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This article compares three-dimensional alterations following the use of autogenous versus allogeneic onlay grafts for augmentation at single tooth sites. Autogenous bone grafts from the chin or ramus were compared to freeze-dried allogeneic bone grafts. Cone beam computed tomography scans were used to evaluate changes in graft and defect volumes at 6 months. Both graft types resulted in significant bone fill, with autogenous grafts showing slightly more volume gain. Allogeneic grafts require less surgery time and morbidity compared to autogenous grafts.

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Click to edit Master title style 1 Hard Tissue Augmentation D r. R i n i s h a S i n h a M D S I I P o s t g r a d u a t e Tr a i n e e
Click to edit Master title style 2 • Introduction • Regenerative Periodontal Surgery • Regenerative capacity of Bone Cells • Principles in Alveolar Bone Regeneration • Bone Augmentation Therapies • Regenerative Materials and Concepts • 1st ARTICLE • Ridge Augmentation Procedures • Evidence based results for Ridge Augmentation Procedures • Emerging Technologies • 2nd ARTICLE • 3rd ARTICLE • 4th ARTICLE • Conclusion 2
Click to edit Master title style 3 Introduction 3
Click to edit Master title style 4 4 Alveolar bone loss can be • Congenital, or • Due to trauma, • Pathologies, • Infection, or • As a consequence of periodontal disease and tooth extraction. Approximately, 25% of the bone is lost during the first year of the bone and 40-60% during the first 3 years after a tooth is lost. The resulting ridge deficiency is primarily the result of the gradual loss of the horizontal dimension accomplished by a rapid loss of bone height. Reference: Carlsson et al. 1967
Click to edit Master title style 5 Regenerative Periodontal Surgery 5
Click to edit Master title style 6 • Regeneration: A reproduction or reconstruction of a lost or injured part in such a way that the architecture and function of the lost or injured tissues are completely restored. • “New Attachment” Is used to describe the formation of new cementum with inserting collagen fibers on a root surface deprived of its periodontal ligament tissue, whether or not this has occurred because of periodontal disease or by mechanical means. • “Reattachment” Is confined to describe the reunion of surrounding soft tissue and a root surface with preserved periodontal ligament tissue. • Four methods have been described to increase the rate of bone formation and to augment bone volume:  Osteoinduction by the use of appropriate growth factors;  Osteoconduction, where a grafting material serves as a scaffold for new bone growth;  Distraction osteogenesis, by which a fracture is surgically induced and the two fragments are then slowly pulled apart; and  Finally, guided tissue regeneration (GTR), which allows spaces maintained by barrier membranes to be filled with new bone. 6 Reference: Glossary of Periodontal Terms, 1992 Reference: Nyman et al. 1982; Isidor et al. 1985 Reference: Isidor et al. 1985 Reference: Reddi 1981; Urist 1965 Reference: Buch et al. 1986; Reddi et al. 1987 Reference: Ilizarov 1989a,b Reference: Dahlin et al. 1988, 1991a; Kostopoulos & Karring 1994; Nyman & Lang 1994 Guided bone regeneration (GBR) is the best documented for the treatment of localized bone defects in the jaws.
Click to edit Master title style 7 Regenerative Capacity of Bone Cells 7
Click to edit Master title style 8 8 • The ability of newly formed tissue originating from bone to produce a new connective tissue attachment was examined in a study by Karring et al. (1980). • Roots of periodontitis-affected teeth were extracted and placed in surgically created sockets in edentulous areas of dogs. • The implanted roots were covered with tissue flaps (submerged) and the results of healing were examined histologically after 3 months. • A periodontal ligament was re-established in the apical portion of the re- implanted roots where, at the time of implantation, remnants of periodontal ligament tissue were preserved. • In the coronal portion of the roots which were previously exposed to periodontitis and then scaled and planed, healing had consistently resulted in ankylosis and root resorption. • On the basis of this finding, it was concluded that tissue derived from bone lacks cells with the potential to produce a new connective tissue attachment.
Click to edit Master title style 9 Principles in Alveolar Bone Regeneration 9
Click to edit Master title style 1010 • The placement of bone grafting materials to favor healing in osseous defects or to augment edentulous ridges to allow dental implant installation has become a gold standard treatment in implant dentistry. Factors assisting in proper Wound Healing • Passive and tension-free wound closure • To reduce the risk of membrane exposure, wound contraction, patient discomfort. Promoting Primary Wound Closure • Provides blood, oxygen and nutrients to the tissues also act as source of angiogenic and osteogenic cells. Enhancing cell proliferation and differentiation Protecting initial wound stability and integrity
Click to edit Master title style 1111 • Space initially becomes occupied by a fibrin clot which serves as a scaffold for the bone cells • Is important for the formation of granulation tissue and subsequent formation of bone • Completely isolating the defect to be regenerated from the overlying soft tissue • Used to prevent gingival fibroblasts / epithelial cells from gaining access to the wound site Cell Exclusion Space created beneath the membrane Scaffolding Protect the clot Reference: Schenk et a;. 1994
Click to edit Master title style 12 DEFECT CLASSIFICATION 12 Class I Class II Class III Reference: According to Seibert; 1983 Alveolar crest defects
Click to edit Master title style 13 Reference: According to Hammerle and Jung; crest defects in fresh extraction sockets Class I Class II Class III
Click to edit Master title style 14 Bone Augmentation Therapies Melcher (1976) developed the concept of using barrier membranes to “guide” the biologic process of wound healing. Early experimental studies demonstrated that the exclusion of soft tissue invasion of the defect by means of a barrier membrane, allowed the cells with regenerative potential to migrate to the site (derived from the periodontal ligament or bone marrow) and promoted periodontal regeneration. 14 Reference: Nyman et al. 1982
Click to edit Master title style 15 AUGMENTATION MATERIALS 15
Click to edit Master title style 16 MEMBRANES 16 Certain critical criteria regarding membranes used for GTR have been formulated: Reference: Hardwick et al. 1994 Biocompatibility Cell occlusiveness Integration by the host tissues Clinical manageability the space making function For bioresorbable and biodegradable membranes additional criteria need to be fulfilled. Tissue reactions resulting from the resorption of the membrane should be minimal, these reactions should be reversible they should not negatively influence regeneration of the desired tissues Reference: Gottlow; 1993 GBR is quite a successful procedure, a better understanding of the factors critical for success or failure is mandatory. Factors : membrane stability, duration of barrier function, enhanced access of bone and bone marrow- derived cells to the area for regeneration, ample blood fill of the space, prevention of soft tissue dehiscence, in situ forming, and delivery of factors influencing tissue formation beneficially.
Click to edit Master title style 17 Barrier membranes 17 The choice of membrane material usually depends on the amount of bone regeneration needed, mainly in the vertical dimension. e‐PTFE barrier membranes have demonstrated more favorable results when compared with resorbable devices, mainly due to their better • space‐making capacity, • longer barrier function, • lack of a resorption process that may negatively affect bone formation Reference: Hammerle and Jung, 2003
Click to edit Master title style 18 Types of membranes : 18 Barrier membranes have been derived to two principal varieties: Non-resorbable • As e-PTFE non‐degradable barrier membranes require a second surgical intervention to remove them. Resorbable • Synthetic • Polylactide • Polyglycolic acid • Vicryl mesh • Cargile membrane • Natural : Collagen Membrane
Click to edit Master title style 19 BONE GRAFTS and BONE SUBSTITUTES 19 Property Description Osteoconduction Provides a passive porous scaffold to support or direct bone formation Osteoinduction Induces differentiation of stem cells into osteogenic cells Osteogenesis Provides stem cells with osteogenic potential, which directly lays down new bone Combined Provides more than one of the above mentioned properties Reference: Ellegaard et al. (1973, 1974, 1975, 1976) and Nielsen et al. (1980) Choice of material should be based on the clinical indication. • For small bone defects requiring mainly horizontal bone augmentation, the use of xenografts and alloplasts has demonstrated excellent results. • Use of xenografts with a much slower resorption rate demonstrated significantly better preservation of the socket walls than the non‐grafted sites. • In large crestal defects for which the aim is both horizontal and vertical bone augmentation, the use of autogenous block grafts is recommended.
Click to edit Master title style 20 20 AUTOGENOUS BONE GRAFT Considered the “ gold standard ” by which other materials are osteoinductive, osteoconductive, and osteogenic properties. No risk of infection. Disadvantages: • Low availability of bone volume • Require a second operative site • Morbidity associated with their harvesting, mainly from the chin particulate autografts, resorption rate is high ALLOGRAFT Bone grafts harvested from cadaver donors and processed by freezing or demineralization and freezing. These allografts are usually used in combination with barrier membranes following the principles of GBR. Disadvantages: Possible infections, and antigenicity risks XENOGRAFT Biomaterials of animal origin, mainly bovine and equine. These graft materials are deproteinized in order to completely remove the organic component and thus avoid any immunogenic reaction. ALLOPLAST are synthetic bone substitutes that include different combinations of calcium phosphates fabricated under different conditions, which yields different physical properties and resorption rates.
Click to edit Master title style 21 ARTICLE NO.1 21 AIM: To compare three‐dimensional alterations following the use of autogenous versus allogeneic onlay grafts for augmentation at single tooth defects. DESCRIPTION: This study is the retrospective evaluation of a novel, cancellous allogeneic bone block derived from the bone of femoral heads of living human donors with respect to horizontal and vertical bone gain and volume stability. These findings are compared to results achieved with autogenous bone blocks in alveolar ridge augmentation. They have compared the 12‐month remodeling rate of cancellous allogeneic bone blocks to the remodeling rate of cortical autogenous bone blocks harvested from the retromolar region. To the best of their knowledge, this is the first longitudinal clinical study comparing freeze‐dried cancellous allogeneic with autogenous bone blocks for vertical and horizontal alveolar ridge augmentation.
