Bone Grafting for implants

Dept. of Oral and Maxillofacial 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 s

can 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 verti

cal 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 th

e anatomic structures Buccal to lingual width will not be apprec

iated 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 plac

ement Diagnostic wax-ups Arch form, tooth spacing, and bony cont

our

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 for

mation of new bone tissue

Mandibular Ramus To create an incision starting on the l

ateral 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 lingual 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 papillae

Cortical Onlay Bone Graft Inadequate buccal to lingual/palatal wid

th Autogenous bone: donor sites-mandibul

ar symphysis, mandibular ramus, calvarium or iliac crest

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

Harvesting Techniques III

Bone Harvasting from the Chin

Buccal sulcus incision: canine to caine Full-thickness mucoperiosteal flap Avoid the mental nerve Level approximately 5mm below the apic

es 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 intt

erupted 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 outfrac

ture 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 Maxillofacial Surgery, School of Dentistry, Wonkwang Univ.

Kwon, Kyung-Hwan

Sinus-Lift Procedure definition

Taum OH(1977) Introduced crestal approach to the sinus m

embrane In 1986, modified Caldwell-Luc lateral wind

ow The grafte material is inserted between t

he antral floor and the Schneiderian membrane(lining of the maxillary sinus floor)

Evaluation of Sinus Fixture failure will result because of the dow

ngrowth 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 gr

afting

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)/ Bioact

ive 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

Maxillary Sinus Lifting Technique

A B C D

A: Sagittal view of maxillary sinus showing relationship of sinus membraneB: Showing outline 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 filling

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

nferior 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 cove

rage

Maxillary Sinus Lifting Technique

Not wear a removable appliance for the first 2 postoperative weeks

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

Maxillary Sinus Lifting 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 pros

thesis

Relative Contraindications

Uncontrolled diabetic patient Significant smocking history Jawbone irradiation less than 1 year bef

ore implant placement Acute psychotic disorders Severe bone resorption in patient who re

fuses 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 adjac

ent 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 up

per/lower casts

Fabrication of plastic stent Peper tacing: sinus and inferior alveolar

nerve Detect thickness and concavities Evaluation of existing periodontal conditi

on Patient education: Risks and complicati

on

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 cons

ulatation Etiology of edentulous or patially edentulous s

tate 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 surg

ical 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 evaluatio

n Oral hygiene reeduca

tion and remotivation Implant recommanda

tion

Diagnostic and Surgical Implant Placement Protocol(7)

Partial Denture ? Or Implant?