Ridge augmentation procedures /orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

ContentsContents
Introduction
Ridge augmentation
Definition
Objectives
Limitations
Graft materials
Preoperative evaluation
Technique to correct alveolar atrophy
Maxillary augmentation
Maxillary onlay graft
Ridge split osteoplasty
Lefort I maxillary osteotomy with interpositional bone grafting
Sinus lift and antral inlay grafting procedure

Mandibular augmentation
Augmentation of the superior border of the mandible
Rib onlay graft
Iliac crest onlay graft
Pedicaled bone augmentation with graft supplementation
Horizontal osteotomy
Vertical/Visor osteotomy
Combined vertical and horizontal osteotomies
Augmentation of the inferior border of the mandible
Augmentation with synthetic graft material – Hydroxylapatite
Surgical technique for minor deficiencies ( Class I & II )
Surgical technique for major deficiencies ( Class III & IV )
Distraction osteogenesis
Conclusion
List of references

RIDGE AUGMENTATIONRIDGE AUGMENTATION:: is a process of replacingis a process of replacing
the lost bone of the residual ridge by grafting natural orthe lost bone of the residual ridge by grafting natural or
synthetic material.synthetic material.
OBJECTIVES
• Functional Biological Platform
• Support Prosthetic Rehabilitation
• Without further bone or tissue loss
LIMITATIONS
• Physical condition of the patient
• Metabolism of the patient
• Nutritional deficiencies
• Availability of adequate soft tissue coverage
• Compliance of the patient for major surgerywww.indiandentalacademy.com
INTRODUCTION

GRAFT MATERIALS :
Cortical Bone Graft
Revascularization – Slow Cell Survival Rate - Less
Cancellous Bone Graft
Allogenic Bone : Genetically unrelated individuals
Ex: 1. Ileac crest graft – Provides cortical bone framework
and cancellous marrow – 30 – 50 %
2. Rib Graft : 5th
to 9th
Ribs
High initial resorbtion rate
Alloplastic materials :
Proplast, Hydroxyapatite, Tricalcium Phosphate.
Hydroxyopatite :
- Biocompatible, Nonresorbable and Nonosteogenic
- Similar to the structure of both bone and tooth.
Tricalcium Phosphate : Resorbable & Osteogenic

Preoperative Evaluation
• Radiographs
• Diagnostic mounted cast
Inter arch space - 16-18 mm
Interocclusal relationship
AP Skeletal Deficiency
Technique to correct alveolar atrophy :
Over the Ridge
Graft Lower Border
Interposed / Pedicle
Preservation of original
mucoperiosteum bone
interface

Factors affecting the success of the treatment :
Technique
Direct Transfer of the graft
Wound Closure
Post operative loading
Maxillary onlay graft :
Indications :
Cawood and Howell Class V
Implant Restoration
Large inter arch space
Maxillary lip length
Ccomplete arch edentulism
Absolute contraindications :
Inadequate inter arch space
Short upper lip
Partial edentulism
Soft tissue volume
Poor blood supply and loss of elasticity
Antral infection, complete loss of basal bonewww.indiandentalacademy.com

Procedure
   Incision above the mucogingival
junction
   Subperiosteal dissection to expose the
lateral piriform aperture, anterior floor
of the nose
   Minimum reflection of palatal
mucoperiosteum
   Catricocancellous blocks of iliac crest
   Thick foil impression
   Contouring and fitting the graft
   Void filled
   Interrupted and continuous mattress
sutures
   Palatal pressure dressing
   Implant placement in 2nd
stage procedure

Ridge split osteoplastyRidge split osteoplasty
 Indication - Knife edge alveolusIndication - Knife edge alveolus
 Sub-periosteal flapSub-periosteal flap
Position of the buccal
fragment after osteotomy
Circumferential osteotomy
Buccal plate outfractured
to complete ridge split
Interpositional corticocancellous
and allogenic bone to maintain the
increased B L Dimensionwww.indiandentalacademy.com

The Lefort I maxillary osteotomy with interpositional bone
grafting :
•Amount of augmentation depends upon  AP
relationship
Indications :
• Adequate palatal vault height  with posterior
   alveolar atrophy, resulting in an increased
   inter arch space.
• True skeletal discrepancies
•Maxillary splint – Fixation aid
Mandibular splint – To interface
•Circumvestibular incision
•Lefort I osteotomy
•Maxilla repositoned inferiorly
•Interpositional iliac crest graft
•If insufficient three grafts
•Cortical surface facing nasal floorwww.indiandentalacademy.com

