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Ridge augmentation

This document provides information on various ridge augmentation techniques. It begins with an introduction describing how tooth loss leads to bone resorption and impaired function. It then discusses the history of using autogenous bone grafts for ridge augmentation. The objectives of ridge augmentation are also outlined. Key techniques discussed include ridge preservation, ridge splitting, use of autogenous bone blocks, and distraction osteogenesis. Advantages and disadvantages of different graft sources and incision designs are compared. The document emphasizes the importance of adequate bone volume for successful implant placement and summarizes various methods to augment bone.

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RIDGE AUGMENTATION DR. RINISHA SINHA MDS III DEPARTMENT OF PERIODONTOLOGY
TABLE OF CONTENTS INTRODUCTION 01 HISTORY 02 OBJECTIVES 03 RIDGE SPLITTING 05 06 AUTOGENOUS BONE BLOCKS RIDGE PRESERVATION 04 TI MESH WITH RHBMP2 07 DISTRACTION OSTEOGENESIS 08 REFERENCES 09
INTRODUCTION Teeth loss  Continuous resorption Diminished volume and strength of residual bone Impaired masticatory function Loss of facial vertical dimension Speech difficulty Facial soft tissue changes Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
SUCCESSFUL IMPLANT THERAPY depends upon “ADEQUATE VOLUME OF BONE” To increase the rate of bone formation and to augment bone volume: Osteoinduction Appropriate growth factors Osteoconduction A grafting material serving as a scaffold for new bone growth Distraction osteogenesis A fracture is surgically induced and the two fragments are then slowly pulled apart Guided Tissue Regeneration Allows spaces maintained by barrier membranes to be filled with new bone 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
The use of autogenous bone grafts with osseointegrated implants was originally discussed by Brånemark et al, who used the iliac crest as a donor site. This early Swedish study looked at completely edentulous cases and proposed the autogenous retransplantation of bone from the iliac crest to add bulk to thin cortex bone. Naturally a learning curve was expressed whereby the authors attempted to simultaneously graft and place implants. However, this resulted in low implant survival. HISTORY Reference: Breine U, Brånemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;14:23–48. Brånemark PI, Lindström J, Hallén O, Breine U, Jeppson PH, Öhman A. Reconstruction of the defective mandible. Scand J Plast Reconstr Surg 1975;9:116–128.
Alveolar ridge augmentation has been one of the most widely performed surgical procedures over the past three decades. These include Ridge preservation Ridge splitting/expansion Horizontal bone augmentation Ridge augmentation with block grafts and with the use of particulate grafts with or without barrier membranes Vertical bone augmentation Guided bone regeneration Onlay bone grafting Distraction osteogenesis Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
OBJECTIVES OF RIDGE AUGMENTATION Function Esthetics Prognosis Straight forward surgical technique Minimal burden for the patient Low morbidity Reduced surgical sessions Low cost, High predictability Lesser healing time Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
BONE DEFECT CLASSIFICATION In 1983, Seibert (1983a, 1983b) classified the different types of alveolar ridge defects that a clinician may encounter. Class I Alveolar ridge defects have a horizontal loss of tissue with normal ridge height. Class II Alveolar ridge defects have a vertical loss of tissue with normal ridge width. Class III Alveolar ridge defects have a combination of class I and class II resulting in loss of normal height and width.
INDICATION When the loss of gingiva or bone compromises the positive outcome of a prosthetic restoration. Easiest to treat : Class I > Class II > Class III Prognosis: Horizontal > Vertical or Combination
The Cologne Classification of Alveolar Ridge Defects (CCARD) classifies volume deficiencies of the alveolar process regardless of their etiology as vertical (V), horizontal (H), or combined (C), possibly in conjunction with a sinus area defect (+S) BONE GRAFT CLASSIFICATION
CCARD CRITERIA • In general, intrabony defects are more easily grafted and result in more predictable outcomes than extrabony defects. • It is easier to stabilize/immobilize and protect an intrabony grafted defect. • In addition, soft tissue coverage and inherent generative capacity is optimized with these defects. • Other considerations during bone grafting include the osteogenic potential of the recipient site. Reference: Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8–17
RIDGE PRESERVATION Overview of the extraction site after 1, 2, 4, and 8 weeks of healing Reference: Araújo and Lindhe; 2005 • Ridge preservation is typically described as a socket or sinus augmentation using nonviable grafts (ie, allografts, allogeneic bone, and xenogeneic bone). The dimensional changes that occur following tooth extraction remain inevitable even if biomaterials are utilized.
Healing process following tooth extraction Reference: Avila-Ortiz and Zadeh; 2019
MATRIX VITRONECTIN FIBRIN & FIBRONECTIN BIOLOGIC PERSPECTIVE OF AUGMENTATION CELL ADHESION MOLECULES SIGNALING MOLECULES
CONVENTIONAL SOCKET GRAFTING AND RIDGE PRESERVATION TECHNIQUES 1. Minimally Traumatic Tooth Extraction USING PERIOTOME, ROTARY BURS AND EXTRACTION FORCEPS
2.2. After tooth removal, the alveolar socket is debrided of all granulation tissue. 3.3. Bleeding is stimulated from the osseous walls through the use of rotary instruments or curettes. To trigger the regional acceleratory phenomenon, which stimulates new bone formation and graft incorporation. Reference: Frost HM; 1989 2.4. The extraction socket should be evaluated visually and tactilely with the help of a periodontal probe. Evaluation done with special attention to direct visualization of the labial plate’s integrity and thisckness; identifying fenestration and dehiscence defects.
