This presentation reviews common functional and esthetic problems associated with extraction of teeth and current methods and surgical techniques to minimize loss of bone and soft tissue

1. Advanced Bone Preservation and
Regeneration
Scott K. Smith, D.D.S.
September 21,2013
A HiOssen Course

2. Dr. Scott K. Smith
1986 Pennsylvania State University B.S. Biochemistry
1990 University of Maryland D.D.S.
1992 University of Maryland Certificate in Periodontics

3. Experience
• 20 years of Regeneration experience
• Lectured for Collagenex for 5 years
• Lectured for BioHorizon on Regenerative
Materials and Implant Surgery
• Lectured for Astra Tech
• Guest on the Wellness Hour

8. Today’s Goals
• Anatomy of Bone and related Structures
• Biology of Healing
• Consequences of extractions, trauma and
disease on Anatomical Structures
• Methods Materials and Techniques for
Regeneration
• Treatment Planning Skills
• K.I.S.S.

9. Mandibular and
Maxillary Bone
• Composed of Compact and Cancellous
• Alveolar bone is specialized bone that
supports teeth via ligamentous insertions.
• 67% Inorganic ad 33% Organic
• Cell Types: Osteoblasts, Osteoclasts,
Osteocyte

10. Alveolar Bone

11. Alveolar Bone
Need Teeth to have Alveolar Bone

12. Edentulous Bone

13. Misch Bone Density

14. Factors for Bone Formation
Bone
Cells
Signals
Matrix

15. Signals
• BMP (Bone Morphogenic Proteins)
• TGF-B (Transforming growth factor)
• PDGF (Platelet Derived Growth Factor)
• Insulin-like growth factor
• Epidermal and Fibroblast Growth Factor
• Tumor Necrosis Growth Factor

16. BMP (Bone Morphogenetic Protein)
1. What is BMP
: Protein extractors from bone could induce
the local formation of new cartilage and bone
when implanted at non-bony site(Dr. Urist)
Ectopic bone formation
: He called that protein extract BMP
(bone morphogenic protein)
: Group of growth factors also known as cytokines

17. PDGF and TGF-B
• PDGF - Mitogenesis of Mesenchymal Stem
cells and endothelial cells
• TGF-B - Chemotaxis of Osteoblast
precursors, bone matrix formation by
osteoblasts

18. Osteoblast
Osteoclast
Organic matrix
Osteocyte
Inorganic matrix

19. Osteoblast Cell
• Derived from Mesenchymal stem cells
• Responsible for Bone Matrix synthesis and
mineralization

20. Osteocyte Cells
• Osteoblasts that become incorporated
within newly formed osteoid
• Osteocytes maintain contact with
Osteoblasts on surface of bone via
canaliculi.

21. Osteoclast Cell
• Responsible for osteoid dissolution
• Large multinucleated cells similar to
macrophages

22. Source of Bone Cells
• Mesenchymal stem cells
– Source of chondrocyte
– Source of osteoblast and osteocyte
– Source of cells in the periosteum and perichondrium
• Hematopoietic stem cells

23. Source of Bone Cells

25. Matrix
• Ground Substance in newly developing
bone
• Cartilage to Bone
• Graft Materials

26. Bone Graft Materials
–
• Autogenous material Particulated marrow and cancellous bone(PMCB)
– Block bone
–
• Allogenic material Demineralized freeze-dried bone allograft(DFDBA
– Freeze-dried bone allograft(FDBA)
– Solvent dehydrated with gamma irradiated bone(ICB)
–
• Xenogenic material Non-organic bovine bone(Bio-oss)
– Bovine bone powder(BBP)
• Alloplastic material Hydroxyapatite(Calcitite, Osteogen)
–
–
–
–
–
–
Beta tricalcium phosphate(Cerasorb)
Bioactive glass ceramics(Biogran, Perioglass)
Calcium carbonate(Biocoral)
Polymer(Bioplant HTR polymer)
BCP: Biphasic Calcium Phosphate(Bone ceramic, MBCP)

