Surgical Augmentation Techniques PDF

Surgical Augmentation Techniques Rachel Uppgaard, DDS, FACS May 17, 2024 Disclosure Products shown in this presentation are meant to illustrate options, not to be a recommendation for that particular product There are many good products on the market I have no relevant financial disclosures Objectiv...

Surgical Augmentation Techniques Rachel Uppgaard, DDS, FACS May 17, 2024 Disclosure Products shown in this presentation are meant to illustrate options, not to be a recommendation for that particular product There are many good products on the market I have no relevant financial disclosures Objectives Define what surgical augmentation techniques are Identify candidates for surgical augmentation techniques List contraindications for bone grafting Review what options are available Define surgical augmentation techniques These are techniques used to improve sites, specifically sites for dental implants, whether it is with bone or soft tissue, or both Goal: to consider the different factors involved in bone and soft tissue healing, and to optimize these Cellular components of bone Osteoprogenitor cells Osteoclasts Osteoblasts Osteocytes Osteoid Our goal is to stimulate bone formation Why bone grafting? Guide healing If the body sees bone, it forms bone The bone graft is a scaffold Prevents soft tissue ingrowth Maintain bone levels Excellent if there is a defect in one or more of the walls Optimize site for implant Implants have different emergence profiles Want as much bone as possible First intention Clean laceration or surgical incision Closed primarily Rapid healing No dehiscence Minimal scar Sometimes you may see grafting procedures done with primary intention closures! Second intention Protracted filling of tissue defect with granulation tissue and connective tissue Avulsive injury, local infection, inadequate closure of the wound Many extraction sites heal with secondary intention, and often with socket preservation we use a membrane to allow secondary intention healing of the keratinized tissue to make sure we have plenty of keratinized tissue Third intention More complex wounds Staged procedure Debridement  allow to granulate and heal for 5-7 days  then suture to close by primary intention ****This does not work well in the oral cavity! Timeline for healing of human extraction sockets Initially: Blood fills extraction site, intrinsic and extrinsic pathways of clotting cascade are activated Week 1: clot replaced with granulation tissue 24-48 hours: Fibrin meshwork with RBCs, organization of clot within 24-48 hours, then formation of a fibrin layer Then epithelialization, osteoclasts come in and angiogenesis proceeds Week 3: Extraction socket filled with granulation, poorly calcified bone forms around the perimeter. Surface is reepithelialized with minimal or no scar formation. Granulation tissue is replaced with collagen Week 2: clot organizes through fibroplasia and new blood vessels penetrate to center of clot Trabeculae of osteoid start to extend into clot from alveolus, osteoclastic resportion Week 8-12: Radiographic evidence of bone formation Identify candidates for surgical augmentation techniques We want to optimize implants and implant restorations The final goal is to have the restoration in the best position possible for occlusal forces, cleansibility We want the work we do to survive and heal Ideal candidates Healthy (well controlled medical comorbidities) Excellent oral hygiene No active oral disease (caries, unstable periodontitis, periapical infections etc) No active sinus disease, especially if working in posterior maxilla Not on medications that will affect bone growth Ability to keep oral cavity clean Realistic expectations Absolute Contraindications to grafting Uncontrolled diabetes mellitus Heavy smoking History of radiation to oropharynx Acutely infected teeth Active chronic periodontal disease Active chemotherapy IV bisphosphonates Pregnancy Relative contraindications/tread lightly Rheumatoid arthritis Chronic periodontitis Corticosteroids Immunosuppressants Osteoporosis Poor oral hygiene Presence of adjacent endodontically treated teeth Oral bisphosphonates What options are available? Socket preservation (ridge preservation) Ridge augmentation—extending beyond the skeletal envelope of the existing edentulous ridge Using allograft Tunnel graft Block grafts (menton, ramus, anterior iliac crest bone grafting) Ridge split technique Autogenous grafts Material harvested from somewhere else “Gold standard”—osteoconductive, osteogenic, osteoinductive Increased morbidity Increased cost Allograft: Particulate grafting material Common forms of allograft Block