16/12/2019

Price: 35

Mays Khanfar

Mays Khanfar
Dr. fadi jarrab

Advanced surgical techniques in

implant dentistry

10

‫يُطلب من جمعية التصوير الطبية‬

 Advanced Surgical Techniques In Implant Dentistry

• Be simple with your treatment plan and cause no harm to the patient.

• After a tooth is extracted, the alveolar ridge decreases in width and height very
rapidly, with as much as 50% loss in width during the first year, two-thirds of
which occurs in the initial 3 months.

• Assessment of the ridge prior to implant placement:

1. Assessing height of the bone:
- Done by using 2D x-rays or 3D CBCT.
- Height of remaining bone >= Height of implant.
- Ex: Missing upper central incisor, on x-ray assessment it showed
14 mm bone to the nasal floor → Use of 13 mm long implant.

2. Assessing width of the bone:

- Very thin ridge → CBCT.
- Wide ridge → Clinical Examination.
- How to clinically examine the ridge?
*Procedure known as Bone Sounding.
*Under LA with the use of a probe, I insert the probe buccally till I hit
bone and measure the distance and do same thing lingually → Here
measuring soft tissue width.
* Then subtract soft tissue width form ridge width to have bone width.
- Knowing Bone width helps us determine the diameter of the implant
to be used.
- Have 1-2 mm Bone buccal to the implant and 1 mm Bone palatal to the
implant.
I. Bone Grafting:

• We have 3 mechanisms of Bone Growth:

1. Osteoconduction:
- Physical effect by which the matrix of the graft forms a scaffold that
favors outside cells to penetrate the graft and form new bone.
- Provides matrix for bone growth – Bone is guided by this matrix to
deposit.

2. Osteoinduction:
- Growth factors encourage mesenchymal cells to differentiate into
osteoblastic lineages.
- Molecules contained in the graft (Ex: Bone Morphogenetic Proteins)
convert the neighboring cells into osteoblasts.
- Bone Morphogenetic Proteins “BMP”:
*More found in the cortical bone.
*Recruits mesenchymal cells from the blood and encourage them to
differentiate into osteoblast.
- Mesenchymal cells are more found in the cancellous bone.

3. Osteogenesis:
- Transplanted osteoblasts and periosteal cells directly produce bone.
- Formation or development of new bone by cells contained in the
graft.

• Osteogenesis and Osteoinduction →

Bone Formation.
• Osteogenesis → Happens at first
then stops by the effect of the
transplanted osteoblasts.
• Osteoinduction → Takes time to
develop and stays for a longer period.
• Osteoconduction → Just a matrix for
the bone to form on.
• 99% of the bone grafts, they do Osteoconduction.
• Ideally, we’re looking for a graft that can do the 3 mechanisms.
• Autografts are capable of doing the 3 mechanisms.

• Types of Bone Grafts: (Most have osteoconductive properties)

1. Autograft – Bone obtained from the same individual.
2. Allograft – Bone obtained from a different individual of the same species.
3. Xenograft – Bone obtained from a different species.
4. Bone graft substitutes – Synthetic Bone.

• Autograft:
- Gold standard material.
- Standard by which other materials are judged.
- May provide osteoconduction, osteoinduction and osteogenesis.
- Drawbacks:
1. Limited supply.
2. Donor site morbidity.

• Bone graft could be:

1. Cortical. Selection depends on the
2. Cancellous. condition of the site.
3. Corticocancellous.

✓ Adv. Of Cortical Bone:

*Structural Stability.
*BMPs.

✓ Adv. Of Cancellous Bone:

*Mesenchymal Cells.
*Blood Supply.
• Example:
- Sometimes in mandible, we have sufficient amount of bone but when we
drill, no blood is coming out “Low Vascularity”. So, I might do a cancellous
bone grafting to enhance the vascularity at the site, thus enhancing implant
healing.
- Low vascularity → Common cause of implant failure.
- Blood is very important in implant healing.