Click to edit Master title style 22 22 MATERIALS AND METHODS: • In accordance to STROBE guidelines. • A total of 42 patients with one tooth missing and insufficient bone quantity for direct implant placement were enrolled into this retrospective study and underwent autogenous or allogeneic bone block augmentation procedures. • INCLUSION CRITERIA: • presence of a clinically relevant bone atrophy of the alveolar ridge in the predominantly horizontal and/or vertical plane as identified by cone beam computed tomography (CBCT) para‐axial reconstruction images. • The minimum defect size was a Type‐II bone defect, defined according to the ITI‐treatment guide categories. • EXCLUSION CRITERIA: • a history of radiotherapy in the head and neck region, • systemic disease that would contraindicate oral surgery, • uncontrolled periodontal disease, • bruxism, • a smoking habit or alcoholism, • pregnancy, • psychiatric problems, • use of medications known to alter bone healing. • SAMPLE SIZE: 42 patients; 14 males and 28 females • The patients chose one of the two procedures themselves out of autogenous or allogeneic bone block augmentation. • 21 patients with comparable demographic characteristics were allocated to each group and one group received a cortical autogenous block graft harvested from the retromolar region and other received a freeze-dried cancellous allogeneic block graft for alveolar ridge augmentation. SURGICAL PROCEDURE: • A thorough initial periodontal examination, including the assessment of plaque, gingivitis, and probing depth. • Immediately before the operation, the patients were instructed to rinse their mouth with 0.2% chlorhexidine mouthwash for 1 min. • A two‐stage approach with implant placement after six months of healing with surgical intervention performed under infiltration of local anesthetics was used for all patients. • The muco‐periosteal flap was prepared by a crestal incision together with a vertical releasing incision and gently elevated from the native bone tissue to allow complete visualization of the defect and surrounding bone. • Any soft tissue remnants were removed from the bone surface and the native bone was perforated with drills during irrigation with saline to ensure vascularization of the block graft and the recipient site.
Click to edit Master title style 2323 • The autogenous and allogeneic bone blocks were both used as full blocks. • The bone blocks were adapted to the defect morphology and fixated onto the host bone site using 1.5 mm osteosynthesis screws. • Resorbable collagen membranes made from porcine pericardium were used for coverage of the augmentation sites. • The muco‐periosteal flaps were repositioned with mattress and interrupted non‐resorbable sutures. Routine postoperative care included administration of • amoxicillin and clavulanic acid (625 mg, administered orally, three times a day for 4 days), • ibuprofen (600 mg, administered orally, every 6 hour as needed), • mouthwash (0.2% chlorhexidine, three times daily for 7 days). The patients were recalled at monthly intervals for a period of 6 months to detect possible complications, such as infection, pain, discomfort, graft exposure, and graft mobility. Graft stability was assessed at the time of dental implant placement. At re‐entry of the surgical site, a crestal incision was placed along the initial incision line in order to prevent the formation of additional scar tissue as a result of installing the implant.
Click to edit Master title style 24 24 RADIOGRAPHIC ANALYSIS • Every patient was subjected to three‐dimensional x‐ray diagnostics (CBCT), followed by computer‐aided planning of the augmentation and subsequent implantation. • In total four CBCTs were recorded for each patient, one before treatment, one directly after augmentation, one after 6 months of healing, and one after 12 months. • At each time point, the alveolar bone levels were measured in their height, width, and depth at the cervical level, the middle height of the defect, and at the apical level. IMPLANTS • Every patient received one titanium implant per augmented region. • The inserted implants were from Straumann (n = 35; Type SLActive ; Straumann Holding AG, Basel, Switzerland), Bredent (n = 6; blueSKY; bredent medical GmbH & Co.KG, Senden, Germany) and BIOMET 3i (n = 1; BIOMET 3i; Munich; Germany). • Defect height (mm): distance between the apical and crestal bone level in the middle of the defect region; represented by line “h” • Apical defect width (mm): distance between the apical root tips of the neighboring teeth; represented by line “e” • Defect width in the middle zone (mm): distance between the roots of the neighboring teeth in the middle of the defect height; represented by line “d” • Cervical defect width (mm): distance between the crestal bone levels of the neighboring teeth; represented by line “a” • Apical defect depth (mm): distance between the labial/buccal and palatal edges of the jaw crest at the level of the apical tips of the neighboring teeth, but in the middle of the defect area; represented by line “f” • Defect depth in the middle zone (mm): distance between the labial/buccal and palatal edges of the jaw crest at the level of the middle zone; represented by line “c” • Cervical defect depth (mm): distance between the labial/buccal and palatal edges of the jaw crest at the cervical level; represented by line “b”
Click to edit Master title style 25 25 RESULTS • All patients were followed for up to 12 months. • There were no signs of infection, wound dehiscence, block graft exposure, or other postoperative complications during the healing period following bone augmentation. • At the time of implant placement, all autogenous and allogeneic bone blocks were successfully integrated into the recipient site. • In all patients, the grafted bone remained stable during drilling and implant placement, without graft separation, and all implants were successfully stabilized and restored three months after implant placement. • All patients received a fixed implant‐supported single crown. • No implant was lost after loading during follow‐up. • Vertical gain • The mean vertical increase directly after augmentation was 1.4 ± 2.2 mm for autogenous blocks and 0.7 ± 1.4 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the vertical gain after augmentation, after 6 months or 12 months. • The vertical dimensions did not differ significantly between autogenous and allogeneic bone grafts at any point in time. • Horizontal gain • The mean horizontal gain at the apical level after augmentation was 1.6 ± 1.5 mm for autogenous grafts and 2.6 ± 2.5 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogenic bone grafts in the horizontal gain at the apical level after augmentation, after 6 months or after 12 months. • The mean horizontal gain at the cervical level after augmentation was 5.6 ± 1.5 mm for autogenous grafts and 5.5 ± 1.3 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the • horizontal gain at the cervical level after augmentation, after 6 months or after 12 months • The horizontal dimensions did not differ significantly between autogenous and allogeneic bone grafts at any point in time.
Click to edit Master title style 26 26 RESULTS • Remodeling • The overall volume gain after augmentation was 543.9 ± 431.5 mm for autogenous grafts and 508.1 ± 187.3 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the overall volume gain after augmentation, after 6 or 12 months. CONCLUSION The quintessence of the study presented here is that freeze‐dried cancellous allogeneic bone blocks are equivalent to autogenous bone blocks regarding their volumetric graft remodeling rates for treating single tooth defects classified as Type‐II to Type‐IV according to the ITI‐treatment guide categories. However, the long‐term effects need further systematic evaluation. Finally, the avoidance of donor site morbidity and unlimited availability is an undisputed advantage of the application of allogeneic bone blocks. DISCUSSION Although autogenous bone block grafting yields satisfactory results, this technique is associated with disadvantages such as prolonged operation times, limited graft acquisition, risk for damage to adjacent teeth, neurosensory deficits, donor area flap exposure, bleeding, and infection. One limitation of this study is that they • compared cancellous allogeneic bone blocks with cortical autogenous bone blocks, while a comparison of cortical autogenous bone blocks and cortical allogeneic bone blocks would have been more appropriate with respect to the materials used. • performed predominantly horizontal augmentation procedures. Reference: Esposito et al. 2009
Click to edit Master title style 27 Comparative evaluation of types of bone grafts 27 Although theoretical assumptions state that autogenous bone grafts are superior to other bone substitute materials, the literature fails to substantiate this fact. The recent systematic reviews reported no superior clinical outcomes with autogenous bone graft over other bone substitute material for routine augmentation, guided bone regeneration (GBR), or maxillary sinus floor augmentation Reference: • Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Interventions for replacing missing teeth: Augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev 2010;CD008397. • Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012; 23(Suppl 5):22-38. • Al-Nawas B, Schiegnitz E. Augmentation procedures using bone substitute materials or autogenous bone — A systematic review and meta-analysis. Eur J Oral Implantol 2014;7(Suppl 2):S219-34. • Carini F, Longoni S, Amosso E, Paleari J, Carini S, Porcaro G. Bone augmentation with TiMesh. Autologous bone versus autologous bone and bone substitutes. A systematic review. Ann Stomatol (Roma) 2014;5(Suppl 2):27-36.
Click to edit Master title style 28 RIDGE AUGMENTATION PROCEDURES 28 Ridge Preservation, Bone Regeneration in fresh extraction sockets, Horizontal Bone Augmentation, Ridge Splitting/Expansion, Vertical Ridge Augmentation
Click to edit Master title style 29 Socket Preservation “Any therapeutic approach carried out immediately after tooth extraction aimed to preserve the alveolar socket architecture and to provide the maximum bone availability for implant placement” 29 Reference: Vignoletti et al. 2012 These ridge preservation approaches have utilized GBR principles using the following regenerative: • Resorbable and non‐ resorbable barrier membranes alone • Resorbable barrier membranes in combination with bone substitutes • Bone substitutes alone • Bone substitutes in combination with soft tissue grafts technologies: hard and soft tissue changes occurring 6 months after tooth extraction in humans and demonstrated a horizontal bone loss 29–63% vertical bone loss 11–22% Reference: Tan et al. 2012
Click to edit Master title style 30 Bone Regeneration in Fresh Extraction Socket Immediate and early implant placement (type 1 and 2) protocols have been indicated as the most suitable for implant placement following tooth extraction. 30
Click to edit Master title style 31 Ridge Split Technique (Book Bone Flap) Another technique used in the maxilla to augment bone width through bone condensation is ridge splitting osteotomy. Ridge splitting is essentially the fracture of the buccal cortical plate and its displacement laterally to accommodate implant placement 31 INDICATION: Horizontal deficiency requiring 2-5 mm of augmentation. Reference: Haggerty CJ, Vogel CT, Fisher GR. Simple bone augmentation for alveolar ridge defects. Oral Maxillofacial Surg Clin North Am 2015;27:203-26. Singh AV, Shimada J. Block grafting for dental implants. In: Singh AV, Shimada J, editors. Clinical Implantology. 1st ed. India: Elsevier; 2013. p. 349-80.