SINGLE-TOOTH ALVEOLAR RIDGE PRESERVATION IN THE NON-ESTHETIC ZONE • A HIGH-DENSITY PTFE (DPTFE) MEMBRANE (CYTOPLAST, OSTEOGENICS) • FDBA (MINEROSS) 1ST SCENARIO
LEUKOCYTE PLATELET-RICH FIBRIN (L-PRF) AS A BARRIER MEMBRANE AS OPPOSED TO USING DPTFE 2ND SCENARIO Reference: Miron RJ, Zucchelli G, Pikos MA, et al; 2017
SINGLE-TOOTH ALVEOLAR RIDGE PRESERVATION IN THE ESTHETIC ZONE F I V E D I A G N O S T I C K E Y S F I V E D I A G N O S T I C K E Y S Reference: Kois JC; 2001 Management guidelines for evaluating tissue degradation Management guidelines for evaluating tissue degradation
ALLOGRAFT; FREE GINGIVAL GRAFT AND DPTFE MEMBRANE 1ST SCENARIO
Two key parameters are noted: 1. To date, there are currently no available options to completely prevent dimensional changes following tooth extraction. Resorption of bundle bone will occur regardless of the alveolar ridge preservation technique utilized. 2. There is no ideal or favored method to preserve dimensional changes of the alveolar ridge, including using GBR techniques, socket fillers, socket seals, or combinations of these Reference: • Morjaria KR, Wilson R, Palmer RM. Bone healing after tooth extraction with or without an intervention: A systematic review of randomized controlled trials. Clin Implant Dent Relat Res 2014;16:1. • Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997;68:563–570. • MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following alveolar ridge preservation: A systematic review. Clin Oral Implants Res 2017;28:982–100
SYNONYMS: Socket Shield Technique; Partial Extraction Therapy; Root Submergence Technique ALTHOUGH SOCKET PRESERVATION METHODS HAVE BEEN SHOWN TO LIMIT DIMENSIONAL CHANGES POST- EXTRACTION AND REDUCE THE UNPLEASANT ESTHETIC EFFECTS OF PHYSIOLOGIC BONE RESORPTION IN THE ESTHETIC ZONE, NONE COMPLETELY PREVENT RESORPTION. ROOT MEMBRANE TECHNIQUE Reference: Chappuis V, Araujo J et al; 2017 For preserving the buccal bone with up to 10 - year follow-up is the in-situ maintenance of the buccal portion of the root in a procedure. Hypothesis: By maintaining the buccal aspect of the root and its associated periodontal ligament (and hence the associated blood vessels), one may be capable of preventing the physiologic bone resorption of the buccal bone. Reference: Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The socket-shield technique: A proof-of-principle report. J Clin Periodontol 2010;37:855–862.
Based on current evidence, there is significant merit for future research attempts to investigate in a controlled fashion whether the benefit from the use of this technique can establish it as the gold standard for immediate implant placement in the esthetic zone.
RIDGE SPLITTING Hilt Tatum is given credit for working with ridge expansion protocols in the 1970s. • The protocol at the time included tapered channel formers, D-shaped osteotomes, and custom implants. Reference: Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229. Indications for ridge expansion Narrow alveolar ridge (minimum 2+ mm, marrow component) Primarily maxillary sites greater than one tooth If in the mandible, only posterior distal-extension edentulous sites with a marrow component Adequate alveolar bone height (approximately 10 mm minimum) Contraindications for ridge expansion Inadequate alveolar bone height Concavities or undercuts of ridge Fused cortices (no marrow) Less than 2-mm ridge width Single-tooth sites
Key points • Ridge expansion and simultaneous implant placement in the maxilla typically result in an exaggerated facial implant inclination because the implant osteotome follows the denser palatal bone. • Factors to consider include interocclusal space and biomechanical force factors (especially parafunction). • The advantages of the ridge splitting technique include faster healing. • The treating clinician must always weigh the pros and cons because ridge split failure can also occur and result in catastrophic bone loss. • This technique is more suitable for the maxillary arch because of its more cancellous nature (ie, lower bone density). Reference: Lustmann J, Lewinstein I. 1995
RIDGE SPLIT TECHNIQUE USING A PIEZOSURGERY DEVICE
RIDGE SPLIT TECHNIQUE USING OSTEOTOMES
MANDIBULAR RIDGE SPLIT TECHNIQUE USING PIEZOSURGERY AND OSTEOTOMES
1. Incision design/flap management 2. Site preparation - angiogenesis 3. Space maintenance 4. Graft stability 5. Tension-free primary closure Reference: Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8–17 Keys for Predictable Bone Augmentation
INCISION DESIGNS
FINGER SWEEP PROTOCOL FOR MANDIBULAR LINGUAL FLAP RELEASE
WORKFLOW DEMONSTRATING KEY PRINCIPLES FOR BONE AUGMENTATION
AUTOGENOUS BONE BLOCK GRAFTING • INCISIONS AT THE DONOR SITE • INCISIONS AT THE RECEIPIENT SITE
INDICATIONS, ADVANTAGES, AND DISADVANTAGES FOR EACH INCISION METHOD
Several possible origins for autogenic bone include the calvarium, tibia, and the iliac crest. Reference: Harsha BC, Turvey TA, Powers SK. 1986. Reference: Breine U, Bränemark PI. 1980. Reference: • Keller EE, van Roekel NB, Desjardins RP, Tolman DE. 1987. • Listrom RD, Symington JM. 1988. • Schwartz-Arad D, Dori S. 2002. • Although the iliac crest is most often used in major jaw reconstruction, it is not always recommended due to its morbidity, altered ambulation, and the need for hospitalization. • There is also significant resorption associated with cortico-cancellous block grafts from endochondral donor sites. • These disadvantages, together with the fact that dental implants do not demand large amounts of bone, led to the growing use of intraoral block bone grafts from intraoral sources, especially from the mandibular symphysis and ramus. Reference: Misch CM; 1996, 1997. Reference: • Misch CM; 1992, 1995, 1997. • Kleinman A et al. 2002