27. Matrix
> Graft and Healing

28. Concept of GBR
SIGNALING
MOLECULE
(PDGF, BMP)
TIME
APPROPRIATE
ENVIRONMENT
CELLS
(Osteoblasts)
SCAFFOLDS
(Bone Graft Material)
REGENERATIO
N OF BONE

29. Extraction Consequences

30. Consequences of
Extraction
• Loss of Functional Support
• Interference with Phonetics
• Compromised Esthetics
• Plaque and Food Accumulation

32. Socket Healing
•
Blood clot forms with Coagulation of Red and
White Blood Cells
•
Replacement of Clot with Granulation tissue 4-5
days
•
Replacement of Granulation tissue by Connective
Tissue 14-16 day process
•
Apical and lateral walls mineralize 10 weeks and
complete fill in 15 weeks
•
Epithelialization of the socket occurs 24-35 days
later

33. Factors that Affect
Resorption
Thin Buccal Bone
Gingival BioType

34. Loss of Bundle Bone
Without Grafting

35. Modifying Factors
• Endodontic Infection
• Periodontal Infection, Recession
• Trauma
• Teeth Relationship - Malposition
• Risk Factors - Diabetes, Smoking, “PPP”

36. Bone Healing and Soft
Tissue Changes
•2/3 rds of the hard and soft tissue changes occur
in the first 3 months.
•50% of crestal width to be lost in a 12-month
period
•2/3 of which (3.8 mm; 30%) occurred in first
twelve weeks
Schropp, et.al

37. Percent of Volume Loss
• Horizontal Loss - 22-63%
• Vertical Loss - 11-22%
Wong
Clin Oral Impl Res:14;2012

40. Vertical Loss

41. Six Month Radiographic
Metanalysis Study
• Average Width Loss 3.87mm
• Average Height Loss 1.67mm
Van Der Weijden
clin oral impl res: 22; 2011

43. What’s Alternative?
Guided Bone Regeneration

44. Guided Bone
Regeneration
• Regeneration of bone through space
maintaining, osteoconductive, inductive and
biologics to encourage osteoblasts to reestablish dominate tissue at the exclusion
of connective tissue.

45. Guided Bone
Regeneration

46. Principles of Guided
Regeneration
• Sterile Enviornment
• Tissue Exclusion
• Graft Containment
• Stable Clot

47. Mechanism of Bone Formation
• Osteogenesis
• OsteoInduction
• OsteoConduction

48. OsteoGenesis
• Bone formation by living or autogenous
osteoblasts
• Formation of bone even without
Mesenchymal Cells

49. OsteoInduction
• Process of Stimulating Osteogenesis
• Transformation of Undifferentiated
Mesenchymal cells into Osteoblasts
• Ability of Graft material to induce
Osteogenesis and bone
• BMP instrumental in this process

50. Bowers et al - New
Attachment
Concept of Regeneration
Originated with DFDBA
developing bone under
skin of Rabbits

51. OsteoConduction
• New bone by “creeping substitution”
• Bone graft material is scaffold to promote
and allow vessel in growth
• Bone formation by margin of host bone

52. Bone Defects
• Closed - contained - Extraction socket
• One Wall - Dehiscence, Fenestration
• Multiple Wall Defects - Horizontal Defect
• Vertical Defect

53. Socket Preservation
Studies:
• Bone Augmentation Will Reduce Bone
Dimensional Changes - Depending on
Technique and Material
Van der Weijden, 2010

54. Socket Preservation
Studies:
• Osteoconductive Materials Do NOT
accelerate bone healing, BUT ALLOWS for
better preservation of Ridge Volume
Pagni, 2012

55. Socket Preservation
Studies:
• Nonabsorbable ePTFE membranes showed
no Volume change of Alveolar Ridge after
Six Months Vs. Significant Changes in
Control
Lekovic, 1997

