Bone augmentation for implants / orthodontics training courses

BONE AUGMENTATION FORBONE AUGMENTATION FOR
IMPLANTSIMPLANTS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 CLASSIFICATION OF AUGMENTATION MATERIALSCLASSIFICATION OF AUGMENTATION MATERIALS
 SURGICAL KEYS OF BONE GRAFTINGSURGICAL KEYS OF BONE GRAFTING
 INRAORAL AUTOGENOUS DONOR BONE GRAFTSINRAORAL AUTOGENOUS DONOR BONE GRAFTS
- General considerations- General considerations
- Donor sites- Donor sites
EXTRAORAL AUTOGENOUS DONOR GRAFTSEXTRAORAL AUTOGENOUS DONOR GRAFTS
MAXILLARY SINUS LIFT AND SINUS GRAFT SURGERYMAXILLARY SINUS LIFT AND SINUS GRAFT SURGERY
- Pathologic assessment- Pathologic assessment
- Premedications- Premedications
- Surgical techniques- Surgical techniques
- Complications- Complications
PREMAXILLA IMPLANT CONSIDERATIONSPREMAXILLA IMPLANT CONSIDERATIONS
- Premaxilla surgery- Premaxilla surgery
- Subnasal Elevation and Augmentation- Subnasal Elevation and Augmentation
BONE GRAFTING AND MAINTENANCE OF ALVEOLAR BONE FORBONE GRAFTING AND MAINTENANCE OF ALVEOLAR BONE FOR
CONVENTIONAL PROSTHESISCONVENTIONAL PROSTHESIS

INTRODUCTIONINTRODUCTION
To satisfy the ideal goals of implant dentistry, the hardTo satisfy the ideal goals of implant dentistry, the hard
and soft tissues need to present ideal volumes andand soft tissues need to present ideal volumes and
quality.quality.
The alveolar process is affected so often after toothThe alveolar process is affected so often after tooth
loss, augmentation is usually indicated to achieveloss, augmentation is usually indicated to achieve
optimum results.optimum results.
Because of an improved understanding ofBecause of an improved understanding of
biomechanics requirements for long term prosthesisbiomechanics requirements for long term prosthesis
survival and the increasing use of implants in estheticsurvival and the increasing use of implants in esthetic
restorations, ridge reconstruction before implantrestorations, ridge reconstruction before implant
placement has become a necessary procedure for aplacement has become a necessary procedure for a
number of edentulous patients.number of edentulous patients.www.indiandentalacademy.comwww.indiandentalacademy.com

Bone Augmentation MaterialsBone Augmentation Materials
ClassificationClassification
Based on Mode of action they areBased on Mode of action they are
classified into:classified into:
1. Osteoconductive1. Osteoconductive
2. Osteoinductive and2. Osteoinductive and
3. Osteogenic Graft materials.3. Osteogenic Graft materials.

Current Osteocunductive Grafting Materials Include:Current Osteocunductive Grafting Materials Include:
1. Calcium Phosphates1. Calcium Phosphates
a. HA synthetic - Calcitea. HA synthetic - Calcite
- orthomatrix HA- orthomatrix HA
- osteogen- osteogen
- osteograf D, LD- osteograf D, LD
b. HA Natural - Bioossb. HA Natural - Biooss
- Osteograf N- Osteograf N
- Osteomin- Osteomin
c. TCP - Augmenc. TCP - Augmen
- CalciResorb- CalciResorb
- SynthoGraf- SynthoGraf
2. Calcium Carbonate2. Calcium Carbonate
- Interpore 200- Interpore 200
- Biocoral- Biocoral
3. Bioactive Glass Ceramics3. Bioactive Glass Ceramics
- Bioglass- Bioglass
- Biogran- Biogran
- Perioglass- Perioglass
4. Biocompatible Composite Polymer4. Biocompatible Composite Polymer
- Bioplant HTR- Bioplant HTR

OSTEOCONDUCTIONOSTEOCONDUCTION
 Osteoconduction characterizes bone growth byOsteoconduction characterizes bone growth by
apposition from the surrounding bone. Thereforeapposition from the surrounding bone. Therefore
this process must occur in the presence of bonethis process must occur in the presence of bone
or differentiated mesenchymal cells.or differentiated mesenchymal cells.
The most common osteoconductive bone graftingThe most common osteoconductive bone grafting
materials used in implant dentistry arematerials used in implant dentistry are alloplastsalloplasts
andand xenograftsxenografts..
Alloplasts are further classified into:Alloplasts are further classified into:
Ceramics - BioinertCeramics - Bioinert
- Bioactive- Bioactive
polymers andpolymers and
composites.composites.www.indiandentalacademy.comwww.indiandentalacademy.com