• Splint insert
• Graft stabilized – Interosseous
suture
• Horizontal mater suture
• Removal of splint – 6-8 weeks
• Definitive prosthesis after stabilitySinus lift and antral inlay grafting procedure :
Indication : Implant restoration
• Crestal incision
• Relieving incision
• Buccal full thickness flap
• Semilunar bone cut
• Schneiderian membrane not to be
perforated
 The opening involves only the
anteroinferior quadrant of the antrum.
• Mobilization bone island
• Mucosa with the bone lifted of the antral
floorwww.indiandentalacademy.com

Coronal section - Position of
the bone graft
•Corticocancellous blocks
•Perforation – Collagen membrane
•GTR membrane
•Vertical mattress sutures
•Denture returned
Mandibular augmentation :
Indications : ↔
Severely atrophic mandible < 8mm & ↑ 5mm
Pt exhibit overclosed, age appearance high risk of pathologic fracture
Contra indications :
Inadequate inter arch space or short lip length.

Augmentation of superior border of the mandible.
Rib onlay graft :
Donor consideration:
•Two rib segments – 16cms long
•Preservation of periosteum
•First rib - Kerfing by Devis in 1979
•Second rib - Pieces of 2 x 3 mm
Recipient site:
•Incision – Retromolar region avoiding mental N
•Plane of dissection → Lateral crest, periosteum
•Buccal lingual & labial flaps developed
•Longitudinal relaxing incisions
•Rib strut adjusted
•Wires through the internal oblique ridge & inferior aspect of the rib
•Anterior segment through rib & lingual cortex to secure the graft
•Ridge contouring & running horizontal mattress suture
•Graft maturation - 4 months, vestibuloplasty is performedwww.indiandentalacademy.com

Disadvantages :
• Donor site morbidity.
• Second surgical site necessary.
• Continued resorption of the grafted sites.
• Soft tissue dehiscence or limitation.
Iliac crest onlay grafts can also used.
Pedicled bone augmentation with graft supplementation:
Concept: Maintenance of lingual periosteum
1. Horizontal osteotomy       - Ideal if reasonable amount of bone
  above mandibular canal
2. Vertical/Visor osteotomy - If insufficient height with adequate
  width (10-15mm)

Horizontal osteotomy with interpositional graft :
•Incision retromolar pad just inferior to the crest of the ridge
•Buccolabial mucoperiosteal flap
•Mental nerves exposed
•Lingual tissue serve as vascular pedical
•Vertical tunnels
•Horizontal osteotomy
•Transosseous holes
•Corticocancellous struts
•Polyglycolic acid sutures
•3-0 Resorbable horizontal mattress suture
•Indresano – overextended stent
•Vestibuloplasty
•Advantages – Stable, shortened post operative period
•Disadvantages – Nerve trauma, paresthesia, fracture & flap dehiscence

Modified interpositional technique :
Lekkas and Wes (1981) osteotomy is performed through a
combined intraoral and extraoral approach, and the inferior segment is
lowered rather than the superior portion being raised.
Advantage: Used in mandible < ↑ 6mm
To avoid mandibular canal – Lip anesthesia or paresthesia
Disadvantage: Extra oral scar
Vertical or Visor osteotomy with graft supplement :
Harle, modified by Peterson & Slade
•Insufficent vertical mandibular bone height
•Buccolabial mucoperiosteal flap
•Narrow vertical lingual subperiosteal tunnels
•Sagittal cut, in molar region angled laterally

•Lingual section elevated
•Cancellous bone graft
•Trans-osteal wires – 3-4 months
•Disfavour unavoidable nerve
trauma
Combined vertical and horizontal osteotomies for mandibular
augmentation :
•Anterior horizontal osteotomy
•Vertical osteotomy
•The combined procedure
- Repositioning of the pedicle segment
to correct AP ridge discrepancy
- Less chance of fracture
- A more stable pedicle bone flap