56. Socket Preservation
Studies:
• Resorbable Collagen Membranes covering
Extraction sites revealed Adequate Bone
Formation for Implant placement at 12
weeks.
Iasella

57. Socket Preservation Healing
•
Iasella - FDBA with Collagen membranes
nonmolar areas - 15% more bone but still loss of
coronal buccal bone
•
Lekovic -Resorbable membrane vs. Nothing - Less
buccal bone resorption 0.38 vs 4.5mm. Vertical
height loss comparable
•
Araujo Lindhe - Is graft material Necessary? Found
althought FDBA did not prevent remodeling increased bone density

58. Graft Materials:
• OsteoConductive Material - Scaffold
Xenograft - BioOss
Alloplast - Calcium Sulfate, Biogran, BTCP
•
OsteoInductive Material - Bone Stimulating
Autograft - Local site, Distant site
Allograft - FDBA Cortical or Cortical/Cancellous, DFDBA,
DBA Paste

61. Occlusive Materials
• Collagen Matrix Light - Gelfoam, Collacote
• Collagen Matrix Durable • Soft Tissue Graft - auto or allograft
• Nonabsorbable Matrix - ePTFE
• Other - Periacryl
• Titanium membrane

62. Resorbable Membranes

64. *Growth Factors
• Platlet Rich Protein (PRP)
• Emdogain (PDGF)
• Gem 21 (PRGF)
• BMP - 2 (Infuse)
• Bone Marrow Derived Stem Cells
(osteocel)

65. Bone Regeneration
• Extraction Socket
• Fenestrations and Dehiscence
• Ridge Augmentation Prior to Implant
• Implant and Ridge Augmentation

66. Five Categories of Defect
2. Fenestrations
- Class II Fenestration
(Outside Bony Envelop)

67. Five Categories of Defect
3. Dehiscences
- Class II Dehiscense
(Outside Bony Envelop)

68. Five Categories of Defect
1. Extraction wounds
Class I Extraction Sockets
Class II Extraction Sockets

69. Why Do Socket Preservation?
• Enable Implant installation and stability
• Reduce loss of Alveolar Bone Volume
• Reduce need for additional bone grafting
• Improve Esthetic and Phonetic Outcome

71. Atraumatic Extraction
• Eliminate Infection and Irritant
• Preserve Existing Bone and Soft Tissue
• Minimize Loss of Volume with
Augmentation materials

72. Atraumatic Extraction
Requirements
• PDL incision
• Periotomes
• Extraction Forceps
• Socket Degranulation
• Socket Inspection

73. Periotome

74. Extraction Morphology
• Intact Bony Socket
• Buccal Bone Loss
• Multiple Walls of Bone Loss - Ridge
Augmentation

75. Intact Buccal Plate
-Materials

76. Soft Tissue Preservation
Pontic Space Retained

77. Good Two Week PO

78. QuickTime™ and a
decompressor
are needed to see this picture.

79. Fenestration Defects

80. Buccal Concavity

82. Width of Buccal Bone
Maxillary Incisor
In the anterior sites, a vast majority of the
•
buccal bony walls (87.2%) had a width of
≤1mm,
•
•
Only 2.6% of buccal walls were 2mm wide or
greater
Proposed Criterion for Stable Buccal Bony wall
following extraction is 2mm - then MOST sites
will LOSE bone.
In most situations, guided bone regeneration may
be needed to achieve adequate bone contour
around the implant and optimal esthetic
outcome.

