describing vertical bone augmentation

1. Company
Logo
Jun
chang
hun
@
VERTICAL RIDGE AUGMENTATION
가천의과대학교 길병원 구강악안면외과

2. Jun chang hun
Edentulism
 Once the teeth are lost, a continuous resorptive process
 Results
 Diminished volume and strength of residual bone
 Loss of facial vertical dimension
 Impaired masticatory function
 Difficulty choosing a balanced diet
 Speech difficulty
 Facial soft tissue changes
 Pathologic fracture possibility

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SITE DEVELOPMENT
 Reconstruction of deficient alveolar ridges that lacks
sufficient volume, contour, or height
 Ultimate surgical goal
 Restore function, form, and long-term stability
 Surgical approach selection
 Type, size, and shape of the defect
 Surgical expertise or experience level of surgeon
 Intended direction of the augmentation

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SITE DEVELOPMENT
 Hard tissue management
 Ridge(socket) preservation
 Ridge augmentation
 Vertical ridge augmentation
 Horizontal ridge augmentation
 Soft tissue management

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SITE DEVELOPMENT
 Hard tissue management
 Ridge(socket) preservation
 Ridge augmentation
 Vertical ridge augmentation
 Horizontal ridge augmentation
 Soft tissue management

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Defect size
 Small edentulous segments (such as single tooth)
 Particulate autogenous bone with membrane
 (Fugazzotto 1997)
 Large ridge reconstructions
 Controversial
 (Lang et al 1994, Chiapasco et al 1999)
 Autogenous block bone
 Extra-oral
 Intra-oral
 Distraction (>5mm vertical deficiency)

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TMI
 Bosker Transmandibular Implant (TMI)
 In the late 1970s
 Without the need for autologous bone graft
 Technique sensitive both surgeon & prosthodontist
 Significant “reversible complication” rate
 22.2% (Keller et al, Int JOMI 1986;1:101)
 Infection, superstructure fx, mandible fx, fail to osseointegrate

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Ridge augmentation methods
 Bone grafting
 Biomaterials
 GBR
 Alveolar distraction osteogenesis

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Distraction Osteogenesis
for vertical ridge augmentation
 History
 1992, McCarthy and coworker
 1996, Block & colleager ; dog
 1996, Chin & Toth ; DO & Implant
 Advantage
 No additional surgery involving a harvesting procedure
 No limit to lengthening
 Simultaneous lengthening of surround soft tissue
 Dis-advantage
 Long treatment period
 Need for suitable distractor
 Danger of infection
 Ilizarov (1989)
 Preservation of blood supply at the corticotomy site
 Kojimoto & coworkers (1988)
 Preservation of periosteum : distraction
 Vestibular incision rather than crestal incision

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Ridge augmentation methods
 Bone grafting
 Biomaterials
 GBR (Guided Bone Regeneration)
 Alveolar distraction osteogenesis

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Titanium membrane only
 Cornelini (2000)
 Ti-memb only, 3mm vertical ridge augmentation

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Simultaneous implant placement and vertical
ridge augmentation with a titanium-reinforced
membrane: A case report
 Vertical ridge augmentation with titanium reinforced memb.
 2nd surgery : 12 months later
 3mm hard tissue augmentation
 2mm dense connective tissue covered the newly formed bone
Cornelini R, Cangini F, Covani U, Andreana S (Int JOMI, 2000;15:883-888)

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Ridge augmentation methods
 Bone grafting
 Biomaterials
 GBR
 Alveolar distraction osteogenesis

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Autogenous bone graft
 Gold standard for bone augmentation procedures
 Block bone or particulate forms
 Block bone - reduced osteogenic activity & slow
revascularization than particulate bone marrow
 Extra-oral or Intra-oral donor-site
 Intraoral harvested intramembraneous bone graft may
have minimal resorption, enhanced revascularization,
and better incorporation at the donor site

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Autogenous bone graft
 Advantage
 Osteogenic potential
 Block grafts that maintain form and shape
 Ability to correct any size or shape deformity
 Elimination of the possibility for an immunogenic reaction
 Disadvantage
 2nd surgical intervention
 Morbidity associated with the donor site
 Unpredictable bone resorption
 Longer recovery period
 Difficulty in managing soft tissue coverage
 Increased treatment time
 Increased risks

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Autogenous block bone grafts
 Width deficiency
 Veneer or saddle graft
 Most predictable and resistant to resorption
 Vertical deficiency
 Onlay or saddle graft
 Difficult to gain and maintain, high resorption rate
 Combined deficiency