grafts—not frequently used Cancellous particulate Cortical particulate Mineralized/demineralized cortical bone particulate Mineralized and demineralized corticocancellous particulate mix Cancellous particulate Cortical particulate Mineralized and demineralized cancellous particulate Demineralized bone matrix putty Demineralized bone matrix putty Allografts From another donor of the same species Most commonly used graft material today Osteoconductive, osteoinductive Xenograft Usually bovine Not biodegradable The scaffold that stays… So many options—which one to choose? Types of membrane Collagen Pericardial membrane Amnion-chorion membrane Nonresorbable (goretex, titanium reinforced) Platelet-rich fibrin ZimVie Snoasis Medical Tunnel graft Tunnel graft Tunnel technique: incision through attached and unattached gingiva +/- collagen membrane Pack in the bone graft Suture….then wait! Other Options rhBMP-2 Fresh Frozen bone PRF rhBMP-2 Bone morphogenic protein Mix with sterile water Soak on absorbable collagen sponge (made from material found in bone, tendons)—allow 15 minutes for it to absorb Place it into the defect Usually use XXS Very expensive SIGNIFICANT SWELLING Avoid in patients with malignancy Fresh Frozen Bone (Vivigen) Cellular allograft Osteogenic: Processing removes bone marrow components while retaining osteoblasts, osteocytes Osteoconductive (corticocancellous chips): provides scaffold Osteoinductive: (demineralized bone, exposes growth factors in the bone matrix Expensive Must be kept in -80 degree freezer Depuy Synthes Types of membrane Collagen Pericardial membrane Amnion-chorion membrane Nonresorbable (goretex, titanium reinforced) Platelet-rich fibrin Fan Y, Perez K, Dym H. (2020) Clinical uses of platelet-rich fibrin in oral and maxillofacial surgery. Dent Clin N Am 64: 291–303 ZimVie Platelet rich fibrin (PRF) A fibrin matrix derived from patient’s platelets Goal: using the patient’s own growth factors from the blooed to promote healing Moldable matrix with delayed release of contents, scaffold that can be penetrated with peripherally proliferating cells Fan Y, Perez K, Dym H. (2020) Clinical uses of platelet-rich fibrin in oral and maxillofacial surgery. Dent Clin N Am 64: 291–303 Procedure workflow Surgeon Assistant Informed consent Seats patient, talks to patient about procedure, after care Excellent anesthesia (palatal, lingual too!) Talks to patient about aftercare, waiting for anesthesia to work Good flap design Atraumatic tooth extraction Assists Curette, curette, curette Irrigate, irrigate, irrigate Hydrates the bone graft with saline or PRP Cut membrane to correct size Graft—gentle condensation Hands surgeon bone graft on #9 Pull membrane over top Holds woodson/#9 periosteal elevator to hold membrane in place during suturing Suture Reviews post-op instructions Flap design—if necessary Envelope flap May need releasing incisions Do not cross mental foramen, canine eminence Don’t create releases on the palate, lingual aspect of mandible Periosteal release may be necessary to help with tension free closure and if you are trying to bulk out the buccal with graft Releasing incisions– don’t cross the canine eminence! Envelope flap—no releasing incisions Periosteal release—incise just through the periosteum Pre- and Post-op Discussion with patient Expect bone spicule exfoliation Expect bone spicule exfoliation Expect bone spicule exfoliation Expect bone spicule exfoliation Avoid touching the socket Sutures fall out early Monitor Mouth rinses Do not recommend re-suturing Bone graft failure Monitor! Peridex Reassure the patient If purulent drainage, need to curette out Questions? [email protected] References Tolstunov L. (2022) Bone grafting in implant dentistry: importance of proper terminology. J Oral Maxillofac Surg 80:1580-1582. Misch CM. Chapter 24, Autogenous bone grafting for dental implants. Hai JH et al. (2020) Antibiotic prescribing practices in periodontal surgeries with and without bone grafting. Journal of Periodontology, 91: 508-515 doi 10.1002/JPER.19-0195 Block MS, Kelley B. (2013) Horizontal posterior ridge augmentation: the use of a collagen membrane over a bovine particulate graft: technique note. J Oral Maxillofac Surg 71:1513-1519. Fan Y, Perez K, Dym H. (2020) Clinical uses of platelet-rich fibrin in oral and maxillofacial surgery. Dent Clin N Am 64: 291–303 Resources Kademani D, Tiwana P. (2016) Atlas of Oral and Maxillofacial Surgery. Elsevier Resnik, RR. (2020) Misch’s Contemporary Implant Dentistry, 4th edition. Mosby IMPLANT III Bone Augmentation, Zimmer implant surgical armamentarium Preclinical Prosthodontics Technique Lecture/Lab VI Implant #3. Table of contents Single implant restoration Treatment Sequence 1. Prosthodontic consultation (Dx, Tx Planning) – Done. 1-1. Imaging (CT, Panoramic radiograph) – Done. 2. Surgical consultation (including grafting) 3. Surgical guide fabrication – Done. 4. 