Surgical methods of

bone replacement

Attila Szűcs DDS, PhD

Semmelweis University, Budapest

Department of Oral and Maxillofacial Surgery and Denistry

Success

for long term

(both by functional + esthetical point of view)

• excellent bone quantity

– vestibulo-oral + vertical dimension

• Good implant system

•Right treatment plan+sugical treatment

The indications of surgical

bone replacement

• After pathological bone loss

• After surgical bone loss

• Before or together with oral

implant rehabilitation

Dentistry has undergone many

changes during the past quarter

century; however, no changes have

been more profound than those

in the field of implant

dentistry

Nevins M., J. T. Mellonig edit.: Implant Therapy

Quintessence 1998.

The implant therapy

belongs to the

everyday dental practice,

because of its

predictability and high

success rate.

Present

The indication of

implant therapy can

be any of those

edentulous

situations, where

the goal is the re-

establishment of the

function and esthetics

of natural teeth

Past

The indication of

implant therapy was

determined by the

anatomic

conditions of bone.re-establishment of

the function and

esthetics of natural

teeth.

The modern surgical

methods of bone

replacement are

prominent parts of

oral surgery.

Indication

„SAC” classification

(ITI):Straightforward,Advanced and Complex

classification system (2007)

Special instruments

„Micross”

„Safescraper”

edge

collector

„Safescraper”

Bone collector

Bone mill

Piezo surgery

Micro screw

Micro saw (Khoury)

Bone splitting set

„Transfer-control”

Oteotom for bone condensation

Scaffolds /matrices//collagen, bone matrix, bone grafts/

Cells/osteoblasts,

fibroblasts/

Growth factors/BMP, PDGF, TGF-β, IGF/

Time

Biologic environment

The basic conditions of new bone formation

Scaffolds /Matrices/

Cells Growth factors

Bone replacement procedure in the

practice

Autogenous

monocortical-block

bone transplantation

Gold-standard

Autogenous bone harvested from the

iliac crest

Harvesting sites on the mandible

Monocortical bone-block-transplantation from the

iliac crest to the mandible /Op. Dr. Barabás J./

Scaffolds /Matrices/

Time

Biologic environment

The basic conditions of new bone formation

OSTEOCONDUCTION:

the use of autolog,

heterolog, or alloplastic

materials for creating a

matrix of new bone

formation

What are the relevant

characteristics of

bone grafting

materials?

Relevant characteristics of bone grafting

materials

• Chemical composition

HA synthetic

Interpore

Osprovit

Osteogen

HA natural

Bio-Oss

Ossnative

TCP

CerasorbTCP

Cerasorb

CHEMICAL COMPOSITION OF GRAFT MATERIALS

Calcium-phosphates

Calcium-carbonate

BioCoral

Bioglass ceramics Bioglass

Biogran

Polymers

Bioplant HTR

Calcium-phosphates

HA

natural

Bio-Oss

Ossnative

HA

synthetic

Interpore

Osprovit

Osteogen

HYDROXILAPATITE

(HA)

(Pentacalciumphosphate)

Ca5(PO4)3OH

Ca : P = 5 : 3

nonresorbable

TRICALCIUMPHOSPHATE

/TCP/

Ca3(PO4)2OH

Ca : P = 3 : 2

resorbable

THE MOST WIDELY USED CALCIUM-

PHOSPHATE GRAFT MATERIALS

Relevant characteristics of bone

grafting materials

• Chemical composition

• Volume of grafting

material

Bone grafting materials in 0,5 g quantities

The porosity of osteoconductive

materials

BONE 70%-80%

Bio-Oss 60%

Osteogen 60%

Interpore 16%

HTR ——

Bio-Oss bone grafting material

Osteointegration of Bio-Oss

Bone

Bio-Oss

The Bio-Oss® particles are

integrated in the newly

formed lamellar bone.

Time: min. 6 months

The matrix produced

by Bio-Oss®, facilitates

the ingrowth of blood

vessels, and the

migration of osteoblast

cells.

So develops the cell-rich

woven /reticular/ bone.