XenograftsXenografts
Are fabricated from the inorganic portionAre fabricated from the inorganic portion
of bone from animals other than manof bone from animals other than man
and are also osteoconductive.and are also osteoconductive.
Ostoconductive matrials for hard tissueOstoconductive matrials for hard tissue
maintenance and augmentation may bemaintenance and augmentation may be
charactrized as:charactrized as:
Nonresorbable – resorbableNonresorbable – resorbable
Dense – porousDense – porous
crystalline - amorphouscrystalline - amorphous

The resorbable osteoconductive materialsThe resorbable osteoconductive materials
are made up of HA, Beta- tricalciumare made up of HA, Beta- tricalcium
phosphate or various combinations ofphosphate or various combinations of
both.both.
““Solution Mediated Resorption”Solution Mediated Resorption” is ais a
consequence of the pH of the surroundingconsequence of the pH of the surrounding
media.media.
““Cell Mediated Resorption”Cell Mediated Resorption” cells
surrounding the grafted material act by
phagocytosis and then intracellular
degradation.

OSTEOINDUCTIONOSTEOINDUCTION
 Osteoinduction involves new boneOsteoinduction involves new bone
formation from osteoprogenitor cellsformation from osteoprogenitor cells
derived from primitivemesenchymal cellsderived from primitivemesenchymal cells
under the influence of one or moreunder the influence of one or more
inducing agents that emnate from theinducing agents that emnate from the
bone matrix.bone matrix.
 The most commonly used osteoinductiveThe most commonly used osteoinductive
materials in implant dentistry arematerials in implant dentistry are bonebone
allografts and autografts.allografts and autografts.www.indiandentalacademy.comwww.indiandentalacademy.com

There are primarily three types ofThere are primarily three types of
bone allograftsbone allografts
 Frozen boneFrozen bone
 Freeze – Dried (FDBAs) andFreeze – Dried (FDBAs) and
 Demineralized freeze – DriedDemineralized freeze – Dried
(DFDBAs)(DFDBAs)

OSTEOGENESISOSTEOGENESIS
 Osteogenesis refers to the growth of boneOsteogenesis refers to the growth of bone
from viable cells transferred within thefrom viable cells transferred within the
graftgraft
 New bone is regenerated from endostealNew bone is regenerated from endosteal
osteoblasts and marrow stem cellsosteoblasts and marrow stem cells
transferred with the graft.transferred with the graft.
 The storage medias includeThe storage medias include
- Sterile saline- Sterile saline
- Lactated ringer’s solution- Lactated ringer’s solution
- D5W- D5Wwww.indiandentalacademy.comwww.indiandentalacademy.com

Surgical Keys of Bone GraftingSurgical Keys of Bone Grafting
The keys of bone grafting are local factors that affect theThe keys of bone grafting are local factors that affect the
prognosis of the procedure and include:prognosis of the procedure and include:
Absence of infectionAbsence of infection
Soft tissue closureSoft tissue closure
Defect morphologyDefect morphology
Autologous boneAutologous bone
Space maintenanceSpace maintenance
Healing timeHealing time
Graft immobilizationGraft immobilization
Nutrient blood vesselsNutrient blood vessels
Growth factorsGrowth factors
Regional acceleratory phenomenonRegional acceleratory phenomenon
Collagen and calcium phosphateCollagen and calcium phosphatewww.indiandentalacademy.comwww.indiandentalacademy.com

Soft Tissue CoverageSoft Tissue Coverage
Primary soft tissue closure and absense of infection are mandatoryPrimary soft tissue closure and absense of infection are mandatory
conditions for the success of grafting procedures.conditions for the success of grafting procedures.
The guidelines to reduce the incidence of postoperativeThe guidelines to reduce the incidence of postoperative
complications include:complications include:
1. The primary incision should be in1. The primary incision should be in
keratinized tissue.keratinized tissue.
2. The crestal incision is designed more palatal in2. The crestal incision is designed more palatal in
maxilla and more facial in the mandiblemaxilla and more facial in the mandible
3. Vertical relief incisions are designed away from the3. Vertical relief incisions are designed away from the
graft sitegraft site
4. Tension free wound closure.4. Tension free wound closure.
5. Should use nonresorbable sutures.5. Should use nonresorbable sutures.
6. Patients are instructed not to smoke until incision line has healed.6. Patients are instructed not to smoke until incision line has healed.