84. Graft Material
• Not 4 wall defect
• Reduced Blood Supply and Less MSC
• Reduced Stability and Retention
• Need to use OsteoInductive - I like FDBA
and DBA paste mix

85. FDBA/DFDBA Paste
Collagen Membrane
Collagen Membrane

87. Graft Containment
• Resorbable Membrane OK
• Trim to cover entire buccal defect and tuck
around healing abutment or under palatal
flap

88. Periosteal Releasing Incision
Coronally Position Tissue
Interrupteds

89. Socket AND Ridge
Augmentation

90. Mandibular anterior
Bone Loss

91. FDBA Graft postioned

92. alloderm Material
Sutured or Tacked to Place

95. Fantastic Bone

96. Marvelous Closure

97. Previous Extraction No Augmentation

101. Adaptation and Suture
Continuous Sling Suture

102. and 12b blades
• 15c Instrumentation
• Rounded Blade Holders
• Pritchard Periosteal Elevator
• Orban Knife
• Addison Tissue Forceps
• Castroviejo Needle Holder

103. Armamentarium

104. Post-Op Medications
•
•
•
•
•
•
Amoxicillin 50mg t.i.d. x 21 OR
Clindamycin 300mg t.i.d. x 21
Lodine 400mg t.i.d. x 21
Chlorhexidine Rinse
*Vicodin 7.5/300 q.i.d. prn x 12
*Medrol Pak

105. Post Op Follow up
• Two week Suture Removal
• Patient Resumes Normal Brushing and Diet
• Six weeks later Xray
• Implant Placement TBD after Xray

106. Complications
• Infection - Swelling, Pain after 3 days
• Flap Retraction
• Soft tissue Slough
• Excessive Bleeding post op
• Nerve Damage
• Sinus Perforation

107. Materials for Ridge
Augmentation
• OsteoInductive Graft (BMP-2, Osteocel)
• Membrane - Collagen, Teflon, Allograft,
Titanium mesh
• Tack Membrane (?)
• Suture - 4-O or 5-O Vicryl, PGA

110. Space Maintenance

112. FDBA - Cortical and
Cancelous Bone

113. Six Months Later

115. Implant Placement and Guided
Bone Regeneration
• Sufficient Bone for Stabilization
• Secure Implant torque (>35N/cm)
• Graft Containment
• Stabilize Site
• Ensure Esthetic Outcome Possible

116. Goals?

117. MidCrestal Incision
Preserve the Keratinized Tissue

118. Extraction and Evaluation

119. Buccal Bone Loss

120. DeCortication

121. FDBA

122. Suturing -
Periosteal Releasing Incision

123. Ridge Augmentation
• Flap Design
•
•
•
•
•
•
•
Incision 15c and 12b
Consider Blood Supply - Vertical Insion?
Flap Elevation
Cortical Perforation
Periosteal Releasing
Membrane Trimming and Graft Placement
Suturing - Interupted, continuous, mattress

125. QuickTime™ and a
H.264 decompressor
are needed to see this picture.

127. SMARTbuilder

128. SMARTmembrane™
Features
• Concept : 3D Pre-formed customizing titanium membrane
• Adaptation: Fixture + Height + Membrane + Cap(healing abt)
• Tool : Cover cap driver, Defect guage
Type 1
(Buccal)
Type 2
(Buccal &
Proximal)
Type 3
(Buccal,
Proximal, &
Lingual)
3D
View
Flat View
187

129. Competitors – FT Wing
Designed and developed by:
Dr. Funato & Dr Tonatsuka
Size: 11.5mm(W) x 29mm(L) x 0.2mm (T)
188

130. Competitors – CTi Membrane
Buccal or
Lingual
Buccal- Lingual Proximal
Submerged &
Non-fixed
*Has 6 different shapes and sizes: 30 different types
** Only few types are being used.
189

131. 190

132. Optimum Pore Size for Ridge
Augmentation
•
Compared Titanium Mesh with Pore size of 0.6mm
and 1.2mm to that of Resorbable Collagen mesh of
1mm size and No pore
•
Macro Mesh of 1.2 best for Total Volume of
Regeneration
•
No pore size prevents most soft tissue ingrowth
with 1.2 titanium next
•
Contaiment of Graft most important criteria

