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Bone Augmentation
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Page 1: Bone Augmentation

Bone Augmentation

Page 2: Bone Augmentation

Bone Augmentation

• For dental implants to be successful, the

jawbone must have enough bone to support

them. You may not have enough bone because

of tooth loss from periodontal (gum) disease,

injury or trauma, or a developmental defect. If

your jaw is too short (up and down), too narrow

(side to side), or both, you will need a procedure

to add bone to your jaw before implants can be

placed.

Page 3: Bone Augmentation

•Bone augmentation is a term that is used to

describe a variety of procedures that are used

to "build" bone so that dental implants can be

placed. These procedures typically involve

grafting (adding) bone or bonelike materials

to the jaw, and waiting for the grafted

material to fuse with the existing bone over

several months.

Page 4: Bone Augmentation

•There are several different procedures that

can be used for bone augmentation. The

dentist will select a procedure depending on

the type, location and number of implants to

be used.  If it needs a bone graft, it is

important that the patient and the dentist

discuss all of the options available.

Page 5: Bone Augmentation

•After a bone-augmentation procedure, the

dentists usually wait 6 to 12 months

before placing implants, although some

dentists may place them sooner.

Page 6: Bone Augmentation

Where Does the Bone Come From?• Most bone-augmentation procedures involve the use of

bone grafts. The best material for a bone graft is our

own bone, which most likely will come from our chin or

ramus (the back part of the lower jaw). If the oral

surgeon cannot get enough bone from these areas, he

may need to get bone from the hip or shin bone (tibia)

instead. The hip is considered to be a better source

because the hip bone has a lot of marrow (soft tissue

within the bone), which contains bone-forming cells.

Page 7: Bone Augmentation

• If the patient don't like the idea of having bone removed

from their body to be placed in their jaw, there are other

options available. The dentist can use materials made

from the bone of human cadavers or cows. There are also

synthetic materials that can be used for bone grafting.

While most dentists prefer using a person's own bone,

possibly in combination with other materials. The dentist

and the patient should discuss their options and their

risks and benefits before any procedures are done.

Page 8: Bone Augmentation

A Typical Bone-Augmentation Procedure

•Local anesthesia will be used to numb the

area where the bone augmentation is needed

(recipient site) as well as the area from where

bone will be removed (donor site). The

specialist first will make an incision in the

gum where the implant will be placed to

determine how much and what type of bone is

needed.

Page 9: Bone Augmentation

• Then will make an incision in the gum below the

lower front teeth to expose the chin bone. A block

of bone will be removed from the chin along with

any bone marrow. The specialist will fill the spot

where the bone was removed with another type of

bone-graft material, and will cover this with a

membrane to keep soft tissue from filling the

space as it heals. The incision then will be

stitched closed.

Page 10: Bone Augmentation

• To place the removed bone in the recipient site, the

specialist first will drill little holes in the existing

bone to cause bleeding. This is done because blood

provides cells that help the bone heal. The block of

bone that was removed from the chin will be

anchored in place with titanium screws. A mixture of

the patient's bone marrow and some other bone-graft

material will then be placed around the edges of bone

block. Finally, the specialist will place a membrane

over the area and will stitch the incision closed.

Page 11: Bone Augmentation

• After a bone-augmentation procedure, the patient

will be given antibiotics, pain medication and an

antibacterial mouthwash. He will be asked to avoid

certain foods, and will be told how to avoid putting

pressure on the area while it heals. If the patient

wear a denture, he may not be able to wear it for a

month or longer while the area heals. If you have

natural teeth near the bone graft, your dentist may

make a temporary removable bridge or denture to

help protect the area.

Page 12: Bone Augmentation

•The bone graft will take about 6 to 12

months to heal before dental implants can

be placed. At that time, the titanium

screws used to anchor the bone block in

place will be removed before the implant

is placed.