Surgical AsepsisSurgical Asepsis
 Contamination of the graft can occur fromContamination of the graft can occur from
endogenous bacteria, lack of asepticendogenous bacteria, lack of aseptic
surgical technique, or failure of primary softsurgical technique, or failure of primary soft
tissue closure.tissue closure.
 Barrier membranes or fixation screws thatBarrier membranes or fixation screws that
become exposed often becomebecome exposed often become
contaminated by bacteria.contaminated by bacteria.
 The bacteria invade the graft site and causeThe bacteria invade the graft site and cause
local inflammation with resultant decrease inlocal inflammation with resultant decrease in
bone formation.bone formation.

Defect Size and TopographyDefect Size and Topography
 The graft material selected for maintenance orThe graft material selected for maintenance or
augmentation of ridge form after tooth extraction isaugmentation of ridge form after tooth extraction is
related to the number of walls of bone remaining afterrelated to the number of walls of bone remaining after
tooth loss.tooth loss.
 A five wall bony defect will grow bone with noA five wall bony defect will grow bone with no
augmentation and almost no alloplast, allograft, oraugmentation and almost no alloplast, allograft, or
autograft.autograft.
 One missing labial plate requires some autologous boneOne missing labial plate requires some autologous bone
or guided bone regeneration.or guided bone regeneration.
 As the number of bony walls decreases, moreAs the number of bony walls decreases, more
autogenous bone is required, and autologous blockautogenous bone is required, and autologous block
onlay grafts are used for defects with only one bony wallonlay grafts are used for defects with only one bony wall
left.left.

Autologous BoneAutologous Bone
 Autologous bone is the only graftAutologous bone is the only graft
material that directly forms bone frommaterial that directly forms bone from
the transplanted cancellous bonethe transplanted cancellous bone
cells.cells.
 It is kept in sterile, normal saline ratherIt is kept in sterile, normal saline rather
than patients blood.than patients blood.

Space MaintenanceSpace Maintenance
Tent screws , Titanium reinforcedTent screws , Titanium reinforced
membranes, and/or graft materialmembranes, and/or graft material
beneath the membrane have beenbeneath the membrane have been
advocated to maintain the desiredadvocated to maintain the desired
space during the augmentationspace during the augmentation
process.process.

Healing TimeHealing Time
Graft volume less than 5mm - four toGraft volume less than 5mm - four to
six months healing timesix months healing time
Graft volume more than 5mm – six toGraft volume more than 5mm – six to
ten monthsten months

Graft ImmobilizationGraft Immobilization
Graft mobility leads to poor bloodGraft mobility leads to poor blood
supply and sequestration of the graftsupply and sequestration of the graft
material.material.
There should not be any load over theThere should not be any load over the
graft.graft.

Blood VesselsBlood Vessels
 The primary source are cortical boneThe primary source are cortical bone
and cancellous bone.and cancellous bone.
 The secondary source for transplantedThe secondary source for transplanted
bone cells is introduced into the graftbone cells is introduced into the graft
site from soft tissues (andsite from soft tissues (and
periosteum).periosteum).

Host Bone Blood VesselsHost Bone Blood Vessels
 The host bone blood vessels are ofThe host bone blood vessels are of
primary importance for predictableprimary importance for predictable
bone augmentation.bone augmentation.
 Blood vessels from bone that enter theBlood vessels from bone that enter the
graft site provide pleuripotentialgraft site provide pleuripotential
perivascular cells that have theperivascular cells that have the
capability to become osteoblasts.capability to become osteoblasts.

Regional AcceleratoryRegional Acceleratory
PhenomenonPhenomenon
 The regional acceleratory phenomenonThe regional acceleratory phenomenon
which is the local response to a noxiouswhich is the local response to a noxious
stimulus, describes a process by whichstimulus, describes a process by which
tissue forms faster than the normal regionaltissue forms faster than the normal regional
regioneration process.regioneration process.
 Noxious stimuli of sufficient magnitude, suchNoxious stimuli of sufficient magnitude, such
as fractures, mechanical abuses, andas fractures, mechanical abuses, and
noninfectious inflammatory injuriesnoninfectious inflammatory injuries
(including dental implant procedures) can(including dental implant procedures) can
evoke RAP.evoke RAP.