Click to edit Master title style 32 Vertical Ridge Augmentation Guided Bone Regeneration 32 Onlay bone – block grafting Distraction Osteogenesis
Click to edit Master title style 33 EMERGING TECHNOLOGIES 33 Growth Factors • to increase bone volume have significantly advanced • the field of periodontal regenerative medicine like PDGF and BMPs Cell therapy • Cell delivery approaches are used to accelerate edentulous ridge regeneration through two primary mechanisms: use of cells as carriers to deliver growth or cellular signals provision of cells which are able to differentiate into multiple cell types to promote regeneration Scaffolding matrices to deliver cells and genes • Scaffolding matrices are used in tissue engineering to provide an environment where space is created and maintained over a period of time for cellular growth and tissue in‐growth. Computer‐based applications in scaffold design and fabrication
Click to edit Master title style 34 Comparative evaluation of various Techniques of Ridge Augmentation 34 • There is no clear evidence supporting any of the specific techniques but GBR. • GBR has been shown to be a predictable technique, especially when Ti-mesh is employed for horizontal as well as vertical augmentation [mean implant survival rate (MISR) of 100%]. • Milinkovic and Cordaro (2014) extracted data from 53 publications for partially edentulous patients and 15 publications for edentulous patients. Although owing to heterogeneity of included studies, no clear-cut indications could be extracted for specific bone augmentation procedures, a few suggestions could be drafted on the basis of magnitude of the mean implant survival rate. The evidence suggested that dehiscence and fenestrations can be treated successfully with GBR at the time of implant placement [MISR 92.2%, mean complication rate (MCR) 4.99%]. Reference: lementini M, Morlupi A, Canullo L, Agrestini C, Barlattani A. Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: A systematic review. Int J Oral Maxillofac Surg 2012;41:847-52. Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg 2014;43:606-25. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants — A Cochrane systematic review. Eur J Oral Implantol 2009;2:167-84. Reference: Rasia-dal Polo M, Poli PP, Rancitelli D, Beretta M, Maiorana C. Alveolar ridge reconstruction with titanium meshes: A systematic review of the literature. Med Oral Patol Oral Cir Bucal 2014; 19:e639-46. Reference: Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg 2014;43:606-25.
Click to edit Master title style 3535 • In partially edentulous ridges, when a horizontal defect is present, procedures such as staged GBR (MISR 100%, MCR 11.9%), bone block grafts (MISR 98.4%, MCR 6.3%), and ridge expansion/splitting (MISR 97.4%, MCR 6.8%) have been proved to be effective. Vertical defects can be treated with simultaneous and staged GBR (MISR 98.9%, MCR 13.1% and MISR 100%, MCR 6.95%, respectively), bone block grafts (MISR 96.3%, MCR 8.1%), and distraction osteogenesis (MISR 98.2%, MCR 22.4%). • In edentulous patients, there is evidence that bone block grafts can be used (MISR 87.75%), and that Le Fort I osteotomies can be applied (MISR 87.9%) but are associated with a high complication rate. • Further, the addition of platelet-rich plasma (PRP) has been reported to confer no additional benefit on either bone volume gain or implant survival. Reference: Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants — A Cochrane systematic review. Eur J Oral Implantol 2009;2:167-84. Arora NS, Ramanayake T, Ren YF, Romanos GE. Platelet-rich plasma in sinus augmentation procedures: A systematic literature review: Part II. Implant Dent 2010;19:145-57.
Click to edit Master title style 36 ARTICLE NO.2 36 AIM: To evaluate the effectiveness of vertical bone augmentation, to correlate it with associated complications and to explore peri-implant health outcomes over time. MATERIALS AND METHODS: • Protocol development and focused question  The protocol followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta- Analyses) statement. • Inclusion criteria  Population: patients older than 18 and in good general health with vertical ridge deficiencies in need of an implant-supported/-retained prosthesis;  Interventions: any given intervention for VRA;  Comparisons: any given intervention for VRA in controlled studies;  Outcomes: changes in the clinical vertical dimension of the ridge;  Study design: randomized clinical trials (RCTs), controlled clinical trials (CCTs), prospective/retrospective cohort studies or prospective/retrospective case series (CS) with a minimum of 10 patients (five per group in controlled studies). • Exclusion criteria  Studies assessing the effectiveness of interventions aimed only at horizontal bone regeneration;  Studies assessing the effectiveness of VRA procedures using only radiographs;  Studies aiming at regenerating extractions sockets before or simultaneous with implant placement;  Studies evaluating solely maxillary sinus floor elevation;  Studies including only oncologic and poly-traumatized patients;  Orthognathic procedures aiming at changing the bone dimensions for different purposes than tooth replacement.
Click to edit Master title style 3737 • Type of intervention and comparisons:  Studies were selected that included interventions for VRA.  The following procedures were considered: (a) GBR; (b) bone blocks, either as onlay or inlay grafts; (c) distraction osteogenesis; (d) other approaches. (e) Inlay graft was used as a synonym for inter- positional graft.  Moreover, the following biomaterials were assessed: (a) autogenous bone grafts; (b) allogeneic bone grafts; (c) xenogeneic bone grafts. • Type of outcomes:  Primary outcome for assessing VRA : change in the clinical vertical alveolar ridge dimension, as determined by direct linear measurements between baseline and re-entry.  Secondary outcomes :  Surgical intra- and post-operative complications, including the need for re- grafting, flap dehiscence, graft or membrane exposure, loss of graft integration, local infection, prolonged pain, and paresthesia;  Implant survival and success rates (%);  Changes in marginal bone levels, defined as the distance between the implant shoulder and the first bone to implant contact measured at both mesial and distal aspects (mm);  Probing pocket depth (PPD);  Gingival or bleeding indexes;  Occurrence of biological complications (%) defined as the occurrence of mucositis (bleeding on probing [BOP] with or without increased PPD and without radiographic bone loss) and/or peri-implantitis (BOP with or without increased PPD and with radiographic bone loss;  Patient-reported outcome measures (PROMs), such as pain, discomfort, and satisfaction. • For the secondary outcome measurements related to implants, only studies with a minimum follow-up of 12 months after definitive loading were considered. Reference: Lang & Berglundh, 2011 Randomized and controlled clinical trials and prospective and retrospective case series were included, and meta-analyses were performed to evaluate vertical bone gain based on the type of procedure and to compare bone gains in controlled studies.
Click to edit Master title style 3838 • Electronic search o Three electronic databases were used as sources in the search for studies satisfying the inclusion criteria: (a) The National Library of Medicine (MEDLINE via PubMed); (b) Cochrane Central Register of Controlled Trials; (c) EMBASE. o These databases were searched for studies published up until January 2018. o The search was limited to human subjects. • Manual search o All reference lists of the selected studies and previously published systematic reviews were checked for cross-references. o The following journals were hand-searched from year 2008 to 2018: Journal of Clinical Periodontology, Journal of Periodontology, Clinical Oral Implants Research, International Journal of Oral & Maxillofacial Implants, European Journal of Oral Implantology, Implant Dentistry, International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, The International Journal of Periodontics and Restorative Dentistry, and Clinical Implant Dentistry and Related Research. • Screening methods Two reviewers (ISS and EM) did the primary search by independently screening the titles and abstracts. RESULTS • Thirty-six publications were included. • Results demonstrated a significant vertical bone gain for all treatment approaches (n = 33; weighted mean effect = 4.16 mm; 95% CI 3.72–4.61; p < 0.001). • Clinical vertical bone gain and complications rate varied among the different procedures, with a weighted mean gain of 8.04 mm and complications rate of 47.3% for distraction osteogenesis, 4.18 mm and 12.1% for guided bone regeneration (GBR), and 3.46 mm and 23.9% for bone blocks. • In comparative studies, GBR achieved a significant greater bone gain when compared to bone blocks (n = 3; weighted mean difference = 1.34 mm; 95% CI 0.76–1.91; p < 0.001). CONCLUSION Vertical ridge augmentation is a feasible and effective therapy for the reconstruction of deficient alveolar ridges, although complications are common. PRACTICAL IMPLICATIONS Clinicians should be aware that VRA is a highly demanding therapy. The decision-making process for the ideal treatment should be made on the basis of site and patient-related factors, in combination with surgical experience and skill.
Click to edit Master title style 39 ARTICLE NO.3 39 AIM: To compare the implant survival rates and complication rates after horizontal augmentation of the alveolar ridge with ARS versus autogenous OBG in the anterior maxilla. DESCRIPTION: This study is a retrospective clinical study. MATERIALS AND METHODS: • 48 patients (20 men and 28 women) with maxillary anterior alveolar crest width deficiency and a mean age of 44.8 years were included in this study. • 28 ARS procedures in 24 patients (11 men and 13 women; ARS group) and 28 OBG procedures in 24 patients (15 men and 9 women; OBG group) were performed. • All autogenous bone blocks were harvested from the mandibular ramus in the OBG group.