Page 13: Bone Augmentation

Success of Bone Grafting

• The success rate for bone grafts in the jaws for

the purpose of placing dental implants is very

high. However, there is always a chance that

the bone graft will fail, even if your own bone

was used. Bone grafts are not rejected like

organ transplants. When they fail, it is usually

because of an infection or because the grafted

bone wasn't stabilized and has come loose from

your jaw.

Page 14: Bone Augmentation

•Dentists don't know why some bone grafts fail,

but they do know that certain people — such

as those who smoke and those with certain

medical conditions — have a higher risk of

graft failure than others.

•A failed graft will be removed. Once the area

has healed, your dentist can place a second

graft.

Page 15: Bone Augmentation

Other Types of Bone-Augmentation Procedures

Page 16: Bone Augmentation

Sinus Lift

•One type of bone-augmentation procedure,

called a sinus lift (or elevation), increases the

height of your upper jaw by filling part of your

maxillary sinus (the area above your jaw on

either side of your nose) with bone. This is done

when there is not enough bone to allow

implants to be placed in the back part of the

upper jaw.

Page 17: Bone Augmentation

Ridge Expansion

• A ridge expansion is a type of bone graft that can be

done when the jaw is not wide enough to support

implants. Your oral surgeon uses a special saw to

split the top of thejaw ridge, and then packs graft

material into the newly created space. Some dentists

will place implants directly after this procedure.

Others will wait several months for the ridge to heal.

This procedure can be done in the dental office under

local anesthesia.

Page 18: Bone Augmentation

Distraction Osteogenesis• One of the newest procedures for augmenting areas of bone is called

distraction osteogenesis. This procedure originally was used for lengthening

the bones of patients with abnormally short legs. It now has been adapted for

use in the mouth. A surgeon makes cuts in your jawbone to separate a piece of

bone from the rest of the jaw. A titanium device inserted into the jaw with pins

or screws holds the piece of bone apart from the rest of the jawbone. Over time,

the space between the piece of bone and the jawbone is widened slightly by

unscrewing the device, and the area between the pieces gradually fills in with

bone. "Distraction" refers to the process of separating the two pieces of bone,

and "osteogenesis" refers to the forming of new bone. Distraction osteogenesis

is used more often to make the jawbone taller, but it can be used to increase

the bone in any direction. The procedure is becoming more common.

Page 19: Bone Augmentation

Nerve Repositioning

• A nerve called the inferior alveolar nerve runs through

the lower jaw. This nerve gives feeling to the lower lip

and chin. In patients who have lost significant amounts

of lower jawbone, it may not be possible to place

implants without damaging this nerve. To address this

problem, an oral surgeon can drill a small window in

the bone and move the nerve to one side. The implants

then can be placed through the bony canal previously

filled by the nerve. This technique is not used very

often because it is possible to damage the nerve just

by moving it.

Page 20: Bone Augmentation

Case Report

•A 53-year-old female patient came to the

Clinic of Oral and Maxillofacial Surgery of

the Ribeirão Preto Dental School, University

of São Paulo, Brazil, complaining of

impairment of her masticatory function

associated with the instability of the

mandibular complete denture.

Page 21: Bone Augmentation

• The clinical exam revealed edentulism in both

arches, while the mandibular arch presented

severe reabsorption resulting in denture

instability and chronic trauma to the oral

mucosa. The radiographic exam showed a

mandibular atrophy class VI, according Cawood

and Howell (12), that made unpredictable any

rehabilitation based on osseointegrated

implants.

Page 22: Bone Augmentation

•Figure 1. Panoramic radiograph exhibiting a class VI Cawood and Howell (18) mandibular resorption.

Page 23: Bone Augmentation

The treatment plan proposed consisted of 3 steps:

• 1) to apply the modified visor osteotomy technique

together with autogenous bone graft harvested

from the iliac crest;

• 2) the placement of at least 5 osseointegrated

implants with a minimum length of 13 mm; and

• 3) to construct a fixed Brånemark’s protocol

prosthesis.