1st stage surgery 5. 2nd stage surgery 6. Impression 7. Final restoration delivery 2. Surgical consultation- Review a. Medical history b. Need for grafting- imaging required c. Surgical plans/protocols: immediate placement, one-stage implant, indirect sinus lift, etc.imaging required d. IV sedation confirmation: antecubital fossa e. Sequence, timeline, fees f. Consent form g. Instructions: NPO, Driver, Pre-medication, etc Topic: 2-b. Grafting & surgical techniques to deal with limited quantity of bone Dr. Rachel Uppgaard, DDS, FACS Clinical Associate Professor, Swift Professorship in Oral and Maxillofacial surgery, Oral Maxillofacila Surgery University of Minnesota Graft materials & properties        Autograft: patient’s own bone Allograft: human cadaver Xenograft: different species like bovine Alloplast: synthetic material Osteogenic: Vital osteoblasts coming from graft contribute to new bone growth. Capability to produce bone tissue by the cell activity (Live bone cell) Osteoconductive: graft such as particulate bone which serves as a scaffold for new bone growth. Framework for new bone to grow into at its normal healing rate. Osteoinductive: stimulate osteoprogenitor cells to differentiate into osteoblast such as rhBMP, PRP, PRF, rhPDGF, etc.. Stimulate bone to grow at an advanced rate. Dr. Lakschevitz Reconstruction of deficient alveolar ridge (Implant site preparation)  Ridge Preservation (extraction socket graft)  Maxillary Sinus Bone Augmentation (sinus lift)  Ridge Augmentation A. Horizontal ridge augmentation (Increasing thickness of bone) - Particulate bone (FDBA: Freeze-Dried Bone Allograft) with membrane (GBR: guided bone regeneration) - Block graft on the side of the ridge - Ridge split w/ chisel or osteotome; greenstick fracture B. Vertical ridge augmentation (Increasing height of bone) - Onlay block graft - Particulate bone with tenting screws - Inter-positional bone graft (sandwich tech.) - distraction osteogenesis (DO) - Mn nerve transposition – risky - **sinus lift; direct/indirect Dr. Lakschevitz Dr. Lakschevitz Dr. Lakschevitz Reconstruction of deficient alveolar ridge (Implant site preparation)  Ridge Preservation (extraction socket graft)  Maxillary Sinus Bone Augmentation (sinus lift)  Ridge Augmentation A. Horizontal ridge augmentation (Increasing thickness of bone) - Particulate bone (FDBA: Freeze-Dried Bone Allograft) with membrane (GBR: guided bone regeneration) - Block graft on the side of the ridge - Ridge split w/ chisel or osteotome; greenstick fracture B. Vertical ridge augmentation (Increasing height of bone) - Onlay block graft - Particulate bone with tenting screws - Inter-positional bone graft (sandwich tech.) - distraction osteogenesis (DO) - Mn nerve transposition – risky - **sinus lift; direct/indirect Guided bone regeneration (GBR) Guided bone regeneration (GBR) is a surgical procedure that utilizes bone grafts with barrier membranes to reconstruct small defects around dental implants. Dr. Lakschevitz Dr. Lakschevitz Split ridge graft: min. 5mm thick Reconstruction of deficient alveolar ridge (Implant site preparation)  Ridge Preservation (extraction socket graft)  Maxillary Sinus Bone Augmentation (sinus lift)  Ridge Augmentation A. Horizontal ridge augmentation (Increasing thickness of bone) - Particulate bone (FDBA: Freeze-Dried Bone Allograft) with membrane (GBR: guided bone regeneration) - Block graft on the side of the ridge - Ridge split w/ chisel or osteotome; greenstick fracture B. Vertical ridge augmentation (Increasing height of bone) - Onlay block graft - Particulate bone with tenting screws - Inter-positional bone graft (sandwich tech.) - distraction osteogenesis (DO) - Mn nerve transposition – risky - **sinus lift; direct/indirect Inadequate mandibular posterior height: Severely resorbed posterior Mn under the distal extension RPD GBR (Guided Bone Regeneration) with Tenting Screws + Autogenous Bone Chips + BMP-2 + Ti-Mesh 8 months healing Inter-positional bone graft (Sandwich Technique) Distraction osteogenesis Distraction osteogenesis Nerve transposition 2-c. Implant surgical placement – Instrumentation Mr. Cory Larose/Chris Bjorklund Minneapolis/Regional Territory Representative, Zimmer Dental Instrumentation handout - Canvas Zimmer tapered screw-vent implant drilling sequence  Zimmer Drill set video on Canvas site.  Topic: 1st & 2nd Stage Implant Surgeries  Video clips Topic: Precision surgery guide – Nobleguide  Video clips Questions?