Click to edit Master title style 40 40 INCLUSION CRITERIA • 3 to 4 mm of initial alveolar crest width and sufficient height from the tip of the alveolar ridge to the nasal floor EXCLUSION CRITERIA • Patients who had previously undergone the same surgery, • Patients who smoked more than 10 cigarettes a day, • patients with any of the following medical conditions: myocardial infarction within 3 months, previous heart surgery or angioplasty, diabetes mellitus, vitamin D deficiency, blood disorder or history of blood disorder (leukemia, lymphoma, von Willebranddisease, hemophilia, platelet disorder), periodontal disease, osteoporosis, use of bisphosphonates, and any other new or uncontrolled medical condition that would affect bone healing • All ARS and OBG procedures were performed by the same surgeon. • The Bio-Oss hydroxyapatite bovine matrix graft material and Bio-Gide resorbable collagen membrane were used for the augmentation procedure in both the ARS group and OBG group to minimize graft resorption. • Implant placement was performed simultaneously with the initial procedure in the ARS group and at 6 months afterthe initial procedure in the OBG group. • All implants were loaded with a fixed prosthesis at 4 months after the surgery. • The survival rates of all implants were evaluated using the clinical and radiographic evaluation criteria of Misch et al. • MINOR COMPLICATIONS: • Temporary graft exposure, • Mild infection, • Temporary paresthesia • Bad split (fracture of buccal bone) • MAJOR COMPLICATIONS: • permanent graft exposure, • graft loss, • permanent paresthesia • The major and minor complications were compared between the ARS and OBG groups.
Click to edit Master title style 4141 RESULTS • The mean follow-up for the dental implants was 38.33 months in the ARS group and 31.6 months in the OBG group. • A total of 42 implants were inserted into the augmented region in the OBG group, whereas 43 implants were inserted into the augmented region in the ARS group. • There were no significant differences between the OBG and ARS groups in terms of mean age and sex distribution. • When the minor complication rates were considered, there was no significant difference between the OBG and ARS groups. • The rate of temporary exposure of the augmented recipient site was 14.3% in the OBG group and 2.3% in the ARS group. • Mild infection of the recipient site was observed in 7.1% of patients in the OBG group and 4.7% of patients in the ARS group, with no significant difference. • Temporary paresthesia was observed in 7.1% of recipient sites in the OBG group, compared with no temporary paresthesia in the ARS group. • A bad split occurred in 7.1% of recipient sites in the ARS group during the surgery. • The minor complications did not affect the treatment prognosis, and the implants were inserted as planned. • When the major complication rates were considered, there was no significant difference between the OBG and ARS groups. The only major complication was permanent exposure of the recipient site in 2 patients in the OBG group, and the augmented grafts were lost in these 2 patients. • In the OBG group, 3 of 42 implants inserted into the augmented bone block failed, and the remaining inserted implants were accepted as satisfactory survival. In the ARS group, all of the inserted implants were accepted as satisfactory survival. The satisfactory survival rate was 92% in the OBG group and 100% in the ARS group, with no significant difference CONCLUSION When reconstructing vertically sufficient but horizontally insufficient alveolar ridges, ridge splitting technique could shorten the treatment period, decrease postoperative swelling and pain, eliminate the need for a second surgical site, reduce the treatment cost, and ease the patient cooperation to the surgery.
Click to edit Master title style 42 ARTICLE 4 42 AIM: This pilot study aims to • evaluate the outcomes of computer-aided design– computer-aided machining (CAD-CAM)– customized titanium mesh loaded with autologous bone chips and anorganic bovine bone (Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland) in a 1:1 ratio and used for prosthetically guided bone augmentation, • calculate the vertical bone volume gain of the mandible and maxilla, • evaluate complications, such as mesh exposure. Ciocca L, Lizio G, Baldissara P, Sambuco A, Scotti R, Corinaldesi G. Prosthetically CAD-CAM-Guided Bone Augmentation of Atrophic Jaws Using Customized Titanium Mesh: Preliminary Results of an Open Prospective Study. J Oral Implantol. 2018 Apr;44(2):131-137. doi: 10.1563/aaid-joi-D-17-00125. Epub 2018 Jan 5. PMID: 29303418.
Click to edit Master title style 4343 MATERIALS AND METHODS: • Case selection • Nine healthy patients, 6 women and 3 men, with a mean age of 50 years (range: 25 to 68 years), with no systemic contraindications for treatment (diabetes mellitus or heavy smoking, 10 cigarettes a day) were included in this preliminary data analysis. • Procedure • Nine patients scheduled for bone augmentation of atrophic sites were treated with custom titanium mesh and particulate bone grafts with autologous bone and anorganic bovine bone in a 1:1 ratio prior to implant surgery. • The bone volume needed to augment was virtually projected based on implant position, width, and length, and the mesh design was programmed for the necessary retaining screws. RESULTS: • After 6 to 8 months, bone augmentations of 1.72 to 4.1 mm (mean: 3.83 mm) for the mandibular arch and 2.14 to 6.88 mm (mean: 3.95 mm) for the maxilla were registered on cone-beam computerized tomography. • Mesh premature (within 4 to 6 weeks) exposure was observed in 3 cases and delayed (after 4 to 6 weeks) in 3 other cases. • One titanium mesh was removed before the programmed time but in all augmented sites was possible implant insertion. • No complication occurred during prosthetic follow- up. • Using CAD-CAM technology for prosthetically guided bone augmentation showed important postoperative morbidity of mesh exposure (66%). CONCLUSION • This study suggests a cautious approach to this procedure, because the CAD-CAM technology used for prosthetically guided bone augmentation was less successful than expected, especially in terms of postoperative morbidity due to mesh exposure. • However, this protocol allowed positioning of all programmed implants according to the treatment plan and simplified the surgery by reducing the number of retaining screws to 1, or at most, 2. • Because of this high prevalence of mesh exposure and the potential infection that could affect the expected bone augmentation, this study suggests a watchful approach to this procedure when designing the titanium mesh, to avoid flap tension that may cause mucosal rupture.
Click to edit Master title style 44 44 FIGURE 3. (a) Evidence of maxillary atrophy especially in width. (b) Rapid prototyping of the mesh and surgical application with 2 screws. FIGURE 4. Prosthetic procedures. (a) Digital impression. (b) Try-in of the prototyped metal framework. (c) Prosthetic rehabilitation.
Click to edit Master title style 45 DECISION PATHWAY FOR RIDGE AUMENTATION IN MAXILLA 45
Click to edit Master title style 46 DECISION PATHWAY FOR RIDGE AUGMENTATION IN MANDIBLE 46
Click to edit Master title style 47 “ In general, ridge augmentation procedures have become increasingly predictable. The correct selection and application of the available techniques and biomaterials are key determinants of implant survival/success rates. Currently, research in the field of advanced bone grafting is directed at overcoming the technical and biologic limitations that continue to challenge implant dentistry. 47 Conclusion
Click to edit Master title style 48 “ 48 Newman, Takei, Klokkevold, Carranza: Carrazanza’s Clinical Periodontology, Saunders, 10th edition. Altiparmak N, Akdeniz SS, Bayram B, Gulsever S, Uckan S. Alveolar Ridge Splitting Versus Autogenous Onlay Bone Grafting: Complications and Implant Survival Rates. Implant Dent. 2017 Apr;26(2):284-287. Lindhe, Lang, Karring: Clinical Periodontology and Implant Dentistry. Blackwell Munksgaard, 5th edition. Urban IA, Montero E, Monje A, Sanz- Sánchez I. Effectiveness of vertical ridge augmentation interventions: A systematic review and meta-analysis. J Clin Periodontol. 2019 Jun;46 Suppl 21:319- 339. Goyal M, Mittal N, Gupta GK, Singhal M. Ridge augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112. Kakar A, Kakar K, Sripathi Rao BH, Lindner A, Nagursky H, Jain G, Patney A. Lateral alveolar ridge augmentation procedure using subperiosteal tunneling technique: a pilot study. Maxillofac Plast Reconstr Surg. 2018 Feb 25;40(1):3. Kloss FR, Offermanns V, Kloss- Brandstätter A. Comparison of allogeneic and autogenous bone grafts for augmentation of alveolar ridge defects-A 12-month retrospective radiographic evaluation. Clin Oral Implants Res. 2018 Nov;29(11):1163-1175. Ciocca L, Lizio G, Baldissara P, Sambuco A, Scotti R, Corinaldesi G. Prosthetically CAD-CAM-Guided Bone Augmentation of Atrophic Jaws Using Customized Titanium Mesh: Preliminary Results of an Open Prospective Study. J Oral Implantol. 2018 Apr;44(2):131-137.
Click to edit Master title style 49

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Hard Tissue Augmentation.pptx

  • 1.
    Click to editMaster title style 1 Hard Tissue Augmentation D r. R i n i s h a S i n h a M D S I I P o s t g r a d u a t e Tr a i n e e
  • 2.
    Click to editMaster title style 2 • Introduction • Regenerative Periodontal Surgery • Regenerative capacity of Bone Cells • Principles in Alveolar Bone Regeneration • Bone Augmentation Therapies • Regenerative Materials and Concepts • 1st ARTICLE • Ridge Augmentation Procedures • Evidence based results for Ridge Augmentation Procedures • Emerging Technologies • 2nd ARTICLE • 3rd ARTICLE • 4th ARTICLE • Conclusion 2
  • 3.