• Types of bone graft based on application:

1. Onlay Bone Graft:

- Bone graft in which transplanted tissue is laid directly
onto surface of recipient bone.
- Block Bone Graft.

2. Interpositional Bone Graft:

- Bone graft between 2 pieces of bone.
- The "sandwich" technique.
- Used in Cleft palate surgeries.

3. Inlay Bone Graft:

- A slot or rectangular defect is created
in the cortex of the host then a graft is
fitted in to the defect.
- Filling the defects or gaps.
- Ex: Bone grafting in maxillary sinus
• Mandibular symphysis as bone graft source:
- Same intra-oral incision as genioplasty “from 4 to 4”.
- We cut through the cortex till we feel a perforation “Reached cancellous
bone”.
- We stay 5 mm away from the root
apices, lower border of mandible and
mental foramen “Not to damage
anterior loop of the mental nerve”.
- Why we must keep a 5mm space from
lower border of mandible?
*To avoid unfavorable fracture.
- Either we take the whole segment or
divide it into 2 pieces leaving middle part. Some keep the middle part to
preserve mentalis muscle attachment.
- It’s Cortical or Corticocancellous Bone Graft.
- Note: I can take cancellous bone from below the segment using curette
and use it as graft.
- Complication:
1. Damage to incisive canal → Pt. complains of dysesthesia.
2. Damage to the mental nerve.
3. Fracture.

• Cases of Onlay Bone Graft:

✓ Case 1:
- Our main problem is
deficiency in the width.
- Criteria of onlay bone grafting:

1. Prior to placing the graft, we drill holes in the recipient bone to induce
bleeding “Increase Vascularity”.

2. Shape the graft based on the defect, adapted

very well on the defect.

3. Graft must have 2 points of fixation (2 Screws).

One point of fixation (1 Screw) →

we’ll have rotation in the segment.

4. Very good primary closure without tension, if any part of the graft is
exposed, we’ll have ultimate failure (Most common cause of failure in
bone grafting).
✓ Case 2:

- Here we covered the graft with a membrane.

- There’s resorbable and non-resorbable membranes.
- When to use a membrane?
*In the cases of synthetic bone graft.
*Reason behind it is to prevent the ingrowth of soft tissue because
synthetic graft takes long time to develop bone.
- No need for the use of membrane with autogenous bone:
1. Due to osteogenesis and osteoinduction.
2. Takes long time to resorb → no room for soft tissue ingrowth.

✓ Case 3:

- Deficiency in the width.

- Circle → Defect due to the
fixation screw.
✓ Case 4:

External Oblique Ridge

- Here we’re using the ramus as a donor site:

1. Intra-oral incision “Wisdom Tooth Incision”.
2. Determine the dimension of the graft segment.

3. Cut the bone using bur:

- At the top “we’re away from the nerve”, go deep with the drilling.
- As we start to go down, we start to go superficial.
*Not to damage the nerve.
*To Easily break the segment.
- Piezosurgery device → new technology utilizing ultrasounds to cut the
bone tissue, minimizing the harmful effect on soft tissue (Main
problem → Time Consuming).
 - Sometimes, we might have fine irregularities after placing the graft →
cover it with synthetic bone graft.
- Complication of using ramus as a donor site:
1. Damage to the ID nerve
2. Segment might fracture into pieces.
3. Swelling and Hematoma.
- Why not use Synthetic bone?
*First, it depends on what I am expecting to achieve in the site (Stability,
Bone Formation, Filling Gaps…etc.)
*Synthetic Bone only do osteoconduction.
*Mainly we use it to fill gaps, minor dehiscence or exposure.
*We don’t expect bone formation with synthetic bone graft.

✓ Case 5:

- In severe cases, we use iliac crest as a donor site.

✓ Case 6:

- Severe ridge resorption.

✓ Case 7:
II. Ridge Expansion:
• Case:
- Pt. has good height in the mandible but
insufficient width.
- To solve the insufficient width, we have 2
ways:
1. Onlay Bone Graft – inapplicable, we
need a large amount of bone.
2. Ridge Expansion.

