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INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com

Rigid probl/cosmetic dentistry course

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INDIAN DENTAL ACADEMY

Leader in continuing dental education

www.indiandentalacademy.com

www.indiandentalacademy.com

Part I

• Introduction

• Keys to bone grafting

Bone grafting materials

Socket grafting

Part II

Maxillary sinus lift & sinus graft surgery

Intraoral autogenous donor bone grafts

Extraoral autogenous donor bone graftswww.indiandentalacademy.com

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Absence of infection

Soft tissue closure

Space maintenance

Graft immobilization

Regional acceleratory phenomenon (RAP)

Host bone vascularization

Growth factors

BMPs

Healing time

Defect size & topography

Transitional prosthesis

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Rapid solution mediated resorption in conditions of

low PH

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Causes of graft material infection

Endogenous bacteria

Lack of aseptic surgical technique

Failure of primary soft tissue closure

Lack of blood supply in early stages of

grafting

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Guidelines

Primary incision should be in keratinized tissue

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Crestal incisionis designed more lingual

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Vertical incisions

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Vertical incisions are made to the height of MGJ &

flap is retracted only 5 mm above the height of MGJ.

This maintains more blood supply to the facial flap

Incision is not extended to mobile mucosa

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Soft tissue reflection distal to graft

Site is split thickness

Maintains some of the periosteum around incision

line

Early vascularization of incision line

Adhesion of the margins to reduce retraction during

initial healing

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2 techniques depending on

If less than 5 mm of advancement is necessary

To expand tissue over larger graft sites (15 x 10 mm)

-- submucosal space technique

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For a small graft site

More apical tissue reflection

Horizontal scoring of the periosteum parallel to

primary incision

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Developed by Misch in early 1980s

Full thickness facial flap is elevated off the facial

bone for 5 mm above the height of vestibule

One incision 1 to 2 mm deep is made through the

periosteum parallel to the crestal incision and 3 to 5

mm above the vestibular height of periosteum

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Blunt dissection is done using soft tissue scissors

(metzenbaum ) to create a tunnel apical to the

vestibule & above the unreflected periosteum

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Thickness of facial flap should be 3 to 5 mm

Facial flap should be able to pass the lingual flap

margin by more than 5 mm

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Disadvantages

Loss of vestibular depth

Lack of keratinized tissue on facial region of grafted

site

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Methods

Tent screws

Barrier membrane

Ti reinforced membranes

Graft material beneath the membrane

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Barrier by bulk

Concept given by Misch

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Methods

Bone tacks

Tent screw

Bone screws work better with block bone grafts

than particulate

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Fixed transitional prosthesis

Indicated with barrier by bulk tech. using particulate

material

Prosthesis should have rest seats & clasps to

prevent loading soft tissues

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Local response to a noxious stimulus by which tissue

forms faster than the normal regional regeneration

rate

Healing is 2 to 10 times faster than normal

physiologic healing

Begins within a few days after injury , peaks at 1 to 2

months usually lasts 4 months in bone & may take

upto 6 to 24 months to subside

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Source of blood vesels

Host cortical bone (few arterioles

Cancellous bone (intensely vascular network

Blood vessels are needed to

Help the autograftmaintain vitality

To repopulate the area with osteoblasts www.indiandentalacademy.com

Host site is decorticated with a rotary drill to increase

amount of host blood vessels at the graft site

There should be spaces available between graft

particles for blood vessels to enter

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Methods to increase tissue growth factors at graft site-

Use of autologous bone in graft

PRP

Use of allografts

RAP

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Gerald D , Carlson ER , Gotcher JE et al

J of Oral Maxillofacial Surg 2006 : 64 (443 – 451)

PDGF mixed with autologous bone can accelerate

mineralization by as much as 40 % during the first

year

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Factors affecting healing time

Local

Number of remaining walls of bone

Amount of autogenous bone in the graft

Size of the defect

Systemic

Diabetes

Hyperparathyroidism

Thyrotoxicosis

Osteomalacia

Osteoporosis

Paget’s diseasewww.indiandentalacademy.com

4 to 6 months -- graft volume is less than

5 mm

6 to 10 months -- graft volume is more

than 5 mm

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Defect size effect following aspects of augmentation