ADVANTAGES OF INTRAORAL BONE GRAFT SOURCES Conventional surgical access and the proximity of donor and recipient sites Reduce operative and anesthesia time Making it ideal for outpatient implant surgery • There is no cutaneous scar • Patients report minimal discomfort and less morbidity compared with extraoral locations
SYMPHYSIS HARVESTING • THREE PRIMARY INCISION DESIGNS CAN BE USED FOR HARVESTING BLOCK BONE FROM THE SYMPHYSIS: SULCULAR, MARGINAL, AND ALVEOLAR MUCOSAL. • SULCULAR INCISION PREFERRED MORE OVER CONVENTIONAL VESTIBULAR APPROACH. • FOLLOWED BY AN OBLIQUE SURFACE RELEASING INCISION. • FULL THICKNESS MUCOPERIOSTEAL FLAP Reference: Linkow LI. Bone transplants using the symphysis, the iliac crest and synthetic bone materials. J Oral Implantol 1983;11:211-247. THE 5-MM RULE
SULCULAR V/S VESTIBULAR APPROACH SULCULAR • EASIER ACCESS • BETTER VISUALISATION OF THE MENTAL NEUROVASCULAR BUNDLES • EASIER SUPERIOR AND INFERIOR RETRACTION OF THE FLAP MARGINS • NO WOUND DEHISCENCE NOTED • POSTOPERATIVE PAIN IS REDUCED, AND NO ASSOCIATED PTOSIS VESTIBULAR • LIMITED ACCESS • INCOMPLETE VISUALIZATION OF THE MENTAL NEUROVASCULAR BUNDLES • MORE DIFFICULTY IN SUPERIOR AND INFERIOR RETRACTION OF THE FLAP MARGINS • BLEEDING IS SECONDARY TO THE MENTALIS MUSCLE INCISION AND RESULTS IN THE NEED FOR HEMOSTASIS • CAN RESULT IN WOUND DEHISCENCE AND SCAR BAND FORMATION
• ONE OF THE MOST FREQUENTLY USED SITES FOR INTRAORAL HARVESTING OF AUTOGENOUS BLOCK GRAFTS. • FULL-THICKNESS MUCOPERIOSTEAL INCISION • OBLIQUE RELEASING INCISION • FULL-THICKNESS MUCOPERIOSTEAL FLAP • “THREE COMPLETE OSTEOTOMIES AND ONE BONE GROOVE” RAMUS BUCCAL SHELF BLOCK GRAFT HARVESTING
1. USING ROTARY FISSURE BURS 2. USING PIEZOSURGERY DEVICE
RAMUS BUCCAL SHELF BLOCK GRAFT TECHNIQUE
TIMING FROM BLOCK GRAFTING TO IMPLANT PLACEMENT HORIZONTAL AUGMENTATION VERTICAL AUGMENTATION MAXILLA 4 MONTHS 5 MONTHS MANDIBLE 5 MONTHS 5 MONTHS ADVANTAGES AND DISADVANTAGES OF AUTOGENOUS BONE GRAFTING Native bone qualities Increased surgical time Optimal bone volume and density Minimal donor bone Volume Predictable volume enhancement More surgical training required Increased patient acceptance Donor site morbidity Lower cost
TITANIUM MESH PARTICULATE GRAFT WITH RHBMP-2
ADVANTAGES OF COLLAGEN MEMBRANES AND TITANIUM-REINFORCED MEMBRANES AND MESH COLLAGEN MEMBRANES • LACK OF NEED FOR STAGE-TWO SURGERY • PHYSIOLOGICALLY FAVORABLE PROPERTIES • IMPROVES HEMOSTATIC FUNCTION BY PLATELET AGGREGATION, WHICH FACILITATES EARLY CLOT FORMATION AND WOUND STABILIZATION • CHEMOTACTIC FUNCTION FOR FIBROBLASTS THAT ASSISTS IN CELL MIGRATION TO PROMOTE PRIMARY WOUND CLOSURE • EFFECTIVE IN INHIBITING EPITHELIAL MIGRATION AND PROMOTING NEW CONNECTIVE TISSUE ATTACHMENT TITANIUM-REINFORCED MEMBRANES AND MESHES • FATIGUE STRENGTH IS NOT AN ISSUE; IT CAN BE USED AT A THICKNESS OF 0.2 MM WITH VERY LITTLE POSSIBILITY OF FRACTURE • HIGH TENSILE STRENGTH ALLOWS IT TO ADAPT NICELY AND BE PHYSIOLOGIC WITH BONE • THICKNESS RANGES FROM 0.1 TO 0.6 MM • HIGH DUCTILITY AND STRENGTH
STEP-BY-STEP GUIDE TO ALVEOLAR BONE AUGMENTATION WITH TITANIUM MESH (MEGAGEN; I-GEN)
• Distraction osteogenesis (DO) was first described by CODIVILLA in1905 and later popularized via the extensive research performed by ILIZAROV in orthopedic literature in 1989. DISTRACTION OSTEOGENESIS Reference: • Codivilla A: On the means of lengthening in the lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353–369. • Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft tissue preservation. Clin Orthop 1989;238:249–281. • Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop 1989;239:263– 285. • Craniofacial DO was first done by SNYDER in 1973 in a canine model and later reported in humans by GUERRERO (1990), MCCARTHY ET AL. (1992), KABANET AL. (1993). Reference: • Snyder CC, Levine GA, Swanson HM, Browne EZ Jr: Mandibular lengthening by gradual distraction. Preliminary report. Plast Reconstr Surg 1973;51:506–508. • Guerrero CA: Expansion rapida mandibular. Rev Venez Ortod 1990;12:48. • McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH: Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1–8. • Perrott DH, Berger R, Vargervik K, Kaban LB: Use of a skeletal distraction device to widen the mandible: a case report. J Oral Maxillofac Surg 1993;51(4):e435–439. • Alveolar distraction was initially reported via animal studies conducted by BLOCK ET AL. and later described via a clinical report by CHIN ET AL. in 1996. Reference: • Troulis MJ, Glowacki J, Perrott DH, et al: Effects of latency and rate on bone formation in a porcine mandibular distraction model. J Oral Maxillofac Surg • 2000;58:507. • Kaban LB, Thurmüller P, Troulis MJ, et al: Correlation of biomechanical stiffness with plain radiographic and ultrasound data in an experimental mandibular distraction wound. Int J Oral Maxillofac Surg 2003;32:296.