Bone and Tissue Growth FactorsBone and Tissue Growth Factors
There are mainly five groups:There are mainly five groups:
1. PDGF – Platelet Derived Growth1. PDGF – Platelet Derived Growth
FactorFactor
2. FGF - Fibroblast Growth Factor2. FGF - Fibroblast Growth Factor
3. TGF - Transforming Growth3. TGF - Transforming Growth
FactorFactor
4. IGF - Insulin like Growth Factor4. IGF - Insulin like Growth Factor
5. BMP - Bone Morphogenic Protiens5. BMP - Bone Morphogenic Protiens

Collagen and Calcium PhosphateCollagen and Calcium Phosphate
 One of the source of type 1 collagen isOne of the source of type 1 collagen is
DFDBA.DFDBA.
 The source of calcium phospahte isThe source of calcium phospahte is
from the surrounding bone and alsofrom the surrounding bone and also
through blood supply.through blood supply.

Intraoral Autogenous Donor Bone Grafts forIntraoral Autogenous Donor Bone Grafts for
Implant DentistryImplant Dentistry
• The advantage of local grafts is their convenientThe advantage of local grafts is their convenient
surgical access. The proximity of donor and recipientsurgical access. The proximity of donor and recipient
sites can reduce operative and anesthsia time.sites can reduce operative and anesthsia time.
• Bone harvested from the maxillofacial region appearsBone harvested from the maxillofacial region appears
to have inherent biologic benefits for augmentation andto have inherent biologic benefits for augmentation and
is attributed to the embryonic origin of the donor boneis attributed to the embryonic origin of the donor bone
as well as biochemical similarity in the protocollagen ofas well as biochemical similarity in the protocollagen of
the donor and recipient bone.the donor and recipient bone.

Preoperative EvaluationPreoperative Evaluation
• Includes esthetic concerns, soft tissueIncludes esthetic concerns, soft tissue
topography, periodontal and endodontic healthtopography, periodontal and endodontic health
of the adjacent teeth.of the adjacent teeth.
• A diagnostic waxing of the reconstructed ridgeA diagnostic waxing of the reconstructed ridge
and restored dentistionand restored dentistion
• Removal of foreign bodies, soft tissue surgery,Removal of foreign bodies, soft tissue surgery,
and tooth extractions.and tooth extractions.

Intra Oral Donor SitesIntra Oral Donor Sites
TheThe mainmain donor sites are:donor sites are:
1. Mandibular Symphysis1. Mandibular Symphysis
2. Mandibular Ramus and2. Mandibular Ramus and
3. Maxillary Tuberosity.3. Maxillary Tuberosity.
TheThe miscellaneousmiscellaneous sites are:sites are:
1. Residual ridge crest area1. Residual ridge crest area
2. Canine eminence areas2. Canine eminence areas
3. Lateral to the nasal spine3. Lateral to the nasal spine
4. Maxillary and mandiblar tori and exostosis4. Maxillary and mandiblar tori and exostosis
5. Particulate bone from implant drills and screw5. Particulate bone from implant drills and screw
taps.taps. www.indiandentalacademy.com

Mandibular Symphysis Donor SiteMandibular Symphysis Donor Site
• Surgical incision through vestibular incision.Surgical incision through vestibular incision.
• Mucoperiosteal flap reflected to the level of pogonion.Mucoperiosteal flap reflected to the level of pogonion.
• The most inferior bone cut is made first and theThe most inferior bone cut is made first and the
superior osteotomy is ideally made at least 5mm belowsuperior osteotomy is ideally made at least 5mm below
the tooth apices.the tooth apices.
• A bone chisel is tapped along the osteotomy with theA bone chisel is tapped along the osteotomy with the
exception of the inferior border to fracture the graftexception of the inferior border to fracture the graft
free.free. www.indiandentalacademy.com

