and D4placement may be performed in D3 and D4
bone.bone.
In D2 bone, an intrapositional bone graft placedIn D2 bone, an intrapositional bone graft placed
after bone expansion may be used to increaseafter bone expansion may be used to increase
the width of the bone.the width of the bone.

B-w Available bone:B-w Available bone:
The B-w available bone represents 2.5 to 4mmThe B-w available bone represents 2.5 to 4mm
in width with adequate height.in width with adequate height.
Bone expansion is less predictable in theseBone expansion is less predictable in these
dimensions, and an autogenous onlay graft isdimensions, and an autogenous onlay graft is
the treatment of choice.the treatment of choice.
The ramus region is the ideal donor site for B-wThe ramus region is the ideal donor site for B-w
bone.bone.

Division C-w:Division C-w:
 Div C with advanced width atrophy, less than 2.5mmDiv C with advanced width atrophy, less than 2.5mm
width requires an onlay graft.width requires an onlay graft.
 Ideal donor site would be symphyseal region whichIdeal donor site would be symphyseal region which
provides a block graft of cortical and trabecular boneprovides a block graft of cortical and trabecular bone
with greater quantity of bone.with greater quantity of bone.
Division C-h:Division C-h:
 When the residual crest is adequate in width but onlyWhen the residual crest is adequate in width but only
8 to 11mm in height, bone grafting and/or sub nasal8 to 11mm in height, bone grafting and/or sub nasal
elevation may be considered to provide adequateelevation may be considered to provide adequate
height for implant placement.height for implant placement.www.indiandentalacademy.comwww.indiandentalacademy.com

Subnasal Elevation andSubnasal Elevation and
Augmentation ProcedureAugmentation Procedure
C-h Maxillary canineC-h Maxillary canine
position implant:position implant:
The nasal mucosa atThe nasal mucosa at
the lateral pyriform rimthe lateral pyriform rim
is identified andis identified and
elevated 3 to 5mmelevated 3 to 5mm
distally and superiorlydistally and superiorly
using a soft tissueusing a soft tissue
curettecurette

Induce RAP with a sharp probe.Induce RAP with a sharp probe.
The subantral graft generally requires less thanThe subantral graft generally requires less than
5ml unilaterally and is easily filled with all5ml unilaterally and is easily filled with all
autogenous bone.autogenous bone.

C-h Maxillary Central to Lateral IncisorC-h Maxillary Central to Lateral Incisor
Implant:Implant:
The maxillary central to lateral incisor region inThe maxillary central to lateral incisor region in
the C-h patient presents 8 -11mm of verticalthe C-h patient presents 8 -11mm of vertical
bone and more than 5mm width.bone and more than 5mm width.
The implant osteotomy is prepared to the finalThe implant osteotomy is prepared to the final
drill for the implant 2mm short of the nasal floor.drill for the implant 2mm short of the nasal floor.
An implant upto 13mm may then be placed intoAn implant upto 13mm may then be placed into
the osteotomy which extends upto 4mm abovethe osteotomy which extends upto 4mm above
the original nasal floor.the original nasal floor.www.indiandentalacademy.comwww.indiandentalacademy.com

ConclusionConclusion

ReferencesReferences
 Contemporary Implant Dentistry – Carl E. MishContemporary Implant Dentistry – Carl E. Mish
 Implants and Restorative Dentistry – Gerard MImplants and Restorative Dentistry – Gerard M
ScortecciScortecci
 Principles and Practice of Implant Dentistry –Principles and Practice of Implant Dentistry –
Charles M WeissCharles M Weiss
 Colour Atlas of Dental Implant Surgery – MichaelColour Atlas of Dental Implant Surgery – Michael
S BlockS Block
 J. Oral Maxillofac Surg 55; 1281 -1286, 1997J. Oral Maxillofac Surg 55; 1281 -1286, 1997
 J.Oral Maxillofac Surg 55; 1397 – 1401,1997J.Oral Maxillofac Surg 55; 1397 – 1401,1997
 J.Oral Maxillofac Surg 50; 237 -39, 1992J.Oral Maxillofac Surg 50; 237 -39, 1992

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