Alveolar augmentation for placement of dental implants In treating moderate to severe maxillary and mandibular alveolar ridge atrophy, mostly in the anterior region. For correcting vertical alveolar ridge defects but can be used for increasing the width as well Some degree simultaneous correction of an alveolar bone horizontally due to often observed pyramidally shaped morphology of the alveolar bone “To increase soft tissue as well as bone” In cases where the bone loss is so severe that the device cannot be placed If the transport segment is not at least 5 mm in size. Patients unable to follow the distractor activation protocol INDICATIONS CONTRAINDICATIONS Reference: • Zimmermann CE, Thurmüller P, Troulis MJ, et al: Histology of the porcine mandibular distraction wound. Int J Oral Maxillofac Surg 2005;34:411.
• Jensen and block presented an alveolar site classification system that could be applied in making treatment decisions: • Class I – mild alveolar deficiency with up to 5 mm of vertical bone loss; • Class II – moderate deficiency with 6–10 mm of vertical bone loss; • Class III – severe deficiency with greater than 10 mm of vertical bone loss; • Class IV – severe bone loss at the edentulous alveolar ridge as well as significant bone loss on adjacent teeth  Class I defects : smaller; hence, treated with traditional sandwich osteotomy or with conventional bone grafting techniques.  Class II defects : more amenable to be reconstructed with Alveolar Distraction Osteogenesis.  Treatment of Class III defects depends on the availability of bone stock in the defect.  If there is enough bone, distraction can be performed but may have to be supplemented by bone grafts later or else will need bone grafting first with secondary Alveolar Distraction Osteogenesis.  Class IV defects : complicated by adjacent teeth that have a poor prognosis. These teeth can be extracted to convert the defect into a Class III type defect and continue treatment as above. Reference: Chiapasco M, Zaniboni M, Rimondini L: Autogenous onlay bone grafts vs. alveolar distraction osteogenesis for the correction of vertically deficient edentulous ridges: a 2–4-year prospective study on humans. Clin. Oral Impl. Res. 2007;18:432–440
ADVANTAGES • Avoids donor site morbidity and surgical risks associated with autogenous bone graft harvest. • Simultaneous distraction of bone and soft tissues decreases or eliminates the need for soft tissue grafting in contrast to other bone augmentation techniques. • The distraction device is maintained and activated by patients themselves at home. DISADVANTAGES • Additional cost of the device • Patient compliance • Difficulty in controlling the vector of distraction
ALVEOLAR DISTRACTION OSTEOGENESIS DEVICES EXTRAOSSEOUS DISTRACTORS Synthes®, distractor track; KLS/Martin®, Tuttlingen, Germany Used in severe alveolar defects Can provide both vertical and horizontal vectors depending on the placement technique Not a great amount of horizontal augmentation achieved Easier to place, as the plates are flexible to be adapted over the remaining bone. The plates can be contoured to control the vector of distraction. The distraction rod of the device extends through the mucosa into the oral cavity INTRAOSSEOUS DISTRACTORS LEAD® System, Leibinger, Kalamazoo, MI; DIS-SIS distraction implant; SIS Systems Trade GmbH, Klagenfurt, Austria Work best in smaller segments The threaded rod is rotated to obtain distraction
COMPLICATIONS The complication rates have been reported to be anywhere between 30% and 100% but the majority of them are reported to be minor. 1. Thinning of the transport segment or the basal bone and excessive force during osteotomy make the transport segment or the mandible more vulnerable to fracture. If small fractured fragment of the transport segment  discarded and treatment continued as planned. If it is significantly large  reduced and stabilized along with abortion of the planned procedure. This complication can be prevented by meticulous case selection with an adequate amount of available bone and appropriate execution of the osteotomy. Avoiding sharp angles in the osteotomy is reported to reduce the incidence of fractures 2. Excessive length of the threaded rod of the distractor can cause occlusal interference, discomfort to the patient, and limit distraction. This can be prevented by appropriate selection or modification of the length of the threaded rod by fitting and/or trimming with application on mounted dental models. 3. Damage to adjacent soft and hard tissue structures occurs usually due to an improper technique or use of excessive force during osteotomy. Using an osteotome for completion of the lingual part of the osteotomy or using a piezoelectric saw blade may help reduce this complication. 4. Dehiscence or perforation of the mucosa by the transport segment/distractor is secondary to poor soft tissue coverage over the osteotomy and sharp edges of bone or excessive tension at closure over the distractor. Reducing the rate of distraction and reduction of the sharp bony edges may be required. Reference: Chin M, Toth BA: Distraction osteogenesis in maxillofacial surgery: using internal devices. J Oral Maxillofac Surg 1996;54:45–53.
1. SANDWICH TECHNIQUE 2. SHELL TECHNIQUE 3. SWINGING INTERPOSITIONAL GRAFT FOR VERTICAL AND HORIZONTAL AUGMENTATION 4. INTERPOSITIONAL GRAFT FOR VERTICAL AUGMENTATION IN THE MAXILLA (LE FORT I LEVEL) 5. TRANSOSSEOUS ANCHOR SUTURE TECHNIQUE 6. KHOURY’S PROTOCOL 7. FENCE TECHNIQUE 8. BOX TECHNIQUE 9. INTERPOSITIONAL GRAFTING 10. FUTURE DEVELOPMEMTS
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.
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Ridge augmentation

  • 1.
    RIDGE AUGMENTATION DR. RINISHASINHA MDS III DEPARTMENT OF PERIODONTOLOGY
  • 2.
    TABLE OF CONTENTS INTRODUCTION 01 HISTORY 02 OBJECTIVES 03 RIDGE SPLITTING 0506 AUTOGENOUS BONE BLOCKS RIDGE PRESERVATION 04 TI MESH WITH RHBMP2 07 DISTRACTION OSTEOGENESIS 08 REFERENCES 09
  • 3.
