VERTICAL RIDGE AUGMENTATION

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Edentulism

 Once the teeth are lost, a continuous resorptive

process
 Results
 Diminished volume and strength of residual bone
 Loss of facial vertical dimension
 Impaired masticatory function
 Difficulty choosing a balanced diet
 Speech difficulty
 Facial soft tissue changes
 Pathologic fracture possibility
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SITE DEVELOPMENT

 Reconstruction of deficient alveolar ridges th

at lacks sufficient volume, contour, or height

 Ultimate surgical goal

 Restore function, form, and long-term stability
 Surgical approach selection
 Type, size, and shape of the defect
 Surgical expertise or experience level of surgeon
 Intended direction of the augmentation
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SITE DEVELOPMENT

 Hard tissue management

 Ridge(socket) preservation
 Ridge augmentation
 Vertical ridge augmentation
 Horizontal ridge augmentation
 Soft tissue management

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SITE DEVELOPMENT

 Hard tissue management

 Ridge(socket) preservation
 Ridge augmentation
 Vertical ridge augmentation
 Horizontal ridge augmentation
 Soft tissue management

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Defect size

 Small edentulous segments (such as single tooth)

 Particulate autogenous bone with membrane
 (Fugazzotto 1997)
 Large ridge reconstructions
 Controversial
 (Lang et al 1994, Chiapasco et al 1999)

 Autogenous block bone

 Extra-oral
 Intra-oral
 Distraction (>5mm vertical deficiency)
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TMI

 Bosker Transmandibular Implant (TMI)

 In the late 1970s
 Without the need for autologous bone graft
 Technique sensitive both surgeon & prosthodontis
t
 Significant “reversible complication” rate
 22.2% (Keller et al, Int JOMI 1986;1:101)
 Infection, superstructure fx, mandible fx, fail to osse
ointegrate

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Ridge augmentation methods

 Bone grafting
 Biomaterials
 GBR
 Alveolar distraction osteogenesis

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Distraction Osteogenesis
for vertical ridge augmentation
 History
 1992, McCarthy and coworker
 1996, Block & colleager ; dog
 1996, Chin & Toth ; DO & Implant
 Advantage
 No additional surgery involving a harvesting procedure
 No limit to lengthening
 Simultaneous lengthening of surround soft tissue
 Dis-advantage
 Long treatment period
 Need for suitable distractor
 Danger of infection
 Ilizarov (1989)
 Preservation of blood supply at the corticotomy site
 Kojimoto & coworkers (1988)
 Preservation of periosteum : distraction
 Vestibular incision rather than crestal incision
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Ridge augmentation methods

 Bone grafting
 Biomaterials
 GBR (Guided Bone Regeneration)
 Alveolar distraction osteogenesis

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Titanium membrane only

 Cornelini (2000)
 Ti-memb only, 3mm vertical ridge augmentation

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Simultaneous implant placement and vertical ridge au
gmentation with a titanium-reinforced membrane: A ca
se report

Cornelini R, Cangini F, Covani U, Andreana S (Int JOMI, 2000;15:883-888)

 Vertical ridge augmentation with titanium reinforced memb.

 2nd surgery : 12 months later
 3mm hard tissue augmentation
 2mm dense connective tissue covered the newly formed bone

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Ridge augmentation methods

 Bone grafting
 Biomaterials
 GBR
 Alveolar distraction osteogenesis

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Autogenous bone graft
 Gold standard for bone augmentation procedures

 Block bone or particulate forms

 Block bone - reduced osteogenic activity & slow revascularization tha
n particulate bone marrow
 Extra-oral or Intra-oral donor-site
 Intraoral harvested intramembraneous bone graft may have minimal r
esorption, enhanced revascularization, and better incorporation at the
donor site

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Autogenous bone graft
 Advantage
 Osteogenic potential
 Block grafts that maintain form and shape
 Ability to correct any size or shape deformity
 Elimination of the possibility for an immunogenic reaction
 Disadvantage
 2nd surgical intervention
 Morbidity associated with the donor site
 Unpredictable bone resorption
 Longer recovery period
 Difficulty in managing soft tissue coverage
 Increased treatment time
 Increased risks

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Autogenous block bone grafts

 Width deficiency
 Veneer or saddle graft
 Most predictable and resistant to resorption
 Vertical deficiency
 Onlay or saddle graft
 Difficult to gain and maintain, high resorption rate
 Combined deficiency

