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VERTICAL RIDGE AUGMENTATION

가천의과대학교 길병원 구강악안면외과

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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 that 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 & prosthodontist Significant “reversible complication” rate

22.2% (Keller et al, Int JOMI 1986;1:101) Infection, superstructure fx, mandible fx, fail to osseointegrate

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Ridge augmentation methods

Bone grafting Biomaterials GBR Alveolar distraction osteogenesis

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Distraction Osteogenesisfor 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 augmentation with a titanium-reinforced

membrane: A case report

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

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

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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 revascularizatio

n than particulate bone marrow Extra-oral or Intra-oral donor-site

Intraoral harvested intramembraneous bone graft may have minimal resorption, 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 Bone

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

as compared to endochondral bone grafts Cortical membranous grafts revascularize more rapidly than endochon

dral bone graft with a thicker cancellous part Zins & Whittacker (1983), Philips & Rhan (1990)

Membranous bone (such as mandible) undergoes less resorption than endochondral 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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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 pain/edema

Moderate Minimal to moderate

Teeth Common(temporary) Uncommon

Nerve damage Common(temporary)Uncommon

Incision dehiscence Occasional(Vestibular) Uncommon

Chin vs Ramus

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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 materials

Bony irregularity contouring Graft fixation

Block bone : at least 2 fixation screws for immobilization

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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 placement) 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 restoration of occlu

sion

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

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Advantage of delayed implantation

Reducing the infection rate & graft failure rate Proper angulation & more precise positioning

After 5 years of masticatory functional loading Onlay grafting & simultaneous implantation in maxilla

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 alveolar ridge augmentation and implant placement: A pilot study

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

Proussaefs P, Lozada J, Kleinman A, Rohrer M (Int JOMI 2002;17:238-248)

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

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

GroupsNo. of aug. sites

Lateral aug. at bone grafting

Lateral aug. at implant placement

% reduction of lateral aug.

Vertical aug. at bone grafting

Vertical aug. at implant placement

% reduction of vertical 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 : Mx 10 6.5+0.6 5.2+0.4 20% 4.75+1.5 2.75+1.5 41.5%

Group 2 : Mn 8 6.5+0.37 4.75+0.12 27.5% 2.4+0.2 1.4+0.2 43.5%

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

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Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants

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

Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (JOMS, 2002;60:1135-1141)

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Complications of grafting in the atrophic edentulous or partially edentulous jaw

Intraoperative complications Bone

Insufficent donor material Over-reduction Inadequate fixation

Soft tissue Perforation Inability to mobile

Teeth Root damage

Other anatomy Sinus : membrane tear Nerve injury

Postoperative complications Gerneral

Infection Bone

Excessive resorption(early exposure, loss of graft)

Inadequate bone for implant Soft tissue

Hematoma Flap retraction Flap necrosis Color or tissue-type mismatch Loss of papilla Shallowing of vestibule

Teeth External root resorption

Other anatomy Sinusities Nasal bleeding Oroantral fistula

Bahat O, Fontanesi RV Int JPRD 21:487-495 2001

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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), Giovannolli & Ren

ouard (1995), Antoun et al (1996) Primary stability (-)

Ridge augmentation should be performed before implantation