Bone Grafting for implants

Dept. of Oral and Maxil lofacial Surgery, School of Dentistry,

Wonkwang Univ.

Kwon, Kyung-Hwan

Diagnosis and Treatment Planning For Bone Augmentation

A complete intraoral examination Radiographs and in select cases a

CT scan Neurovascular bundles must be avoided. Paranasal sinus must be identified.

Study models

Clinical Examination

Minimal obtain 1 to 2mm of attached gingiva

Cross section of the alveolar depicting periodontal probe placement for “sounding the bone”.

To determine bone width Cutting the study model in the exact

vertical location

Diagnosis and Treatment Planning For Bone Augmentation

To Determine Bone Width

Harry Dym, Orrett E. Ogle: Atlas of Minor Oral Surgery. W.B. Saunders company. 2001

Radiographic Examination

Panoramic radiograph 20 to 30% distortion/magnification of

the anatomic structures Buccal to lingual width will not be

appreciated Alveolar bone height, adjacent teeth

and anatomic structure

Diagnosis and Treatment Planning For Bone Augmentation

Fabricate a surgical stent Guiding to the exact site of implant

placement Diagnostic wax-ups

Arch form, tooth spacing, and bony contour

Study Models

Diagnosis and Treatment Planning For Bone Augmentation

Types of Bone Grafts

Autograft A graft taken from on anatomic location and placed in

another location in the same individual(e.g., iliac crest)

Allograft A graft taken from a cadever treated wit certain

sterilization and antiantigenic procedures and placed into a living host

Alloplast A chemically derived nonanimal material

Xenograft A graft taken from a nonhuman host for implantation into

a human host

Biology of Bone Grafts

Phase I Osteogenesis: Immediate proliferation of

transplanted osteocytes and subsequent formation of osteoid(immature bone)

Phase II Osteoinduction: inducement of mesenchymal

cells to produce bone(BMP) Osteoconduction: framework or scaffold for the

formation of new bone tissue

Mandibular Ramus

To create an incision starting on the lateral border of the ramus approximately 1.5cm above the mandiblular occlusal plane and ending at the mandibular second molar region

#9 Molt periosteal elevator: full thickness mucoperiosteal flap

Harvesting Techniques I

0.9% Sodium chloride solution/ Crushed into small particles or used as block

Mandibular Ramus

Mandibular Tori as a Donor site

Harvesting Techniques II

Monobevel Chisel is used, With the bevel positioned facing the l ingual cortex

Grafting of the Extraction Socket

The teeth are extracted atraumatically preserving the buccal bone.

All granulation tissue is excised with the use of a surgical curette or a Rongeur.

DFDBA(deminerized freeze-dried bone allograft) + Gore Tex Mem.

Extraction Socket Grafting

A. Extraction socket with particulate graft in placeB. Closure of extraction site with interdigitating

papil lae

Cortical Onlay Bone Graft

Inadequate buccal to lingual/palatal width

Autogenous bone: donor sites-mandibular symphysis, mandibular ramus, calvarium or iliac crest

Allografts: demineralized freeze dried bone allograft blocks, freeze-dried blocks, and/or particles

Harvesting Techniques II I

Bone Harvasting from the Chin

Buccal sulcus incision: canine to caine

Full-thickness mucoperiosteal flap Avoid the mental nerve

Level approximately 5mm below the apices of the mandibular anterior teeth

Small curve monoplane osteotome

Hemostasis: Avitene(MedChem Products Inc., Woburn, MA)

3-0 Vicryle suture on a tapered needle

First approximate periosteum with multiple intterupted sutures being careful to maintain the mentalis muscle

Bone Harvasting from the Chin

그림

Interpositional Ridge Graft

The approximate depth of the osteotomy should be 1cm.

A bibevel chisel is used to gently outfracture the buccal plate and allow enough width for the proposed implant

Split ridge technique

Rigde split technique 에 대한 그림

Sinus-Lift Procedure

Dept. of Oral and Maxil lofacial Surgery, School of Dentistry,

Wonkwang Univ.

Kwon, Kyung-Hwan

Sinus-Lift Procedure definition

Taum OH(1977) Introduced crestal approach to the sinus

membrane In 1986, modified Caldwell-Luc lateral

window

The grafte material is inserted between the antral floor and the Schneiderian membrane(lining of the maxillary sinus floor)

Evaluation of Sinus

Fixture failure will result because of the downgrowth of antral epithelium aroud the fixture rather than by the superior growth of oral epithelium

Protocol of Sinus Lifting Indication 4 mm below: Lateral window technique 4-6mm :Summer’s Osteotome technique 6mm above: Simultaneous implant with bone

grafting

Graft Material for Sinus Lift

Autogeous Bone Hip/ Tibia/ Symphysis/ Ramus/ Maxillary

tuberosity Allograft(obtained from human cadavers)

Freeze-dried bone/DFDB Xenografts(Bone from nonhuman species)

