Increasing Alveolar Ridge Height: Techniques?

This kind of site should not be used for learning ridge augmentation.You should take some GOOD surgical courses available to GP.

If you have not done extensive bone graft cases, to achieve width, I would avoid cases that you are trying to get height. No matter if you are a GP or a specialist. It is very technique sensitive and requires a good deal of experience, in my humble opinion. I have used Gore-Tex membranes reinforced with Titanium, but have achieved the best results with Titanium mesh. If you try these procedures be prepared to handle complications.

Vertical GBR appears to be a relatively reliable reconstructive technique, but to be successful, it needs autogenous bone harvesting, which increases operating times and postoperative morbidity. In addition, early membrane exposure may cause infection that may compromise the final outcome of the rehabilitation. This technique has been mainly applied to limited defects with vertical bone gains ranging from 2 to 7 mm, on average. Alveolar Distractor (AD) has proven to be a reliable technique. The vertical bone gain may reach more than 15 mm; it is obtained in a more ‘physiologic’ way, with no need of bone transplantation, thus reducing morbidity. Another advantage may include a progressive elongation of the surroundings oft tissues (neo-histogenesis) with very limited risk of wound dehiscence and bone exposure. Alveolar Distractor (AD), as compared to GBR, may offer a better long-term prognosis as far as bone gain maintenance and peri-implant bone resorption after prosthetic loading are concerned. Survival rates of implants do not differ between AD and GBR groups, whereas success rates of implants are different significantly. GBR techniques may be more indicated for small defects and in case of a combination of vertical and horizontal defects. AD with intraoral extraosseous distractors of a single-tooth space may be in fact more difficult to perform, due to the limited space available for osteotomies and to the dimensions of the distraction device. Instead, in case of severe vertical defects with the presence of a broad bony base, AD may be more indicated because more vertical gain may be achieved by AD than GBR. We should never forget that alveolar distraction osteogenesis is a kind of segmental jaw osteotomy and any clinician that is attempting to perform it, should be very well familiar with the principles of orthognathic surgery and rigid fixation techniques.

Dear Dr K. Gaining alveolar bone height in a predictable manner requires surgical skills and experience. In your case I would not suggest using Distraction nor Bone Blocks.I would go to GBR using Titanium mesh or titanium reinforced gortex membranes with an allograft.Other possibility would be using alloplastic rigid membrane like Inion with an allograft or autogenous particles harvested with a bone scraper. Do not forget- there is a learning curve...

The use of one technique/bone substitute over another, in my opinion, is a secondary consideration. Having used all of the mentioned surgical techniques, and most of the available bone graft materials, success or failure is really determined by flap management. Dehisence of the flap is the number one cause of graft failure. We prefer our residents learn how to advance flaps predictably, get tension free closure, use matress sutures rather than interupted, and then, even in less experienced hands, the success rate goes up dramatically. Take some bone grafting courses, and you will see how much time is dedicated to this part of the paradigm, and how many failures are attributed to soft tissue problems. THEN make a decision as to which graft to use.

I completely agree with Robert. Flap management is the most important part of any bone grafting procedure. Learning how to design your flap and then achieving passive primary closure is of absolute importance. Unforunately, I did go through a learning curve during my residency, dealing with these complications are gut wrenching.

Dear Dr. K concerning augmentation for the alveolar ridge hight is challenging procedure, a lot of methods were used in the past as GTR membrane, bone blocks with bone substitute including freezed dried bone, hydroxpapatite and bioactive glass materials and so on.finally we have to thank Dr.llizarov for his magic idea for bone distraction technique, so, using the alveolar ridge distractor will solve a lot of problems in implant cases and maxillofacial surgeries. Thanks Dr.Ossama Ghorab

I agree with comments regarding the importance of flap management. Essentially we are talking about the need for adequate blood supply to the site. This is via the flap periostium and angiogenesis through the cortical bone at the receipient site. The latter is gained by aggressive cortical drilling to initiate bleeding (numerous but not deep small holes). This step is essential. Regardless of the graft type, I seem to be getting even better results when I add GEMS-21 to the mix. The liquid component contains a recombinant bone morphogenic protein that may aid in initial healing and integration. Supposedly higher concentrations than platelet rich plasma. It is expensive. As the studies with PRP show; not more bone but maybe better healing with this product. Also remember pure autogenous grafts have the greatest amount of resorption.

Just to clarify, Gem 21s has rhPDGF not BMP. BMPs are coming and are much more expensive.