Healing time

Vascularization

Transitional prosthesis

Graft material selection

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Augmentation will be faster in an

extraction socket surrounded by 5

walls than for a onlay graft on div

D bone

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Transitional resto. effects

Soft tissue closure

Maintenance of space

Immobilization of graft during healing

Restores esthetics & function

Contours the soft tissue

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Transitional acrylic FPD

Metal reinforced acrylic FPD

Resin bonded prosthesis

Fixed temporary - eg temporaray implants

Removable restoration

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Bone graft materials

collagen

Osteogenic

Eg autologousbone

Osteoinductive

Eg DFDB

osteoconductive

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Sources

Bovine collagen from achilles tendon in the

leg

DFDB

Collagen barrier membranes used for GBR

Resorption rates vary from a few months

to 1 year

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Autogenous trabecular bone

• Contains more osteoblasts

• More osteogenic

Autogenous cortical bone

• Contains more bone growth factors

• More osteoinductive

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Should remain vital to be able to produce osteoid

Recipient site is prepared first

Should be placed immediately after harvesting or stored

in

Sterile saline

lactated ringers solution

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Should not be mixed with other synthetic graft

materials

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Decortication of host bone

Directly placed on host bone

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Phase I

Osteogenesis

Bone regeneration by

surviving cells (osteoid)

4 weeks

Phase II

Osteoinduction

BMP release

2 wks to 6 months , peak at

6 wks

Phase III

Osteoconduction

Inorganic matrix

replaced by creeping

substitution

Phase IV

Cortical plate acts as a

barrier membrane

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The only osteogenic graft material

Osteoinductive property

Osteoconduction

Space maintenance- maintains contour of desired

augmentation

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Bone autografts

Allograftsosseous transplanted tissues from the same species as the recepientbut of different genotype

• Frozen bone

• Freeze dried bone

• Demineralized freeze dried bonewww.indiandentalacademy.com

Bone can be harvested , frozen & stored to be used

in the same patient at a later date

Allograft frozen bone is rarely used because of risk

of rejection & disease transmission

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Cortical & trabecular bone is harvested in a sterile

fashion from a disease free donor

Washed in distilled water & ground to a particle size of

500 micron to 5 mm

Immersed in 100 % ethanol to remove fat

Frozen in nitrogen

Freeze dried & ground to smaller particle size of 250 to

1500 micron

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Marx RE , Wong ME

J of Oral & maxillofacial surg 1987 : 45 ( page 988)

Solvent prserved products have been developed

instead of freeze drying to reduce antigenicity &

assure a minimal risk of contamination

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Ground bone powder is demineralized in 0.6 N HCl

or nitric acid for 6 to 16 hrs.

After acid bath it is washed & dehydrated

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Irradiation

• Doses greater than 2.5 Mrad are destructive to BMPs

Ethylene oxide sterilization

• 5 hr sterilization at 29 degree celsiusto maintain osteoinductive properties

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Age of cadaver

Type of bone

Cortical bone contains higher conc. Of BMPs than trabecularbone

Membranous cortical bone exhibits greater conc. Of BMPs than endochondral cortical bone

Particle size

Particles smaller than 150 micron are less effective than 250 micron or larger

Fibres of cortical bone (eg grafton ) are more effective than particles.

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Putty consistency products

Fillers do not participate in bone formation

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Allografts

• Freeze dried bone

Alloplasts

• Ceramics

• Polymers

• composites

Xenografts

• Fabricated from inorganic portion of bone from animals other than humans

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• Aluminium oxide

• Ti oxideBioinert

• Ca Phosphate

• Synthetic HA

• Bovine derived bone matrix

• Tricalcium phosphates

• Calcium carbonates

Bioactive

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• Non resorbable

• resorbable

• Dense

• porous

• Crysstalline

• amorphous

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Atraumatic tooth extraction

Socket grafting

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Periosteum should not be reflected if bone volume is

ideal as it helps bone remodellimg or repair

Soft tissue drape around the tooth is also affected by

reflection of periosteum

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An incision within the sulcus is made preferrably with

a thin scalpel blade , 360 degree around the tooth

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Tooth to be extracted should be reduced mesio

distally if the path of removal is obstructed by

adjacent teeth

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Time period for socket regeneration is usually 3 to 6

months depending on

Tooth size

Root no.

