Surgical methods of bone replacement - Semmelweis
Transcript of Surgical methods of bone replacement - Semmelweis
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Surgical methods of
bone replacement
Attila Szűcs DDS, PhD
Semmelweis University, Budapest
Department of Oral and Maxillofacial Surgery and Denistry
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Success
for long term
(both by functional + esthetical point of view)
• excellent bone quantity
– vestibulo-oral + vertical dimension
• Good implant system
•Right treatment plan+sugical treatment
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The indications of surgical
bone replacement
• After pathological bone loss
• After surgical bone loss
• Before or together with oral
implant rehabilitation
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Dentistry has undergone many
changes during the past quarter
century; however, no changes have
been more profound than those
in the field of implant
dentistry
Nevins M., J. T. Mellonig edit.: Implant Therapy
Quintessence 1998.
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The implant therapy
belongs to the
everyday dental practice,
because of its
predictability and high
success rate.
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Present
The indication of
implant therapy can
be any of those
edentulous
situations, where
the goal is the re-
establishment of the
function and esthetics
of natural teeth
Past
The indication of
implant therapy was
determined by the
anatomic
conditions of bone.re-establishment of
the function and
esthetics of natural
teeth.
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The modern surgical
methods of bone
replacement are
prominent parts of
oral surgery.
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Indication
„SAC” classification
(ITI):Straightforward,Advanced and Complex
classification system (2007)
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Special instruments
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„Micross”
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„Safescraper”
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edge
collector
„Safescraper”
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Bone collector
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Bone mill
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Piezo surgery
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Micro screw
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Micro saw (Khoury)
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Bone splitting set
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„Transfer-control”
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Oteotom for bone condensation
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Scaffolds /matrices//collagen, bone matrix, bone grafts/
Cells/osteoblasts,
fibroblasts/
Growth factors/BMP, PDGF, TGF-β, IGF/
Time
Biologic environment
The basic conditions of new bone formation
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Scaffolds /Matrices/
Cells Growth factors
Bone replacement procedure in the
practice
Autogenous
monocortical-block
bone transplantation
Gold-standard
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Autogenous bone harvested from the
iliac crest
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Harvesting sites on the mandible
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Monocortical bone-block-transplantation from the
iliac crest to the mandible /Op. Dr. Barabás J./
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Scaffolds /Matrices/
Time
Biologic environment
The basic conditions of new bone formation
OSTEOCONDUCTION:
the use of autolog,
heterolog, or alloplastic
materials for creating a
matrix of new bone
formation
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What are the relevant
characteristics of
bone grafting
materials?
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Relevant characteristics of bone grafting
materials
• Chemical composition
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HA synthetic
Interpore
Osprovit
Osteogen
HA natural
Bio-Oss
Ossnative
TCP
CerasorbTCP
Cerasorb
CHEMICAL COMPOSITION OF GRAFT MATERIALS
Calcium-phosphates
Calcium-carbonate
BioCoral
Bioglass ceramics Bioglass
Biogran
Polymers
Bioplant HTR
Calcium-phosphates
HA
natural
Bio-Oss
Ossnative
HA
synthetic
Interpore
Osprovit
Osteogen
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HYDROXILAPATITE
(HA)
(Pentacalciumphosphate)
Ca5(PO4)3OH
Ca : P = 5 : 3
nonresorbable
TRICALCIUMPHOSPHATE
/TCP/
Ca3(PO4)2OH
Ca : P = 3 : 2
resorbable
THE MOST WIDELY USED CALCIUM-
PHOSPHATE GRAFT MATERIALS
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Relevant characteristics of bone
grafting materials
• Chemical composition
• Volume of grafting
material
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Bone grafting materials in 0,5 g quantities
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The porosity of osteoconductive
materials
BONE 70%-80%
Bio-Oss 60%
Osteogen 60%
Interpore 16%
HTR ——
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Bio-Oss bone grafting material
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Osteointegration of Bio-Oss
Bone
Bio-Oss
The Bio-Oss® particles are
integrated in the newly
formed lamellar bone.
Time: min. 6 months
The matrix produced
by Bio-Oss®, facilitates
the ingrowth of blood
vessels, and the
migration of osteoblast
cells.