- In order to do ridge expansion, I need to

make sure that there’s cancellous bone
between the 2 cortical plates → By the
use of CBCT.
- No cancellous bone → no expansion.
- Expansion of cortical bone only →
fracture.

- Ridge expansion:
1. Do a cut reaching cancellous bone.
2. Expand the ridge using chisel and
mallet or osteotomes “from internet”.
3. Place implants to aid in expansion.
- Some put bone graft → let it heal → then
do implantation.
- Complications:
*Fracture → fixed with plates.
- We could fill the gap with bone graft, or
we can leave it.
- Commonly used in the maxilla
Implant placement
(Abundance of cancellous bone).

- Defer from the use of synthetic bone as much as possible → if the site gets
infected, all synthetic bone particles Must be removed → Impedes the
healing.
III. Sinus Lifting:
• Limitations to implant placement in the maxilla:
1. Ridge width.
2. Ridge height.
3. Bone quality.

• Limitations to implant placement in posterior maxilla:

1. Sinus – low bone quantity.
2. Poor quality of bone.

• Sinus lift procedures:

A. External (Direct) Sinus lifting:

- Lateral window sinus lift.
- Same as Caldwell-Luc approach/surgery.

- Case #1:

✓ Intra-Oral incision same as in Caldwell-

Luc procedure.
✓ Expose wall of maxillary sinus by
removing the bone.
✓ Carefully lift the maxillary membrane
with the bone “Lift the floor”.
✓ It’s very important not to cause any Schneiderian membrane
perforation in the maxillary membrane
while we’re lifting it → otherwise, we’ll
have a communication with nasal cavity
and the site will get infected “Failure”.
✓ How to make sure that the membrane is
intact?
*Blow Test.
*Ask pt. to blow while his nose is closed
→ air bubble coming out → Perforation.
 ✓ After Lifting, either I place the implant immediately or not.
▪ Decision is based on the primary stability.
▪ Good primary stability → Half of the implant length is integrated in
the bone → so, I place my bone graft with the implant.
▪ Less than half is integrated in bone → Poor primary stability → Bone
grafting and wait for 6 – 9 months.

✓ Some don’t place bone graft (Implant tenting the membrane) → based on
the theory that maxillary sinus membrane has osteogenic potentials →
Once it’s lifted → bone formation will be triggered.
✓ Type of bone graft here is INLAY BONE GRAFT.

- Case #2:

Before

After
B. Internal (Indirect) Sinus Lifting:
- Osteotome technique.
- Indicated when I need 2 – 3 mm of bone (no more).
- Lifting the sinus through the implant osteotomy.
- Procedure:
1. Drill an osteotomy.
2. Leave 1 mm of bone below the membrane.
3. Using osteotomes → break the remaining bone and lift the membrane
without tear.
4. Immediate implantation.

- Summers Osteotomes that are used in internal lifting:

*Strat with a small diameter then go up

*their diameter match with implant
*graded in order to know the length
- Cases:

• What Dr do in external sinus lifting:

1. Cut in the buccal bone reaching membrane.
2. Don’t remove buccal bone → lift the sinus using buccal bone as the new
floor of the sinus.
3. Place the implant → fill the gap with synthetic bone and place a membrane.

• What to do if the implant got displaced in the sinus:

- Don’t leave it – foreign body leads to infections.
- Caldwell-Luc surgery to remove it
- You can’t reuse the implant after its removal.
IV. Nerve Repositioning:
- Lateralization of the inferior alveolar nerve.
- Indicated when we don’t have
enough height in posterior mandible.
- Procedure:
1. Intra- oral incision.
2. Open a window in the bone.
3. Lateralization of the inferior
alveolar nerve.
4. Implant placement.

- Offers the following advantages:

1. Implants of greater length can be placed in the same surgical step.
2. Greater primary implant stability is afforded thanks to the possibility of
bi-cortical mandibular fixation.

3. No bone grafting is needed, and donor site morbidity is avoided.

- Case:

Good Luck ^_^

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Slide (9-14)

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