No. of bony walls around the socket

Size of alveolus

Trauma of extraction

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In 1993 Miesch & Dietsh suggested different graft

materials & techniques based on the no. of bony

walls remaining after tooth is removed-

5 bony wall defect

4-5 wall defect

2-3 wall defect

1 wall defect

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Any resorbable graft material such as alloplast ,

allograft or autograft

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Socket grafting is indicated if

Labial plate of bone is missing

One of the lateral plates is thinner than 1.5 mm

Height is desired

2 techniques

BM with a mineralized alloplast or freeze dried bone

Modified socket seal surgery

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A periotome or thin periosteal elevator is used to

tunnel under the bone periosteum

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barrier membrane is then slid into the pocket created

under the tissue & it extends apical , mesial & distal

beyond the extraction site

Approx 6-8 mm of BM should extend above the

marginal tissue

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Bone graft material is placed & BM covers the top of

the socket & is tucked in below the palatal tissue

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Developed by Misch et al

It’s a composite graft consisting of connective tissue

, periosteum & trabecular bone used to seal a fresh

extraction socket

J of Oral Implantology 1999 ; 25 (pages 244 – 250 )

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Advantages

CT graft blends into the surrounding attached

gingiva , offering similar colour & texture of the

epitheliumcontains autogenous bone

Blood supply is established from the surrounding soft

tissue

Rapid healing (4 – 5 months )

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• Treated similar to 4 wall defect

Defect size is larger so more bone is

reqd.

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Block graft or cortical autogenous

bone

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Misch in 1990, Implant Dent 1993 ;2 (pages 158- 167)

Layers in GBR include the following

host bone -: decorticated to enhance blood supply , growth factors & RAP

An autograft-: results in more predictable & rapid bone growth by osteogenesis & osteoinduction

Mixture of DFDB (30%) , FDB (70%) , & PRP --: Provides growth factors & space maintenance

BM & Tent screw -:

BM prevents fibroblasts from invading the graft site for at least 6 wks.

Tent screw decreases mobility

Primary closure without tension -: prevents contamination & loss of graft materialwww.indiandentalacademy.com

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Sinus grafting was introduced by Tatum in 1970s

In early 1970s Tatum began to augment post. Maxilla

with autogenous rib bone to produce adequate vertical

bone for implant support

In 1974 he developed modified caldwell luc procedure

In 1975 he developed a lateral approach surgical

technique toelevate sinus membrane & place implant

simultaneously

From 1974 to 1979 primary material for sinus grafting

was autologous bone. In 1980 , Tatum introduced the use

of synthetic bonewww.indiandentalacademy.com

Initial publication on sinus grafting was by Boyne &

James in 1980s

In 1983 Misch observed that the most predictable

intraoral region to grow boneis the max. sinus floor

once the mucosa has been elevated

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Root tips in the antrum

Pseudocysts

Oral antral opening

Extraction of hopeless teeth

Unerupted teeth

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Narrowing of osteomeatal complex

Enlargement of an air cell in the roof of sinus ( haller

cell )

Smoking

Smokers have a 7 % greater failure rate than non

smokers

Pt. should refrain from smoking at least 15 days

before surgery & 4-6 weeks after surgery

Chronic maxillary rhinosinusitiswww.indiandentalacademy.com

Active sinus infection on the day of surgery

Significant recurrent history of chronic

sinusitis

Significant recurrent history of fungal

sinusitis

Uncontrolled late stage diabetes

Cystic fibrosis

maxillary sinus hypoplasia

Neoplasms

Inferior turbinate or meatus pneumatizationwww.indiandentalacademy.com

Antimicrobial medication

Administered at least 1 full day before surgery &

extended for 5 days after surgery

Local antibiotic medications

To ensure adequate antibiotic levels in a sinus graft ,

it is recommended to add antibiotic to the graft

mixture

Mabry TW , Yukna RA J Periodontology 1985 ; 56 (74

– 81)www.indiandentalacademy.com

Oral antimicrobial rinse

Gentle oral rinses of chlorhexidine gluconate 0.12 % should be used twice daily for 2 weeks after surgery

Glucocorticoids

Initiated 1 day before surgery & continued foe 2 days after surgery to control oedeme

Decongestant medications

Oxymetazoline (0.05%)

Phenylephrine (1% )

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Analgesics

Codeine containing drugs such as tylenol 3 are the

drug of choice as they have a potent antitussive

effect

Cryotherapy

Cold dressings for the first 24 – 48 hrs ,elevation of

head & limited activity for 2-3 days helps reduce

swelling

After 2-3 days heat may be applied to increase blood

flow & lymph flowwww.indiandentalacademy.com

In 1984 Misch organised a treatment approach for

posterior maxilla based upon the amount of bone

below the antrum

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in 1995 , Misch modified his classificationto include

the lateral dimension of sinus cavity to modify the

healing period protocol

Smaller width sinnus (0-10 mm) -: less healing time

Larger width(> 15 mm) -: more time

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SA1 conventional implant placement