Page 24: Bone Augmentation

•The first surgical procedure was applied

under general anesthesia at the Hospital

of Clinics at the Medical School,

University of São Paulo, Brazil.

Page 25: Bone Augmentation

•Figure 2. Visor shape of mandibular distal segment after the mobilizing the segments.

Page 26: Bone Augmentation

•Figure 3. Autogenous corticocancellous bone grafts placed in an intepositional fashion, fixed with 2.0 titanium screws. Only particulated bone was placed in the posterior aspect of the mandible.

Page 27: Bone Augmentation

• After 6 months, 6 osseointegrated implants with dimension of 3.75 x 15

mm were implanted according to a previous prosthetic treatment plan.

Four months later, these implants were exposed to the oral cav-ity using

abutment healings preserving the keratinized gingiva, and 3 weeks after

that the patient was referred to the prosthesist. Twelve months after the

installation of the final Brånemark protocol prosthesis, the evaluation of

the osseointegrated implants revealed suc-cess according to the

previously established criteria (15).

Page 28: Bone Augmentation

•Figure 4. Different views of modified visor osteotomy in a dry mandible.

Page 29: Bone Augmentation

Figure 5. Uniform augmentation both in anterior and posterior region of the mandible, as demonstrated in a panoramic radiograph. 

Figure 6. Placement of long implants for rehabilitation of the edentulous mandible.

Page 30: Bone Augmentation

•Figure 7. Good oral health after 12 months of follow up.

Page 31: Bone Augmentation

•The modified visor osteotomy technique,

applied together with autogenous bone

graft harvested from the iliac crest, offers

predictable results for reconstruction of

the severely resorbed edentulous mandible

and posterior rehabilitation with

osseointegrated implants.

Page 32: Bone Augmentation

Video Presentation:

Box Technique - Vertical

Ridge Augmentation

Procedure in Severe

Mandibular Atrophy.

Page 33: Bone Augmentation
Page 34: Bone Augmentation

Box Technique

•Box technique was invented in November

2008 by Dr. Andrea Menoni. It is the first

prosthetically guided by bone

regeneration technique aimed at fully

restoring the lost bone volume by using

only Polylactic acid absorbable materials.

Page 35: Bone Augmentation

•The technique allows bone regenration in

3 dimension of space without the need for

bone grafts to the patients, thus

minimizing the trauma of surgery.

•The aim of box technique is to fully

restore the bone to approximately its

original condition so that it is not only

functional but also aesthetically pleasing.

Page 36: Bone Augmentation

•The use af absorbable material is

beneficial for the following reasons:

•1. a second operation for their removal is

not required.

•2. the surgical intervention is far less

traumatic for the patient

•3. in cases of osseointegrated implants, the

rehabilitation period is significantly

reduced.

Page 37: Bone Augmentation

• The poly DL lactic acid is an absorbable material

which is completely amorphous as both

components are present in equal proportions. As

a result, the biodegration process is completely

predictable and safe. This new material is fully

tolerated by human tissue and does not result in

inflammation after contact with the PDLLA after

application sonic weld methodology.

Page 38: Bone Augmentation

• The degredation of PDLLA and its componentsis

through the metabolic process of hydrolysis,

where upon the final product is water and

carbondioxide, both of which are physiologically

eliminated from the body. This innovative

material presents the prime advantage of being

reabsorbed while simultaneously maintaining its

structural strength for the time necessary to

ensure the stability of the dot, the graft, and the

load resistance. All of which is important in GBR

(guided bone regeneration).

Page 39: Bone Augmentation

• The box technique is a new technique which

prosthetically used a guided bone regeneration

and only uses absorbable materials which are

processed naturally by the body. This

revolutionary method does not require the use

of the patient’s bone in the regeneration

process. Instead it uses a choice of either

XENOGRAFT or ALLOGRAFT creating

discomfort to the patient.

Page 40: Bone Augmentation