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Donor Sites of Autogenous Bone
 Cortical Bone
 Mandible, Cranium
 Cancellous Bone
 Mx. Tuberosity
 Inner Cancellous part
 Cortico-Cancellous Bone
 Iliac bone

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Intra-oral vs Extra-oral
 Kusiak et al (1985)
 Intramembranous bone grafts accelerate revascularization
and healing as compared to endochondral bone grafts
 Cortical membranous grafts revascularize more rapidly than
endochondral bone graft with a thicker cancellous part
 Zins & Whittacker (1983), Philips & Rhan (1990)
 Membranous bone (such as mandible) undergoes less
resorption than endochondral bone (such as iliac crest)
 Intraoral harvested intramembraneous bone grafts
 Minimal resorption
 Enhanced revascularization
 Better incorporation at the donor site

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Iliac bone

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Chin bone

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Ramus bone

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Ramus bone

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Chin vs Ramus
 Complication (chin vs ramus)
 Less cosmetic concern
 Less wound dehiscence
 No gingival recession
 Less sensory disturbance
 Less discomfort complain
 Trismus & edema (medication)

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Parameter Symphysis Ramus
Surgical access Good Fair to good
Cosmetic concern High Low
Graft shape Thick rectangular Thinner rectangular veneer
Graft Size >1cm3 <1cm3
Graft Morphology Corticocancellous Cortical
Graft Resorption Minimal Minimal
Healed Bone Quality Type 2>type 1 Type1>Type2
Post-OP
pain/edema
Moderate Minimal to moderate
Teeth Common(temporary) Uncommon
Nerve damage Common(temporary)
Uncommon
Incision dehiscence Occasional(Vestibular) Uncommon
Chin vs Ramus

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Maxilla vs Mandible
 Maxilla
 More vascularity
 Mandible
 Less vascularity
 Cortical bone perforation with bur

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Critical Success Factors
 Stability of grafting materials
 Condition of recipient sites
 No infections
 Resistance to resorptions
 Soft tissue coverage

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Stability of grafting materials
 Bony irregularity contouring
 Graft fixation
 Block bone : at least 2 fixation screws for immobilization

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Condition of recipient sites
 Inlay graft (3~4 wall defect)
 More favorable
 Onlay graft (1~2 wall defect)
 More prone to resorption

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Infection
 Disrupt the process and halts the growth of new bone
 Rupture of the soft tissue closure
 Block graft exposure
 Exposure time (2002, proussaefs)
 Late exposure : no clinical & histologic sign of pathosis or
necrosis
 Early exposure : partial or total necrosis
 Fixation screw infection
 Adjacent teeth(structure) pathologic conditions

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Resistance to resorption
 Immobilization
 Satisfactory to restore mandibular volume
 In function the grafted bone underwent rapid resorption
 Onlay graft
 Use membranous bone & graft stability
(Philips & Rhan 1990)
 Cortical bone
 Use of membrane
 Adequate implant placement timing

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Soft tissue coverage
 Crestal incision with releasing incisions
 Lingual flap
 Mesially at least 3 teeth include
 Raise extending beyond mylohyoid muscle
 Tension-free suture
 Mattress suture : contact over 3mm
 Soft tissue graft
 Free graft : FGG, CT
 Pedicle graft : palatal or labial

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Controversy
 1 stage surgery (bone graft & implant placement)
 Single surgical intervention
 Potentially reduced healing time
 2 stage surgery
 Prosthetically better implant placement
 Superior esthetics

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1 stage surgery
 1 stage surgery (bone graft & implantation)
 Long-term implant survival rates : 25~100%
 Implant position & angulation are critical factors
 Implant survival alone does not predict successful
restoration of occlusion
 Verhoeven et al 1997
 Carr & Laney 1987
 Marx & Morales 1988

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Advantage of delayed implantation
 Reducing the infection rate & graft failure rate
 Proper angulation & more precise positioning
 After 5 years of masticatory functional loading
 Onlay grafting & simultaneous implantation in maxilla
 Success rate : 51~83%
 Secondary implantation
 Schliephake et al (1997, JOMS)
 20% higher success rate

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Resorption rate
 Proussaefs, Lozada et al (2002)
 Block graft with Bio-oss : 16.34 %, 17.58 %
 Cordaro et al (2002)
 Block bone : Mn 41.5%, Mx 43.5% (mean 42%)
 Wang and colleagues (1976) : onlay bone graft
 During the first 3 years : 14%~100%
 Bell et al (2002)
 Iliac crest block bone : 33%