Modified three-piece osteotomy
Outline of osteotomies designed to
Avoid damage to the inf alv N
Anterior segment is held by bone
struts and midline circummand wire
which pulls the fragment forward
•Posterior segment rotated horizontally
•Interposition of the cancellous bone graft
•Gap over the mental foramen is filled with chips

Inferior border augmentation : Sanders and Cox
Bur holes drilled
Entire specimen is
fixed rigidly using
screw fixation
•Preexisting prosthesis
•Increased stabilization of the mandible
•Nochange in vertical dimension
•Nodirect masticatory forces
•Extraoral scar
•Sensory or motor nerve deficiencies
•Submadibular incision
•Inferior border exposed
•Cadeveric mandibular adjustment – Scalloped
tray to incorporate autogenous bone

Ridge augmentation with synthetic graft materials :
Hydroxylapatite:
Nonresorbable ceramic bone substitutes – Calcium phosphate,
radioopque, sterilized
HA – Bone mixture (1:1) Loaded in a syringe to facilitate
its placement in graft site
Classification alveolar ridge deficiency :
Class I: Inadequate width, undercut areas → HA
Class II: Deficient in Height & width, knife edge → HA
Class III: Resorbed to the level of basilar bone,
concave form → HA/HA-bone
Class IV: Resorption of the basilar bone → HA-Bonewww.indiandentalacademy.com

Surgical Technique for Minor Deficiencies (Class I & II )
•For complete augmentation ridge crest or single midline
vertical incision
•For only posterior aspects ridge crest or bilateral vertical
incision in cuspid areas
•Periosteum is elevated only in the area of augmentation
•Traction sutures
•Filling of HA from posterior ends bilaterally to these incision
•Denture or Splint

Surgical Technique for Major Deficiencies ( Class III & IV )
Maxillary Augmentation
Vertical midline incision with
combined submucosal dissection
and subperiosteal reflection
Periosteum is cut at
crestal tissue junction
Incising anterior
bulbous tissue

Large pocket is
produced
Injection of
HA or HA with bone
Enlargement of flat
maxilla with HA
just before splint is fixed

Maxillary augmentation with custom titanium mesh tray :
Indication :
•Maxillary atrophy with Sever V & H Bone loss
•Enlarged maxillary sinus
Repositioning of lateral
wall and reflection of
the antral lining
HA-Bone injected
Tray in place with graft beneath
•Horizontal running suture
•Two weeks after denture relined placed for
esthetic use onlywww.indiandentalacademy.com

Mandibular augmentation :
Combined mandibular mucosal dissection
with periosteal reflection and detachment
of developed large pocket
Inferior alveolar nerve arising from crest of
severely resorbed Class IV mandible. Placement
of HA frequently required in lateral nerve
repositioning with bone grafting
Delivery of HA particles on a Class IV
mandible after circummandibular sutures
are placed to secure a splint

Denture can be placed at one month, in cases augmented with HA only
and in six to eight weeks, in cases with HA-Bone
Postoperative complications
1. Dehiscence with extrusion of particles
2. Abrasion through the mucosa
3. Infection
4. Abnormal colour
5. Mental nerve neuropathy
Advantages :
1. Local augmentation
2. Composite grafting in severe Class III & IV
3. No donor site

Alveolar distraction osteogenesis :
Pincipal : “Law of tension – stress”
Force → Bone cut → Widening the gap → Bone + Soft tissue
regeneration
Atrophic mandible in preparation
for alveolar ridge distraction
Distraction device in place
Bony regenerate at the distraction site is
visible at the time of device removal

• Peterson’s principle of oral and maxillo facial surgery second
edition Vol 1.
• Reconstructive preposthetic oral and maxillofacial surgery-Fonseca
and Davis, 2nd edition.
• Text Book of oral and maxillofacial surgery V:2 by Daniel. M.
Laskin
• Text Book of oral and maxillofacial surgery by Gustav. D. Kruger
• Preprosthetic oral surgery by Thomas. J. Starshak
• Essentials of complete denture prosthodontics by Sheldon Winkler
• Prosthodontic treatment for edentulous patients by Boucher
• Syllabus of complete dentures by Charles. M. Heartwell, Jr.
Arther. www.indiandentalacademy.com
CONCLUSION

Ridge augmentation procedures /orthodontic courses by Indian dental academy

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