SA2 sinus lift & simultaneous implant placement

SA3 sinus graft with immediate or delayed

endosteal implant placement

SA4 sinus graft healing & extended delay of implant

insertion

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Indicated when sufficient bone height is present

for the placement of endosteal implants

Evaluation of sinus is less critical

Implants left to heal for 4-8 months

Progressive loading suggested in d3 & d4 bone

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Root form implants are used

At least a 12 mm in height implant for a 4

mm threaded implant

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Osteoplasty or augmentation is suggested to

increase width of bone

Augmentation may be done by

Bone spreading

Autogenous onlay

Appositional grafts

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Onlay autogenous bone grafts are

indicated

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indicated when10-12 mm of vertical bone is present

Tatum originally developed the technique in 1970 &

Misch published it in 1987

Antral floor is elevated through implant osteotomy by

0-2mm

Compresses the bone below the antrum , causes a

greenstick fracture in the antral floor & slowly

elevates the unprepared bone & sinus membrane

over the broad based osteotome

Prosthetic treatment similar to SA1 after 4-6 months

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Indicated when at least 5 mm of vertical bone &

sufficient width are present between the anral floor &

crest of residual ridge

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Anesthesia

Maxillary branch of trigeminal nerve is blocked

Long acting anesthetic such as bupivacaine(0.5%) or etidocaine(1.5%) is preferred

Incision line & reflection

Crest incision is made on the palatal aspect of maxilla from tuberosity to one tooth anterior to the anterior wall of sinus

Vertical relief incision is made on the distal to enhance access to max. tuberosity

Anterior incision is made at least 10 mm ant to the ant wall of sinus

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Access window

Tatum access window is 2-5 mm above the antral

floor , 2-5 mm from the anterior wall 15 mm long &

10 mm in height

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Carbide bur in paint brush stroke is used to outline the

access window

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Flat ended metal punch & mallet is used to lightly

tap & green stick fracture the access window from

the lateral wall of maxilla

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Sharp blade of the curette is placed against the inner

wall of bone & is used to scrape off the sinus

membrane from the bone

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Layered approach to grafting

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Implant placement

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Soft tissue closure

Soft tissues & periosteum must be approximated for

closure without tension

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Indicated when less than 5 mm bone exists between

sinus floor & crest of residual ridge

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Lateral wall approach is performed for sinus graft as

in SA 3 procedure

Medial wall of sinus membrane is elevated at least

16 mm fron the crest so that adequate height is

available for implant placement

If bone from max tuberosity is not enough ,

additional bone may be harvested from above the

roots of maxillary premolars or mandibular

ascending ramus www.indiandentalacademy.com

Intra operative

Membrane perforation

Antral septa

Bleeding

Short term

Incision line opening

Paresthesia

Acute maxillary rhinosinusitis

Long term

Oroantral fistula

Maxillary surgical cysts

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Mandible

Symphysis

Body

Ramus

Maxillary tuberosity

Extraosseous tori

Ridge osteoplasty

Extraction sites

Implant osteotomy

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Convenient surgical access

No cutaneous scar

Patients report minimal donor site discomfort

Inherent biological benefits attributable to the

embryologic origin of donor bone

Experimental evidence shows that grafts from

membranous bone show less resorption than

endochondral bone. Maxilla & body of mandible are

membranous bones

J Oral Maxillofacial surgery 1996 : 54 (15-

20)www.indiandentalacademy.com

Early revascularization of membranous bone grafts

helps in improved maintenance of graft volume

Bone from the maxillofacial skeleton contains

increased concentration of growth factors & BMPs

Plastic reconstructive surgery 1994 : 93 ( 732 –

738)

Improved survival of craniofacial bone grafts is

caused by their 3-D structure

J oral maxillofacial surg 1996 :54 (15 –

20 )

Mand. Cortical bone grafts show little volume loss &

show good incorporation at short healing timeswww.indiandentalacademy.com

In 1992 Misch et al used mandibular symphysis &

ramus bone grafts for endosteal dental implants

J of oral maxillofacial implants 1992 : 7 ( 360 –

366 )

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Symphysis

Ramus

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Easier graft harvest

Less post – op discomfort

Less neurosensory complications

Less incision line opening

Less anesthesia reqd.