    INTRODUCTION Teeth loss Continuous resorption Diminished volume and strength of residual bone Impaired masticatory function Loss of facial vertical dimension Speech difficulty Facial soft tissue changes Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
  • 4.
    SUCCESSFUL IMPLANT THERAPYdepends upon “ADEQUATE VOLUME OF BONE” To increase the rate of bone formation and to augment bone volume: Osteoinduction Appropriate growth factors Osteoconduction A grafting material serving as a scaffold for new bone growth Distraction osteogenesis A fracture is surgically induced and the two fragments are then slowly pulled apart Guided Tissue Regeneration Allows spaces maintained by barrier membranes to be filled with new bone 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
  • 5.
    The use ofautogenous bone grafts with osseointegrated implants was originally discussed by Brånemark et al, who used the iliac crest as a donor site. This early Swedish study looked at completely edentulous cases and proposed the autogenous retransplantation of bone from the iliac crest to add bulk to thin cortex bone. Naturally a learning curve was expressed whereby the authors attempted to simultaneously graft and place implants. However, this resulted in low implant survival. HISTORY Reference: Breine U, Brånemark PI. Reconstruction of alveolar jaw bone. An experimental and clinical study of immediate and preformed autologous bone grafts in combination with osseointegrated implants. Scand J Plast Reconstr Surg 1980;14:23–48. Brånemark PI, Lindström J, Hallén O, Breine U, Jeppson PH, Öhman A. Reconstruction of the defective mandible. Scand J Plast Reconstr Surg 1975;9:116–128.
  • 6.
    Alveolar ridge augmentationhas been one of the most widely performed surgical procedures over the past three decades. These include Ridge preservation Ridge splitting/expansion Horizontal bone augmentation Ridge augmentation with block grafts and with the use of particulate grafts with or without barrier membranes Vertical bone augmentation Guided bone regeneration Onlay bone grafting Distraction osteogenesis Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
  • 7.
    OBJECTIVES OF RIDGEAUGMENTATION Function Esthetics Prognosis Straight forward surgical technique Minimal burden for the patient Low morbidity Reduced surgical sessions Low cost, High predictability Lesser healing time Reference: Cordaro, L., H. Terheyden, D. Wismeijer, Stephen T. Chen, and Daniel Buser. ITI Treatment Guide. A Staged Approach Vol. 7, Vol. 7. Berlin: Quintessence Publishing Co. Ltd, 2014
  • 8.
    BONE DEFECT CLASSIFICATION In1983, Seibert (1983a, 1983b) classified the different types of alveolar ridge defects that a clinician may encounter. Class I Alveolar ridge defects have a horizontal loss of tissue with normal ridge height. Class II Alveolar ridge defects have a vertical loss of tissue with normal ridge width. Class III Alveolar ridge defects have a combination of class I and class II resulting in loss of normal height and width.
  • 9.
    INDICATION When theloss of gingiva or bone compromises the positive outcome of a prosthetic restoration. Easiest to treat : Class I > Class II > Class III Prognosis: Horizontal > Vertical or Combination
  • 10.
    The Cologne Classificationof Alveolar Ridge Defects (CCARD) classifies volume deficiencies of the alveolar process regardless of their etiology as vertical (V), horizontal (H), or combined (C), possibly in conjunction with a sinus area defect (+S) BONE GRAFT CLASSIFICATION
  • 11.
    CCARD CRITERIA • Ingeneral, intrabony defects are more easily grafted and result in more predictable outcomes than extrabony defects. • It is easier to stabilize/immobilize and protect an intrabony grafted defect. • In addition, soft tissue coverage and inherent generative capacity is optimized with these defects. • Other considerations during bone grafting include the osteogenic potential of the recipient site. Reference: Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8–17
  • 12.
    RIDGE PRESERVATION Overview ofthe extraction site after 1, 2, 4, and 8 weeks of healing Reference: Araújo and Lindhe; 2005 • Ridge preservation is typically described as a socket or sinus augmentation using nonviable grafts (ie, allografts, allogeneic bone, and xenogeneic bone). The dimensional changes that occur following tooth extraction remain inevitable even if biomaterials are utilized.
  • 13.
    Healing process followingtooth extraction Reference: Avila-Ortiz and Zadeh; 2019
  • 14.
    MATRIX VITRONECTIN FIBRIN & FIBRONECTIN BIOLOGIC PERSPECTIVEOF AUGMENTATION CELL ADHESION MOLECULES SIGNALING MOLECULES
  • 15.
    CONVENTIONAL SOCKET GRAFTINGAND RIDGE PRESERVATION TECHNIQUES 1. Minimally Traumatic Tooth Extraction USING PERIOTOME, ROTARY BURS AND EXTRACTION FORCEPS
  • 16.
    2.2. After toothremoval, the alveolar socket is debrided of all granulation tissue. 3.3. Bleeding is stimulated from the osseous walls through the use of rotary instruments or curettes. To trigger the regional acceleratory phenomenon, which stimulates new bone formation and graft incorporation. Reference: Frost HM; 1989 2.4. The extraction socket should be evaluated visually and tactilely with the help of a periodontal probe. Evaluation done with special attention to direct visualization of the labial plate’s integrity and thisckness; identifying fenestration and dehiscence defects.
  • 17.
    SINGLE-TOOTH ALVEOLAR RIDGE PRESERVATION INTHE NON-ESTHETIC ZONE • A HIGH-DENSITY PTFE (DPTFE) MEMBRANE (CYTOPLAST, OSTEOGENICS) • FDBA (MINEROSS) 1ST SCENARIO
  • 18.
    LEUKOCYTE PLATELET-RICH FIBRIN(L-PRF) AS A BARRIER MEMBRANE AS OPPOSED TO USING DPTFE 2ND SCENARIO Reference: Miron RJ, Zucchelli G, Pikos MA, et al; 2017
  • 19.
    SINGLE-TOOTH ALVEOLAR RIDGEPRESERVATION IN THE ESTHETIC ZONE F I V E D I A G N O S T I C K E Y S F I V E D I A G N O S T I C K E Y S Reference: Kois JC; 2001 Management guidelines for evaluating tissue degradation Management guidelines for evaluating tissue degradation
  • 20.