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Donor Sites of Autogenous Bo
ne
 Cortical Bone
 Mandible, Cranium
 Cancellous Bone
 Mx. Tuberosity
 Inner Cancellous part
 Cortico-Cancellous Bone
 Iliac bone

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Intra-oral vs Extra-oral
 Kusiak et al (1985)
 Intramembranous bone grafts accelerate revascularization and healing a
s compared to endochondral bone grafts
 Cortical membranous grafts revascularize more rapidly than endochondr
al bone graft with a thicker cancellous part
 Zins & Whittacker (1983), Philips & Rhan (1990)
 Membranous bone (such as mandible) undergoes less resorption than en
dochondral bone (such as iliac crest)

 Intraoral harvested intramembraneous bone grafts

 Minimal resorption
 Enhanced revascularization
 Better incorporation at the donor site

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Iliac bone

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Chin bone

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Ramus bone

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Ramus bone

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Chin vs Ramus

 Complication (chin vs ramus)

 Less cosmetic concern
 Less wound dehiscence
 No gingival recession
 Less sensory disturbance
 Less discomfort complain
 Trismus & edema (medication)

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 Chin vs Ramus
Parameter Symphysis Ramus
Surgical access Good Fair to good
Cosmetic concern High Low
Graft shape Thick rectangular Thinner rectangular veneer
Graft Size >1cm3 <1cm3
Graft Morphology Corticocancellous Cortical
Graft Resorption Minimal Minimal
Healed Bone Quality Type 2>type 1 Type1>Type2
Post-OP
Moderate Minimal to moderate
pain/edema
Teeth Common(temporary) Uncommon
Uncommon
Nerve damage Common(temporary)

Incision dehiscence Occasional(Vestibular) Uncommon

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Maxilla vs Mandible

 Maxilla
 More vascularity
 Mandible
 Less vascularity
 Cortical bone perforation with bur

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Critical Success Factors

 Stability of grafting materials

 Condition of recipient sites
 No infections
 Resistance to resorptions
 Soft tissue coverage

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Stability of grafting materi
als
 Bony irregularity contouring
 Graft fixation
 Block bone : at least 2 fixation screws for immobiliz
ation

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Condition of recipient sites

 Inlay graft (3~4 wall defect)

 More favorable
 Onlay graft (1~2 wall defect)
 More prone to resorption

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Infection

 Disrupt the process and halts the growth of new bone

 Rupture of the soft tissue closure

 Block graft exposure
 Exposure time (2002, proussaefs)
 Late exposure : no clinical & histologic sign of pathosis or necrosis
 Early exposure : partial or total necrosis

 Fixation screw infection

 Adjacent teeth(structure) pathologic conditions

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Resistance to resorption

 Immobilization
 Satisfactory to restore mandibular volume
 In function the grafted bone underwent rapid resorption
 Onlay graft
 Use membranous bone & graft stability
(Philips & Rhan 1990)
 Cortical bone
 Use of membrane
 Adequate implant placement timing

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Soft tissue coverage

 Crestal incision with releasing incisions

 Lingual flap
 Mesially at least 3 teeth include
 Raise extending beyond mylohyoid muscle
 Tension-free suture
 Mattress suture : contact over 3mm
 Soft tissue graft
 Free graft : FGG, CT
 Pedicle graft : palatal or labial
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Controversy

 1 stage surgery (bone graft & implant placem

ent)
 Single surgical intervention
 Potentially reduced healing time
 2 stage surgery
 Prosthetically better implant placement
 Superior esthetics

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1 stage surgery
 1 stage surgery (bone graft & implantation)
 Long-term implant survival rates : 25~100%
 Implant position & angulation are critical factors
 Implant survival alone does not predict successful re
storation of occlusion

 Verhoeven et al 1997
 Carr & Laney 1987
 Marx & Morales 1988

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Advantage of delayed implant
ation
 Reducing the infection rate & graft failure rate
 Proper angulation & more precise positioning

 After 5 years of masticatory functional loading

 Onlay grafting & simultaneous implantation in maxil
la
 Success rate : 51~83%
 Secondary implantation
 Schliephake et al (1997, JOMS)
 20% higher success rate

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Resorption rate

 Proussaefs, Lozada et al (2002)

 Block graft with Bio-oss : 16.34 %, 17.58 %
 Cordaro et al (2002)
 Block bone : Mn 41.5%, Mx 43.5% (mean 42%)