More profound LA with fewer drugs

Less concern of changes in facial

morphology

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Less width & length of bone

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Slight curved triangular shape in the midlineis often

well suited for re-establishing the arch form in

maxillary anterior ridges

Average interforaminal distance is greater than 4 cm

, so more bone volume is available

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Width & height requirements for augmentation

Mandibular symphysis : when more than 4 cm of

bone is desired ( C-w bone volume )

Mandibular ramus :when graft width is less than 4

mm ( div. B to B-w bone volume )

Mandibular symphysis along with its cortical inferior

border : when an augmentation for height is required

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Location of the host or recepient site

Recepient site

• Anterior mandible

• Posterior mandible

• maxilla

Donor site

• Symphysis

• Ramus

• ramus

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host site prepration

Bone harvest

Graft fixation

Post operative instructions

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Presence or absence of molars

Width & height of external oblique ridge in the body

of the mandible

Distance from the external oblique ridge & ramus to

the inferior alveolar nerve

Width of posterior ramus is evaluated using

reformatted CT image

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As a result of these

variables a rectangular

piece of cortical bone

about 3 – 6 mm in

thickness may be

harvested from the

ramus. Length may

range from 1 – 3.5 cm &

height usually is not

greater than 1 cm

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After harvesting graft may be stored in sterile saline

or immediately fixed to the recepient site

Trabecular surface of the graft should be in contact

with decorticated surface of the host bone

Donor block & recepient site contouring

2 or more fixation screw sites should be prepared for

each bone block

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Holes in the donor

block should be

slightly larger than the

outer diameter of

fixation screws but

smaller in diameter

than the head of the

screw

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A high speed lindemann bur or carbides are then

used to recontour the block bone & smmothen any

sharp edges or corner after it is fixed

Barrier membrane

Not routinely used with cortical block bone grafts

Indicated if more particulate or trabecular bone is

used

Indicated if block graft is inadequate to fill the entire

space

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Flap should be approximated &

sutures placed such that there is no

incision line tension or tissue ischemia

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Stop smoking at least 3 days before surgery &

until incision line has healed

Removeble soft tissue prosthesis should not be

worn

Confirm to regular post operative follow up

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Intraoral block grafts

4 months for maxillary recepient

5 – 6 months for mandibular recepient sites

Particulate onlay grafts

6 -9 months

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Iliac crest

Tibia

Cranium

Rib

fibula

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Advantages

Large volumeouter portion of the graft may be

primarily cortical with major portion of trabecular

bone underneath

Volume of the bone harvested permits contouring of

2/3 of the mandible or maxilla or filling a large bony

defect

Relative ease of access & harvesting

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Disadvantages

Rapid bone resorption of 30 – 90 % has been

reported when conventional dentures are placed on

top of the reconstruction

Curtis et al JPD 1987 ; 57 (73-

78)

• post operative pain & gait disturbances

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Complications

Pain

Herniation of the abdominal contents

Fracture neuralgia

Hematoma seroma

Infection cosmetic deformity

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Proximal tibial metaphysis provides an excellent

source of trabecular bone

Primarily used with with BM & GBR procedure

because major part of the harvest is trabecular in

nature

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Disadvantages

Contraindicated in adolescents & children coz

disruption of epiphyseal growth centre my occur

Fat content of the marrow is sometimes greater than

that found in the ilium

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Complications

Hematoma

Post operative pain

Infection

Dhiscence ( incidence ranging from 1-4% )

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Sites

Iliac crest

Scapula

indications

Blood supplybto the graft site is severely

compromised

Recipient bed is scarred

Carcinoma patients who have undergone radiation

therapy

Div. E bone anatomy : discontinuity defects of the

jaw

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Advantages

Maintains normal physiologic function

Simultaneous placement of implants with

microvascular bone flap reconstruction has shown

an approximately 80% success rateusing Ti implants

with a short follow up

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Disadvantages

Attaing primary graft stability is often

difficult coz graft is often very

spongeous with a thin cortical layer

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Refers to the formation of new bone between

vascular bone surfaces created by an osteotomy &

separated by gradual distraction

Indications

Mucoskeletal conditions such as post traumatic

defects

Repair of continuity defects

Mandibular lengthening

Maxillary advancement

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Contemporary implant dentistry by Carl E Misch ; 3

ed

Dental update 1997 ; 24 (332-337)

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