• Hemostatic materials (collagen, gelatin, sponge,Hemostatic materials (collagen, gelatin, sponge,
oxidized regenerated cellulose) can be placedoxidized regenerated cellulose) can be placed
into the area after bone harvest.into the area after bone harvest.
• The soft tissue superior to the initial vestibularThe soft tissue superior to the initial vestibular
incision is elevated to reduce tension on the flapincision is elevated to reduce tension on the flap
from edema and lip movement.from edema and lip movement.
• The two layered suturing is recommended forThe two layered suturing is recommended for
suturing.suturing. www.indiandentalacademy.com

Mandibular Ramus Donor SiteMandibular Ramus Donor Site
• A rectangular piece of cortical bone upto 4mmA rectangular piece of cortical bone upto 4mm
in thickness may be harvested from the ramus.in thickness may be harvested from the ramus.
• This bone may also be particulated and used inThis bone may also be particulated and used in
sinus grafting.sinus grafting.
• Smaller bone blocks /trphine cores may beSmaller bone blocks /trphine cores may be
procured from the retromolar regionprocured from the retromolar region

• An incision begins in the buccal vestibule medialAn incision begins in the buccal vestibule medial
to the external oblique ridge and extendsto the external oblique ridge and extends
anteriorly and laterally to the retromolar pad.anteriorly and laterally to the retromolar pad.
• The mucoperiosteal flap is reflected from theThe mucoperiosteal flap is reflected from the
mandibular body exposing the lateral aspect ofmandibular body exposing the lateral aspect of
the ramus.the ramus.
• The flap is elevated with the notched ramusThe flap is elevated with the notched ramus
retractor.retractor.

• The osteotomy is started anterior to theThe osteotomy is started anterior to the
coronoid process at a point where adequatecoronoid process at a point where adequate
thickness develops.thickness develops.
• The osteotomy is extended anteriorly to theThe osteotomy is extended anteriorly to the
distal aspect of the first molar area.distal aspect of the first molar area.
• The posterior superior cut is made on the lateralThe posterior superior cut is made on the lateral
aspect of the ramus.aspect of the ramus.
• The inferior osteotomy is extended into theThe inferior osteotomy is extended into the
cortex only.cortex only.

• Wedge chisel/Potts elevator is levered to pry theWedge chisel/Potts elevator is levered to pry the
buccal segment free.buccal segment free.
• A hemostatic dressing is placed into the donorA hemostatic dressing is placed into the donor
area and closure of the site may be completedarea and closure of the site may be completed
following fixation of the graft.following fixation of the graft.

Maxillary Tuberosity Donor SiteMaxillary Tuberosity Donor Site
• Convenient for use in maxillary sinus grafting.Convenient for use in maxillary sinus grafting.
• A vertical incision is made posteriorly at theA vertical incision is made posteriorly at the
lateral aspect of the maxilla.lateral aspect of the maxilla.
• Following reflection of a mucoperiosteal flap,Following reflection of a mucoperiosteal flap,
bone may be harvested from the tuberositybone may be harvested from the tuberosity
with a rongeur or chisel.with a rongeur or chisel.

Comparison of Donor SitesComparison of Donor Sites
Syphysis Ramus TuberositySyphysis Ramus Tuberosity
Surgical access good fair to good good to fairSurgical access good fair to good good to fair
Patient cosmetic high low lowPatient cosmetic high low low
ConcernsConcerns
Graft Shape Thicker block Thinner veneer Porous blockGraft Shape Thicker block Thinner veneer Porous block
Graft Morphology Coticocancellous cortical cancellousGraft Morphology Coticocancellous cortical cancellous
Graft Size >1cm3 <1cm3 <1cm3Graft Size >1cm3 <1cm3 <1cm3
Graft resorption minimal minimal minimalGraft resorption minimal minimal minimal
Healed Bone D1,D2 D1,D2 D3Healed Bone D1,D2 D1,D2 D3
QualityQuality
Donor site Complications:Donor site Complications:
Postop pain/edema moderate minimal to moderate minimalPostop pain/edema moderate minimal to moderate minimal
Neurosensory –teeth common(temp) uncommon noneNeurosensory –teeth common(temp) uncommon none
Neurosensory tissue common(temp) uncommon uncommonNeurosensory tissue common(temp) uncommon uncommon
Icision Dehiscence Occasional(vestibular) uncommon uncommonIcision Dehiscence Occasional(vestibular) uncommon uncommon
Sinus Perforation None None occasionalSinus Perforation None None occasional

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