    ALLOGRAFT; FREE GINGIVALGRAFT AND DPTFE MEMBRANE 1ST SCENARIO
  • 21.
    Two key parametersare noted: 1. To date, there are currently no available options to completely prevent dimensional changes following tooth extraction. Resorption of bundle bone will occur regardless of the alveolar ridge preservation technique utilized. 2. There is no ideal or favored method to preserve dimensional changes of the alveolar ridge, including using GBR techniques, socket fillers, socket seals, or combinations of these Reference: • Morjaria KR, Wilson R, Palmer RM. Bone healing after tooth extraction with or without an intervention: A systematic review of randomized controlled trials. Clin Implant Dent Relat Res 2014;16:1. • Lekovic V, Kenney EB, Weinlaender M, et al. A bone regenerative approach to alveolar ridge maintenance following tooth extraction. Report of 10 cases. J Periodontol 1997;68:563–570. • MacBeth N, Trullenque-Eriksson A, Donos N, Mardas N. Hard and soft tissue changes following alveolar ridge preservation: A systematic review. Clin Oral Implants Res 2017;28:982–100
  • 22.
    SYNONYMS: Socket ShieldTechnique; Partial Extraction Therapy; Root Submergence Technique ALTHOUGH SOCKET PRESERVATION METHODS HAVE BEEN SHOWN TO LIMIT DIMENSIONAL CHANGES POST- EXTRACTION AND REDUCE THE UNPLEASANT ESTHETIC EFFECTS OF PHYSIOLOGIC BONE RESORPTION IN THE ESTHETIC ZONE, NONE COMPLETELY PREVENT RESORPTION. ROOT MEMBRANE TECHNIQUE Reference: Chappuis V, Araujo J et al; 2017 For preserving the buccal bone with up to 10 - year follow-up is the in-situ maintenance of the buccal portion of the root in a procedure. Hypothesis: By maintaining the buccal aspect of the root and its associated periodontal ligament (and hence the associated blood vessels), one may be capable of preventing the physiologic bone resorption of the buccal bone. Reference: Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The socket-shield technique: A proof-of-principle report. J Clin Periodontol 2010;37:855–862.
  • 23.
    Based on current evidence,there is significant merit for future research attempts to investigate in a controlled fashion whether the benefit from the use of this technique can establish it as the gold standard for immediate implant placement in the esthetic zone.
  • 24.
    RIDGE SPLITTING Hilt Tatumis given credit for working with ridge expansion protocols in the 1970s. • The protocol at the time included tapered channel formers, D-shaped osteotomes, and custom implants. Reference: Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am 1986;30:207–229. Indications for ridge expansion Narrow alveolar ridge (minimum 2+ mm, marrow component) Primarily maxillary sites greater than one tooth If in the mandible, only posterior distal-extension edentulous sites with a marrow component Adequate alveolar bone height (approximately 10 mm minimum) Contraindications for ridge expansion Inadequate alveolar bone height Concavities or undercuts of ridge Fused cortices (no marrow) Less than 2-mm ridge width Single-tooth sites
  • 25.
    Key points • Ridgeexpansion and simultaneous implant placement in the maxilla typically result in an exaggerated facial implant inclination because the implant osteotome follows the denser palatal bone. • Factors to consider include interocclusal space and biomechanical force factors (especially parafunction). • The advantages of the ridge splitting technique include faster healing. • The treating clinician must always weigh the pros and cons because ridge split failure can also occur and result in catastrophic bone loss. • This technique is more suitable for the maxillary arch because of its more cancellous nature (ie, lower bone density). Reference: Lustmann J, Lewinstein I. 1995
  • 26.
    RIDGE SPLIT TECHNIQUE USINGA PIEZOSURGERY DEVICE
  • 27.
  • 28.
    MANDIBULAR RIDGE SPLITTECHNIQUE USING PIEZOSURGERY AND OSTEOTOMES
  • 29.
    1. Incision design/flap management 2.Site preparation - angiogenesis 3. Space maintenance 4. Graft stability 5. Tension-free primary closure Reference: Wang HL, Boyapati L. “PASS” principles for predictable bone regeneration. Implant Dent 2006;15:8–17 Keys for Predictable Bone Augmentation
  • 30.
  • 31.
  • 32.
  • 34.
    AUTOGENOUS BONE BLOCKGRAFTING • INCISIONS AT THE DONOR SITE • INCISIONS AT THE RECEIPIENT SITE
  • 35.
    INDICATIONS, ADVANTAGES, ANDDISADVANTAGES FOR EACH INCISION METHOD
  • 36.
    Several possible originsfor autogenic bone include the calvarium, tibia, and the iliac crest. Reference: Harsha BC, Turvey TA, Powers SK. 1986. Reference: Breine U, Bränemark PI. 1980. Reference: • Keller EE, van Roekel NB, Desjardins RP, Tolman DE. 1987. • Listrom RD, Symington JM. 1988. • Schwartz-Arad D, Dori S. 2002. • Although the iliac crest is most often used in major jaw reconstruction, it is not always recommended due to its morbidity, altered ambulation, and the need for hospitalization. • There is also significant resorption associated with cortico-cancellous block grafts from endochondral donor sites. • These disadvantages, together with the fact that dental implants do not demand large amounts of bone, led to the growing use of intraoral block bone grafts from intraoral sources, especially from the mandibular symphysis and ramus. Reference: Misch CM; 1996, 1997. Reference: • Misch CM; 1992, 1995, 1997. • Kleinman A et al. 2002
  • 37.
    ADVANTAGES OF INTRAORALBONE GRAFT SOURCES Conventional surgical access and the proximity of donor and recipient sites Reduce operative and anesthesia time Making it ideal for outpatient implant surgery • There is no cutaneous scar • Patients report minimal discomfort and less morbidity compared with extraoral locations
  • 38.