The highly porous

Bio-Oss® ceramic

stabilizes the

coagulum

The healing of bone

grafting material depends

on

• the blood supply of the

surrounding bone

The geometrical form of bone defects

5 walls 4 walls

bone graft bone graft + membrane

2-3 walls 1 wall

bone graft + fixed

membrane

bone graft + membrane +

autogenous bone

Therapy:

Therapy:

The healing of bone grafting

material depends on

• the blood supply of the surrounding bone

• surgical technique

GBR = Guided Bone Regeneration

The intensity of growth of

different tissues

connective tissue 0,5 mm/day

bone tissue 50 μm/day

Schematic

illustration of

GBR technique

Different types of

membranes

Resorbable

collagen, synthetic

Non resorbable

titanium, PTFE

BIO-GIDE® MEMBRANE

• Resorbable collagen

• Two-layers

(dense, porous)

• Slow resorption

(5-6 months)

Surgical methods with the use of

bone grafting materials

• Lateral augmentation

Implant

+

bone graft + membrane

6-7 months healing time

Immediate implantation with

bone replacement

Lateral augmentation with

simultaneous implant placement

Lateral augmentation with simultaneous

implant placement

The integration of bone graft

Lateral augmentation with simultaneous

implant placementNew bone formation, ready for implant prosthesis

Immediate implantation

after 6 months

Late implantation after bone

replacement

bone graft + membrane

6-8 month

healing

Implant placement

Lateral augmentationInsufficient bone volume for implant placement

Lateral augmentationPerforations of outer cortical layer

Lateral augmentationThe placement of bone graft and membrane

Lateral augmentationThe integration of bone graft

Lateral augmentationNewly formed bone, implant placement

Fixation of Bio-Gide membrane with

two layers

Vertical cross-section histologic picture

in the site of augmentation

bone

bone + bone graft

connective tissue + bone graft

The osteointegration

of bone grafting

materials is limited

Growth factors

Scaffolds /matrices/

The basic conditions of new bone formation

OSTEOINDUCTION

Mesenchymal

cell

Osteoblast

Osteocyte

THE TRANSFORMATION OF

OSTEOGENETIC CELLS

BMP

Bone Morphogenetic Proteins

Site of occurrence, synthesis:

- produced by the osteoblasts

- stored in the bone

Effects: influence on cell differentiation

• 13 osteoinductive BMPs have been discovered so

far

• Clinical trial with BMP-2 /rhBMP-2/.

Growth factors

Scaffolds /Matrices/

Bone replacement procedure in the

practice

Bone grafting material+GBR technique

+Autogenous bone

particles

Intraoral bone harvesting sites

Harvesting bone-blocks from the chin

Surgical methods with the use of

bone graft materials

• Lateral augmentation

• Bone-splitting, bone

spreading

Bone-splitting procedure

Insufficient bone volume for implant

placement

Bone-splitting procedureThe surgical technique of bone-splitting

Bone-splitting procedure

The placement of bone graft and membrane

Bone-splitting procedure

The osteointegration of grafting material

Bone-splitting procedure

Bone-healing, implant placement

Bone-splitting procedure

Bone-healing, implant placement

after 7 months

Surgical methods with the use of

bone graft materials

• Lateral augmentation

• Bone-splitting, bone-spreading

• Sinus-lift, sinus elevation

Sinus-lift procedure

Sinus-lift procedureCompleting lateral bone-window

Sinus-lift procedurePreparation of sinus mucosa, with hinging the

bone-window

SINUS-LIFT PROCEDUREPreparation of sinus mucosa

Sinus-lift procedurePlacement of grafting material and the

barrier membrane

Sinus-lift procedureOsteointegration of the bone grafting

material

Sinus-lift procedureNew bone formation, placement of implant

Past

The indication of

implant therapy was

determined by the

anatomic conditions

of bone.

Present

The indication of

implant therapy

can be any of those

edentulous

situations, where

the goal is the re-

establishment of the

function and

esthetics of natural

teeth

Future =

Tissue engineering