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 gin
giva Cross section of the alveolar depicting p
eriodontal 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 ModelsDiagnosis 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 pr
eserving the buccal bone. All granulation tissue is excised with the
use of a surgical curette or a Rongeur. DFDBA(deminerized freeze-dried bone all
ograft) + 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 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 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)/ Bioacti
ve 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 ProtocolMaxillary 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 st
ate 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?