    SYMPHYSIS HARVESTING • THREEPRIMARY INCISION DESIGNS CAN BE USED FOR HARVESTING BLOCK BONE FROM THE SYMPHYSIS: SULCULAR, MARGINAL, AND ALVEOLAR MUCOSAL. • SULCULAR INCISION PREFERRED MORE OVER CONVENTIONAL VESTIBULAR APPROACH. • FOLLOWED BY AN OBLIQUE SURFACE RELEASING INCISION. • FULL THICKNESS MUCOPERIOSTEAL FLAP Reference: Linkow LI. Bone transplants using the symphysis, the iliac crest and synthetic bone materials. J Oral Implantol 1983;11:211-247. THE 5-MM RULE
  • 39.
    SULCULAR V/S VESTIBULARAPPROACH SULCULAR • EASIER ACCESS • BETTER VISUALISATION OF THE MENTAL NEUROVASCULAR BUNDLES • EASIER SUPERIOR AND INFERIOR RETRACTION OF THE FLAP MARGINS • NO WOUND DEHISCENCE NOTED • POSTOPERATIVE PAIN IS REDUCED, AND NO ASSOCIATED PTOSIS VESTIBULAR • LIMITED ACCESS • INCOMPLETE VISUALIZATION OF THE MENTAL NEUROVASCULAR BUNDLES • MORE DIFFICULTY IN SUPERIOR AND INFERIOR RETRACTION OF THE FLAP MARGINS • BLEEDING IS SECONDARY TO THE MENTALIS MUSCLE INCISION AND RESULTS IN THE NEED FOR HEMOSTASIS • CAN RESULT IN WOUND DEHISCENCE AND SCAR BAND FORMATION
  • 40.
    • ONE OFTHE MOST FREQUENTLY USED SITES FOR INTRAORAL HARVESTING OF AUTOGENOUS BLOCK GRAFTS. • FULL-THICKNESS MUCOPERIOSTEAL INCISION • OBLIQUE RELEASING INCISION • FULL-THICKNESS MUCOPERIOSTEAL FLAP • “THREE COMPLETE OSTEOTOMIES AND ONE BONE GROOVE” RAMUS BUCCAL SHELF BLOCK GRAFT HARVESTING
  • 41.
    1. USING ROTARYFISSURE BURS 2. USING PIEZOSURGERY DEVICE
  • 42.
    RAMUS BUCCAL SHELFBLOCK GRAFT TECHNIQUE
  • 43.
    TIMING FROM BLOCKGRAFTING TO IMPLANT PLACEMENT HORIZONTAL AUGMENTATION VERTICAL AUGMENTATION MAXILLA 4 MONTHS 5 MONTHS MANDIBLE 5 MONTHS 5 MONTHS ADVANTAGES AND DISADVANTAGES OF AUTOGENOUS BONE GRAFTING Native bone qualities Increased surgical time Optimal bone volume and density Minimal donor bone Volume Predictable volume enhancement More surgical training required Increased patient acceptance Donor site morbidity Lower cost
  • 44.
    TITANIUM MESH PARTICULATEGRAFT WITH RHBMP-2
  • 45.
    ADVANTAGES OF COLLAGENMEMBRANES AND TITANIUM-REINFORCED MEMBRANES AND MESH COLLAGEN MEMBRANES • LACK OF NEED FOR STAGE-TWO SURGERY • PHYSIOLOGICALLY FAVORABLE PROPERTIES • IMPROVES HEMOSTATIC FUNCTION BY PLATELET AGGREGATION, WHICH FACILITATES EARLY CLOT FORMATION AND WOUND STABILIZATION • CHEMOTACTIC FUNCTION FOR FIBROBLASTS THAT ASSISTS IN CELL MIGRATION TO PROMOTE PRIMARY WOUND CLOSURE • EFFECTIVE IN INHIBITING EPITHELIAL MIGRATION AND PROMOTING NEW CONNECTIVE TISSUE ATTACHMENT TITANIUM-REINFORCED MEMBRANES AND MESHES • FATIGUE STRENGTH IS NOT AN ISSUE; IT CAN BE USED AT A THICKNESS OF 0.2 MM WITH VERY LITTLE POSSIBILITY OF FRACTURE • HIGH TENSILE STRENGTH ALLOWS IT TO ADAPT NICELY AND BE PHYSIOLOGIC WITH BONE • THICKNESS RANGES FROM 0.1 TO 0.6 MM • HIGH DUCTILITY AND STRENGTH
  • 46.
    STEP-BY-STEP GUIDE TOALVEOLAR BONE AUGMENTATION WITH TITANIUM MESH (MEGAGEN; I-GEN)
  • 47.
    • Distraction osteogenesis(DO) was first described by CODIVILLA in1905 and later popularized via the extensive research performed by ILIZAROV in orthopedic literature in 1989. DISTRACTION OSTEOGENESIS Reference: • Codivilla A: On the means of lengthening in the lower limbs, the muscles and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353–369. • Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft tissue preservation. Clin Orthop 1989;238:249–281. • Ilizarov GA: The tension stress effect on the genesis and growth of tissues. Part II. The influence of the rate and frequency of distraction. Clin Orthop 1989;239:263– 285. • Craniofacial DO was first done by SNYDER in 1973 in a canine model and later reported in humans by GUERRERO (1990), MCCARTHY ET AL. (1992), KABANET AL. (1993). Reference: • Snyder CC, Levine GA, Swanson HM, Browne EZ Jr: Mandibular lengthening by gradual distraction. Preliminary report. Plast Reconstr Surg 1973;51:506–508. • Guerrero CA: Expansion rapida mandibular. Rev Venez Ortod 1990;12:48. • McCarthy JG, Schreiber J, Karp N, Thorne CH, Grayson BH: Lengthening the human mandible by gradual distraction. Plast Reconstr Surg 1992;89:1–8. • Perrott DH, Berger R, Vargervik K, Kaban LB: Use of a skeletal distraction device to widen the mandible: a case report. J Oral Maxillofac Surg 1993;51(4):e435–439. • Alveolar distraction was initially reported via animal studies conducted by BLOCK ET AL. and later described via a clinical report by CHIN ET AL. in 1996. Reference: • Troulis MJ, Glowacki J, Perrott DH, et al: Effects of latency and rate on bone formation in a porcine mandibular distraction model. J Oral Maxillofac Surg • 2000;58:507. • Kaban LB, Thurmüller P, Troulis MJ, et al: Correlation of biomechanical stiffness with plain radiographic and ultrasound data in an experimental mandibular distraction wound. Int J Oral Maxillofac Surg 2003;32:296.
