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VERTICAL RIDGE AUGMENTATION

VERTICAL RIDGE AUGMENTATION. 가천의과대학교 길병원 구강악안면외과. 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

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VERTICAL RIDGE AUGMENTATION

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  1. VERTICAL RIDGE AUGMENTATION 가천의과대학교 길병원 구강악안면외과

  2. 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 Jun chang hun

  3. 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 Jun chang hun

  4. SITE DEVELOPMENT • Hard tissue management • Ridge(socket) preservation • Ridge augmentation • Vertical ridge augmentation • Horizontal ridge augmentation • Soft tissue management Jun chang hun

  5. SITE DEVELOPMENT • Hard tissue management • Ridge(socket) preservation • Ridge augmentation • Vertical ridge augmentation • Horizontal ridge augmentation • Soft tissue management Jun chang hun

  6. 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) Jun chang hun

  7. 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 Jun chang hun

  8. Ridge augmentation methods • Bone grafting • Biomaterials • GBR • Alveolar distraction osteogenesis Jun chang hun

  9. 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 Jun chang hun

  10. Ridge augmentation methods • Bone grafting • Biomaterials • GBR (Guided Bone Regeneration) • Alveolar distraction osteogenesis Jun chang hun

  11. Titanium membrane only • Cornelini (2000) • Ti-memb only, 3mm vertical ridge augmentation Jun chang hun

  12. 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) Jun chang hun

  13. Ridge augmentation methods • Bone grafting • Biomaterials • GBR • Alveolar distraction osteogenesis Jun chang hun

  14. Autogenous bone graft • Gold standard for bone augmentation procedures • Block bone or particulate forms • Block bone - reduced osteogenic activity & slow revascularization 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 Jun chang hun

  15. 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 Jun chang hun

  16. 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 Jun chang hun

  17. Donor Sites of Autogenous Bone • Cortical Bone • Mandible, Cranium • Cancellous Bone • Mx. Tuberosity • Inner Cancellous part • Cortico-Cancellous Bone • Iliac bone Jun chang hun

  18. 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 endochondral 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 Jun chang hun

  19. Iliac bone Jun chang hun

  20. Chin bone Jun chang hun

  21. Ramus bone Jun chang hun

  22. Ramus bone Jun chang hun

  23. 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) Jun chang hun

  24. Chin vs Ramus Jun chang hun

  25. Maxilla vs Mandible • Maxilla • More vascularity • Mandible • Less vascularity • Cortical bone perforation with bur Jun chang hun

  26. Critical Success Factors • Stability of grafting materials • Condition of recipient sites • No infections • Resistance to resorptions • Soft tissue coverage Jun chang hun

  27. Stability of grafting materials • Bony irregularity contouring • Graft fixation • Block bone : at least 2 fixation screws for immobilization Jun chang hun

  28. Condition of recipient sites • Inlay graft (3~4 wall defect) • More favorable • Onlay graft (1~2 wall defect) • More prone to resorption Jun chang hun

  29. 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 Jun chang hun

  30. 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 Jun chang hun

  31. 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 Jun chang hun

  32. Controversy • 1 stage surgery (bone graft & implant placement) • Single surgical intervention • Potentially reduced healing time • 2 stage surgery • Prosthetically better implant placement • Superior esthetics Jun chang hun

  33. 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 occlusion • Verhoeven et al 1997 • Carr & Laney 1987 • Marx & Morales 1988 Jun chang hun

  34. 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 Jun chang hun

  35. Jun chang hun

  36. 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% Jun chang hun

  37. 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) Jun chang hun

  38. Clinical results of alveolar ridge augmentation with mandibular block bone grafts in partially 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 Jun chang hun

  39. Staged reconstruction of the severely atrophic mandible with autogenous bone graft and endosteal implants Bell RB, Blakey GH, White RP, Hillebrand DG, Molina A (JOMS, 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 Jun chang hun

  40. 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 Complications of grafting in the atrophic edentulous or partially edentulous jaw Bahat O, Fontanesi RV Int JPRD 21:487-495 2001 Jun chang hun

  41. CASE REPORT LINK

  42. Conclusions • Autogenous block bone graft (chin or ramus) • 5~7mm gaining • About 30% resorption rate • Staging the grafting and implant procedure Jun chang hun

  43. Primary stability (+) • Exposed threads can be covered with autogenous bone associated with a membrane • Jovanovic et al (1992), Jovanovic & Buser (1994), Giovannolli & Renouard (1995), Antoun et al (1996) • Primary stability (-) • Ridge augmentation should be performed before implantation Jun chang hun

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