This document summarizes an oral presentation on advanced surgical procedures in implant dentistry. It discusses various grafting techniques like alveolar socket preservation, onlay grafting, interpositional grafting, sandwich osteotomy, alveolar ridge split osteotomy, distraction osteogenesis, and sinus lift surgery. It also covers principles of grafting, types of grafts including autogenous, allogenic and xenogenic grafts. Soft tissue management techniques like palatal connective tissue grafting are presented. Complications of grafting procedures and post-operative care are also summarized.

1. ORAL AND MAXILLOFACIAL
SURGEON’S DAY
13’TH FEB 2014

2. ADVANCED SURGICAL
PROCEDURES IN IMPLANT
DENTISTRY
Dr Sejal K M (Reader)
Department of Oral and Maxillofacial Surgery
M.S. Ramaiah Dental College and Hospital
Bangalore

3. CONTENTS
I. Alveolar socket
preservation
II. Principles of grafting
III.Hard tissue management
IV.Soft tissue management
V. Post operative care
VI.Complications

4. Alveolar socket
preservation
• Use of instrument like
periotome luxator and
physics forceps to aid in
preservation of alveolar
bone
• Use of inward fragmentation
and apical transalveolar
extraction techniques
• Avoid compression of
extraction sockets

7. Principles of grafting
1. Host bone regeneration
capacity
2. Surgical asepsis
3. Host site preparation
4. Optimization of growth factor
5. Graft immobilization
6. Soft tissue coverage

8. Types of grafts
Autogenous bone grafts  osteocompetent cells
Allogenic grafts  different member of the same
species , femur head (donors from tissue bank)
Xenogenic bone  genetically dissimilar species
(osteoconductive) scafold for creeping substitution

9. Graft volume available for harvest
SITE
GRAFT VOLUME
Maxillary tuberosity
2cm 3
Lateral ramus
1.5x3cm3
Mandibular symphysis
10x30mm2
Coronoid process
1.8x1.7x0.5 cm block
Zygomatic buttress
1.5x2 cm block

10. Graft volume available for harvest
from different site
SITE
CORTICOCANCELLOUS
GRAFT VOLUME
Tibia
25-40cm3
Anterior Ilium
50cm3
Posterior Ilium
100-125cm3
Calvarium
Minimal

11. Tibial Bone Graft

12. Iliac Bone Graft

13. Calvarial bone graft

14. GRAFTING PROCEDURES

15. Onlay grafting
Procedure

18. Interpositional bone graft
Sandwich osteotomy
It is used for increasing the vertical
height in severe atrophic maxilla &
mandible
Advantage of this technique include
minimal bone resorption & stability
as compared to onlay bone grafting
Minimal soft tissue exposure to
make a horizontal & 2 divergent

19. Sandwich Osteotomy

20. Alveolar ridge split osteotomy
 Used to widen thin ridges of less than 3-4
mm and used to gain 2-3mm width
 Achieved through a crestal incision with
minimal reflection
 Ridge is split with small osteotomies
used in increasing size to force the
direction of the initial osteotomised
segments
 Wound closed primarily

21. Distraction Osteogenesis
Used for severe defects that
require more than 5mm expansion
in vertical or horizontal
dimensions
Osteotomy with minimal periosteal
stripping
Latency period – 3 to 7 days
Distraction rate of 1mm/day
Consolidation - 6 to 12weeks

22. Sinus lift surgery

23. • Lateral window technique was
first demonstrated by Tatum
using a modified Cald wel Luc
approach
• 4 linear osteotomies with a
round bur
• First inferior horizontal
osteotomy as close to the floor
of the sinus
• Brushing stroke so as to not tear
the schneiderian
membrane

24. Superior horizontal osteotomy
performed at the level of the
planned augmentation height
Superior and inferior
osteotomies connected
anteriorly and posteriorly
with vertical osteotomies

25. Adjuncts to Bone Grafts
Xenografts
Bio Oss- anorganic bovine bone.
Coralline Hydroxyapatite

26. Adjuncts to Bone Grafts
Synthetic Calcium Phosphate
 Tetracalcium phosphate
 Hydroxyapatite
 Octacalcium phosphate
 ßTricacium phosphate
 Dicalcium phosphate
To be placed in gaps between the
block graft or in the jumping
distance.