    Click to editMaster title style 3 Introduction 3
  • 4.
    Click to editMaster title style 4 4 Alveolar bone loss can be • Congenital, or • Due to trauma, • Pathologies, • Infection, or • As a consequence of periodontal disease and tooth extraction. Approximately, 25% of the bone is lost during the first year of the bone and 40-60% during the first 3 years after a tooth is lost. The resulting ridge deficiency is primarily the result of the gradual loss of the horizontal dimension accomplished by a rapid loss of bone height. Reference: Carlsson et al. 1967
  • 5.
    Click to editMaster title style 5 Regenerative Periodontal Surgery 5
  • 6.
    Click to editMaster title style 6 • Regeneration: A reproduction or reconstruction of a lost or injured part in such a way that the architecture and function of the lost or injured tissues are completely restored. • “New Attachment” Is used to describe the formation of new cementum with inserting collagen fibers on a root surface deprived of its periodontal ligament tissue, whether or not this has occurred because of periodontal disease or by mechanical means. • “Reattachment” Is confined to describe the reunion of surrounding soft tissue and a root surface with preserved periodontal ligament tissue. • Four methods have been described to increase the rate of bone formation and to augment bone volume:  Osteoinduction by the use of appropriate growth factors;  Osteoconduction, where a grafting material serves as a scaffold for new bone growth;  Distraction osteogenesis, by which a fracture is surgically induced and the two fragments are then slowly pulled apart; and  Finally, guided tissue regeneration (GTR), which allows spaces maintained by barrier membranes to be filled with new bone. 6 Reference: Glossary of Periodontal Terms, 1992 Reference: Nyman et al. 1982; Isidor et al. 1985 Reference: Isidor et al. 1985 Reference: Reddi 1981; Urist 1965 Reference: Buch et al. 1986; Reddi et al. 1987 Reference: Ilizarov 1989a,b Reference: Dahlin et al. 1988, 1991a; Kostopoulos & Karring 1994; Nyman & Lang 1994 Guided bone regeneration (GBR) is the best documented for the treatment of localized bone defects in the jaws.
  • 7.
    Click to editMaster title style 7 Regenerative Capacity of Bone Cells 7
  • 8.
    Click to editMaster title style 8 8 • The ability of newly formed tissue originating from bone to produce a new connective tissue attachment was examined in a study by Karring et al. (1980). • Roots of periodontitis-affected teeth were extracted and placed in surgically created sockets in edentulous areas of dogs. • The implanted roots were covered with tissue flaps (submerged) and the results of healing were examined histologically after 3 months. • A periodontal ligament was re-established in the apical portion of the re- implanted roots where, at the time of implantation, remnants of periodontal ligament tissue were preserved. • In the coronal portion of the roots which were previously exposed to periodontitis and then scaled and planed, healing had consistently resulted in ankylosis and root resorption. • On the basis of this finding, it was concluded that tissue derived from bone lacks cells with the potential to produce a new connective tissue attachment.
  • 9.
    Click to editMaster title style 9 Principles in Alveolar Bone Regeneration 9
  • 10.
    Click to editMaster title style 1010 • The placement of bone grafting materials to favor healing in osseous defects or to augment edentulous ridges to allow dental implant installation has become a gold standard treatment in implant dentistry. Factors assisting in proper Wound Healing • Passive and tension-free wound closure • To reduce the risk of membrane exposure, wound contraction, patient discomfort. Promoting Primary Wound Closure • Provides blood, oxygen and nutrients to the tissues also act as source of angiogenic and osteogenic cells. Enhancing cell proliferation and differentiation Protecting initial wound stability and integrity
  • 11.
    Click to editMaster title style 1111 • Space initially becomes occupied by a fibrin clot which serves as a scaffold for the bone cells • Is important for the formation of granulation tissue and subsequent formation of bone • Completely isolating the defect to be regenerated from the overlying soft tissue • Used to prevent gingival fibroblasts / epithelial cells from gaining access to the wound site Cell Exclusion Space created beneath the membrane Scaffolding Protect the clot Reference: Schenk et a;. 1994
  • 12.
    Click to editMaster title style 12 DEFECT CLASSIFICATION 12 Class I Class II Class III Reference: According to Seibert; 1983 Alveolar crest defects
  • 13.
    Click to editMaster title style 13 Reference: According to Hammerle and Jung; crest defects in fresh extraction sockets Class I Class II Class III
  • 14.
    Click to editMaster title style 14 Bone Augmentation Therapies Melcher (1976) developed the concept of using barrier membranes to “guide” the biologic process of wound healing. Early experimental studies demonstrated that the exclusion of soft tissue invasion of the defect by means of a barrier membrane, allowed the cells with regenerative potential to migrate to the site (derived from the periodontal ligament or bone marrow) and promoted periodontal regeneration. 14 Reference: Nyman et al. 1982
  • 15.
    Click to editMaster title style 15 AUGMENTATION MATERIALS 15
  • 16.
    Click to editMaster title style 16 MEMBRANES 16 Certain critical criteria regarding membranes used for GTR have been formulated: Reference: Hardwick et al. 1994 Biocompatibility Cell occlusiveness Integration by the host tissues Clinical manageability the space making function For bioresorbable and biodegradable membranes additional criteria need to be fulfilled. Tissue reactions resulting from the resorption of the membrane should be minimal, these reactions should be reversible they should not negatively influence regeneration of the desired tissues Reference: Gottlow; 1993 GBR is quite a successful procedure, a better understanding of the factors critical for success or failure is mandatory. Factors : membrane stability, duration of barrier function, enhanced access of bone and bone marrow- derived cells to the area for regeneration, ample blood fill of the space, prevention of soft tissue dehiscence, in situ forming, and delivery of factors influencing tissue formation beneficially.
  • 17.
    Click to editMaster title style 17 Barrier membranes 17 The choice of membrane material usually depends on the amount of bone regeneration needed, mainly in the vertical dimension. e‐PTFE barrier membranes have demonstrated more favorable results when compared with resorbable devices, mainly due to their better • space‐making capacity, • longer barrier function, • lack of a resorption process that may negatively affect bone formation Reference: Hammerle and Jung, 2003
  • 18.
    Click to editMaster title style 18 Types of membranes : 18 Barrier membranes have been derived to two principal varieties: Non-resorbable • As e-PTFE non‐degradable barrier membranes require a second surgical intervention to remove them. Resorbable • Synthetic • Polylactide • Polyglycolic acid • Vicryl mesh • Cargile membrane • Natural : Collagen Membrane
  • 19.
    Click to editMaster title style 19 BONE GRAFTS and BONE SUBSTITUTES 19 Property Description Osteoconduction Provides a passive porous scaffold to support or direct bone formation Osteoinduction Induces differentiation of stem cells into osteogenic cells Osteogenesis Provides stem cells with osteogenic potential, which directly lays down new bone Combined Provides more than one of the above mentioned properties Reference: Ellegaard et al. (1973, 1974, 1975, 1976) and Nielsen et al. (1980) Choice of material should be based on the clinical indication. • For small bone defects requiring mainly horizontal bone augmentation, the use of xenografts and alloplasts has demonstrated excellent results. • Use of xenografts with a much slower resorption rate demonstrated significantly better preservation of the socket walls than the non‐grafted sites. • In large crestal defects for which the aim is both horizontal and vertical bone augmentation, the use of autogenous block grafts is recommended.
  • 20.
    Click to editMaster title style 20 20 AUTOGENOUS BONE GRAFT Considered the “ gold standard ” by which other materials are osteoinductive, osteoconductive, and osteogenic properties. No risk of infection. Disadvantages: • Low availability of bone volume • Require a second operative site • Morbidity associated with their harvesting, mainly from the chin particulate autografts, resorption rate is high ALLOGRAFT Bone grafts harvested from cadaver donors and processed by freezing or demineralization and freezing. These allografts are usually used in combination with barrier membranes following the principles of GBR. Disadvantages: Possible infections, and antigenicity risks XENOGRAFT Biomaterials of animal origin, mainly bovine and equine. These graft materials are deproteinized in order to completely remove the organic component and thus avoid any immunogenic reaction. ALLOPLAST are synthetic bone substitutes that include different combinations of calcium phosphates fabricated under different conditions, which yields different physical properties and resorption rates.
  • 21.
    Click to editMaster title style 21 ARTICLE NO.1 21 AIM: To compare three‐dimensional alterations following the use of autogenous versus allogeneic onlay grafts for augmentation at single tooth defects. DESCRIPTION: This study is the retrospective evaluation of a novel, cancellous allogeneic bone block derived from the bone of femoral heads of living human donors with respect to horizontal and vertical bone gain and volume stability. These findings are compared to results achieved with autogenous bone blocks in alveolar ridge augmentation. They have compared the 12‐month remodeling rate of cancellous allogeneic bone blocks to the remodeling rate of cortical autogenous bone blocks harvested from the retromolar region. To the best of their knowledge, this is the first longitudinal clinical study comparing freeze‐dried cancellous allogeneic with autogenous bone blocks for vertical and horizontal alveolar ridge augmentation.
  • 22.
