Vertical ridge augmentation
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Vertical ridge augmentation is sometimes required for dental implant placement. The presentation looks at various conventional and newer techniques for ridge augmentation in the oral cavity.
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Vertical ridge augmentation
- 1. VERTICAL RIDGE AUGMENTATION RAKESH CHANDRAN
- 3. • Classification • Materials used • Techniques • Complications • Conclusion Presentation outline
- 5. Cologne Classification of Alveolar Ridge Defects Cologne Classification of Alveolar Ridge Defects 2013. 8th European Consensus Conference of BDIZ EDI
- 6. Three part codes to describe the effect of the alveolar ridge as comprehensively as possible with a view to existing therapeutic options: Part 1: Orientation of the defect h: horizontal V: vertical c: combined S (or +S): sinus area Part 2: Reconstruction needs associated with the defect 1. low: <4mm 2. medium: 4-8mm 3. high: >8mm Part 3: Relation of augmentation and defect region i: internal, inside the contour e: external, outside the ridge contour Cologne Classification of Alveolar Ridge Defects Cologne Classification of Alveolar Ridge Defects 2013. 8th European Consensus Conference of BDIZ EDI
- 7. Cologne Classification of Alveolar Ridge Defects Cologne Classification of Alveolar Ridge Defects 2013. 8th European Consensus Conference of BDIZ EDI
- 8. MATERIALS
- 9. Materials that can be used theoretically Autogenous Autogenous intraoral Autogenous extraoral Block and particulate Allograft Demineralised freeze dried bone Freeze dried bone allograft Block and particulate Xenograft Bovine Porcine Block and particulate Alloplast Bioactive glass Calcium phosphate Calcium sulphate Calcium carbonate Synthetic polymers Particulate HA Membranes Resorbable: Collagen Poly L lactic acid (PLLA), Poly glycolic acid (PGA), PLGA Acellular dermal matrix graft Non resorbable: Titanium ePTFE, dPTFE, textured dPTFE Biological agents PRF, PRP Growth factors BMP Combinations of the above are also used.
- 10. Nograft Allograft Alloplast Xenograft mean loss of buccolingual width at crest level (mm) 2.79 1.63 2.13 1.3 mean loss was in the buccal wall height (mm) 1.74 0.58 0.77 0.57 vital bone formation (%) 41.07 29.93 45.53 35.72 remnant graft material (%) 0 21.75 13.67 19.30 connective tissue (%) 52.53 51.03 38.39 44.42 Jambhekar et al 2015. Clinical and histologic outcomes of socket grafting after flapless tooth extraction: A systematic review of randomized controlled clinical trials. J Prosth Dent. Comparison of different grafting materials • clinical and histologic outcomes of socket grafting after flapless tooth extraction • minimum healing period of 12 weeks • systematic review of randomized controlled clinical trials • xenografts and allografts resulted in the least loss of socket dimensions • alloplasts had the maximum amount of vital bone and the least amount of remnant graft material and remnant connective tissue.
- 11. PTFE (original Goretex membrane) • synthetic polymer, non-resorbable, biologically inert, chemically non-reactive Expanded PTFE (ePTFE) • heating PTFE and then applying force to make expanded PTFE • highly porous structure - allows ingrowth of bacteria when membrane is exposed • highly porous structure - allows soft tissue ingrowth, which complicates removal Dense PTFE (high-density PTFE or dPTFE) • micro-porous (0.2 micron) material that is impervious to bacteria • designed to withstand exposure in the oral environment. • immediately coated with plasma proteins, facilitating cellular adhesion • removal of dense PTFE is simplified due to the lack of tissue ingrowth Textured dense PTFE (cytoplast) • increase in surface area and may increase the pull-out strength of the material • increased stability in the wound may result in less flap retraction and reduce risk of membrane movement and loosening PTFE is also available with titanium reinforcement. Polytetrafluoroethylene (PTFE)
- 12. Pagni G et al 2012. Bone repair cells for craniofacial regeneration. Adv Drug Deliv Rev. Cell therapy
- 13. TECHNIQUES
- 14. Conventional techniques (3 main groups) • Onlay bone block grafting • Guided bone regeneration • Distraction osteogenesis Other techniques • Khoury's protocol • Tenting screws • Orthodontic bone regeneration • Fence technique • I Gen • 3D printed bone • Box technique • Interpositional grafting Complex surgical procedures • Le Fort 1 osteotomy • Nerve transposition (technically not an augmentation) Techniques for vertical ridge augmentation