27. Adjuncts to Bone Grafts
Platelet rich fibrin (PRF) is a fibrin
matrix in which platelet
cytokines, growth factors, and
cells and can serve as a
resorbable membrane.
rh BMP and rh BMP available as
powder mixed with sterile water
and carried to the recipient site
2
7

28. Choukroun and his associates were
amongst the pioneers for using PRF
protocol in oral and maxillofacial
surgery to improve bone healing in
implant dentistry.
Autologous PRF is considered to be a
healing biomaterial.

29. Advantage of PRF over
PRP
1. No biochemical handling of blood.
2. Simplified and cost-effective
process.
3. Use of bovine thrombin and
anticoagulants not required.
4. Favorable healing due to slow
polymerization.
5. More efficient cell migration and
proliferation.
6. PRF has supportive effect on
immune system.

30. Bone Substitutes
Allografts
Demineralised freeze
dried bone with
hydroxyapetite.(
DFDBA )
Freeze dried bone
allografts (FDBA)
It is preferred when
large particulate
graft is required and
patient is not willing

31. BARRIER MEMBRANE
Rigid (fixed with screws)
Nonrigid (secured
underneath the flap)
Resorbable
Non-resorbable

33. Recommended options for
defect reconstruction
Horizontal segmental defects
 Onlay bone graft with rigid
membrane
 Onlay particulate graft with
membrane
 Sandwich osteotomy
Horizontal deficiency of the entire arch
 Onlay block graft with membrane
 Onlay particulate graft with rigid
membrane
 Onlay particulate mineralized graft

34. Vertical segmental defects
Onlay block graft with
membrane
Onlay particulate graft with
rigid membrane
Sandwich osteotomy
Sandwich osteotomy and rigid
stabilization
Vertical deficiency of the entire
arch
Onlay block graft with

35. SOFT TISSUE COVERAGE

36. Preservation of adequate soft
tissue coverage is a very
important factor in the success
of bone grafts
Dehiscence of the mucosa and
early exposure of the grafted
bone are the most common
etiological factors that may
lead to graft failure.
One of the possible etiological
factors is the presence of thin
soft tissue coverage around the
block.

37. Scoring of the periosteum

38. Palatal Connective
tissue graft

39. Soft tissue Grafting prior
to Bone grafting
The acellular dermal matrix
(ADM) allograft seems to be a
good
substitute
for
the
connective
tissue
graft
(CTG),
having
been
used
successfully for soft tissue
augmentation.
Saudi Med J 2013; Vol. 34 (6): 609-615

40. Soft tissue coverage
Intra-oral soft tissue coverage can
be achieved with the help of
barrier membrane and PRF as
biomembrane.
Hydrogel expansion of the
periosteum is an applicable
method to achieve a surplus of
soft tissue to cover bone grafts.

41. Tissue Expanders for oral
soft tissue

42. Post operative care
Antibiotics such as amoxycillin
or clindamycin for 7 to 10days.
Chlorhexidine mouth rinse for
first 2 to 4 weeks.
To avoid pressure on the
wound,
in
patients
where
hardware has been placed.
Use of nasal decongestants
following sinus lift procedure.

43. Strict non chew diet for 6 to 8
weeks is recommended to
minimise the risk of fracture.
Autogenous block grafts should
heal for approximately 4
months before placement of
implant.

44. Complications of grafting
procedures
1. Perforation of the Schneiderian
membrane
2. Soft tissue dehiscence
3. Infection
4. Exposure of GBR membrane
5. Mobilisation of the graft
6. Graft resorption
7. Cyst formation
8. Transmission of diseases like

45. Acknowledgement
All Staffs and Post graduate students of
Department of Oral And maxillofacial
Surgery; MSRDC
Department of Prosthodontics; MSRDC
Department of Periodontics; MSRDC

46. Thank you