    Click to editMaster title style 22 22 MATERIALS AND METHODS: • In accordance to STROBE guidelines. • A total of 42 patients with one tooth missing and insufficient bone quantity for direct implant placement were enrolled into this retrospective study and underwent autogenous or allogeneic bone block augmentation procedures. • INCLUSION CRITERIA: • presence of a clinically relevant bone atrophy of the alveolar ridge in the predominantly horizontal and/or vertical plane as identified by cone beam computed tomography (CBCT) para‐axial reconstruction images. • The minimum defect size was a Type‐II bone defect, defined according to the ITI‐treatment guide categories. • EXCLUSION CRITERIA: • a history of radiotherapy in the head and neck region, • systemic disease that would contraindicate oral surgery, • uncontrolled periodontal disease, • bruxism, • a smoking habit or alcoholism, • pregnancy, • psychiatric problems, • use of medications known to alter bone healing. • SAMPLE SIZE: 42 patients; 14 males and 28 females • The patients chose one of the two procedures themselves out of autogenous or allogeneic bone block augmentation. • 21 patients with comparable demographic characteristics were allocated to each group and one group received a cortical autogenous block graft harvested from the retromolar region and other received a freeze-dried cancellous allogeneic block graft for alveolar ridge augmentation. SURGICAL PROCEDURE: • A thorough initial periodontal examination, including the assessment of plaque, gingivitis, and probing depth. • Immediately before the operation, the patients were instructed to rinse their mouth with 0.2% chlorhexidine mouthwash for 1 min. • A two‐stage approach with implant placement after six months of healing with surgical intervention performed under infiltration of local anesthetics was used for all patients. • The muco‐periosteal flap was prepared by a crestal incision together with a vertical releasing incision and gently elevated from the native bone tissue to allow complete visualization of the defect and surrounding bone. • Any soft tissue remnants were removed from the bone surface and the native bone was perforated with drills during irrigation with saline to ensure vascularization of the block graft and the recipient site.
  • 23.
    Click to editMaster title style 2323 • The autogenous and allogeneic bone blocks were both used as full blocks. • The bone blocks were adapted to the defect morphology and fixated onto the host bone site using 1.5 mm osteosynthesis screws. • Resorbable collagen membranes made from porcine pericardium were used for coverage of the augmentation sites. • The muco‐periosteal flaps were repositioned with mattress and interrupted non‐resorbable sutures. Routine postoperative care included administration of • amoxicillin and clavulanic acid (625 mg, administered orally, three times a day for 4 days), • ibuprofen (600 mg, administered orally, every 6 hour as needed), • mouthwash (0.2% chlorhexidine, three times daily for 7 days). The patients were recalled at monthly intervals for a period of 6 months to detect possible complications, such as infection, pain, discomfort, graft exposure, and graft mobility. Graft stability was assessed at the time of dental implant placement. At re‐entry of the surgical site, a crestal incision was placed along the initial incision line in order to prevent the formation of additional scar tissue as a result of installing the implant.
  • 24.
    Click to editMaster title style 24 24 RADIOGRAPHIC ANALYSIS • Every patient was subjected to three‐dimensional x‐ray diagnostics (CBCT), followed by computer‐aided planning of the augmentation and subsequent implantation. • In total four CBCTs were recorded for each patient, one before treatment, one directly after augmentation, one after 6 months of healing, and one after 12 months. • At each time point, the alveolar bone levels were measured in their height, width, and depth at the cervical level, the middle height of the defect, and at the apical level. IMPLANTS • Every patient received one titanium implant per augmented region. • The inserted implants were from Straumann (n = 35; Type SLActive ; Straumann Holding AG, Basel, Switzerland), Bredent (n = 6; blueSKY; bredent medical GmbH & Co.KG, Senden, Germany) and BIOMET 3i (n = 1; BIOMET 3i; Munich; Germany). • Defect height (mm): distance between the apical and crestal bone level in the middle of the defect region; represented by line “h” • Apical defect width (mm): distance between the apical root tips of the neighboring teeth; represented by line “e” • Defect width in the middle zone (mm): distance between the roots of the neighboring teeth in the middle of the defect height; represented by line “d” • Cervical defect width (mm): distance between the crestal bone levels of the neighboring teeth; represented by line “a” • Apical defect depth (mm): distance between the labial/buccal and palatal edges of the jaw crest at the level of the apical tips of the neighboring teeth, but in the middle of the defect area; represented by line “f” • Defect depth in the middle zone (mm): distance between the labial/buccal and palatal edges of the jaw crest at the level of the middle zone; represented by line “c” • Cervical defect depth (mm): distance between the labial/buccal and palatal edges of the jaw crest at the cervical level; represented by line “b”
  • 25.
    Click to editMaster title style 25 25 RESULTS • All patients were followed for up to 12 months. • There were no signs of infection, wound dehiscence, block graft exposure, or other postoperative complications during the healing period following bone augmentation. • At the time of implant placement, all autogenous and allogeneic bone blocks were successfully integrated into the recipient site. • In all patients, the grafted bone remained stable during drilling and implant placement, without graft separation, and all implants were successfully stabilized and restored three months after implant placement. • All patients received a fixed implant‐supported single crown. • No implant was lost after loading during follow‐up. • Vertical gain • The mean vertical increase directly after augmentation was 1.4 ± 2.2 mm for autogenous blocks and 0.7 ± 1.4 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the vertical gain after augmentation, after 6 months or 12 months. • The vertical dimensions did not differ significantly between autogenous and allogeneic bone grafts at any point in time. • Horizontal gain • The mean horizontal gain at the apical level after augmentation was 1.6 ± 1.5 mm for autogenous grafts and 2.6 ± 2.5 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogenic bone grafts in the horizontal gain at the apical level after augmentation, after 6 months or after 12 months. • The mean horizontal gain at the cervical level after augmentation was 5.6 ± 1.5 mm for autogenous grafts and 5.5 ± 1.3 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the • horizontal gain at the cervical level after augmentation, after 6 months or after 12 months • The horizontal dimensions did not differ significantly between autogenous and allogeneic bone grafts at any point in time.
  • 26.
    Click to editMaster title style 26 26 RESULTS • Remodeling • The overall volume gain after augmentation was 543.9 ± 431.5 mm for autogenous grafts and 508.1 ± 187.3 mm for allogeneic blocks. • There were no statistically significant differences between autogenous and allogeneic bone grafts in the overall volume gain after augmentation, after 6 or 12 months. CONCLUSION The quintessence of the study presented here is that freeze‐dried cancellous allogeneic bone blocks are equivalent to autogenous bone blocks regarding their volumetric graft remodeling rates for treating single tooth defects classified as Type‐II to Type‐IV according to the ITI‐treatment guide categories. However, the long‐term effects need further systematic evaluation. Finally, the avoidance of donor site morbidity and unlimited availability is an undisputed advantage of the application of allogeneic bone blocks. DISCUSSION Although autogenous bone block grafting yields satisfactory results, this technique is associated with disadvantages such as prolonged operation times, limited graft acquisition, risk for damage to adjacent teeth, neurosensory deficits, donor area flap exposure, bleeding, and infection. One limitation of this study is that they • compared cancellous allogeneic bone blocks with cortical autogenous bone blocks, while a comparison of cortical autogenous bone blocks and cortical allogeneic bone blocks would have been more appropriate with respect to the materials used. • performed predominantly horizontal augmentation procedures. Reference: Esposito et al. 2009
  • 27.
    Click to editMaster title style 27 Comparative evaluation of types of bone grafts 27 Although theoretical assumptions state that autogenous bone grafts are superior to other bone substitute materials, the literature fails to substantiate this fact. The recent systematic reviews reported no superior clinical outcomes with autogenous bone graft over other bone substitute material for routine augmentation, guided bone regeneration (GBR), or maxillary sinus floor augmentation Reference: • Esposito M, Grusovin MG, Rees J, Karasoulos D, Felice P, Alissa R, et al. Interventions for replacing missing teeth: Augmentation procedures of the maxillary sinus. Cochrane Database Syst Rev 2010;CD008397. • Vignoletti F, Matesanz P, Rodrigo D, Figuero E, Martin C, Sanz M. Surgical protocols for ridge preservation after tooth extraction. A systematic review. Clin Oral Implants Res 2012; 23(Suppl 5):22-38. • Al-Nawas B, Schiegnitz E. Augmentation procedures using bone substitute materials or autogenous bone — A systematic review and meta-analysis. Eur J Oral Implantol 2014;7(Suppl 2):S219-34. • Carini F, Longoni S, Amosso E, Paleari J, Carini S, Porcaro G. Bone augmentation with TiMesh. Autologous bone versus autologous bone and bone substitutes. A systematic review. Ann Stomatol (Roma) 2014;5(Suppl 2):27-36.
  • 28.
    Click to editMaster title style 28 RIDGE AUGMENTATION PROCEDURES 28 Ridge Preservation, Bone Regeneration in fresh extraction sockets, Horizontal Bone Augmentation, Ridge Splitting/Expansion, Vertical Ridge Augmentation
  • 29.
    Click to editMaster title style 29 Socket Preservation “Any therapeutic approach carried out immediately after tooth extraction aimed to preserve the alveolar socket architecture and to provide the maximum bone availability for implant placement” 29 Reference: Vignoletti et al. 2012 These ridge preservation approaches have utilized GBR principles using the following regenerative: • Resorbable and non‐ resorbable barrier membranes alone • Resorbable barrier membranes in combination with bone substitutes • Bone substitutes alone • Bone substitutes in combination with soft tissue grafts technologies: hard and soft tissue changes occurring 6 months after tooth extraction in humans and demonstrated a horizontal bone loss 29–63% vertical bone loss 11–22% Reference: Tan et al. 2012
  • 30.
    Click to editMaster title style 30 Bone Regeneration in Fresh Extraction Socket Immediate and early implant placement (type 1 and 2) protocols have been indicated as the most suitable for implant placement following tooth extraction. 30
  • 31.