 Wang and colleagues (1976) : onlay bone graft

 During the first 3 years : 14%~100%
 Bell et al (2002)
 Iliac crest block bone : 33%
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The use of ramus autogenous block grafts for vertical al
veolar ridge augmentation and implant placement: A pilot
studyProussaefs P, Lozada J, Kleinman A, Rohrer M (Int JOMI 2002;17:238-248)

 Ramus block autograft for vertical alveolar ridge augmentation

 Ramus block bone, Fixation screws, Periphery : Bio-Oss
 4~8 months later : HA implant (Steri-Oss)
 Results
 Radiographic
 6.12 mm (1 month)  5.12 mm (4~6 months) : 16.34 %
 Laboratory volumetric
 0.91 mL (1 month)  0.75 mL (6 months) : 17.58 %
 Peripheral pariculate bone (Bio-Oss)
 Bone (34.33%), fibrous tissue (42.17%), residual Bio-Oss particle (23.50%)
 Discussion
 Early exposure appeared to compromised the results, while late exposure did not
affect the vitality of the block autografts

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Clinical results of alveolar ridge augmentation with mandibular block bone grafts in par
tially edentulous patients prior to implant placement

Cordaro L, Amade DS, Cordaro M (Clin oral impl res, 2002;13:103-111)

 15 partially edentuous patients

 Ramus & symphysis block bone
 Fixed with titanium screw
 After 6 months screw remove, implant placed
 12 months later implant supported fixed bridges
 Mean reduction rate
 Lateral : 23.5%
 Vertical : 42 %
 Mandibular site more resorption rate than maxillary sites

Lateral Lateral % Vertical Vertical %

No. of aug. aug. at aug. at reduction aug. at aug. at reduction
Groups
sites bone implant of lateral bone implant of vertical
grafting placement aug. grafting placement aug.
Group 1 & 2 18 6.5+0.33 5.0+0.23 23.5% 3.4+0.66 2.2+0.66 42%
Group 1
10 6.5+0.6 5.2+0.4 20% 4.75+1.5 2.75+1.5 41.5%
: Mx
Group 2
8 6.5+0.37 4.75+0.12 27.5% 2.4+0.2 1.4+0.2 43.5%
: Mn

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 Staged reconstruction of the severely atrophic mandible wit
h Blakey
Bell RB, autogenous
GH, White RP, bone
Hillebrandgraft
DG, Molinaand endosteal
A (JOMS, implants
2002;60:1135-1141)

 Materials and Methods

 Vertical mandibular height <7mm (atrophic mandible)
 Iliac crest bone graft to the mandible via an extraoral approach
 After 4~6 months, implantation
 Results
 Mean pre-op bone height : 9mm (midline), 5mm (body)
 Before implantation (4~6months) vertical bone loss : 33%
 After implantation (24 months)
 Non-implant supported region bone loss 11% per year
 Implant-supported region bone loss negligible
 Conclusions (improve success rates)
 Prosthetically sound implant positioning
 Provide an affordable reconstructive option
 Staged reconstruction

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Complications of grafting in the atrophic edentulous or partial
Bahat O, Fontanesi RV
ly edentulous jaw Int JPRD 21:487-495 2001

 Intraoperative complications  Postoperative complications

 Gerneral
 Bone  Infection
 Insufficent donor material  Bone
 Over-reduction  Excessive resorption
 Inadequate fixation (early exposure, loss of graft)
 Inadequate bone for implant
 Soft tissue  Soft tissue
 Perforation  Hematoma
 Inability to mobile  Flap retraction
 Flap necrosis
 Teeth  Color or tissue-type mismatch
 Root damage  Loss of papilla
 Shallowing of vestibule
 Other anatomy
 Teeth
 Sinus : membrane tear
 External root resorption
 Nerve injury  Other anatomy
 Sinusities
 Nasal bleeding
 Oroantral fistula

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CASE REPORT

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Conclusions

 Autogenous block bone graft (chin or ramus)

 5~7mm gaining
 About 30% resorption rate
 Staging the grafting and implant procedure

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 Primary stability (+)
 Exposed threads can be covered with autogenous
bone associated with a membrane
 Jovanovic et al (1992), Jovanovic & Buser (1994), G
iovannolli & Renouard (1995), Antoun et al (1996)
 Primary stability (-)
 Ridge augmentation should be performed before i
mplantation

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