37. Jun chang hun
The use of ramus autogenous block grafts for
vertical alveolar ridge augmentation and implant
placement: A pilot study
 Ramus block autograft for vertical alveolar ridge augmentation
 Ramus block bone, Fixation screws, Periphery : Bio-Oss
 4~8 months later : HA implant (Steri-Oss)
 Results
 Radiographic
 6.12 mm (1 month)  5.12 mm (4~6 months) : 16.34 %
 Laboratory volumetric
 0.91 mL (1 month)  0.75 mL (6 months) : 17.58 %
 Peripheral pariculate bone (Bio-Oss)
 Bone (34.33%), fibrous tissue (42.17%), residual Bio-Oss particle
(23.50%)
 Discussion
 Early exposure appeared to compromised the results, while late
exposure did not affect the vitality of the block autografts
Proussaefs P, Lozada J, Kleinman A, Rohrer M (Int JOMI 2002;17:238-248)

38. Jun chang hun
Clinical results of alveolar ridge augmentation with mandibular block bone
grafts in partially edentulous patients prior to implant placement
 15 partially edentuous patients
 Ramus & symphysis block bone
 Fixed with titanium screw
 After 6 months screw remove, implant placed
 12 months later implant supported fixed bridges
 Mean reduction rate
 Lateral : 23.5%
 Vertical : 42 %
 Mandibular site more resorption rate than maxillary sites
Groups
No. of aug.
sites
Lateral aug.
at bone
grafting
Lateral aug.
at implant
placement
%
reduction
of lateral
aug.
Vertical
aug. at
bone
grafting
Vertical
aug. at
implant
placement
%
reduction
of vertical
aug.
Group 1 & 2 18 6.5+0.33 5.0+0.23 23.5% 3.4+0.66 2.2+0.66 42%
Group 1
: Mx
10 6.5+0.6 5.2+0.4 20% 4.75+1.5 2.75+1.5 41.5%
Group 2
: Mn
8 6.5+0.37 4.75+0.12 27.5% 2.4+0.2 1.4+0.2 43.5%
Cordaro L, Amade DS, Cordaro M (Clin oral impl res, 2002;13:103-111)

39. Jun chang hun
Staged reconstruction of the severely atrophic mandible
with autogenous bone graft and endosteal implants
 Materials and Methods
 Vertical mandibular height <7mm (atrophic mandible)
 Iliac crest bone graft to the mandible via an extraoral approach
 After 4~6 months, implantation
 Results
 Mean pre-op bone height : 9mm (midline), 5mm (body)
 Before implantation (4~6months) vertical bone loss : 33%
 After implantation (24 months)
 Non-implant supported region bone loss 11% per year
 Implant-supported region bone loss negligible
 Conclusions (improve success rates)
 Prosthetically sound implant positioning
 Provide an affordable reconstructive option
 Staged reconstruction
Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (JOMS, 2002;60:1135-1141)

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Complications of grafting in the atrophic edentulous or
partially edentulous jaw
 Intraoperative complications
 Bone
 Insufficent donor material
 Over-reduction
 Inadequate fixation
 Soft tissue
 Perforation
 Inability to mobile
 Teeth
 Root damage
 Other anatomy
 Sinus : membrane tear
 Nerve injury
 Postoperative complications
 Gerneral
 Infection
 Bone
 Excessive resorption
(early exposure, loss of graft)
 Inadequate bone for implant
 Soft tissue
 Hematoma
 Flap retraction
 Flap necrosis
 Color or tissue-type mismatch
 Loss of papilla
 Shallowing of vestibule
 Teeth
 External root resorption
 Other anatomy
 Sinusities
 Nasal bleeding
 Oroantral fistula
Bahat O, Fontanesi RV Int JPRD 21:487-495 2001

41. Company
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Jun
chang
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CASE REPORT
LINK

42. Jun chang hun
Conclusions
 Autogenous block bone graft (chin or ramus)
 5~7mm gaining
 About 30% resorption rate
 Staging the grafting and implant procedure

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 Primary stability (+)
 Exposed threads can be covered with autogenous bone
associated with a membrane
 Jovanovic et al (1992), Jovanovic & Buser (1994),
Giovannolli & Renouard (1995), Antoun et al (1996)
 Primary stability (-)
 Ridge augmentation should be performed before
implantation