- 16. Bone blocks can be processed in a bone mill to obtain particulate grafts Tibia grafts can be performed in an outpatient setting Extraoral bone grafts Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub Site Indication Tibia 5 – 40 mL uncompressed cancellous marrow Anterior ilium 30 – 50 mL of corticocancellous marrow 1- 5 cm corticocancellous bone block Posterior ilium 40 – 120 mL uncompressed cancellous marrow 4 – 12 cm corticocancellous bone block Cranial bone corticocancellous bone block (onlay graft) for midface, orbital, zygomatic and nasal reconstructions
- 17. Bone blocks can be processed in a bone mill to obtain particulate grafts Comparison of intraoral sites Marx & Stevens 2010. Atlas of Oral and Extraoral Bone Harvesting. Quintessence Pub Stern and Barzani 2015. Autogenous Bone Harvest for Implant Reconstruction. Dent Clin N Am Carlson and Marx 1996. Mandibular Reconstruction Using Cancellous Cellular Bone Grafts. J Oral Maxillofac Surg Nkenke and Neukam 2014. Autogenous bone harvesting and grafting in advanced jaw resorption: Morbidity, resorption and implant survival. Eur J Oral Implantol Site Indication Chin 0.5 X 1.5 X 6 cm corticocancellous bone block Mandibular ramus 0.4 X 3 X 5 cm mostly cortical bone block, J graft (thin) Maxillary tuberosity 1 -3 mL cancellous marrow
- 19. • Primary wound closure • Angiogenesis • Space • Stability PASS principles for predictable bone regeneration Wang and Boyapati 2006. “PASS” principles for predictable bone regeneration. Implant Dent
- 20. Guided Bone Regeneration and Augmentation around dental implants Authors Membrane Substrate Vertical bone gain Simion et al 1994 Titanium reinforced ePTFE Just a blood clot facilitated by perforating the cortical bone 0.5 to 4mm (average: 2.97 mm) Simion et al 2001 Titanium reinforced ePTFE blood clot only, DFDBA, and autogenous bone chips >4mm only with autogenous bone chips. Simion et al 2007 Titanium reinforced ePTFE autogenous bone chips and anorganic bovine bone-derived mineral (1:1) 3.15mm (SD ±1.12 mm) Urban et al 2009 (1-6 years after loading) Titanium reinforced ePTFE autogenous bone chips 5.5mm (±2.29 mm) (Sinus augmentation included) Urban et al 2014 Titanium reinforced dPTFE autogenous bone chips and anorganic bovine bone-derived mineral (1:1) 5.45mm (SD 1.93) (Sinus augmentation included)
- 21. Guided Bone Regeneration and Augmentation around dental implants Authors Membrane Substrate Vertical bone gain Urban et al 2017 (1-15 years after loading) Titanium reinforced ePTFE, dPTFE or resorbable autogenous bone chips alone or with anorganic bovine bone- derived mineral (1:1) 5.1mm (± 1.8 mm) (Sinus augmentation included) Park et al 2017 (3 year) Collagen membrane Titanium mesh Autogenous bone block Allogenous bone block Particulated bone 5.13 (± 1.61 mm) 4.54 (± 2.48 mm) 3.90 (± 0.85 mm)
- 22. 1. Preoperative view 2. Application of a mixture (1:1) of autologous bone and Geistlich Bio-Oss®. 3. Geistlich Bio-Gide® is tightly fixed and pinned and sutured (sausage-like) 4. Primary wound closure 5. 8 months after augmentation Sausage technique-I Urban I Urban. Innovative Treatment Concepts in oral and maxillofacial surgery. Geistlich Biomaterials
- 24. • pioneered by Chin and McCarthy • the biologic process of new bone formation between the surfaces of bone segments that are gradually separated by incremental traction. • a mechanical apparatus, the distraction device, is used to provide gradual, controlled transport of a mobilized bone segment. • The prerequisites for optimal bone augmentation of defects via distraction osteogenesis are a minimum of 6 to 7 mm of bone height above vital structures, such as neurovascular bundles or air passages/sinus cavities, and a vertical ridge defect of 3 to 8 mm. • Distraction is usually performed over a period of 30 days • The advantage of this technique is distraction histogenesis of associated soft tissues, which provides sufficient keratinized tissue coverage of the increased volume of the expanded crest. The overall treatment time for alveolar distraction is 3 to 4 months, as opposed to 6 months with traditional grafting techniques. Distraction osteogenesis Maron 2012. Dental Implant Prosthetic Rehabilitation: Vertical Distraction Osteogenesis. Chapter 20.