So develops the cell-rich
woven /reticular/ bone.
The highly porous
Bio-Oss® ceramic
stabilizes the
coagulum
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The healing of bone
grafting material depends
on
• the blood supply of the
surrounding bone
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The geometrical form of bone defects
5 walls 4 walls
bone graft bone graft + membrane
2-3 walls 1 wall
bone graft + fixed
membrane
bone graft + membrane +
autogenous bone
Therapy:
Therapy:
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The healing of bone grafting
material depends on
• the blood supply of the surrounding bone
• surgical technique
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GBR = Guided Bone Regeneration
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The intensity of growth of
different tissues
connective tissue 0,5 mm/day
bone tissue 50 μm/day
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Schematic
illustration of
GBR technique
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Different types of
membranes
Resorbable
collagen, synthetic
Non resorbable
titanium, PTFE
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BIO-GIDE® MEMBRANE
• Resorbable collagen
• Two-layers
(dense, porous)
• Slow resorption
(5-6 months)
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Surgical methods with the use of
bone grafting materials
• Lateral augmentation
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Implant
+
bone graft + membrane
6-7 months healing time
Immediate implantation with
bone replacement
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Lateral augmentation with
simultaneous implant placement
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Lateral augmentation with simultaneous
implant placement
The integration of bone graft
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Lateral augmentation with simultaneous
implant placementNew bone formation, ready for implant prosthesis
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Immediate implantation
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after 6 months
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Late implantation after bone
replacement
bone graft + membrane
6-8 month
healing
Implant placement
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Lateral augmentationInsufficient bone volume for implant placement
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Lateral augmentationPerforations of outer cortical layer
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Lateral augmentationThe placement of bone graft and membrane
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Lateral augmentationThe integration of bone graft
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Lateral augmentationNewly formed bone, implant placement
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Fixation of Bio-Gide membrane with
two layers
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Vertical cross-section histologic picture
in the site of augmentation
bone
bone + bone graft
connective tissue + bone graft
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The osteointegration
of bone grafting
materials is limited
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Growth factors
Scaffolds /matrices/
The basic conditions of new bone formation
OSTEOINDUCTION
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Mesenchymal
cell
Osteoblast
Osteocyte
THE TRANSFORMATION OF
OSTEOGENETIC CELLS
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BMP
Bone Morphogenetic Proteins
Site of occurrence, synthesis:
- produced by the osteoblasts
- stored in the bone
Effects: influence on cell differentiation
• 13 osteoinductive BMPs have been discovered so
far
• Clinical trial with BMP-2 /rhBMP-2/.
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Growth factors
Scaffolds /Matrices/
Bone replacement procedure in the
practice
Bone grafting material+GBR technique
+Autogenous bone
particles
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Intraoral bone harvesting sites
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Harvesting bone-blocks from the chin
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Surgical methods with the use of
bone graft materials
• Lateral augmentation
• Bone-splitting, bone
spreading
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Bone-splitting procedure
Insufficient bone volume for implant
placement
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Bone-splitting procedureThe surgical technique of bone-splitting
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Bone-splitting procedure
The placement of bone graft and membrane
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Bone-splitting procedure
The osteointegration of grafting material
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Bone-splitting procedure
Bone-healing, implant placement
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Bone-splitting procedure
Bone-healing, implant placement
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after 7 months
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Surgical methods with the use of
bone graft materials
• Lateral augmentation
• Bone-splitting, bone-spreading
• Sinus-lift, sinus elevation
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Sinus-lift procedure
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Sinus-lift procedureCompleting lateral bone-window
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Sinus-lift procedurePreparation of sinus mucosa, with hinging the
bone-window
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SINUS-LIFT PROCEDUREPreparation of sinus mucosa
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Sinus-lift procedurePlacement of grafting material and the
barrier membrane
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Sinus-lift procedureOsteointegration of the bone grafting
material
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Sinus-lift procedureNew bone formation, placement of implant
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Past
The indication of
implant therapy was
determined by the
anatomic conditions
of bone.
Present
The indication of
implant therapy
can be any of those
edentulous
situations, where
the goal is the re-
establishment of the
function and
esthetics of natural
teeth
Future =
Tissue engineering