    Click to editMaster title style 31 Ridge Split Technique (Book Bone Flap) Another technique used in the maxilla to augment bone width through bone condensation is ridge splitting osteotomy. Ridge splitting is essentially the fracture of the buccal cortical plate and its displacement laterally to accommodate implant placement 31 INDICATION: Horizontal deficiency requiring 2-5 mm of augmentation. Reference: Haggerty CJ, Vogel CT, Fisher GR. Simple bone augmentation for alveolar ridge defects. Oral Maxillofacial Surg Clin North Am 2015;27:203-26. Singh AV, Shimada J. Block grafting for dental implants. In: Singh AV, Shimada J, editors. Clinical Implantology. 1st ed. India: Elsevier; 2013. p. 349-80.
  • 32.
    Click to editMaster title style 32 Vertical Ridge Augmentation Guided Bone Regeneration 32 Onlay bone – block grafting Distraction Osteogenesis
  • 33.
    Click to editMaster title style 33 EMERGING TECHNOLOGIES 33 Growth Factors • to increase bone volume have significantly advanced • the field of periodontal regenerative medicine like PDGF and BMPs Cell therapy • Cell delivery approaches are used to accelerate edentulous ridge regeneration through two primary mechanisms: use of cells as carriers to deliver growth or cellular signals provision of cells which are able to differentiate into multiple cell types to promote regeneration Scaffolding matrices to deliver cells and genes • Scaffolding matrices are used in tissue engineering to provide an environment where space is created and maintained over a period of time for cellular growth and tissue in‐growth. Computer‐based applications in scaffold design and fabrication
  • 34.
    Click to editMaster title style 34 Comparative evaluation of various Techniques of Ridge Augmentation 34 • There is no clear evidence supporting any of the specific techniques but GBR. • GBR has been shown to be a predictable technique, especially when Ti-mesh is employed for horizontal as well as vertical augmentation [mean implant survival rate (MISR) of 100%]. • Milinkovic and Cordaro (2014) extracted data from 53 publications for partially edentulous patients and 15 publications for edentulous patients. Although owing to heterogeneity of included studies, no clear-cut indications could be extracted for specific bone augmentation procedures, a few suggestions could be drafted on the basis of magnitude of the mean implant survival rate. The evidence suggested that dehiscence and fenestrations can be treated successfully with GBR at the time of implant placement [MISR 92.2%, mean complication rate (MCR) 4.99%]. Reference: lementini M, Morlupi A, Canullo L, Agrestini C, Barlattani A. Success rate of dental implants inserted in horizontal and vertical guided bone regenerated areas: A systematic review. Int J Oral Maxillofac Surg 2012;41:847-52. Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg 2014;43:606-25. Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants — A Cochrane systematic review. Eur J Oral Implantol 2009;2:167-84. Reference: Rasia-dal Polo M, Poli PP, Rancitelli D, Beretta M, Maiorana C. Alveolar ridge reconstruction with titanium meshes: A systematic review of the literature. Med Oral Patol Oral Cir Bucal 2014; 19:e639-46. Reference: Milinkovic I, Cordaro L. Are there specific indications for the different alveolar bone augmentation procedures for implant placement? A systematic review. Int J Oral Maxillofac Surg 2014;43:606-25.
  • 35.
    Click to editMaster title style 3535 • In partially edentulous ridges, when a horizontal defect is present, procedures such as staged GBR (MISR 100%, MCR 11.9%), bone block grafts (MISR 98.4%, MCR 6.3%), and ridge expansion/splitting (MISR 97.4%, MCR 6.8%) have been proved to be effective. Vertical defects can be treated with simultaneous and staged GBR (MISR 98.9%, MCR 13.1% and MISR 100%, MCR 6.95%, respectively), bone block grafts (MISR 96.3%, MCR 8.1%), and distraction osteogenesis (MISR 98.2%, MCR 22.4%). • In edentulous patients, there is evidence that bone block grafts can be used (MISR 87.75%), and that Le Fort I osteotomies can be applied (MISR 87.9%) but are associated with a high complication rate. • Further, the addition of platelet-rich plasma (PRP) has been reported to confer no additional benefit on either bone volume gain or implant survival. Reference: Esposito M, Grusovin MG, Felice P, Karatzopoulos G, Worthington HV, Coulthard P. The efficacy of horizontal and vertical bone augmentation procedures for dental implants — A Cochrane systematic review. Eur J Oral Implantol 2009;2:167-84. Arora NS, Ramanayake T, Ren YF, Romanos GE. Platelet-rich plasma in sinus augmentation procedures: A systematic literature review: Part II. Implant Dent 2010;19:145-57.
  • 36.
    Click to editMaster title style 36 ARTICLE NO.2 36 AIM: To evaluate the effectiveness of vertical bone augmentation, to correlate it with associated complications and to explore peri-implant health outcomes over time. MATERIALS AND METHODS: • Protocol development and focused question  The protocol followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta- Analyses) statement. • Inclusion criteria  Population: patients older than 18 and in good general health with vertical ridge deficiencies in need of an implant-supported/-retained prosthesis;  Interventions: any given intervention for VRA;  Comparisons: any given intervention for VRA in controlled studies;  Outcomes: changes in the clinical vertical dimension of the ridge;  Study design: randomized clinical trials (RCTs), controlled clinical trials (CCTs), prospective/retrospective cohort studies or prospective/retrospective case series (CS) with a minimum of 10 patients (five per group in controlled studies). • Exclusion criteria  Studies assessing the effectiveness of interventions aimed only at horizontal bone regeneration;  Studies assessing the effectiveness of VRA procedures using only radiographs;  Studies aiming at regenerating extractions sockets before or simultaneous with implant placement;  Studies evaluating solely maxillary sinus floor elevation;  Studies including only oncologic and poly-traumatized patients;  Orthognathic procedures aiming at changing the bone dimensions for different purposes than tooth replacement.
  • 37.
    Click to editMaster title style 3737 • Type of intervention and comparisons:  Studies were selected that included interventions for VRA.  The following procedures were considered: (a) GBR; (b) bone blocks, either as onlay or inlay grafts; (c) distraction osteogenesis; (d) other approaches. (e) Inlay graft was used as a synonym for inter- positional graft.  Moreover, the following biomaterials were assessed: (a) autogenous bone grafts; (b) allogeneic bone grafts; (c) xenogeneic bone grafts. • Type of outcomes:  Primary outcome for assessing VRA : change in the clinical vertical alveolar ridge dimension, as determined by direct linear measurements between baseline and re-entry.  Secondary outcomes :  Surgical intra- and post-operative complications, including the need for re- grafting, flap dehiscence, graft or membrane exposure, loss of graft integration, local infection, prolonged pain, and paresthesia;  Implant survival and success rates (%);  Changes in marginal bone levels, defined as the distance between the implant shoulder and the first bone to implant contact measured at both mesial and distal aspects (mm);  Probing pocket depth (PPD);  Gingival or bleeding indexes;  Occurrence of biological complications (%) defined as the occurrence of mucositis (bleeding on probing [BOP] with or without increased PPD and without radiographic bone loss) and/or peri-implantitis (BOP with or without increased PPD and with radiographic bone loss;  Patient-reported outcome measures (PROMs), such as pain, discomfort, and satisfaction. • For the secondary outcome measurements related to implants, only studies with a minimum follow-up of 12 months after definitive loading were considered. Reference: Lang & Berglundh, 2011 Randomized and controlled clinical trials and prospective and retrospective case series were included, and meta-analyses were performed to evaluate vertical bone gain based on the type of procedure and to compare bone gains in controlled studies.
  • 38.
    Click to editMaster title style 3838 • Electronic search o Three electronic databases were used as sources in the search for studies satisfying the inclusion criteria: (a) The National Library of Medicine (MEDLINE via PubMed); (b) Cochrane Central Register of Controlled Trials; (c) EMBASE. o These databases were searched for studies published up until January 2018. o The search was limited to human subjects. • Manual search o All reference lists of the selected studies and previously published systematic reviews were checked for cross-references. o The following journals were hand-searched from year 2008 to 2018: Journal of Clinical Periodontology, Journal of Periodontology, Clinical Oral Implants Research, International Journal of Oral & Maxillofacial Implants, European Journal of Oral Implantology, Implant Dentistry, International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, The International Journal of Periodontics and Restorative Dentistry, and Clinical Implant Dentistry and Related Research. • Screening methods Two reviewers (ISS and EM) did the primary search by independently screening the titles and abstracts. RESULTS • Thirty-six publications were included. • Results demonstrated a significant vertical bone gain for all treatment approaches (n = 33; weighted mean effect = 4.16 mm; 95% CI 3.72–4.61; p < 0.001). • Clinical vertical bone gain and complications rate varied among the different procedures, with a weighted mean gain of 8.04 mm and complications rate of 47.3% for distraction osteogenesis, 4.18 mm and 12.1% for guided bone regeneration (GBR), and 3.46 mm and 23.9% for bone blocks. • In comparative studies, GBR achieved a significant greater bone gain when compared to bone blocks (n = 3; weighted mean difference = 1.34 mm; 95% CI 0.76–1.91; p < 0.001). CONCLUSION Vertical ridge augmentation is a feasible and effective therapy for the reconstruction of deficient alveolar ridges, although complications are common. PRACTICAL IMPLICATIONS Clinicians should be aware that VRA is a highly demanding therapy. The decision-making process for the ideal treatment should be made on the basis of site and patient-related factors, in combination with surgical experience and skill.
  • 39.