  • 48.
    Alveolar augmentation forplacement of dental implants In treating moderate to severe maxillary and mandibular alveolar ridge atrophy, mostly in the anterior region. For correcting vertical alveolar ridge defects but can be used for increasing the width as well Some degree simultaneous correction of an alveolar bone horizontally due to often observed pyramidally shaped morphology of the alveolar bone “To increase soft tissue as well as bone” In cases where the bone loss is so severe that the device cannot be placed If the transport segment is not at least 5 mm in size. Patients unable to follow the distractor activation protocol INDICATIONS CONTRAINDICATIONS Reference: • Zimmermann CE, Thurmüller P, Troulis MJ, et al: Histology of the porcine mandibular distraction wound. Int J Oral Maxillofac Surg 2005;34:411.
  • 49.
    • Jensen andblock presented an alveolar site classification system that could be applied in making treatment decisions: • Class I – mild alveolar deficiency with up to 5 mm of vertical bone loss; • Class II – moderate deficiency with 6–10 mm of vertical bone loss; • Class III – severe deficiency with greater than 10 mm of vertical bone loss; • Class IV – severe bone loss at the edentulous alveolar ridge as well as significant bone loss on adjacent teeth  Class I defects : smaller; hence, treated with traditional sandwich osteotomy or with conventional bone grafting techniques.  Class II defects : more amenable to be reconstructed with Alveolar Distraction Osteogenesis.  Treatment of Class III defects depends on the availability of bone stock in the defect.  If there is enough bone, distraction can be performed but may have to be supplemented by bone grafts later or else will need bone grafting first with secondary Alveolar Distraction Osteogenesis.  Class IV defects : complicated by adjacent teeth that have a poor prognosis. These teeth can be extracted to convert the defect into a Class III type defect and continue treatment as above. Reference: Chiapasco M, Zaniboni M, Rimondini L: Autogenous onlay bone grafts vs. alveolar distraction osteogenesis for the correction of vertically deficient edentulous ridges: a 2–4-year prospective study on humans. Clin. Oral Impl. Res. 2007;18:432–440
  • 50.
    ADVANTAGES • Avoids donorsite morbidity and surgical risks associated with autogenous bone graft harvest. • Simultaneous distraction of bone and soft tissues decreases or eliminates the need for soft tissue grafting in contrast to other bone augmentation techniques. • The distraction device is maintained and activated by patients themselves at home. DISADVANTAGES • Additional cost of the device • Patient compliance • Difficulty in controlling the vector of distraction
  • 51.
    ALVEOLAR DISTRACTION OSTEOGENESISDEVICES EXTRAOSSEOUS DISTRACTORS Synthes®, distractor track; KLS/Martin®, Tuttlingen, Germany Used in severe alveolar defects Can provide both vertical and horizontal vectors depending on the placement technique Not a great amount of horizontal augmentation achieved Easier to place, as the plates are flexible to be adapted over the remaining bone. The plates can be contoured to control the vector of distraction. The distraction rod of the device extends through the mucosa into the oral cavity INTRAOSSEOUS DISTRACTORS LEAD® System, Leibinger, Kalamazoo, MI; DIS-SIS distraction implant; SIS Systems Trade GmbH, Klagenfurt, Austria Work best in smaller segments The threaded rod is rotated to obtain distraction
  • 53.
    COMPLICATIONS The complication rates havebeen reported to be anywhere between 30% and 100% but the majority of them are reported to be minor. 1. Thinning of the transport segment or the basal bone and excessive force during osteotomy make the transport segment or the mandible more vulnerable to fracture. If small fractured fragment of the transport segment  discarded and treatment continued as planned. If it is significantly large  reduced and stabilized along with abortion of the planned procedure. This complication can be prevented by meticulous case selection with an adequate amount of available bone and appropriate execution of the osteotomy. Avoiding sharp angles in the osteotomy is reported to reduce the incidence of fractures 2. Excessive length of the threaded rod of the distractor can cause occlusal interference, discomfort to the patient, and limit distraction. This can be prevented by appropriate selection or modification of the length of the threaded rod by fitting and/or trimming with application on mounted dental models. 3. Damage to adjacent soft and hard tissue structures occurs usually due to an improper technique or use of excessive force during osteotomy. Using an osteotome for completion of the lingual part of the osteotomy or using a piezoelectric saw blade may help reduce this complication. 4. Dehiscence or perforation of the mucosa by the transport segment/distractor is secondary to poor soft tissue coverage over the osteotomy and sharp edges of bone or excessive tension at closure over the distractor. Reducing the rate of distraction and reduction of the sharp bony edges may be required. Reference: Chin M, Toth BA: Distraction osteogenesis in maxillofacial surgery: using internal devices. J Oral Maxillofac Surg 1996;54:45–53.
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    1. SANDWICH TECHNIQUE 2.SHELL TECHNIQUE 3. SWINGING INTERPOSITIONAL GRAFT FOR VERTICAL AND HORIZONTAL AUGMENTATION 4. INTERPOSITIONAL GRAFT FOR VERTICAL AUGMENTATION IN THE MAXILLA (LE FORT I LEVEL) 5. TRANSOSSEOUS ANCHOR SUTURE TECHNIQUE 6. KHOURY’S PROTOCOL 7. FENCE TECHNIQUE 8. BOX TECHNIQUE 9. INTERPOSITIONAL GRAFTING 10. FUTURE DEVELOPMEMTS
  • 55.
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