Bovine bone(Bio-Oss) Alloplastic(Natural and synthetic bone

substitute) Hydrozyapatite/ Tricalcium phosphate(TCP)/

Bioactive glass ceramics

Time Tables

Waiting between 4 and 9 after grafting for implant placement and an additional 4 to 6 months before placing final restoration

In my clinics, Simultaneous implantation study show result of 95% success rate. but, case by case

Surgical Protocol

Maxil lary Sinus Lift ing Technique

A B C D

A: Sagittal view of maxil lary sinus showing relationship of sinus membraneB: Showing outl ine of bony cuts for creation of lateral windowC: Mucosal flap elevated and slow round bur being used to create bony windowD: Antral membrane shown tented upwards with implant place and bone fil l ing

Surgical Protocol

Round diamond #6 burr Surgical curette is place in the edges of

the inferior osteotomy between the bone and the antrum and gently used to peel away the membrane from the inside wall of the sinus

Perforation of membrane: CollaTape used Leave sutures in place fo 7 to 10 days Antibiotics, analgesics and decongestant

coverage

Maxil lary Sinus Lift ing Technique

Not wear a removable appliance for the first 2 postoperative weeks

The most common postoperative complication: Infection- irrigated daily until resolution

Maxil lary Sinus Lift ing Technique

Sinus lifting 그림

Principles of Implant Surgery

Essential Critical Factors-Implant placement success-

Minimal trauma Biocompatible material Buried and untouched for 3 to 4

months before prosthetic loading Copious internal or external irrigation

to minimize thermal bone demage Precious attachment of implant and

prosthesis

Relative Contraindications

Uncontrolled diabetic patient Significant smocking history

Jawbone irradiation less than 1 year before implant placement

Acute psychotic disorders Severe bone resorption in patient

who refuses bone grafting

Implant Placement

Minimal Dimensional Parameters

At least 1mm of excess bone: both the lingual and buccal or labial side

At least 2 mm of bone: implant and any adjacent tooth or implant

Vertical ridge height must ideally provide a 1- or 2 mm margin of safety from the inferior alveolar mandibular canal, maxillary sinus, and other adjacent vital structures

Adequate vertical space: minimum of 8mm

Implant Work-Up ProtocoI(1)

Appropriate X-rays Panoramic film Periapical X-rays CAT scan(if deemed necessary) Lateral cephalogram(when indicated in

edentulous lower arch)

Models of upper/lower arches

Mock wax-up of missing teeth on mounted upper/lower casts

Fabrication of plastic stent Peper tacing: sinus and inferior

alveolar nerve Detect thickness and concavities Evaluation of existing periodontal

condition Patient education: Risks and

complication

Implant Work-Up Protocol(2)

Diagnostic and Surgical Implant Placement Protocol

Initial Dental Consultation Clinical Evaluation and Diagnosis

Therapeutic Plan Presurgical Mouth Preparation

Surgical Implantation

Prosthetic Management Follow-Up Care and Maintenance

Initial Dental Consultation

Patient’s reason an motivation for dental consulatation

Etiology of edentulous or patially edentulous state

General medical history Indications and contraindications Specific dental/oral complaints Oral Examination Psychosocial evaluation Preliminary diagnosis

Diagnostic and Surgical Implant Placement Protocol (1)

Clinical Evaluation and Dx.

Review of indications and contraindications Oral examination Evaluation of existing dentition Periodontal evaluation: prophyaxis Occlusal analysis Analysis of models in a semiadjastabl articulator Radiographic findings Full mount Panorex radiogaph Specific periapical and/or lateral jaw radiographs Photographic documentation

Diagnostic and Surgical Implant Placement Protocol(2)

Therapeutic Plan

Implant position and sizes Prosthetic restoration

Explanation of treatment plan Establishment of treatment sequence

and schedule Establishment of financial

arrangements

Diagnostic and Surgical Implant Placement Protocol(3)

Presurgical Mouth Preparation

Extractions

Necessary restorative dental procedures

Periodontal therapy

Endodontal therapy

Orthodontal therapy

Prophylatic splinting

Presurgical measurement radiograph with surgical template in place

Diagnostic and Surgical Implant Placement Protocol(4)

Surgical Implantation

Confirm measurement of potential implant sites on radiograph

Positioning of the surgical template Surgical insertion of implant(Stage 1)

Reopening of the implant sites(Stage 2) Removal of first phase healing screw

Diagnostic and Surgical Implant Placement Protocol(5)

Prosthetic Management

Preparation of adjacent natural teeth Removal of second phase healing

screw Making impression

Fabrication of master model Try-un and adjustment of prosthesis Delivery of prosthesis

Diagnostic and Surgical Implant Placement Protocol(6)

Follow-Up Care and Maintenance

Oral prophylaxis

Periodotnal evaluation

Oral hygiene reeducation and remotivation

Implant recommandation

Diagnostic and Surgical Implant Placement Protocol(7)

Partial Denture ? Or Implant?