    Click to editMaster title style 39 ARTICLE NO.3 39 AIM: To compare the implant survival rates and complication rates after horizontal augmentation of the alveolar ridge with ARS versus autogenous OBG in the anterior maxilla. DESCRIPTION: This study is a retrospective clinical study. MATERIALS AND METHODS: • 48 patients (20 men and 28 women) with maxillary anterior alveolar crest width deficiency and a mean age of 44.8 years were included in this study. • 28 ARS procedures in 24 patients (11 men and 13 women; ARS group) and 28 OBG procedures in 24 patients (15 men and 9 women; OBG group) were performed. • All autogenous bone blocks were harvested from the mandibular ramus in the OBG group.
  • 40.
    Click to editMaster title style 40 40 INCLUSION CRITERIA • 3 to 4 mm of initial alveolar crest width and sufficient height from the tip of the alveolar ridge to the nasal floor EXCLUSION CRITERIA • Patients who had previously undergone the same surgery, • Patients who smoked more than 10 cigarettes a day, • patients with any of the following medical conditions: myocardial infarction within 3 months, previous heart surgery or angioplasty, diabetes mellitus, vitamin D deficiency, blood disorder or history of blood disorder (leukemia, lymphoma, von Willebranddisease, hemophilia, platelet disorder), periodontal disease, osteoporosis, use of bisphosphonates, and any other new or uncontrolled medical condition that would affect bone healing • All ARS and OBG procedures were performed by the same surgeon. • The Bio-Oss hydroxyapatite bovine matrix graft material and Bio-Gide resorbable collagen membrane were used for the augmentation procedure in both the ARS group and OBG group to minimize graft resorption. • Implant placement was performed simultaneously with the initial procedure in the ARS group and at 6 months afterthe initial procedure in the OBG group. • All implants were loaded with a fixed prosthesis at 4 months after the surgery. • The survival rates of all implants were evaluated using the clinical and radiographic evaluation criteria of Misch et al. • MINOR COMPLICATIONS: • Temporary graft exposure, • Mild infection, • Temporary paresthesia • Bad split (fracture of buccal bone) • MAJOR COMPLICATIONS: • permanent graft exposure, • graft loss, • permanent paresthesia • The major and minor complications were compared between the ARS and OBG groups.
  • 41.
    Click to editMaster title style 4141 RESULTS • The mean follow-up for the dental implants was 38.33 months in the ARS group and 31.6 months in the OBG group. • A total of 42 implants were inserted into the augmented region in the OBG group, whereas 43 implants were inserted into the augmented region in the ARS group. • There were no significant differences between the OBG and ARS groups in terms of mean age and sex distribution. • When the minor complication rates were considered, there was no significant difference between the OBG and ARS groups. • The rate of temporary exposure of the augmented recipient site was 14.3% in the OBG group and 2.3% in the ARS group. • Mild infection of the recipient site was observed in 7.1% of patients in the OBG group and 4.7% of patients in the ARS group, with no significant difference. • Temporary paresthesia was observed in 7.1% of recipient sites in the OBG group, compared with no temporary paresthesia in the ARS group. • A bad split occurred in 7.1% of recipient sites in the ARS group during the surgery. • The minor complications did not affect the treatment prognosis, and the implants were inserted as planned. • When the major complication rates were considered, there was no significant difference between the OBG and ARS groups. The only major complication was permanent exposure of the recipient site in 2 patients in the OBG group, and the augmented grafts were lost in these 2 patients. • In the OBG group, 3 of 42 implants inserted into the augmented bone block failed, and the remaining inserted implants were accepted as satisfactory survival. In the ARS group, all of the inserted implants were accepted as satisfactory survival. The satisfactory survival rate was 92% in the OBG group and 100% in the ARS group, with no significant difference CONCLUSION When reconstructing vertically sufficient but horizontally insufficient alveolar ridges, ridge splitting technique could shorten the treatment period, decrease postoperative swelling and pain, eliminate the need for a second surgical site, reduce the treatment cost, and ease the patient cooperation to the surgery.
  • 42.
    Click to editMaster title style 42 ARTICLE 4 42 AIM: This pilot study aims to • evaluate the outcomes of computer-aided design– computer-aided machining (CAD-CAM)– customized titanium mesh loaded with autologous bone chips and anorganic bovine bone (Bio-Oss, Geistlich Pharma, Wolhusen, Switzerland) in a 1:1 ratio and used for prosthetically guided bone augmentation, • calculate the vertical bone volume gain of the mandible and maxilla, • evaluate complications, such as mesh exposure. Ciocca L, Lizio G, Baldissara P, Sambuco A, Scotti R, Corinaldesi G. Prosthetically CAD-CAM-Guided Bone Augmentation of Atrophic Jaws Using Customized Titanium Mesh: Preliminary Results of an Open Prospective Study. J Oral Implantol. 2018 Apr;44(2):131-137. doi: 10.1563/aaid-joi-D-17-00125. Epub 2018 Jan 5. PMID: 29303418.
  • 43.
    Click to editMaster title style 4343 MATERIALS AND METHODS: • Case selection • Nine healthy patients, 6 women and 3 men, with a mean age of 50 years (range: 25 to 68 years), with no systemic contraindications for treatment (diabetes mellitus or heavy smoking, 10 cigarettes a day) were included in this preliminary data analysis. • Procedure • Nine patients scheduled for bone augmentation of atrophic sites were treated with custom titanium mesh and particulate bone grafts with autologous bone and anorganic bovine bone in a 1:1 ratio prior to implant surgery. • The bone volume needed to augment was virtually projected based on implant position, width, and length, and the mesh design was programmed for the necessary retaining screws. RESULTS: • After 6 to 8 months, bone augmentations of 1.72 to 4.1 mm (mean: 3.83 mm) for the mandibular arch and 2.14 to 6.88 mm (mean: 3.95 mm) for the maxilla were registered on cone-beam computerized tomography. • Mesh premature (within 4 to 6 weeks) exposure was observed in 3 cases and delayed (after 4 to 6 weeks) in 3 other cases. • One titanium mesh was removed before the programmed time but in all augmented sites was possible implant insertion. • No complication occurred during prosthetic follow- up. • Using CAD-CAM technology for prosthetically guided bone augmentation showed important postoperative morbidity of mesh exposure (66%). CONCLUSION • This study suggests a cautious approach to this procedure, because the CAD-CAM technology used for prosthetically guided bone augmentation was less successful than expected, especially in terms of postoperative morbidity due to mesh exposure. • However, this protocol allowed positioning of all programmed implants according to the treatment plan and simplified the surgery by reducing the number of retaining screws to 1, or at most, 2. • Because of this high prevalence of mesh exposure and the potential infection that could affect the expected bone augmentation, this study suggests a watchful approach to this procedure when designing the titanium mesh, to avoid flap tension that may cause mucosal rupture.
  • 44.
    Click to editMaster title style 44 44 FIGURE 3. (a) Evidence of maxillary atrophy especially in width. (b) Rapid prototyping of the mesh and surgical application with 2 screws. FIGURE 4. Prosthetic procedures. (a) Digital impression. (b) Try-in of the prototyped metal framework. (c) Prosthetic rehabilitation.
  • 45.
    Click to editMaster title style 45 DECISION PATHWAY FOR RIDGE AUMENTATION IN MAXILLA 45
  • 46.
    Click to editMaster title style 46 DECISION PATHWAY FOR RIDGE AUGMENTATION IN MANDIBLE 46
  • 47.
    Click to editMaster title style 47 “ In general, ridge augmentation procedures have become increasingly predictable. The correct selection and application of the available techniques and biomaterials are key determinants of implant survival/success rates. Currently, research in the field of advanced bone grafting is directed at overcoming the technical and biologic limitations that continue to challenge implant dentistry. 47 Conclusion
  • 48.
    Click to editMaster title style 48 “ 48 Newman, Takei, Klokkevold, Carranza: Carrazanza’s Clinical Periodontology, Saunders, 10th edition. Altiparmak N, Akdeniz SS, Bayram B, Gulsever S, Uckan S. Alveolar Ridge Splitting Versus Autogenous Onlay Bone Grafting: Complications and Implant Survival Rates. Implant Dent. 2017 Apr;26(2):284-287. Lindhe, Lang, Karring: Clinical Periodontology and Implant Dentistry. Blackwell Munksgaard, 5th edition. Urban IA, Montero E, Monje A, Sanz- Sánchez I. Effectiveness of vertical ridge augmentation interventions: A systematic review and meta-analysis. J Clin Periodontol. 2019 Jun;46 Suppl 21:319- 339. Goyal M, Mittal N, Gupta GK, Singhal M. Ridge augmentation in implant dentistry. J Int Clin Dent Res Organ 2015;7:94-112. Kakar A, Kakar K, Sripathi Rao BH, Lindner A, Nagursky H, Jain G, Patney A. Lateral alveolar ridge augmentation procedure using subperiosteal tunneling technique: a pilot study. Maxillofac Plast Reconstr Surg. 2018 Feb 25;40(1):3. Kloss FR, Offermanns V, Kloss- Brandstätter A. Comparison of allogeneic and autogenous bone grafts for augmentation of alveolar ridge defects-A 12-month retrospective radiographic evaluation. Clin Oral Implants Res. 2018 Nov;29(11):1163-1175. Ciocca L, Lizio G, Baldissara P, Sambuco A, Scotti R, Corinaldesi G. Prosthetically CAD-CAM-Guided Bone Augmentation of Atrophic Jaws Using Customized Titanium Mesh: Preliminary Results of an Open Prospective Study. J Oral Implantol. 2018 Apr;44(2):131-137.
  • 49.
    Click to editMaster title style 49