- 25. Maron 2012. Dental Implant Prosthetic Rehabilitation: Vertical Distraction Osteogenesis. Chapter 20. Distraction osteogenesis • The basic principles include: • Latency period of 7 days for initial post-surgical soft tissue wound healing • A distraction phase during which the two pieces of bone undergo gradual incremental separation at a rate of 0.5–1 mm/day • A consolidation phase that allows bone regeneration in the created space
- 26. Laster and Jensen 2016. Distraction Osteogenesis for Height and Width of the Alveolar Crest. Chapter 21 Distraction osteogenesis
- 27. Distraction osteogenesis. Stabilization of the ridge using a unidirectional vector distractor and successful vertical ridge compensation in the anterior maxilla. Distraction osteogenesis
- 28. • Onlay block bone grafting- minor related to the morbidity from harvesting the block and graft shrinkage. • GBR- reported complication rates were 0–45.5% and complications were mainly related to membrane exposure. • distraction osteogenesis- complication rates were higher (10–75.7%), and complications included fractures of the distractor, neurologic alterations, fractures of the distracted or basal bone, and lingual or palatal inclination of the distracted bone. Complication rates Rocchietta et al 2008. Clinical outcomes of vertical bone augmentation to enable dental implant placement: a systematic review. J Clin Periodontol
- 29. Other techniques
- 30. Khoury technique- Micro-Saw® Khoury and Hanser 2015. Mandibular Bone Block Harvesting from the Retromolar Region: A 10-Year Prospective Clinical Study. Int J Oral Maxillofac Implants Gluckman and Du Toit 2015. Reconstruction of a single-tooth traumatic defect in the anterior maxilla using the Khoury bone plate graft.
- 31. 1. Intraoral view of the defect in the posterior right mandible. 2. Cortical perforations and tenting screws 3. Geistlich Bio-Oss® and autologous bone (1:1) 4. ePTFE barrier membrane secured with two fixation screws Tenting screws and particulate bone graft M Simion. Innovative Treatment Concepts in oral and maxillofacial surgery. Geistlich Biomaterials
- 32. Orthodontic bone regeneration de Molon et al 2013. Forced orthodontic eruption for augmentation of soft and hard tissue prior to implant placement
- 33. 1. Preoperative radiograph depicting the severe bony atrophy in the posterior mandible. 2. Fixation of the pre-formed osteosynthesis plate with miniscrews. 3. Autologous bone mixed with Geistlich Bio-Oss® 4. osteosynthesis plate is covered with Geistlich Bio-Gide® and the tensile collagen membrane is pinned down. Fence technique M Merli. Innovative Treatment Concepts in oral and maxillofacial surgery. Geistlich Biomaterials
- 34. I Gen. Megagen I Gen- Titanium membrane from Megagen
- 35. I Gen. Megagen I Gen- Titanium membrane from Megagen
- 36. I Gen. Megagen I Gen- Titanium membrane from Megagen
- 37. • Poly D,L-lactide acid (PDLLA) resorbable mesh plates (KLS Martin) placed bilaterally • Allograft particulate bone covered with a resorbable bovine pericardium membrane Box technique- Andrea Menoni Menoni et al 2012. Full-Arch Vertical Reconstruction of an Extremely Atrophic Mandible With “Box Technique.” A Novel Surgical Procedure: A Clinical and Histologic Case Report. Implant Dent
- 38. 5 to 7 mm of available bone above the inferior alveolar nerve An interpositional bone graft is placed after elevation of a pedicled segmental alveolar osteotomy. Four years later, bone levels appear unchanged around 2 restored osseointegrated implants. The osteotomy site is not visible. Jensen 2006. Alveolar Segmental “Sandwich” Osteotomies.... J Oral Maxillofac Surg Interpositional bone graft/ Sandwich technique
- 39. 1. Exposure of the alveolar ridge and buccal bone 2. Horizontal and vertical osteotomies of the distracted segment. 3. upward lift of the transported segment, achieving a height gain of 7 mm. 4. Geistlich Bio-Oss® Block 5. fixed with miniplates and miniscrews 6. Geistlich Bio-Gide® Interpositional grafting with xenograft block P Felice. Innovative Treatment Concepts in oral and maxillofacial surgery. Geistlich Biomaterials
- 40. Materials used to print • Titanium • PEEK • Hydroxypatiite • Calcium phosphate 3D Printed bone • CT Bone • Calcium phosphate • (Xilloc Medical Ltd) • Hyperelastic bone • hydroxyapatite and either polycaprolactone or poly(lactic-co-glycolic acid)
- 42. • vertical ridge augmentation is safe and predictable but highly technique‐sensitive • onlay bone block grafting remains the gold standard for vertical ridge augmentation. • autogenous bone particles combined with a bone substitute material and covered with a barrier membrane has been highly effective in vertical ridge augmentation • vertically augmented bone responds to implant placement like native, non- regenerated bone. Conclusion
- 43. Thank you for your attention
- 44. (a) implants can be placed in adjacent sites (b) short implants can be used (c) pink ceramic can be used to create an illusion of “normal” soft-tissue anatomy. Alternatives to vertical ridge augmentation Carranza’s Clinical Periodontology. 2015.12th Ed.