133. Journal Analysis
Courtesy by Dr. Lee DH
 Optimal Pore size ?
Specimen :
•Macro porous Ø1.2 (titanium)
•Micro porous Ø0.6 (titanium)
•Resorbable mesh Ø1.0 (poliactic aid)
•Any containment (titanium)
Each side of cube size is 10mm.
Where, tibia bone of Hound dog
1,2,4 week sacrificed
R&M Biometrics image analysis SW
FIGURE 6. Microsection revealing bone formation
with microporous mesh.
10mm
10mm
FIGURE 5. Microsection revealing bone formation
with macro porous mesh.
1-face open of cube
FIGURE 7. Microsection revealing bone formation FIGURE 8. Microsection revealing minimal bone
with resorbable mesh
formation in the site without any containment.
© 2009 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofacial Surg 67:1218-1225, 2009

134. Journal Analysis
< Result >
Courtesy by Dr. Lee DH
 Optimal Pore size ?
Mesh type
Regeneration
area(mm2)
Soft tissue
Ingrowth (mm2)
Mar rate
(Mineral apposition rate)
Macro mesh
With porous Ø1.2
66.26±13.78
16.96
1.09μm/day
Micro mesh
With porous Ø0.6
52.82±24.75
22.29
-
Resorbable mesh
With Ø1.0
46.76±21.22
23.47
2.41μm/day
Without pore
29.80±9.35
9.41
-
• Bone regeneration : Macro mesh > other comparison group
• Prevent soft tissue ingrowth : Without pore > Macro mesh > other comparison group
• Containment of bone graft is most critical parameter in success bone regeneration
• Cortical perforation did not have any effect on the quantity of bone regeneration.
Result and conclusion,
Need Bone regeneration or reconstruction and Prevent soft tissue ingrowth
therefore Mesh size : Ø1.0 ~ Ø1.2

135. Optimum Pore Size
• For optimum Bone Regeneration and
exclusion of soft tissue need Mesh size of 1.0
- 1.2mm size.
J Oral Maxillofacial Surg 67:1218-1225, 2009

136. Components
• Healing Cap or Cover
• SMARTbuilder Mesh
• Height
• Fixture

137. SMARTbuilder
•
•
3-D Customized Preformed Mesh
Side and Bottom pores smaller for
graft containment.
•
•
Main pore 1.0mm
Smooth edges (!)

138. SMARTbuilder
• Type of Defect: 1 wall, 2 wall, 3 wall
• Content Specification: Height, Healing
abutment, caps
• Assemble: Fixture + Height +Membrane +
Cap
• Requires Cover Cap Driver

139. ™
1. Check the defect and determine the type of the SMARTmembrane ™
198

140. SMARTmembrane™
Place the Height on the fixture already placed
bone grafting.
200

141. SMARTbuilder
3. Choose Height Component - If Implant submerged or want to
gain vertical height use longer one
4. Place Bone Material into defect and over fill

142. SMARTmembrane™
4. Connect the SMARTmembrane on the height through the hole in the middle.
5. Use 1.2 hex driver for healing abutment, use Cap driver for Cover cap.
6. Suture.
202

143. Indications for
SMARTbuilder
• Fenestration defects
• Dehiscence defects
• Immediate Extraction moat defects

144. SMARTmembrane™
204

145. Types of Defects
Classification of dehiscence defect
< 1 wall augmentation>
< 2 wall augmentation>
< 3 wall augmentation>

146. Dental model
< 1 wall augmentation>
< 2 wall augmentation>
< 3 wall augmentation>

147. Dental model
< 2 wall augmentation >

148. Dental model
< 3 wall augmentation >

149. Multiple Membranes

150. A
B
C
D

152. SMARTbuilder
> Case 1
A
B
C

153. SMARTbuilder
> Case 1
A
B
C

154. SMARTbuilder
> Case 2
• UJS (M/64)
• #4 Extraction d/t Crown Fx. ( 2 months ago)

155. SMARTbuilder
>
A
B
C
D

156. SMARTbuilder
> Case 2

157. SMARTbuilder
> Case 2
POD 24 weeks 2nd Stage surgery

158. SMARTbuilder
> Case 2
Before
After

159. SMARTbuilder
> Case 2

160. SMARTbuilder indication (I)
Case presentation

161. SMARTbuilder indication (I)
Extrasocket overlay augmentation with Nonsubmerged GBR
Preoperative view(#6)

162. Buccal bone envelope defect

163. Vertical augmentation
Intrasocket graft
Extrasocket overlay graft

164. Selection Height and 3D titanium mesh
2 wall augmentation

165. Maximum effect of 3D extrasocket overlay augmentation
Excellent space maintenance
PRF for surgical isolation
2 wall augmentation
Easy circular approximation
by slim healing Abutment

166. PRF for surgical isolation & meticulous circular approximation
Healing after 18ds
Never brush
Never touch
PRF
Healing after 1 month
Postop CT

167. SMARTbuilder removal technique
a. Minimal invasive sulcus incision

168. SMARTbuilder removal technique
Tissue integration
b. Pouch technique

169. Reposition of transmucosal area
4 weeks later

170. Final Prosthesis
4 ms later
1 year later

171. 6 ms 15ds postop. CT (#6)
Incredible GBR

172. 1year postop. CT (#6)
Incredible GBR

173. SMARTbuilder Guidelines
• Accurate Membrane size for Defect!
• Bone Material should have Large particle
size - 1mm or so
• Make sure Membrane Secure and Adapted
well to Bone
• No Dead Space - Fill voids with bone

174. SMARTbuilder indication (II)
Case presentation

175. Preoperative intraoral view (post ext. 4ms)
Horizontal deficiency at labial side (#12)
Implantation & Sinus lifting
Labial bone deficiency

176. Selection of 3D titanium mesh
1 wall augmentation
• Bone Graft for
labial augmentation

177. 2 months later
Good nonsubmerged healing of GBR

178. 2nd stage surgery after 4 months
Excellent tissue integration

179. Good bone regeneration
Before
After (4 ms later)
Good space maintenance at labioincisal area

180. 6 ms later postop. CT (#12)
6 ms later final prosthesis

181. 7 ms later postop. CT (#12)
Preop. view
Postop. view

182. Preoperative intraoral view
Horizontal & Vertical
bone deficiency
Palatal bone deficiency

183. Labial & Palatal & Vertical bone augmentation
3 wall augmentation type

184. 3 wall augmentation type
PRF for surgical isolation

185. PRF for surgical isolation & meticulous circular approximation
Postop CT

186. 6 weeks later
Never touch
Never brush

187. Excellent Space maintenance
Horizontal augmentation
Vertical augmentation

188. Surgical isolation by PRF
PO 1 week

189. 4 months later(GBR)

190. Limitation of SMARTbulder
1.
Fenestration wound

191. Limitations of SMARTbuilder
• Extensive Palatal Defects
• Extensive Ridge Augmentation without
implant Stabilization

192. Limitation of SMARTbuilder
1.Fenestration

193. Why SMARTbuilder?
• Excellent Mechanical properties:
• Sufficiently Rigid for space maintenance
• Elasticity - Prevents Mucosal Compression
• Stabilizes Bone graft material

194. Conclusion; Why
SMARTbuilder?
• Single implant defect
• Common clinical situation
• Low cost(vs. membrane)
• Easy to use & removal
• Predictable result

195. GBR is Predictable
• Understand Normal Anatomy, Cause of
Defect, and Anticipated Result
• Understand Healing capabilities and
Limitations
• Understand Surgical Concepts
• Utilize Optimum Techniques and Materials
• Continue to Learn and Care!

197. The End